Examining the Effect of Maternity Cash Incentives Under Nepal’s Aama Program on the Continuum of Maternity Care: A Difference-in-Differences Analysis of NDHS 2011 to 2022

This study examines whether higher maternity cash incentives under Nepal's Aama Program-intended to reduce household out-of-pocket (OOP) expenditures for delivery care-are associated with completion of the continuum of maternity care across Nepal's three ecological regions: mountainous, hilly, and Terai. A difference-in-differences (DID) analysis was conducted using data from the Nepal Demographic and Health Surveys 2011 and 2022. The treatment group included mountainous and hilly districts (n = 55), which received higher cash incentives for facility deliveries, while the control group comprised Terai districts (n = 20). The primary outcome was a binary 'continuum of care' indicator, coded as 1 if a woman received 4 or more antenatal care (ANC) visits, at least 1 ANC from a skilled provider, and skilled birth attendance (SBA) during delivery, and 0 otherwise. From 2011 to 2022, continuum-of-care coverage increased from 16.2% to 46.3% in treatment districts and from 18.9% to 42.4% in control districts, yielding an unadjusted DID of 6.7 percentage points. The regression DID analysis found that the higher cash incentive in hilly and mountainous regions was associated with a statistically significant 0.7 percentage point increase in the likelihood of completing the continuum of maternity care (P = .014). While statistically significant, the magnitude is modest, indicating incremental improvement rather than a transformational shift in service utilization. Mother's age, mother's education, and husband's education were positively associated with completion, whereas poverty, rural residence, and higher parity were negatively associated (all P < .001). These findings suggest that targeted financial incentives can positively influence maternal health service utilization, but achieving larger improvements will likely require refining the program and addressing non-financial barriers. Limitations include the two-period DID design, reliance on parallel trends, and potential residual confounding.