Measuring The Impact Of Cash Transfers And Behavioral ‘Nudges’ On Maternity Care In Nairobi, Kenya

Abstract

Many patients in low-income countries express preferences for high-quality health care but often end up with low-quality providers. We conducted a randomized controlled trial with pregnant women in Nairobi, Kenya, to analyze whether cash transfers, enhanced with behavioral "nudges," can help women deliver in facilities that are consistent with their preferences and are of higher quality. We tested two interventions. The first was a labeled cash transfer (LCT), which explained that the cash was to help women deliver where they wanted. The second was a cash transfer that combined labeling and a commitment by the recipient to deliver in a prespecified desired facility as a condition of receiving the final payment (L-CCT). The L-CCT improved patient-perceived quality of interpersonal care but not perceived technical quality of care. It also increased women's likelihood of delivering in facilities that met standards for routine and emergency newborn care but not the likelihood of delivering in facilities that met standards for obstetric care. The LCT had fewer measured benefits. Women preferred facilities with high technical and interpersonal care quality, but these quality measures were often negatively correlated within facilities. Even with cash transfers, many women still used poor-quality facilities. A larger study is warranted to determine whether the L-CCT can improve maternal and newborn outcomes.

Towards gender equality: A review of evidence on social safety nets in Africa

“…a. Gender-based targeting: One of the most prevalent gender-aware design features is the targeting of transfers or benefits to women, rather than to men or to households. Some programs specifically target women (girls) as primary caregivers of young children, or do so to meet program objectives related to maternity benefits (Grépin, Habyarimana, and Jack 2019;Cohen et al 2017), or widow pension programs, or those aimed at specifically benefiting adolescent girls (Baird, De Hoop, and Özler 2013;Kilburn, Pettifor, et al 2018). While putting benefits in the hands of women (girls) may enhance pre-conditions for favorable impacts, simply reaching women (girls) does not equal benefiting women (girls) for transformative outcomes.…”

“…Despite these initial differences, two years post-intervention, the CCT benefits on education and fertility were largely only sustained for the group of females who were out-of-school at baseline, while the UCT benefits had largely dissipated (Baird et al 2019). 8 A maternity benefit program implemented in the slums around Nairobi randomized labeled cash transfers with and without additional top-ups for delivering at a pre-committed health facility to pregnant women to encourage institutional deliveries (Cohen et al 2017). The authors find significant positive effects of the labelling with the pre-commitment on institutional delivery, as well as on quality of the facility as compared to control group; however, they find no significant impacts of the labeling alone.…”

Delivering quality: safe childbirth requires more than facilities

“…Women express strong stated and revealed preferences for high-quality maternal care, but evidence is scant regarding how to inform and empower women to choose and reach high-quality providers. 11 More evidence is needed on how to make simple and transparent quality information readily available to pregnant women and on how to remove barriers to reaching high-quality care more generally. Together with system-level quality improvement efforts, reducing barriers between women and high-quality maternity providers can accelerate the transformation from facility delivery to safe delivery.…”

Can conditional cash transfers improve maternal health care? Evidence from El Salvador's Comunidades Solidarias Rurales program

“…As more cash transfer programs are scaled‐up, future impact evaluations could more rigorously examine maternal health outcomes, particularly in Africa and Asia. Recent rigorous evaluations of diverse schemes in these settings have shown promise in some cases, although questions remain as to the role of program design and impact pathways (Handa et al, ; Triyana & Shankar, ; Cohen et al, ). The impacts and cost effectiveness of poverty and human capital focused social protection schemes should be carefully considered, alongside targeted programs such as health vouchers and removal of user fees.…”