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The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers’ ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N = 112) with government actors, development partners and civil societies in three districts or counties in each country (N = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach.

In the past few decades, climate-smart agriculture (CSA) has been promoted to improve food security and raise incomes as a strategy for sustainable agricultural development. The adoption rates among smallholder farmers, particularly in Africa, remain low and have varied in different contexts. We investigated the market participation spill over effects from the adoption of CSA practices in central Malawi. We tested the hypothesis that the extent of the use of CSA practices in the past 10 years can lead to production surpluses that enable smallholder farmers to participate in markets and thereby increase agricultural incomes. The findings suggest, among others, the need to intensify efforts to promote CSA adoption specifically over a longer period for benefits of the technologies to materialise. The adoption of CSA practices over time enhances crop market participation – an important aspect required for production sustainability as well as for transforming agriculture towards greater market orientation among smallholder farmers.

Many years of significant investment into the production and adoption of productivity-enhancing technologies and practices in agriculture have not yielded the desired results. Most smallholder farmers in Africa remain trapped in poverty. Having realised that addressing production challenges alone is not enough to impact the lives of poor smallholder farmers, resources and attention have now shifted to the marketing side of agriculture. Organising farmers into farmer producer organisations (FPOs), like clubs, associations and cooperatives, has been one of the strategies aimed at commercialising smallholder agriculture. In Malawi, smallholder farmers have been organised into FPOs of various types and sizes. This qualitative study interrogated the effectiveness of FPOs in Malawi in meeting their objectives, including the objective of enhancing commercialisation of smallholder farmers through increased access to farm inputs, markets, and agricultural extension and advisory services.

This study was carried out to understand the underlying dynamics of agricultural commercialisation in Malawi, especially among smallholder farmers. Despite various concerted efforts to accelerate agricultural growth and transformation, the progress among smallholder farmers has been less satisfactory. Most of the smallholder farmers do not engage with markets on a consistent and sustainable basis. Consequently, the aim of this paper was to demonstrate that there is no one ideal type of agricultural commercialisation that can be realised through investment and policy intervention.

Many sub-Saharan African countries implementing agricultural input subsidies programmes (AISP) concentrate on fertilizers and staple food crops which may have little or no effect on consumption of diverse nutrient dense non-staple foods. The programme in Malawi – the Farm Input Subsidy Programme (FISP) – includes legume seeds, but little research has been undertaken to evaluate the effects of this strategy on household dietary diversity. In this study, we used two waves of integrated household panel survey data of 2013 and 2016 to examine the dietary diversity gains from inclusion of legume seed coupons in the programme. The control function approach for dealing with selection bias into a programme is used in Poisson regression of panel data. The results show that access as well as redemption of legume coupons is positively associated with diversified diets. This is especially through location fixed effects in the southern region of Malawi, higher production diversity, greater land holding sizes and the sale of maize. Further, households that had less need to satisfy hunger through the growing of maize were those likely to redeem legume coupons. The results suggest a more nuanced pathway of impact from coupon access, redemption or type of crop produced to dietary diversity than the pathway that might be expected, and have implications for how best to understand and conceptualise the tensions and synergies between addressing different aspects of malnutrition in all its forms – and suggest the importance of addressing food insecurity constraints that potentially limit the growing of nutrient-rich legume crops as well as wider increases to dietary diversity. The results also point to the importance of the income pathway and food markets in facilitating greater dietary diversity. Further consideration of these issues by policymakers and the wider agri-nutrition community will be important to advance the discussion and research of how best to design AISP and other public policy to address malnutrition in all its forms.

Agricultural commercialisation is widely recognised as a catalyst to economic growth and development in low and middle-income countries. This study investigates gender and social differences in agricultural commercialisation in rural Malawi. Specifically, the paper analyses different levels of agricultural commercialisation among gender and wealth categories; the specific gender and social issues that facilitate or impede agricultural commercialisation among gender and wealth categories; and their implications for commercialisation and livelihoods among gender and wealth categories.

