Maternal Death, Neonatal Death
Conditions
Brief summary
The purpose of this study is to identify the causal impact of performance-based monetary incentives in increasing postnatal care (PNC) referrals by traditional birth attendants (TBAs), via a randomized controlled trial (RCT).
Interventions
BEHAVIORALPerformance-based monetary incentives
Sponsors
Harvard School of Public Health (HSPH)
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
* community-based providers of antenatal and/or delivery care, and who are non-formally trained * must be resident within the community * must not plan to relocate over the intervention duration * identified in partnership with community leadership * be willing to participate fully in the study, including having their clients contacted for verification
Exclusion criteria
* plan to relocate over the intervention duration * refusal to provide informed consent for the entire study protocol including agreeing to have their delivery clients contacted for verification
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Maternal Postnatal Care Referral | Within 48 hours of delivery | The proportion of delivery clients that are successfully referred by the traditional birth attendant for postnatal care within 48 hours of delivery. For each delivery client that the traditional birth attendant reported, we visited at least three days after delivery to ascertain if they had been asked to visit the postnatal clinic, clarify if they had visited the clinic within 48 hours of delivery, and what care they had received (if yes). The team visited traditional birth attendants every two weeks to identify new clients. Where a new client was not up to three days post-delivery, the interview was postponed until the next visit by the team to the community. This occurred repeatedly, over a five-month frame. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Neonatal Postnatal Care Referral | Within 48 hours of delivery | Proportion of neonates delivered by the traditional birth attendant that are successfully referred for postnatal care within 48 hours of delivery |
Participant flow
Recruitment details
Participants were recruited from the community within 128 wards in Ebonyi State in August 2016.
Pre-assignment details
Of the 269 TBAs identified through community leaders and facility heads that met the inclusion criteria and were recruited, 20 declined to participate and 27 could not be located at the given addresses.
Participants by arm
| Arm | Count |
|---|---|
| Control Arm Traditional birth attendants will receive an offer of two-weekly payouts per reported delivery they take that is verified by client. | 104 |
| Referral Incentive Arm Traditional birth attendants will receive an offer of two-weekly payouts per reported delivery they take that is verified by client.
Traditional birth attendants randomized to this arm will also receive an offer of two-weekly payouts per successful referral of delivery clients to postnatal care within 48 hours of delivery in a facility if verified.
Performance-based monetary incentives | 103 |
| Total | 207 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | Death | 0 | 1 |
| Overall Study | Legal Case | 0 | 1 |
| Overall Study | Lost to Follow-up | 1 | 3 |
| Overall Study | Protocol Violation | 1 | 0 |
Baseline characteristics
| Characteristic | Referral Incentive Arm | Total | Control Arm |
|---|---|---|---|
| Age, Continuous | 44.75728 years STANDARD_DEVIATION 16.23206 | 48.10628 years STANDARD_DEVIATION 18.30641 | 51.42308 years STANDARD_DEVIATION 19.67241 |
| Average income per pregnancy | 2265.437 Naira STANDARD_DEVIATION 2992.071 | 2027.053 Naira STANDARD_DEVIATION 2491.036 | 1790.962 Naira STANDARD_DEVIATION 1852.523 |
| Monthly average of delivery clients | 9.553398 clients STANDARD_DEVIATION 48.90622 | 11.69082 clients STANDARD_DEVIATION 77.21418 | 13.80769 clients STANDARD_DEVIATION 97.70553 |
| Number of participants lacking formal education | 40 Participants | 87 Participants | 47 Participants |
| Number of participants offering postnatal care | 60 Participants | 130 Participants | 70 Participants |
| Number of participants that are literate in English | 47 Participants | 91 Participants | 44 Participants |
| Number of participants that are literate in non-English Language | 29 Participants | 55 Participants | 26 Participants |
| Number of participants who are leaders of any association | 46 Participants | 76 Participants | 30 Participants |
| Number of participants who are members of any association | 89 Participants | 177 Participants | 88 Participants |
| Number of participants who are the main income earner in household | 28 Participants | 54 Participants | 26 Participants |
| Sex: Female, Male Female | 97 Participants | 198 Participants | 101 Participants |
| Sex: Female, Male Male | 6 Participants | 9 Participants | 3 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 104 | 1 / 103 |
| other Total, other adverse events | 0 / 104 | 0 / 103 |
| serious Total, serious adverse events | 0 / 104 | 0 / 103 |
Outcome results
Primary
Maternal Postnatal Care Referral
The proportion of delivery clients that are successfully referred by the traditional birth attendant for postnatal care within 48 hours of delivery. For each delivery client that the traditional birth attendant reported, we visited at least three days after delivery to ascertain if they had been asked to visit the postnatal clinic, clarify if they had visited the clinic within 48 hours of delivery, and what care they had received (if yes). The team visited traditional birth attendants every two weeks to identify new clients. Where a new client was not up to three days post-delivery, the interview was postponed until the next visit by the team to the community. This occurred repeatedly, over a five-month frame.
Time frame: Within 48 hours of delivery
Population: The analysis did not include information from the 7 TBAs lost to follow-up.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Control Arm | Maternal Postnatal Care Referral | 0.044 proportion of maternal clients referred |
| Referral Incentive Arm | Maternal Postnatal Care Referral | 0.154 proportion of maternal clients referred |
Secondary
Neonatal Postnatal Care Referral
Proportion of neonates delivered by the traditional birth attendant that are successfully referred for postnatal care within 48 hours of delivery
Time frame: Within 48 hours of delivery
Population: The analysis did not include data from 7 TBAs lost to follow-up.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Control Arm | Neonatal Postnatal Care Referral | 0.032 proportion of neonates referred |
| Referral Incentive Arm | Neonatal Postnatal Care Referral | 0.126 proportion of neonates referred |