Study setting

We will conduct this study in the health districts Antananarivo North (Avaradrano), Centre (Renivohitra), and South (Atsimondrana) within the region of Analamanga, Madagascar. The districts are urban, peri-urban, and rural and include Antananarivo, the capital of the country. The study region has 2.2 million inhabitants, 31% of whom live under the national poverty line (535,603 Malagasy Ariary per capita income; 248.42 USD, 2011 PPP), considerably less than the Malagasy average (71%) [32, 42]; 77.4% of the Malagasy population live below the international poverty line of 1.9$ per day (2011 PPP) [43]. The lingua franca is Malagasy. In the study region Analamanga, 65% of pregnant women complete at least 4 ANC visits, 68% deliver at a public or private health facility while 74% have qualified assistance during birth [34]. Public healthcare in these districts is provided by 65 public-sector health facilities, comprising 61 primary-care health facilities (“Centre de santé de base”) and four public reference hospitals for maternal healthcare. Primary-care health facility staff includes at least one doctor and two midwives or nurses. Each primary-care health facility has approximately 15–30 affiliated community health workers (CHWs) who advise pregnant women to seek ANC at the primary-care health facility [44]. In addition, CHWs provide information on general health aspects, possible complications, and nutrition during pregnancy. Each of the primary-care health facilities in the study region performed between 40 and 5437 prenatal examinations and 0 to 1150 deliveries in 2017. If complications occur or more specific treatment is required, primary-care health facilities can refer patients, at the patient’s expense, to a reference hospital. ANC, vaginal and C-section deliveries as well as accommodation are free of charge for patients at primary-care health facilities and reference hospitals. However, any medication, lab tests or materials required for delivery or surgery must be purchased in cash by patients from the pharmacy, which is affiliated with a health facility. A vaginal delivery without complications costs on average about 12 USD and a C-section costs around 128 USD in total, representing 3% and 32% of the average annual salary in the region, respectively [45–47].