Evaluation Highlights In Nigeria, more than one in 10 children will not survive to see a fifth birthday, and nearly one in 20 women will die in childbirth. In collaboration with the Government of Nigeria, researchers are evaluating a program that aims to save the lives of mothers and their babies by improving access to reliable health services and increasing the demand for these services.

The results of the evaluation will help policymakers in Nigeria and other countries understand how to help protect and support the lives of women and infants. In many developing countries, pregnant women and infants are at risk of dying from often-preventable disease and complications related to pregnancy and birth. Prenatal care, midwife assistance and proper health facilities all help improve survival rates and ensure healthy births, but even such basic services are often not available or accessible to women in Nigeria. The Government of Nigeria has implemented a multi-pronged program that includes a variety of new or improved services, including steps to encourage women to use healthcare. This impact evaluation will provide evidence on what works for protecting and improving the health of pregnant women and infants.

Nigeria, Africa’s most populous country, cut maternal and infant and child mortality by half between 1990 and 2008. Still, with an estimated 36,000 women dying annually in pregnancy or during childbirth Nigeria accounts for 13 percent of the world’s maternal deaths. Reasons include a shortage of trained midwives, low quality health clinics, high costs for patients, and low awareness of the importance of prenatal care and giving birth with a midwife or another trained health worker. The Government of Nigeria has been introducing reforms to improve health care and is working with World Bank researchers to evaluate the programs. The evidence gathered from the impact evaluation can help the government in its future maternal-child health care planning. 

The Government of Nigeria introduced the SURE-P Maternal and Child Health Initiative (SURE-P MCH) in 2012 to improve health care for pregnant women and their babies. There are two main components: 1.Improving the supply of services. This includes training and placing midwives and community health extension workers in 1,000 previously under-staffed health facilities; training tens of thousands of village health workers to act as a liaison between pregnant women and primary health facilities; and upgrading facility infrastructure and providing drugs and commodities. 2.Improving the use of services. This includes cash transfers for pregnant women who register at a participating primary healthcare center, get health check-ups while pregnant, deliver at a health center, and take their baby for the first series of vaccinations. Women receive cash each time they meet one of the conditions, up to a total of about US$30. An informational campaign is also being carried out on the availability and benefits of maternal healthcare. 3.As part of the move to improve services, the program includes a component to measure the impact of financial and non-financial incentives (clocks, uniforms and other items) on midwife retention.

The program is currently active in 1,000 public primary healthcare facilities spread across Nigeria’s 36 states and the capital region of Abuja.

The impact evaluation will measure the overall program’s effect on the health of women and infants, test whether monetary or non monetary incentives are better for encouraging midwifes to stay on the job, and measure the impact of conditional cash transfers on women’s use of health services. 1.Because the health program was not randomly assigned when rolled-out, researchers will use the quasi-experimental difference-in-differences method to match program areas with non-program areas to measure impact of the overall health program. 2.To measure the impact of incentives on retention of midwives, the evaluation is using cluster level randomization – at the health facility level – to randomly assign midwives to one of four groups. One group qualifies for financial incentives, one group qualifies for non-financial incentives, one group qualifies for both, and the control group receives no incentives. 3.To test the marginal impact of conditional cash transfers within the broader program on women’s use of skilled birth attendants and prenatal and antenatal check-ups, researchers will randomly assign health facility clusters to one of two groups. One group will offer cash transfers to women who meet one or more conditions, while the other will be the control group and not offer any conditional cash transfers.

Surveys will collect data from recent mothers and their households, midwives, health facility managers, and other local leaders.

Policy Impacts
Nigeria introduced a program in 2009 to improve the availability of midwives at health clinics. Retentions, however, has proven a problem, and the SURE-P health initiative was designed with that in mind. The results of this evaluation will help the government decide what steps can be implemented to boost retention of skilled midwives, while encouraging women to use health services.

Pedro Rosa Dias - University of Sussex, Marcos Vera-Hernández - University College London, Marcus Holmlund - World Bank

SURE-P MCH Research Team 
Ugo Okoli, Project Director, Adetokunbo Oshin, Deputy Project Director, Sidi Ali Mohammed, Head of Health Workforce and Supplies, Chichi Aigbe, Operations Unit Lead, Jamila Bello-Malabu, Health Workforce Officer, Oluwafemi Adedipe, Head, ICT and Data Management, Chukwuebuka Ejeckam, Monitoring and Evaluation Officer, Chioma Oduenyi, Communications Officer, Nonso Onwudinjo, Communications Officer, Amina Muhtar, former Planning and Evaluation Lead, Laura Morris, former Planning and Evaluation Officer


Resource Information

Countries: Nigeria
Date of Publication: January 2015

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