This study has attempted to assess the impact of the community based IMNCS intervention on utilization and equity of maternity services. Though the intervention was aimed at improvement of maternal, neo-natal and child health services, this study looked mainly at selected maternal health services. Significant improvements in utilization was observed in all areas except ANC provided by medically trained providers. The amount of change that could be attributed to the intervention varied and was greatest for utilization of ANC and PNC. Home delivery by trained attendant and C-section in public facility also increased considerably. Where the intervention had a positive effect on utilization it also seemed to have had a positive effect on equity.
The most significant impacts attributable to the intervention were increased utilization of ANC care and accessing PNC within 48 hours. This might be because of the door to door free services provided by the BRAC SKs. The findings are similar to a community based intervention in Burma . In another intervention, the home-based skilled birth attendance (SBA) programme in Bangladesh which provided domiciliary ANC, skilled delivery care and PNC, there was a substantial increase in the utilization of ANC but very little increase in the utilization of PNC .
This study found that the utilization of ANC (one or more than four ANC visits) increased and became more pro-poor over time indicating that the programme can reach mothers irrespective of the wealth quintiles. However, utilization of ANC by Medically trained provider (MTP) gives an example of an unintended consequence of the programme. The proportion of women receiving ANC care from a medically trained provider decreased over time and the decline was high among the poorer quintiles. During their domiciliary ANC services CHWs encouraged mothers to obtain at least one ANC from a medically trained provider during their pregnancy. This will enable the mothers to identify potential risks in pregnancies and delivery care. In community based interventions in Tanzania  and Pakistan  the counseling by CHWs during household visits resulted in increased number of early ANC bookings and ANC visits in the health facilities. In the IMNCS intervention areas the reason for not seeking ANC services from MTP may be due to receiving several ANC visits from a BRAC CHW; women do not perceive the need to go for further care from MTP. In other studies common reasons negatively associated with seeking ANC from health facilities by poor women were found to be the distance to heath facilities, the mother’s level of education and socioeconomic status .
Utilization of trained providers for delivery at home in the intervention areas also increased which could be attributed to the BRAC NHWs and this increase was greatest among the poor. This result was in contrast with the findings of a study in Matlab, Bangladesh where the use of trained attendants for home delivery was found to be pro-rich . However, the midwifery programme in Indonesia, with an emphasis on outreach services at the women’s home and the community skilled birth attendance programme was successful in increasing skilled attendance in birth among the poor but the access to emergency obstetric care in hospital remained neglected .
C-section rates in public facilities in the IMNCS intervention areas increased among the poor. The increase in C-sections indicates that the BRAC CHWs were likely to be effective in early identification of pregnancy related complications and increased referral of such cases to public hospitals . Results of a study in rural Bangladesh indicate that the strongest determinant of whether a rural family uses medically trained personnel for childbirth is when delivery complications are anticipated or encountered . In Tanzania, failure to plan in advance for transport was also recognized as an obstacle to receiving emergency obstetric care . In addition, insufficient counseling during ANC visits at facility level can have a potentially negative effect on the utilization of skilled delivery and immediate post natal care. Studies in India and Cambodia show that women who attend ANC care are more likely to seek skilled delivery care [40, 41].
The uptake of post natal care (PNC) significantly increased in the IMNCS intervention areas. The increase in utilization for PNC services is greater than that for home delivery by trained attendant. This may be because women who had labour during the night might find it convenient to deliver the child with attendance by the TBAs residing in the neighbourhood. But irrespective of who conducted the delivery, the mother would receive a PNC from the SK as soon as she is informed by the family members.
Very few studies have assessed the impact of community level interventions on equity and utilization of maternal health care. In this study the use of DiD and PSM provides a robust estimate of the impact of the intervention. However, one of the major limitations in using the DiD is that, it assumes the trends are parallel before and after the start of the intervention. It also assumes that differences between groups are attributed to the intervention rather than the impact of unmeasured factors. We were restricted to select only two comparison districts for the three intervention districts, instead of one for each. This was due to logistic and resource constraints. It needs to be mentioned here that if the interventional was designed as a cluster randomized trial, the impact of the intervention could be examined better.