Health insurance coverage and quality of care for reproductive and maternal health in LMICs: a multicountry propensity score matching study

Introduction Poor maternal and child health remains a major challenge, particularly in low- and middle-income countries (LMICs). This study assessed differences in the reproductive, maternal and child health (RMCH) continuum of care between insured and uninsured populations across nine LMICs.Methods We analysed the latest two Demographic and Health Survey waves collected in Cambodia, Dominican Republic, Ghana, Guatemala, India, Indonesia, Jordan, Kyrgyz Republic and Peru, constituting around 23% of the global population. Propensity score matching assessed associations between health insurance and effective coverage across the care cascade for family planning, antenatal care (ANC), maternal delivery and postnatal care (PNC). Average treatment effect on the treated with 95% CIs was reported.Results Insurance effects varied substantially across countries. Family planning service contact was significantly higher among insured population in five of seven countries with available data, with the largest effect in Ghana (16.9 percentage points (pp), 95% CI 11.2 to 22.5). ANC quality-adjusted coverage was significantly higher among insured women in six countries, with the largest effect in India (17.2 pp, 95% CI 15.8 to 18.6). Maternal delivery service contact was significantly associated with insurance coverage in five countries, with the largest effect in Ghana (10.5 pp, 95% CI 6.1 to 14.9). PNC service contact showed significant associations in four countries, with the largest effect in Cambodia (10.3 pp, 95% CI 4.3 to 16.4). Pooled analyses showed positive associations across all outcomes, largest for ANC quality-adjusted coverage (9.9 pp, 95% CI 8.6 to 11.2) and family planning service contact (7.7 pp, 95% CI 6.0 to 9.4). Importantly, insurance coverage was concentrated among more educated women in seven countries and wealthier populations in five, highlighting persistent equity concerns.Conclusions Health insurance coverage was associated with higher RMCH coverage and quality, but persistent socioeconomic inequalities raise equity concerns. Expanding insurance coverage without ensuring inclusivity risks exacerbating disparities and undermining progress towards universal health coverage.