{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T05:08:42Z","timestamp":1772168922219,"version":"3.50.1"},"update-to":[{"DOI":"10.12688\/f1000research.159261.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2025,5,29]],"date-time":"2025-05-29T00:00:00Z","timestamp":1748476800000}}],"reference-count":66,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2025,5,29]],"date-time":"2025-05-29T00:00:00Z","timestamp":1748476800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001411","name":"Indian Council of Medical Research","doi-asserted-by":"publisher","award":["FileNo.5\/7\/1725\/CH\/Adhoc-RBMCH"],"award-info":[{"award-number":["FileNo.5\/7\/1725\/CH\/Adhoc-RBMCH"]}],"id":[{"id":"10.13039\/501100001411","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["f1000research.com"],"crossmark-restriction":false},"short-container-title":["F1000Res"],"abstract":"<ns3:p>Background Universal access to maternal, newborn, and child healthcare is essential for achieving Sustainable Development Goal 3, but the effectiveness of various incentive-based programs for pregnant mothers in low- and middle-income countries (LMICs) remains uncertain. Objective of this systematic review was to determine if incentive-based interventions influenced maternal and neonatal health outcomes. Methods We conducted a search in various databases from inception. All incentive-based interventional studies conducted on pregnant women in LMICs were included. Evidence from the included trials was synthesized using risk ratios (RRs) to compare the outcomes between groups receiving incentives and not receiving incentives. The meta-analysis was conducted using random-effects model. We assessed the quality of the included studies using the Cochrane Risk of Bias 2.0 tool and reviewed the collected data to determine its suitability for meta-analysis. This study is registered in PROSPERO (CRD42021247681). Results Of the 3,897 records that were identified, 11 met eligibility criteria, all of which exhibited varying degrees of risk of bias, ranging from high to some concerns. Analysis of maternal outcomes across studies revealed no significant differences in the likelihood of delivering at a healthcare facility (RR 1.13, 95% CI: 0.86 to 1.47) and in frequency of prenatal care (RR 0.99, 95% CI: 0.88 to 1.12) between intervention and control groups. However, high levels of statistical heterogeneity were observed for both outcomes indicating variability among study results. Similarly, analysis of tetanus vaccine coverage showed no significant difference between groups (RR 1.00, 95% CI: 0.92 to 1.08), with moderate statistical heterogeneity observed. Conclusion The maternal and neonatal outcomes examined in this review did not have any significant differences in intervention group when compared to the control group. The interventions to address maternal health concerns need to follow a multifactorial approach. There is a need for extensive primary research studies in the future.<\/ns3:p>","DOI":"10.12688\/f1000research.159261.2","type":"journal-article","created":{"date-parts":[[2025,5,29]],"date-time":"2025-05-29T11:50:10Z","timestamp":1748519410000},"page":"1512","update-policy":"https:\/\/doi.org\/10.12688\/f1000research.crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Incentives for pregnant mothers during antenatal care for better maternal and neonatal health outcomes in low and middle income countries: A Systematic Review and Meta-Analysis"],"prefix":"10.12688","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2296-3719","authenticated-orcid":false,"given":"Ramesh","family":"Holla","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0418-5797","authenticated-orcid":false,"given":"Rosemol","family":"Johnson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5788-2978","authenticated-orcid":false,"given":"Nisha A","family":"Khader","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-6427-2539","authenticated-orcid":false,"given":"Mithun","family":"Rao","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0892-8551","authenticated-orcid":false,"given":"Bhaskaran","family":"Unnikrishnan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anju","family":"Sinha","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Darshan","family":"BB","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ravishankar","family":"N","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2025,5,29]]},"reference":[{"key":"ref2","doi-asserted-by":"publisher","first-page":"e0247413","DOI":"10.1371\/journal.pone.0247413","article-title":"Relationship between mortality and health care expenditure: Sustainable assessment of health care system.","volume":"16","author":"P Owusu","year":"2021 Feb","journal-title":"PLoS One [Internet]."},{"key":"ref3","first-page":"115-136","article-title":"Interventions to Reduce Maternal and Newborn Morbidity and Mortality. 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\n<i>Posted: 17 Mar 2025<\/i>; Point to point response to the reviewer\u2019s comments:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  1.&nbsp;&nbsp; &nbsp;Comment: Please could you move the detail of the SDG (MMR less than 70 per 100,000 live births) to earlier on in the first paragraph in the Introduction? At the moment, the reader has to wait till the sentence about Liberia to find out what the detail is.  Author\u2019s response: Thank you for your suggestion. We have moved the SDG detail (MMR less than 70 per 100,000 live births) to the first paragraph of the Introduction for better clarity and immediate context.