What compels enrollment in a mobile maternal health wallet? A mixed-methods doer/non-doer analysis in Analamanga,...

Care-seeking during antenatal and intrapartum periods has remained persistently low in Madagascar, largely due to financial barriers. To bolster both care-seeking and health financing, a Mobile Maternal Health Wallet (MMHW) was developed and implemented in the Analamanga region, Madagascar. The MMHW, a service based on mobile money, enabled users to digitally save and pay for services at participating public health facilities. Here, we compare perspectives of those who enrolled (doers) and those who did not enroll (non-doers) in the MMHW to understand decision-making processes, interpersonal dynamics, and other factors that informed enrollment.

In this mixed methods study, we analyzed data from a quantitative survey (n = 477) examining predictors of enrollment using logistic probability models, followed by applying Reflexive Thematic Analysis to qualitative in-depth interviews (n = 29) to gain insights from 11 doers, 12 non-doers, three family members, and three MMHW outreach team members.

Quantitatively, significant predictors of enrollment included: learning about the MMHW from a midwife, having a pre-existing maternal medical risk factor, and residing in the Avaradrano district of Antananarivo. Predictors of non-enrollment included: learning about the MMHW from family or friends, having a higher salary, and being diagnosed with medical warning signs during pregnancy. Qualitative findings mostly mirrored the quantitative data, revealing that women enrolled due to early, comprehensive information from trusted sources (e.g., midwives) and because they found the offer of financial benefits and expanded medical services meaningful and reliable. Women sometimes reported that peer influence played a role as driver of enrollment, though not uniformly. Women who were non-doers described a sense of incredulity about the MMHW (often citing rumors or others' negative experiences), incomplete information, spousal disagreements about enrolling, and implementation-related barriers (e.g., lacking an ID card, which was needed for enrollment).

This study underscores the importance of evaluating sensitization activities among target populations. Our findings highlight a critical need to identify trusted information sources (individuals and channels) and to convey innovative programs via these sources. Effective communication and the elimination of implementation barriers remain essential to bolster care-seeking and improve maternal health outcomes in Madagascar and beyond.

This study is a component of the 4MOTHERS trial, which was registered on March 12, 2021, in the German Clinical Trials Register (DRKS), identifier: DRKS00014928, https://drks.de/search/en/trial/DRKS00014928 .