The authors of this paper attempt use quantitative methods to determine the different factors of livelihood trajectories in the context of agricultural commercialisation. To do this, they draw on primary evidence from household surveys conducted over a span of ten years in Mchinji and Ntchisi districts, in rural Malawi. The authors hypothesise that households that are more commercialised are more likely to expand their investments in agriculture and/or take up livelihoods outside of agriculture. Crucially, they find that factors driving livelihood trajectories are not the same for farmers in different pathways, and highlight the need for policymakers to study findings emphasise the need to adopt context-dependent development approaches, in order to provide sustainable relief from poverty for farming households.

The application of mixed methods in Health Policy and Systems Research (HPSR) has expanded remarkably. Nevertheless, a recent review has highlighted how many mixed methods studies do not conceptualize the quantitative and the qualitative component as part of a single research effort, failing to make use of integrated approaches to data collection and analysis. More specifically, current mixed methods studies rarely rely on emergent designs as a specific feature of this methodological approach. In our work, we postulate that explicitly acknowledging the emergent nature of mixed methods research by building on a continuous exchange between quantitative and qualitative strains of data collection and analysis leads to a richer and more informative application in the field of HPSR. We illustrate our point by reflecting on our own experience conducting the mixed methods impact evaluation of a complex health system intervention in Malawi, the Results Based Financing for Maternal and Newborn Health Initiative. We describe how in the light of a contradiction between the initial set of quantitative and qualitative findings, we modified our design multiple times to include additional sources of quantitative and qualitative data and analytical approaches. To find an answer to the initial riddle, we made use of household survey data, routine health facility data, and multiple rounds of interviews with both healthcare workers and service users. We highlight what contextual factors made it possible for us to maintain the high level of methodological flexibility that ultimately allowed us to solve the riddle. This process of constant reiteration between quantitative and qualitative data allowed us to provide policymakers with a more credible and comprehensive picture of what dynamics the intervention had triggered and with what effects, in a way that we would have never been able to do had we kept faithful to our original mixed methods design.

Background Social cohesion, defined as a glue holding society together, has been found to influence several aspects of human behavior. Social cohesion, being composed of social trust and social participation, is a social factor that may influence sexual behaviors. Unfortunately, studies investigating the influence of social cohesion on sexual behaviors among young people are scarce. This study examined the influence of social cohesion on safe sexual behavior among adolescents in rural Tanzania. Methods A cross-sectional study was conducted among 403 school adolescents of the Newala district, between May and August 2010. Socio-demographic characteristics, social cohesion (social trust and social participation) and sexual behavior (age at sexual debut, intention to use and reported condom use, number of sexual partners) were obtained through self-administered questionnaires. Data analysis was performed using descriptive statistics and binary logistic regression. Results Sexual debut at under 13 years of age was reported by 12% of the respondent. A majority (71%) reported multiple sexual partnerships and half of the participants reported to have used a condom at their last sexual encounter. The intention to use a condom was reported by 77% of the respondents. Having multiple sexual partnerships was associated with social trust only (odds ratio: 3.5, 95% CI 1.01–12.3) whereas reported condom use was related with social cohesion (odds ratio 4.8 95% CI 1.66–14.06). Social cohesion, trust or participation was not associated with young age at sexual debut or intention to use a condom. Being a female (odds ratio 2.07 95% CI 1.04–4.12.) was associated with intention to use a condom. Conclusion This study indicates that social cohesion and socio-demographic factors influence actual behavior performance and behavioral intentions. The findings point to the importance of collecting more evidence on social cohesion and sexual behaviors in different settings and designing interventions that enhance social cohesion among adolescents in order to reinforce positive sexual behaviors. Electronic supplementary material The online version of this article (10.1186/s12889-019-6428-7) contains supplementary material, which is available to authorized users.

Food markets have been found to be, in many settings, important in shaping diets and nutritional outcomes. However, more evidence and improved metrics are needed to understand these relationships. We examined relationships between food market participation and household dietary diversity in populations of rural Malawi facing hunger and poor nutrition. We analysed, using Poisson regression, survey data from 400 households in two districts of rural Malawi in post-harvest and lean seasons of 2017/18. We also developed a new metric of food purchases to support our examination of food market participation. The findings include clear associations between food purchase diversity and household dietary diversity, and suggest households engaging more with food markets are more likely to have diversified diets and better nutrition.

