Social Incentives for Prenatal Care and Skilled Delivery in Sierra Leone
Can social incentives increase demand for skilled pregnancy care? How much do people care to signal to others that they looked after their and their children's health? How much do people learn from observing others’ actions? In Sierra Leone, Innovations for Poverty Action is working with researchers to rigorously evaluate the impact of social incentives—in the form of highly visible bracelets for pregnant women, signaling they have received care—on the demand for prenatal care and delivery with a skilled attendant.
Reducing maternal and child mortality is a public health priority in many sub-Saharan African countries, but finding cost-effective ways to improve service delivery has been a challenge. One barrier to improving maternal and newborn health is that many women do not seek timely prenatal care, and many do not deliver their babies with a skilled attendant. Difficulty reaching or paying for transportation to clinics is one barrier, but other likely barriers include lack of trust in health institutions and/or the human tendency to be “present-biased,” i.e., to weight current desires and demands on our time higher than future ones, which may lead people to put-off seeking preventive care, even when they want to.
Small incentives that motivate people to seek care for themselves and their children may help people overcome present-bias, build trust in health institutions, and spur more care seeking behavior. While there is ample evidence on the role of financial incentives (as well as consumption incentives, like food), less is known about how social incentives, such as public recognition and peer influence, influence health behavior. Yet given the low-cost of such incentives, shedding light on this question is very important from a policy perspective. This research aims to contribute to our understanding of the role of social incentives in changing social norms.
Context of the Evaluation
Sierra Leone has one of the highest rates of infant and maternal mortality in the world with a maternal mortality ratio of 1,100 per 100,000 live births and under-five mortality at 156 per 1,000 live births.1 2 Most women attend at least one prenatal care visit, but in some districts as many as 43 percent of women do not complete the recommended number of five visits. Further, only 54 percent of women give birth with a skilled attendant. The Government of Sierra Leone, together with development partners is heavily investing in strengthening health services. However, there is a shortage of information on cost-effective ways to do this in a state with weak capacity.
This study is taking place in four out of the country’s 14 districts: Kambia, Bombali, Tonkolili and Western Area Rural districts.
Details of the Intervention
Innovations for Poverty Action is working with researchers to rigorously measure the impact of social incentives, in the form of colored bracelets, on pregnancy care decisions. The design enables researchers to test both the effectiveness of the bracelets and to understand if behavior change is driven by social signaling.
A pregnancy care (prenatal care and delivery) bracelet program was rolled out six months after a related, immunization program began (see link below). Pregnant women are receiving differently colored bracelets when they come for prenatal care visits and deliver with a skilled attendant.
Among 120 clinics in the immunization study, researchers randomly assigned 90 clinics into to three groups:
- Four color, uninformative bracelets: Every woman receives a pink, purple, yellow, or multicolor bracelet when coming for their first prenatal visit. Women can choose their preferred color. The bracelet is exchanged for a bracelet of the same color at the fifth prenatal care visit and at delivery. The bracelets show that a woman has visited the clinic for a prenatal care visit, but do not show how many visits a woman has made to the clinic. (30 clinics)
- Four color, informative bracelets: Women receive a purple bracelet when coming on time for the first prenatal care visit (within 16 weeks of pregnancy). A woman receives a pink bracelet when coming late for her first visit. The purple or pink bracelet is exchanged for a yellow bracelet when coming for a fifth or later prenatal care visit during the eight or ninth month of pregnancy. Finally, a woman receives a multicolor bracelet when delivering her child with a skilled attendant. It is now observable whether a woman completed all recommended prenatal care visits and delivered safely. (30 clinics)
- Pure comparison group: No bracelets are given. It is unobservable whether a woman went for one, two or five prenatal care visits or whether she delivered with a skilled attendant. (30 clinics)
Data on prenatal care visits and deliveries with a skilled attendant is being collected from administrative records throughout the program to measure the impacts of the intervention.
Results and Policy Lessons
Project ongoing; results forthcoming.
 World Health Organization, UNICEF, World Bank, United Nations Population Division. Trends in maternal mortality: 1990 to 2013. Geneva, Switzerland: World Health Organization; 2014. http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en.
 Save the Children. Surviving the first day: state of the world's mothers 2013. http://www.refworld.org/docid/51a5ad654.html.