Table 2.

A summary of perceptions towards incentives to promote institutional deliveries

Coding tree	Key findings
1.0. Context
1.1. Geographical inaccessibility	Long distances to health facilities and remoteness of some villages. Lack of reliable means of transportation and high transportation costs.
1.2. Poor quality and inadequate health services	HC IIs, which served a majority of the community members, were perceived to be providing poor quality and inadequate health services
2.0. Community support for the interventions
2.1. Acceptability and impact of the interventions	Incentives perceived to be reducing maternal and newborn deaths and improving health-seeking behaviours. Incentives also perceived to have reduced a financial burden on families, which prevented loss of household assets and household food insecurity. Interventions perceived to be helpful particularly to the most vulnerable and poor women.
2.2. The need to scale up the incentive schemes	The interventions need to be scaled up to cover the entire district to achieve district-wide increased utilisation of maternal health services.
2.3. Preferred intervention	Transport vouchers preferred over baby kits. However, simultaneous implementation of the two interventions was necessary given the high level of poverty and barriers to access health services in the district.
3.0. Health-seeking behaviours postintervention
3.1. Increased utilisation of maternal health services	The interventions were perceived to have increased the number of ANC attendance and institutional deliveries. The transport voucher system facilitated efficient referral of women in need of emergency obstetric care to the HC IV and the hospital.
3.2. Bypassing resident health facilities in favour of intervention facilities	The incentives encouraged some women in the neighbouring subcounties to by-pass health facilities in their own subcounties for services at HCs in the intervention subcounties.
3.3. Home deliveries and changing roles of traditional birth attendants (TBAs)	Transport vouchers were perceived to have encouraged some TBAs to escort pregnant women to HCs thereby reducing the no of home deliveries.
3.4. Men’s involvements in maternal and newborn healthcare	The incentives motivated men to transport their partners to health facilities for ANC and delivery and to participate in birth preparedness.
3.5. Community health awareness	Health information and education associated with the interventions increased the community’s maternal health awareness.
4.0. Perceived undesirable effects of incentives
4.1. Increased workload for health workers and beyond	Increased utilisation of maternal health services led to an increased workload for health workers and transporters. Concerns over the sustainability of the workloads.
4.2. Sustainability of the interventions	Concerns about the sustainability of the interventions beyond the project period.
4.3. Encouraging ‘increased fertility’	Interventions could encourage more births. Family planning messages not included in the interventions.
4.4. Encouraging dependency	Long-term use of the interventions could encourage dependency.
5.0. Implementation issues and lessons learnt
5.1. Information gaps and consequences	Information gaps during the implementation of interventions leading to confusion, mistrust and discontent among users and transporters.
5.2. Transport voucher design, implementation and payment issues	Transport vouchers designed in English, yet most beneficiaries were illiterate. Uncooperative transporters who demanded immediate refunds instead of monthly refunds, delayed refunds, overcharging at night, double payments and the preferred costing method (negotiable price vs flat rate).
5.3. Insecurity and effects on transport voucher system	Refusal by some transporters to operate at night because of insecurity. Overcharging to ‘compensate’ for a perceived increased insecurity risk at night.
5.4. Poor attitudes and poor quality of care	Poor attitudes of some health workers towards transporters and women and their partners. Some community leaders lost interest in the interventions because of unfriendly behaviours of some midwives.
5.5. Shortage of baby kits	Shortages of baby kits. Some women had to make repeat visits to the facility to collect their kits.
5.6. Community suggestions for improvement	Community dialogues generated useful suggestions to address implementation challenges.

ANC, antenatal care; HC, health centre.