BackgroundTeenage pregnancies and childbearing are important health concerns in low-and middle-income countries (LMICs) including Malawi. Addressing these challenges requires, among other things, an understanding of the socioeconomic determinants of and contributors to the inequalities relating to these outcomes. This study investigated the trends of the inequalities and decomposed the underlying key socioeconomic factors which accounted for the inequalities in teenage pregnancy and childbearing in Malawi.MethodsThe study used the 2004, 2010 and 2015-16 series of nationally representative Malawi Demographic Health Survey covering 12,719 women. We used concentration curves to examine the existence of inequalities, and then quantified the extent of inequalities in teenage pregnancies and childbearing using the Erreygers concentration index. Finally, we decomposed concentration index to find out the contribution of the determinants to socioeconomic inequality in teenage pregnancy and childbearing.ResultsThe teenage pregnancy and childbearing rate averaged 29% (pConclusionThe findings suggest that there is a need for sustained investment in the education of young women concerning the disadvantages of early sexual debut and early marriages, and in addressing the wealth inequalities in order to reduce the incidences of teenage pregnancies and childbearing.

Background Documentary evidence points to high unmet need for family planning across sub-Saharan Africa. Modern contraceptive use has been staggering over decades with unacceptable marginal increases given that one in three women still report unmet need in Ghana. This study sought to re-examine through a further analysis on the prevalence and determinants of unmet need for family planning in Ghana using married women extracted from the recent 2014 Ghana Demographic and Health Survey. Method Data was analyzed using univariate, bivariate, logistic and multinomial logistic regression models. Results Of the 4527 women, more than a third (35.17%) experienced unmet need of which 20.19% had unmet need for spacing while 14.98% reported unmet need for limiting. The logistic results showed that older aged women, being employed and women with higher ideal number of children were less likely to experience unmet need. However, women who did not know the couples’ preferred number of children, women who had more than one union and those with higher number of living biological children were more likely to report unmet need. From the multinomial model, an increase in age, residing in a rural area, and being employed were associated with lower risk of unmet need for spacing. Additionally, Women who did not know the couples’ ideal number of children, women who had higher age when they got married, and women with higher number of biological children were more likely to report unmet need for spacing. Women who had a higher number of ideal children, women who had secondary or higher education, women from higher socio-economic households, were less likely to report unmet need for limiting. . Conclusions We recommend the strengthening of contraception services in order to address the various age specific needs and women within the different socio-demographic sects so as to reduce unmet need. Addressing the needs of women with increasing number of living biological children is equally paramount. Electronic supplementary material The online version of this article (10.1186/s40834-018-0083-8) contains supplementary material, which is available to authorized users.

Summary boxMuch of the global burden of malnutrition, particularly shifts towards an increased prevalence of overweight and obesity, is driven by dietary changes described as the ‘nutrition transition’.The nutrition transition appears to be driven by shifts in diets towards more ‘ultraprocessed’ foods high in sugar, fat, salt, low in fibre and less nutrient dense - but little is known about actual food consumption in many populations.Standard instruments used for measuring diets in low-income and middle-income countries are inadequate for assessing changing diets in the context of the nutrition transition, as they do not provide appropriate provision in response to categories for consumption of ultraprocessed food products.There is a need for a validated standardised food frequency questionnaire designed to measure changing dietary patterns that have appropriate provision for highly processed food types - and with the implementation of such questonnaires there is a need to consider food source and the importance of capturing foods eaten outside of the home as well as in the home.Malnutrition in all its forms—both underweight and micronutrient deficiencies, as well as overweight, obesity and associated non-communicable disease—is a global health issue, with the majority of cases arising in low-income and middle-income countries (LMICs).1 Much of this malnutrition, particularly shifts towards an increased prevalence of overweight and obesity, is driven by dietary changes described as the ‘nutrition transition’, whereby populations move from traditional diets high in fibre and micronutrients, to more highly processed diets high in sugar, fat, salt, low in fibre and less nutrient dense–with these dietary changes accompanied by changes in eating behaviours and physical activity patterns.2 Ultraprocessed food products have been defined by Monteiro et al as ‘not entirely or mostly made from foods, but from industrial ingredients and additives, and are highly profitable’.3 Distinctions are made between processed …