&nbsp; We rephrased the original paragraph to &quot;The Million Death Study (2015) found that neonatal mortality in India was particularly high in rural areas, largely attributed to premature births and low birth weights (6). In view of the current trends, it will be difficult for India to achieve the NMR targets for SDG-2030 and National Health Policy 2025 (7). A gap analysis indicated that Liberia would take an additional 12.5 years beyond 2030 to meet the SDG target for MMR, with a similar 12.9-year delay projected for NMR (8).&quot;to maintain readability.  Action taken in the manuscript: The change can be seen in the \u201cIntroduction\u201d section, where the SDG goal is now introduced earlier in the first paragraph of the Introduction.&nbsp; The rephrased sentences can be found in the last two paragraphs of introduction section   2.&nbsp;&nbsp; &nbsp;Comment: I think this section would benefit too from a sentence or two on the overall issue with LMICs \u2013 you start off with describing South Africa and Asia in the second sentence. Could you add a bit to the first sentence along the lines of \u2018.....countries and regions, particularly between higher and LMICs\u2019 \u2013 or something similar.  Author\u2019s response: Note your suggestion. We have added a phrase to the first sentence of the Introduction to emphasize disparities between higher-income countries (HICs) and low-and-middle-income countries (LMICs).  Action taken in the manuscript: The change can be seen in the \u201cIntroduction\u201d section, where the first sentence of the introduction section now highlights disparities between HICs and LMICs.&nbsp;   3.&nbsp;&nbsp; &nbsp;Comment: I was also confused by the last sentence in the first paragraph: \u2018The model also forecasts that 13 countries would achieve the target between 2030 to 2050; while the remaining 13 countries are likely to succeed after 2050\u2019. In the previous sentence you stated that the study looks at data from 31 countries, the 2 comments about 13 countries would suggest that the study you cite looks at 26 countries. Please could you clarify why the 2 amounts in your last sentence don\u2019t add up to 31?  Author\u2019s response: We have added a clarification that mortality projections were unavailable for three countries due to data quality limitations to ensure the total sums up to 31.  Action taken in the manuscript: The change can be seen in introduction section, last line of the fourth paragraph  4.&nbsp;&nbsp; &nbsp;Comment: In the Introduction you focus on maternal and neonatal mortality rates. It is not immediately obvious to me why you have chosen these outcomes to discuss. Please consider adding a short explanation of why you chose these specific outcomes, you might say that they are key outcomes that are linked to other important maternal\/neonatal outcomes, or that they are proxies for other outcomes  Author\u2019s response: Thank you for your valuable comment. We have added an explanation stating that maternal and neonatal mortality rates are key indicators of healthcare system effectiveness, reflecting both direct health outcomes and broader factors such as healthcare accessibility, service quality, and social health determinants. These statistics also serve as indicators of pregnancy-related complications, perinatal health risks, and the efficacy of healthcare interventions  Action taken in the manuscript: The change can be seen in second paragraph of the Introduction, where this explanation has been added. New references 2 and 3 has been added.  5.&nbsp;&nbsp; &nbsp;Comment: For example, in the second paragraph of the \u2018Rationale: Why is this important?\u2019 section in the Introduction, in the first sentence, you introduce some relevant outcomes such as pregnancy and childbirth-related complications. Maybe introduce some of these in the first paragraph of the Introduction?.  Author\u2019s response: Added a sentence introducing pregnancy-related complications, including miscarriage, preterm labour, stillbirth, and maternal or neonatal morbidity and mortality, emphasizing that these complications can occur at any stage of pregnancy, during labour, or postpartum  Action taken in the manuscript: The change can be seen in the \u201cIntroduction\u201d section, and a new reference (4) has been added  6.&nbsp;&nbsp; &nbsp;Comment: The \u2018What is already known\u2019 section could benefit from a short introduction paragraph. At the moment, it starts with smoking cessation incentives. It would be good to set the scene with something along the lines of how incentives could benefit this area (in terms of reducing smoking and improving engagement with antenatal care, for example) and improve maternal and child outcomes. This would help orient the reader to what to expect in this section before it starts with more specific details.  Author\u2019s response: Added an introductory paragraph explaining that incentive-based interventions, including conditional cash transfers (CCTs) and vouchers, have been implemented globally with some success in maternal and neonatal health programs. These initiatives aim to overcome healthcare access barriers, improve maternal health practices, and enhance birth outcomes .  Action taken in the manuscript: The change can be seen in the first paragraph under the &quot;What is already known&quot; section, and new references (11\u201321) have been added&nbsp;  7.&nbsp;&nbsp; &nbsp;Comment: In the research questions section please could you write out in full what \u2018IFA\u2019 and \u2018Inj TT\u2019 refer to in 1b.  