Effectiveness of conditional cash transfers (Afya credits incentive) to retain women in the continuum of care during pregnancy, birth and the postnatal period in Kenya: a cluster-randomised trial

Abstract

ObjectivesGiven high maternal and child mortality rates, we assessed the impact of conditional cash transfers (CCTs) to retain women in the continuum of care (antenatal care (ANC), delivery at facility, postnatal care (PNC) and child immunisation).DesignWe conducted an unblinded 1:1 cluster-randomised controlled trial.Setting48 health facilities in Siaya County, Kenya were randomised. The trial ran from May 2017 to December 2019.Participants2922 women were recruited to the control and 2522 to the intervention arm.InterventionsAn electronic system recorded attendance and triggered payments to the participant’s mobile for the intervention arm (US$4.5), and phone credit for the control arm (US$0.5). Eligibility criteria were resident in the catchment area and access to a mobile phone.Primary outcomesPrimary outcomes were any ANC, delivery, any PNC between 4 and 12 months after delivery, childhood immunisation and referral attendance to other facilities for ANC or PNC. Given problems with the electronic system, primary outcomes were obtained from maternal clinic books if participants brought them to data extraction meetings (1257 (50%) of intervention and 1053 (36%) control arm participants). Attendance at referrals to other facilities is not reported because of limited data.ResultsWe found a significantly higher proportion of appointments attended for ANC (67% vs 60%, adjusted OR (aOR) 1.90; 95% CI 1.36 to 2.66) and child immunisation (88% vs 85%; aOR 1.74; 95% CI 1.10 to 2.77) in intervention than control arm. No intervention effect was seen considering delivery at the facility (90% vs 92%; aOR 0.58; 95% CI 0.25 to 1.33) and any PNC attendance (82% vs 81%; aOR 1.25; 95% CI 0.74 to 2.10) separately. The pooled OR across all attendance types was 1.64 (1.28 to 2.10).ConclusionsDemand-side financing incentives, such as CCTs, can improve attendance for appointments. However, attention needs to be paid to the technology, the barriers that remain for delivery at facility and PNC visits and encouraging women to attend ANC visits within the recommended WHO timeframe.Trial registrationNCT03021070.

Implementation of the Afya conditional cash transfer intervention to retain women in the continuum of care: a mixed-methods process evaluation

“…Both nurses and clients who participated in the trial found the intended cash transfer system using the Afya card linked to M-Pesa to be acceptable when it worked as intended. Results of the impact study indicated that the intervention arm was slightly more likely to be retained in ANC and to attend immunisation appointments, but had no effect on delivery at the facility or on attendance of at least one PNC visit 26. In line with this, nurses perceived the intervention to be effective at reaching targeted numbers of ANC visits, which were a challenge to achieve prior to the trial, as well as improving immunisation visits.…”

“…Results of the impact study indicated that the intervention arm was slightly more likely to be retained in ANC and to attend immunisation appointments, but had no effect on delivery at the facility or on attendance of at least one PNC visit. 26 In line with this, nurses perceived the intervention to be effective at reaching targeted numbers of ANC visits, which were a challenge to achieve prior to the trial, as well as improving immunisation visits. While nurses perceived that clients came earlier for the first ANC visit, there was no difference between the intervention and controls arms in mean gestational age at first ANC visit.…”

“…Results are presented in two sections comprising intervention delivery and acceptability of the intervention. A description of participants is included in the associated impact paper 26…”

“…While nurses perceived that clients came earlier for the first ANC visit, there was no difference between the intervention and controls arms in mean gestational age at first ANC visit. 26 However, other aspects of acceptability were lower from the perspective of nurses, including an extra burden of work created by the intervention, and ethical concerns related to cash transfers for maternal health visits. Some nurses viewed attendance at visits as part of the responsibility of the clients, and similar findings related to personal responsibility have been reported in a financial incentive intervention in Johannesburg, South Africa, to improve retention in HIV care among pregnant women.…”

“…Visits were also recorded in participants’ clinic books, which is the normal procedure for maternal healthcare at health facilities. These data were later manually collected and inputted into a database at the end of the trial as it was viewed as the most accurate data on visits (see Data supplement 1 of Vanhuyse et al 26 for more information on this process). However, clinic book data were not available for all participants, particularly some in the control arm, as some participants did not return to the facility for data abstraction at the end of the trial.…”