Objective To identify factors associated with delivery outside a health facility in rural Malawi. Method A cross-sectional survey was conducted in Balaka, Dedza, Mchinji and Ntcheu districts in Malawi in 2013 among women who had completed a pregnancy 12 months prior to the day of the survey. Multilevel logistic regression was used to assess factors associated with delivery outside a facility. Results Of the 1812 study respondents, 9% (n = 159) reported to have delivered outside a facility. Unmarried women were significantly more likely [OR = 1.88; 95% CI (1.086–3.173)] to deliver outside a facility, while women from households with higher socio-economic status [third-quartile OR = 0.51; 95% CI (0.28–0.95) and fourth-quartile OR = 0.48; 95% CI (0.29–0.79)] and in urban areas [OR = 0.39; 95%-CI (0.23–0.67)] were significantly less likely to deliver outside a facility. Women without formal education [OR 1.43; 95% CI (0.96–2.14)] and multigravidae [OR = 1.14; 95% CI (0.98–1.73)] were more likely to deliver outside a health facility at 10% level of significance. Conclusion About 9% of women deliver outside a facility. Policies to encourage facility delivery should not only focus on health systems but also be multisectoral to address women's vulnerability and inequality. Facility-based delivery can contribute to curbing the high maternal illness burden if authorities provide incentives to those not delivering at the facility without losing existing users. Objectif Identifier les facteurs associes a l'accouchement en dehors d'un etablissement de sante en milieu rural au Malawi. Methode Une enquete transversale a ete menee dans les districts de Balaka, Dedza, Mchinji et Ntcheu au Malawi en 2013 chez les femmes qui avaient mene une grossesse a terme, 12 mois avant le jour de l'enquete. La regression logistique a multi-niveaux a ete utilisee pour evaluer les facteurs associes a l'accouchement en dehors d'un etablissement. Resultats Sur les 1812 repondantes de l’etude, 9% (n = 159) ont declare avoir accouche en dehors d'un etablissement. Les femmes non mariees etaient significativement plus susceptibles (OR = 1,88; IC95%:1,086 a 3,173) d'accoucher en dehors d'un etablissement, alors que celles dans des menages avec un statut socioeconomique plus eleve (troisieme quartile OR = 0,51; IC95%: 0,28- 0,95 et quatrieme quartile OR = 0,48; IC95%:0,29 a 0,79) et dans les zones urbaines (OR = 0,39; IC95%: 0,23 a 0,67) etaient significativement moins susceptibles d'accoucher en dehors d'un etablissement. Les femmes sans une education formelle (OR: 1,43; IC95%: 0,96 a 2,14) et les multipares (OR = 1,14; IC95%: 0,98 a 1,73) etaient plus susceptibles d'accoucher en dehors d'un etablissement de sante avec un degre de signification de 10%. Conclusion Environ 9% des femmes accouchent en dehors d'un etablissement. Les politiques visant a encourager l'accouchement dans un etablissement ne devraient pas seulement se concentrer sur les systemes de sante, mais devraient aussi etre multisectorielles afin de tacler la vulnerabilite et l'inegalite chez les femmes. L'accouchement dans un etablissement peut contribuer a reduire la charge elevee de la maladie maternelle si les autorites fournissent des incitations a celles qui n'accouchent pas dans un etablissement sans affecter les utilisatrices regulieres. Objetivo Identificar los factores asociados con un parto fuera de un centro sanitario en zonas rurales de Malawi. Metodo Se realizo un estudio croseccional en los distritos de Balaka, Dedza, Mchinji y Ntcheu en Malawi durante el 2013, entre mujeres que habian completado el embarazo 12 meses antes del dia de la encuesta. Se utilizo una regresion logistica multinivel para evaluar los factores asociados con el haber dado a luz fuera de un centro sanitario. Resultados De las 1,812 mujeres que respondieron al estudio, un 9% (n=159) reportaron haber dado a luz fuera de un centro sanitario. Las mujeres no casadas tenian una mayor probabilidad significativa (OR=1.88; IC95 [1.086-3.173]) de tener un parto fuera de un centro sanitario, mientras que las mujeres pertenencientes a hogares con un mayor estatus socioeconomico (tercer cuartil OR=0.51; IC 95% [0.28-0.95] y cuarto cuartil OR=0.48; IC 95% [0.29-0.79]), y de areas urbanas (OR=0.39; IC 95%[0.23-0.67]) tenian una probabilidad significativamente menor de dar a luz fuera de un centro sanitario. Las mujeres sin educacion formal (OR1.43; IC 95%-CI[0.96-2.14]), y multigravidas (OR=1.14; IC 95% [0.98-1.73]) tenian una mayor probabilidad de dar a luz fuera de un centro sanitario, con un nivel de significancia del 10%. Conclusion Aproximadamente un 9% de las mujeres dan a luz fuera de un centro sanitario. Las politicas para promover los partos intrahospitalarios no se deberian centrar solamente en los sistemas sanitarios sino que deberian ser multisectoriales para abordar las vulnerabilidades e inequidades relacionadas con el ser mujer. Los partos intrahospitalarios pueden contribuir a mejorar la alta carga por enfermedad materna si las autoridades proveen incentivos a quienes no dan a luz en centros sanitarios, sin perder usuarios ya existentes.

