Background: Starting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS). This program provides pregnant women with vouchers that can be exchanged for health services from eligible public and private sector providers. In this study, we examined whether access to the MHVS was associated with maternal health services utilization, stillbirth, and neonatal and infant mortality. Methods and findings: We used information on pregnancies and live births between 2000 to 2016 reported by women 15 to 49 years of age surveyed as part of the Bangladesh Demographic and Health Surveys. Our analytic sample included 23,275 pregnancies lasting at least 7 months for analyses of stillbirth and between 15,125 and 21,668 live births for analyses of health services use, neonatal, and infant mortality. With respect to live births occurring prior to the introduction of the MHVS, 31.3%, 14.1%, and 18.0% of women, respectively, reported receiving at least 3 antenatal care visits, delivering in a health institution, and having a skilled birth attendant at delivery. Rates of neonatal and infant mortality during this period were 40 and 63 per 1,000 live births, respectively, and there were 32 stillbirths per 1,000 pregnancies lasting at least 7 months. We applied a difference-in-differences design to estimate the effect of providing subdistrict-level access to the MHVS program, with inverse probability of treatment weights to address selection into the program. The introduction of the MHVS program was associated with a lagged improvement in the probability of delivering in a health facility, one of the primary targets of the program, although associations with other health services were less evident. After 6 years of access to the MHVS, the probabilities of reporting at least 3 antenatal care visits, delivering in a health facility, and having a skilled birth attendant present increased by 3.0 [95% confidence interval (95% CI) = −4.8, 10.7], 6.5 (95% CI = −0.6, 13.6), and 5.8 (95% CI = −1.8, 13.3) percentage points, respectively. We did not observe evidence consistent with the program improving health outcomes, with probabilities of stillbirth, neonatal mortality, and infant mortality decreasing by 0.7 (95% CI = −1.3, 2.6), 0.8 (95% CI = −1.7, 3.4), and 1.3 (95% CI = −2.5, 5.1) percentage points, respectively, after 6 years of access to the MHVS. The sample size was insufficient to detect smaller associations with adequate precision. Additionally, we cannot rule out the possibility of measurement error, although it was likely nondifferential by treatment group, or unmeasured confounding by concomitant interventions that were implemented differentially in treated and control areas. Conclusions: In this study, we found that the introduction of the MHVS was positively associated with the probability of delivering in a health facility, but despite a longer period of follow-up than most extant evaluations, we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Further work and engagement with stakeholders is needed to assess if the MHVS has affected the quality of care and health inequalities and whether the design and eligibility of the program should be modified to improve maternal and neonatal health outcomes. Arijit Nandi and colleagues evaluate maternal health services utilization, stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh. Author summary: Why was this study done?: Most women in Bangladesh do not receive essential maternal health services, with especially low rates of coverage for poorer households in rural areas. Starting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS) to increase demand for and equitable use of maternal health services. Prior studies suggest that access to the MHVS, consistent with the broader literature on maternal voucher programs, was associated with greater use of priority maternal health services. However, it is unclear if short-term increases in maternal health service use are sustained over time and evidence for impacts on perinatal, infant, and maternal health outcomes, including mortality, is inconclusive. What did the researchers do and find?: We linked details on the rollout of the MHVS across subdistricts (i.e., upazilas) to information on pregnancies and live births reported by women surveyed as part of the Bangladesh Demographic and Health Surveys between 2000 to 2016. We used a difference-in-differences design to evaluate the association between upazila-level access to the MHVS and maternal health services utilization, stillbirth, and neonatal and infant mortality. We observed increases in the use of maternal health services, particularly on the probability of delivering in a health facility, that materialized 2 or more years after program implementation. However, improvements in stillbirths, neonatal, and infant mortality were not demonstrated, raising important questions about program implementation. What do these findings mean?: Potential explanations of the gap between increased services and improved outcomes include that the program may not have been targeted to reach the highest risk mothers, that implementation may have failed to increase use by mothers at highest risk, that in the absence of simultaneous supply-side interventions quality of services provided may have declined with increased numbers of patients or been inadequate, and that hospital births are associated with higher rates of bottle feeding in Bangladesh and lower rates of protective breastfeeding. Additionally, it is possible that small but consequential effects in health outcomes could not be discerned due to imprecision in these estimates. Further research is needed to examine why increased services have not yet translated into improved health outcomes as it pertains to the MHVS and other voucher programs. This could include cluster randomized experimental designs with the potential to address the main limitations of this study, specifically the potential for observational studies to conflate the impact of a voucher program with the effects of other population-level health and social interventions. [ABSTRACT FROM AUTHOR]