The Association of Health Insurance with institutional delivery and access to skilled birth attendants: evidence from the Kenya Demographic and health survey 2008-09.

BACKGROUND: Healthcare financing through health insurance is gaining traction as developing countries strive to achieve universal health coverage and address the limited access to critical health services for specific populations including pregnant women and their children. However, these reforms are taking place despite limited evaluation of impact of health insurance on maternal health in developing countries including Kenya. In this study we evaluate the association of health insurance with access and utilization of obstetric delivery health services for pregnant women in Kenya.

METHODS: Nationally representative data from the Kenya Demographic and Health Survey 2008-09 was used in this study. 4082 pregnant women with outcomes of interest - Institutional delivery (Yes/No - delivery at hospital, dispensary, maternity home, and clinic) and access to skilled birth attendants (help by a nurse, doctor, or trained midwife at delivery) were selected from 8444 women ages 15-49 years. Linear and logistic regression, and propensity score adjustment are used to estimate the causal association of enrollment in insurance on obstetric health outcomes.

RESULTS: Mothers with insurance are 23 percentage points (p < 0.01) more likely to deliver at an institution and 20 percentages points (p < 0.01) more likely have access to skilled birth attendants compared to those not insured. In addition mothers of lower socio-economic status benefit more from enrollment in insurance compared to mothers of higher socio-economic status. For both institutional delivery and access to skilled birth attendants, the average difference of the association of insurance enrollment compared to not enrolling for those of low SES is 23 percentage points (p < 0.01), and 6 percentage points (p < 0.01) for those of higher SES.

CONCLUSIONS: Enrolling in health insurance is associated with increased access and utilization of obstetric delivery health services for pregnant women. Notably, those of lower socio-economic status seem to benefit the most from enrollment in insurance.