BACKGROUND: Adverse childhood experiences (ACEs) and intimate partner violence (IPV) are recognized global health problems. Both ACEs and IPV have been linked to adverse physical and mental health problems for both mothers and infants. The aim of this study was to determine the prevalence of physical and/or sexual ACEs and IPV and their association to symptoms of postpartum depression among postpartum women in sub-Saharan Africa. METHODS: A cross-sectional survey was conducted in three health centers in the three districts of Dar es Salaam, comprising Ilala, Kinondoni and Temeke. A total of 500 women were interviewed by two trained midwife nurses during their routine postnatal care. The women were asked about their experiences of adverse childhood experiences, intimate partner violence and symptoms of postpartum depression. RESULTS: Of the 500 women who were interviewed, 39.4% (n = 197) reported to have experienced physical and/or sexual ACE and 18.8% (n = 94) experienced physical and/or sexual IPV during their index pregnancy. Physical ACE (AOR 2.6, 95% CI: 1.50-4.57), sexual ACE (AOR 2.7, 95% CI: 1.35-5.41), physical IPV (AOR 5.8, 95% CI: 2.98-11.43) and Sexual IPV (AOR 5.5, 95%CI: 2.51, 12.09) were significantly associated with symptoms of postpartum depression. CONCLUSION: Four out of ten women reported to have experienced ACEs and two out of ten women reported IPV in the index pregnancy which was significantly associated with symptoms of postpartum depression. These results are alarming and call upon the attention of health workers and the community at large in prevention, screening and early intervention of ACEs, IPV and symptoms of postpartum depression.

Background: In 2013, Malawi with its development partners introduced a Results-Based Financing for Maternal and Newborn Health (RBF4MNH) intervention to improve the quality of maternal and newborn health-care services. Financial incentives are awarded to health facilities conditional on their performance and to women for delivering in the health facility. We assessed the effect of the RBF4MNH on quality of care from women’s perspectives. Methods: We used a mixed-method prospective sequential controlled pre- and post-test design. We conducted 3060 structured client exit interviews, 36 in-depth interviews and 29 focus group discussions (FGDs) with women and 24 in-depth interviews with health service providers between 2013 and 2015. We used difference-in-differences regression models to measure the effect of the RBF4MNH on experiences and perceived quality of care. We used qualitative data to explore the matter more in depth. Results: We did not observe a statistically significant effect of the intervention on women’s perceptions of technical care, quality of amenities and interpersonal relations. However, in the qualitative interviews, most women reported improved health service provision as a result of the intervention. RBF4MNH increased the proportion of women reporting to have received medications/treatment during childbirth. Participants in interviews expressed that drugs, equipment and supplies were readily available due to the RBF4MNH. However, women also reported instances of neglect, disrespect and verbal abuse during the process of care. Providers attributed these negative instances to an increased workload resulting from an increased number of women seeking services at RBF4MNH facilities. Conclusion: Our qualitative findings suggest improvements in the availability of drugs and supplies due to RBF4MNH. Despite the intervention, challenges in the provision of quality care persisted, especially with regard to interpersonal relations. RBF interventions may need to consider including indicators that specifically target the provision of respectful maternity care as a means to foster providers’ positive attitudes towards women in labour. In parallel, governments should consider enhancing staff and infrastructural capacity before implementing RBF.

