Performance-based financing, health sectors, and health seeking behavior of women attending antenatal care and skilled birth delivery: evidence from Cameroon

Introduction
High maternal mortality rates (up to 536/100,000 live births) remain a concern in Came­roon, despite multiple intervention strategies targeting antenatal care (ANC) and delivery. Up to 90% of women attend at least one ANC appointment, but only about 40% have 4 or more ANC visits, and some women who receive ANC prefer to deliver using a traditional birth attendant. Improvement in the quality of care by providers, incentivised by performance-based financing (PBF), could affect women’s health-seeking behaviour over time and have an impact on the utilisation of services.

Material and methods
We conducted a cross-sectional survey of 848 pregnant women attending antenatal clinics in 3 districts in the southwest region of Cameroon in April-August 2021. The survey and the qualitative questions were informed by the Andersen behavioural model. Descriptive analyses were conducted, together with logistic regression analysis. Follow-up focus-group discussions were conducted with a subset of the women from the survey responses who had used ANC and delivery services before and after the implementation of PBF, and there was an exploration of providers’ experiences of health-seeking behaviour of women attending ANC in the time of COVID-19.

Results
Responses from 735 women were included in the quantitative analysis. Cost and quality of care are important determining factors in the choice of seeking care for antenatal care and skilled birth deli­very; however, quality of care (with a focus on patient-provider communication) is important in women’s decision to use the same health facility for subsequent skilled birth delivery.

Conclusions
The heterogenous nature of health-seeking behaviour calls for specific intervention strategies tailored to specific health facilities and districts. PBF has the potential to improve quality of care to stimulate behaviour change in seeking care amongst poor and vulnerable women, but there is a need for proper definition and identification of the poor and vulnerable.