Author\u2019s response: Expanded the abbreviations to Iron and Folic Acid (IFA) tablets intake and Tetanus Toxoid injection (Inj TT) for clarity  Action taken in the manuscript: The change can be seen in 1b in \u201cOur Research Questions\u201d Section   8.&nbsp;&nbsp; &nbsp;Comment: I was unable to see the search strategy in the repository \u2013 only PRISMA checklists and flowchart.  Author\u2019s response: The search strategy was shared via Figshare and is available under the Data Availability section&nbsp;  Action taken in the manuscript: No changes were made   9.&nbsp;&nbsp; &nbsp;Comment: In Outcomes \u2013 please could you clarify your definition of preterm delivery \u2013 i.e. born alive before 37 weeks, also for perinatal and neonatal deaths, and maternal deaths  Author\u2019s response: Thank you for the suggestion. We have incorporated the clear definitions for preterm delivery, low birthweight, perinatal deaths, and neonatal deaths  Action taken in the manuscript: The change can be seen in first few lines under the Outcomes section, with new references (36\u201339) added   10.&nbsp;&nbsp; &nbsp;Comment: Fourth paragraph in the Discussion section \u2013 the last 2 sentences are very similar \u2013 could this be a duplication.  Author\u2019s response: Identified and removed duplicate sentences in the fourth paragraph of the Discussion section  Action taken in the manuscript: The change can be seen in the \u201cDiscussion\u201d section, where the duplicated content has been deleted   11.&nbsp;&nbsp; &nbsp;Comment: Would it be possible to highlight that previously there were a small number of studies and with small sample sizes \u2013 and this study has not found a large number of studies \u2013 but most studies were RCTs \u2013 so assumably suitably powered? It would be good to have that additional information.  Author\u2019s response: Added a clarification that previous reviews had a limited number of studies with small sample sizes, reducing their reliability. Our review also did not find a significantly larger number of studies; however, most were RCTs, which are generally well-powered to detect meaningful effects, strengthening the evidence base  Action taken in the manuscript: The change can be seen in last paragraph of the \u201cDiscussion\u201d section   12.&nbsp;&nbsp; &nbsp;Comment: Would it be possible to add another sentence or two to this paragraph if there is more evidence available similar to the violence you discussed in the second sentence?  Author\u2019s response: Expanded the paragraph to include additional barriers to maternal healthcare access, such as challenges faced by healthcare workers, patriarchal norms limiting women\u2019s autonomy, cultural preferences for home births, and poor healthcare infrastructure .  Action taken in the manuscript: The change can be seen in last paragraph under the &quot;Implication of Research&quot; section, with new references (71\u201379) added  13.&nbsp;&nbsp; &nbsp;Comment: In the \u2018Implications for research\u2019 section, please could you consider moving the 4th and 5th paragraphs (evidence limited to LMICs and limited study resources for searching for non-English records) to the \u2018Strengths and limitations of the study\u2019 section \u2013 they read more like strengths and limitations rather than implications.  Author\u2019s response: Thank you for your valuable comment. We have moved the 4th and 5th paragraphs from the &quot;Implications for Research&quot; section to the &quot;Strengths and Limitations of the Study&quot; section for better alignment .  Action taken in the manuscript: The change can be seen in the &quot;Strengths and Limitations&quot; section  14.&nbsp;&nbsp; &nbsp;Comment: In \u2018Neonatal outcomes \u2013 2. Perinatal and neonatal deaths\u2019 \u2013 \u2018the data has not been adequate to conduct any analysis\u2019 would read better as \u2018the data was not adequate to conduct any analysis\u2019. You also mix present and past tense in the Discussion: Second paragraph \u2013 \u2018there is no separate data on the same\u2019 should read \u2018there was no separate data on the same\u2019, and \u2018there is no adequate evidence to show the impact of incentives...\u2019 should read \u2018there was no adequate evidence to show the impact of incentives......\u2019.  Author\u2019s response: Revised the text to ensure consistent past tense usage: &quot;No separate data was available, and there was no adequate evidence to show the impact of incentives on maternal and neonatal outcomes.&quot;.  Action taken in the manuscript: The change can be seen in second paragraph of the \u201cDiscussion\u201d section.&nbsp;","URL":"https:\/\/f1000research.com\/articles\/13-1512\/v2#referee-comment-13573","order":1,"name":"referee-comment-13573","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.179546.r418442, Mohammed Shoyaib Khazi, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, 07 Oct 2025, version 2, indexed","URL":"https:\/\/f1000research.com\/articles\/13-1512\/v2#referee-response-418442","order":2,"name":"referee-response-418442","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.179546.r418444, Rohith Motappa, ESIC Medical College & PGIMSR and Model Hospital, Bangalore, Karnataka, 09 Oct 2025, version 2, indexed","URL":"https:\/\/f1000research.com\/articles\/13-1512\/v2#referee-response-418444","order":3,"name":"referee-response-418444","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This work was supported by the Indian Council of Medical Research, Ministry of Health and Family Welfare, New Delhi, Government of India. File No. 5\/7\/1725\/CH\/Adhoc-RBMCH. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":4,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}