Modest improvements in skilled birth attendants at delivery with increased Mutuelles coverage in Rwanda

We revisit the question of the role health insurance coverage played in increasing use of skilled birth attendants (SBA) at delivery in Rwanda. Previous studies have suggested that enrollment in Mutuelles health insurance increased the odds of using an SBA by up to 163%.

We take advantage of latest Rwanda Demographic Health Survey (NISR M, Macro O. Rwanda Demographic and Health Survey 2010. National Institute of Statistics of Rwanda and Ministry of Health, 2012.) to increase the sample size and extend the time frame of analysis to 5 years (2005-10). We also adopt a stronger matching method, coarsened exact matching, to control for model dependence.

We find that although enrollment in Mutuelles insurance increases use of SBAs at delivery, the size of the effect is an order of magnitude lower than previously published (12-18% versus 78-163%). We also find that the effect of education on use of SBA is similar in magnitude to that of Mutuelles insurance enrollment.

Our findings lead us to conclude that Mutuelles only had a modest effect on increasing use of SBA at delivery and therefore insurance alone may not be the 'magic bullet' that solves the problem of non-use of SBA at delivery.