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.
Highlights
Ethical Approval And Trial RegistrationImplementation The study was approved by Institutional Review Boards at AMREF Health Africa and the Harvard T
Margaret McConnell is an assistant professor in the Department of Global Health and Population, Harvard T
Outcome Measurement And Analysis The first outcomes we report are whether the mother delivered at the facility she most wanted and perceived as having the highest quality, and whether the cash transfers influenced the mode of transport or distance traveled to the facility
Summary
Implementation The study was approved by Institutional Review Boards at AMREF Health Africa and the Harvard T. Implementation of the randomized controlled trial was conducted in collaboration with Jacaranda Health, and facility assessments were conducted in collaboration with Innovations for Poverty Action–Kenya. The trial was registered in the AEA RCT Registry (Trial No AEARCTR-0000563)
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