Assessing the impact of complex health systems strengthening program on maternal health care utilization in fragile and conflict-affected states: evidence from the Democratic Republic of the Congo

Background The maternal mortality ratio in the Democratic Republic of the Congo (DRC) remains among the highest in the world. However, to date, only limited evidence is available on the impact of maternal health care interventions on service quality and utilization in the DRC (11). The purpose of the study was to investigate the impact of a large, complex health systems strengthening program on maternal health care utilization in DRC. Methods The study used difference-in-differences models based on data collected from population-based household surveys at baseline (2014) and endline (2017) in treatment and matched comparison areas in three provinces. The dependent variables consist of the use of antenatal care (ANC) and facility-based delivery. Qualitative analyses were also incorporated in the study to explore perceptions of maternal health care offered and strategies to improve care. Results The health systems strengthening program was found to have had a positive impact on the probability of a woman delivering in a health care facility. There was not a significant impact on the receipt of at least four ANC consultations. The qualitative results indicated that uptake of ANC consultations in program areas was challenged by distance to facilities and the time involved in ANC, limited community outreach, and cultural norms. Conclusions The research points to the sample population’s high reliance on health centers and posts that provide basic maternal services and low accessibility to hospitals offering lifesaving comprehensive emergency obstetric care. The findings also highlight the need for formative research to inform interventions so that they better match social norms and address contextual needs.