Impact of the Salud Mesoamerica Initiative on delivery care choices in Guatemala, Honduras, and Nicaragua

Published January 3, 2022, in BMC Pregnancy Childbirth (opens in a new window)


The Salud Mesoamérica Initiative (SMI) is a public-private collaboration aimed to improve maternal and child health conditions in the poorest populations of Mesoamerica through a results-based aid mechanism. We assess the impact of SMI on the staffing and availability of equipment and supplies for delivery care, the proportion of institutional deliveries, and the proportion of women who choose a facility other than the one closest to their locality of residence for delivery.


We used a quasi-experimental design, including baseline and follow-up measurements between 2013 and 2018 in intervention and comparison areas of Guatemala, Nicaragua, and Honduras. We collected information on 8754 births linked to the health facility closest to the mother’s locality of residence and the facility where the delivery took place (if attended in a health facility). We fit difference-in-difference models, adjusting for women’s characteristics (age, parity, education), household characteristics, exposure to health promotion interventions, health facility level, and country.


Equipment, inputs, and staffing of facilities improved after the Initiative in both intervention and comparison areas. After adjustment for covariates, institutional delivery increased between baseline and follow-up by 3.1 percentage points (β = 0.031, 95% CI -0.03, 0.09) more in intervention areas than in comparison areas. The proportion of women in intervention areas who chose a facility other than their closest one to attend the delivery decreased between baseline and follow-up by 13 percentage points (β = − 0.130, 95% CI -0.23, − 0.03) more than in the comparison group.


Results indicate that women in intervention areas of SMI are more likely to go to their closest facility to attend delivery after the Initiative has improved facilities’ capacity, suggesting that results-based aid initiatives targeting poor populations, like SMI, can increase the use of facilities closest to the place of residence for delivery care services. This should be considered in the design of interventions after the COVID-19 pandemic may have changed health and social conditions.


This work was supported in whole or in part by Salud Mesoamérica Initiative (SMI), which is a public-private partnership funded by the Bill & Melinda Gates Foundation (Grant Number OPPGH5328), Agencia Española de Cooperación Internacional para el Desarrollo (10.13039/501100004892), the Government of Canada (P000554/D000168), and the Carlos Slim Foundation ( Under the grant conditions of the Bill & Melinda Gates Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. AMK is funded by the National Institutes of Health T32 grant (T32GM086270). The funders had no role in study design, data collection, analysis, interpretation of results, or writing of the manuscript. The opinions expressed in this publication are those of the authors and do not necessarily reflect the views of the Inter-American Development Bank, its Board of Directors, or the countries they represent.

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Hernandez, B., Harris, K.P., Johanns, C.K. et al. Impact of the Salud Mesoamerica Initiative on delivery care choices in Guatemala, Honduras, and Nicaragua. BMC Pregnancy Childbirth 22, 5 (2022).