Implementation barriers, facilitators, and fidelity of a mobile money-based savings tool for pregnant women in the Analamanga region of Madagascar: an ex-post process evaluation

Abstract

Abstract Background Mobile payment services could improve access to obstetric care by easing saving, raising revenue, and pooling resources. Between 2019 and 2022, a mobile money-based savings tool for obstetric care was implemented in the Analamanga region of Madagascar following a randomized controlled trial design. We conducted an ex-post process evaluation of the intervention. Methods We assessed implementation fidelity and reach of the trial using five indicators from a population-based survey of 6,234 women who were pregnant during the intervention period and lived in catchment areas of 63 public primary-care health facilities (Centres de Santé de Base, CSBs) included in the trial: whether a woman (a) had heard of the tool, (b) could explain what it was, (c) had registered with it, (d) had used it to save, (e) had used it to pay for costs of childbirth. Combining the population-based survey with a healthcare provider survey and in-depth interviews with women, healthcare workers, and implementation staff, we examined factors associated with implementation quality, and barriers and facilitators to take-up. Results Sensitization led to statistically significantly higher take-up by women living in catchment areas of intervention CSBs compared to control CSBs: 39% vs 13% of surveyed women had heard of the tool, 33% vs 9% knew what it was, 15% vs 4% had registered, 15% vs 3% had saved with it and 10% vs 2% had paid with it. However, awareness and registration varied across intervention CSBs (4%-78%, 0%-54%). Key barriers to take-up included technical difficulties faced by providers, a disruption of informal benefits for providers, and mobile phone access. Learning about the tool from midwives was a facilitator. Conclusion This study highlights the complexity of introducing a mobile money-based savings tool for obstetric care and the importance of evaluating implementation fidelity to understand trial impact. Strengthening community mobilization, providing more personalized support, and improving intervention compatibility with routine workflows could improve intervention delivery. User-centred design and phased roll-out allowing for continuous improvement cycles may help optimize effective implementation at scale. Trial registration The 4MOTHERS trial was registered on March 12, 2021, in the German Clinical Trials Register (DRKS), identifier: DRKS00014928.