This paper examines the extent to which locally informed intermediaries can be exploited and provided with incentives to change the health-seeking behavior of pregnant women in rural Kenya. Despite Kenya being the largest and most advanced economy of East Africa, maternal and infant health outcomes are typical for those of other sub-Saharan countries, which lag significantly behind the developed world. There is evidence that antenatal care (ANC) is associated with improved maternal health outcomes, yet the majority of women in rural Kenya fail to meet recommendations for ANC timing and use, despite the availability of government subsidized healthcare. I examine whether a local intermediary, whose own incentives might oppose those of the government, can be co-opted to assist the government’s objective of increasing women’s ANC utilization.

I use a randomized controlled trial (RCT) to evaluate a program, which provides financial incentives for TBAs to encourage pregnant women to seek ANC at a formal medical facility. Competition between the TBAs and the formal clinics makes the effect of the program an empirical question, as there is no guarantee that the TBAs will respond to the incentive.

I find that living in a TBA treatment village increases the likelihood of attending the recommended number of visits by 20.7%. Women living in TBA treatment villages are 4.4 percentage points more likely to attend the recommended number of visits than women living in control villages, who attend the recommended number of visits 21.3% of the time. The results of this experiment, the first to study the extent to which TBAs can be motivated to encourage women to attend the prenatal clinic, could have important policy implications. The program’s success suggests that despite having a risk of losing clients, TBAs can be utilized as intermediaries of health facilities. Furthermore, finding that TBAs can induce pregnant women to attend ANC visits indicates that cultural norms, which discourage women going to ANC visits, can be overcome with relatively small financial incentives. By increasing the demand for formal maternal healthcare, TBAs’ encouragement of ANC attendance by women may help achieve improved maternal and child health outcomes.

That’s Georgetown’s Nisha Rai, in an excellent paper on the possibilities of integrating the use of traditional birth attendants with the formal healthcare system in Kenya (and developing countries in general). You can find a summary of the paper at the Bank’s Development Impact blog here.

If you know a policymaker in the health ministry of a developing country, please have them read this paper.