Given the current low contraceptive use and corresponding high levels of unwanted pregnancies leading to induced abortions and poor maternal health outcomes among rural populations, a detailed understanding of the factors that limit contraceptive use is essential. Our study investigated household and health facility factors that influence contraceptive use decisions among rural women in rural Burkina Faso. We collected data on fertile non-pregnant women in 24 rural districts in 2014. Of 8,657 women, 1,098 used a modern contraceptive. Women having a living son, a child younger than one year, and household wealth were more likely to use modern contraceptives. Women in polygamous marriages and women living at least 5 kilometers from a health facility were less likely to use contraception. We conclude that modern contraceptive use remains weak, hence, programs aiming to encourage contraceptive use must address barriers at both the health facility and the household level.

Background While perceived quality of care is now widely recognized to influence health service utilization, limited research has been conducted to explore and measure perceived quality of care using quantitative tools. Our objective was to measure women’s perceived quality of maternal and newborn care using a composite scale and to identify individual and service delivery factors associated with such perceptions in Malawi. Methods We conducted a cross-sectional survey in selected health facilities from March to May 2013. Exit interviews were conducted with 821 women convenience sampled at antenatal, delivery, and postnatal clinics using structured questionnaires. Experiences and the corresponding perceived quality of care were measured using a composite perception scale based on 27 items, clustered around three dimensions of care: interpersonal relations, conditions of the consultation and delivery rooms, and nursing care services. Statements reflecting the 27 items were read aloud and the women were asked to rate the quality of care received on a visual scale of 1 to 10 (10 being the highest score). For each dimension, an aggregate score was calculated using the un-weighted item means, representing three outcome variables. Descriptive statistics were used to display distribution of explanatory variables and one-way analysis of variance was used to analyse bivariate associations between the explanatory and the outcome variables. Results A high perceived quality of care rating was observed on interpersonal relations, conditions of the examination rooms and nursing care services with an overall mean score of 9/10. Self-introduction by the health worker, explanation of examination procedures, consent seeking, encouragement to ask questions, confidentiality protection and being offered to have a guardian during delivery were associated with a high quality rating of interpersonal relations for antenatal and delivery care services. Being literate, never experienced a still birth and, first ANC visit were associated with a high quality rating of room conditions for antenatal care service. Conclusions The study highlights some of the multiple factors associated with perceived quality of care. We conclude that proper interventions or practices and policies should consider these factors when making quality improvements. Electronic supplementary material The online version of this article (doi:10.1186/s12884-015-0560-x) contains supplementary material, which is available to authorized users.

Results-based financing (RBF) schemes–including performance based financing (PBF) and conditional cash transfers (CCT)-are increasingly being used to encourage use and improve quality of institutional health care for pregnant women in order to reduce maternal and neonatal mortality in low-income countries. While there is emerging evidence that RBF can increase service use and quality, little is known on the impact of RBF on costs and time to seek care for obstetric complications, although the two represent important dimensions of access. We conducted this study to fill the existing gap in knowledge by investigating the impact of RBF (PBF+CCT) on household costs and time to seek care for obstetric complications in four districts in Malawi. The analysis included data on 2,219 women with obstetric complications from three waves of a population-based survey conducted at baseline in 2013 and repeated in 2014(midline) and 2015(endline). Using a before and after approach with controls, we applied generalized linear models to study the association between RBF and household costs and time to seek care. Results indicated that receipt of RBF was associated with a significant reduction in the expected mean time to seek care for women experiencing an obstetric complication. Relative to non-RBF, time to seek care in RBF areas decreased by 27.3% (95%CI: 28.4–25.9) at midline and 34.2% (95%CI: 37.8–30.4) at endline. No substantial change in household costs was observed. We conclude that the reduced time to seek care is a manifestation of RBF induced quality improvements, prompting faster decisions on care seeking at household level. Our results suggest RBF may contribute to timely emergency care seeking and thus ultimately reduce maternal and neonatal mortality in beneficiary populations. publishedVersion