Healthcare at the Beginning of Life and Child Survival: Evidence from a Cash Transfer Experiment in Nigeria

Abstract

Households in poor countries are encouraged (and sometimes coerced) to increase investments in formal health care services during pregnancy and childbirth. Is this good policy? The answer to a large extent depends on its effects on child welfare. We study the effects of a cash transfer program in Nigeria in which households were offered a payment of $14 conditioned on uptake of health services. We show that the transfer led to a large increase in uptake and a substantial increase in child survival driven by a decrease in in-utero child deaths. We present evidence suggesting that the key driver is prenatal health investments.

Keywords: I10; I12; I15; O15; cash transfers; child mortality; developing countries; maternal health services.

Figures

Figure A.1:

Map of Nigeria showing the Program States The program sites were drawn from five states (shaded areas) representing three of Nigeria’s six geopolitical regions: Akwa Ibom (south-south), Bauchi and Gombe (north-east), Jigawa and Kano (north-west).

Figure A.2:

Participant Flowchart

Figure A.3:

Effect of the Conditional Cash Payment by State The figure shows the effect of the conditional cash payment on each component of the care package and on child survival by state (AK = Akwa Ibom; BA = Bauchi; GO = Gombe; JG = Jigawa; KN = Kano). The full care package consists of all three components. We plot coefficients and 95% confidence intervals from a linear regression of each outcome on the treatment indicator interacted with dummies for each state. The models include strata (HSA) fixed effects and the following controls: dummies for mother’s age (35 years), dummies for mother’s educational attainment (no schooling, Islamic schooling, some primary school, some secondary school, and some tertiary schooling), a dummy denoting Hausa or Fulani extraction, dummies for mother’s number of prior births, dummies indicating a prior fetal loss or a stillbirth, and household wealth quintiles. Standard errors in parentheses are clustered at the level of the health service area (HSA). *p < 0.1,** p < 0.05,*** p < 0.01.

Figure A.4:

Distribution of estimated pregnancy trimester at enrollment by treatment and control arms The treatment is a cash payment of $14 paid to households if eligible pregnant women used a package of health services consisting of at least three antenatal visits, a health facility delivery, and one postnatal visit. We impute pregnancy at enrollment using the month of birth and assuming a standard pregnancy duration. Pregnancy age cannot be imputed for women with a fetal loss so for these women we rely on their reported pregnancy age.

Figure A.5:

Distribution of treatment saturation and program pressure variables Treatment saturation is the fraction of EAs in the HSA that are treated, and program pressure is the number of treated women in the HSA divided by the baseline average monthly facility patient count.

Figure 1:

Effect of the Conditional Cash Payment on Uptake of Health Services The figure shows the proportion of participants in each arm of the trial that attended at least three prenatal visits, gave birth in a health institution, and attended at least one postnatal visit. Means and 95% confidence intervals are shown.

Figure 2:

Effect of the Conditional Cash Payment on Child Survival The figure shows the proportion of treated children in each arm of the trial that survived to follow-up. Means and 95% confidence intervals are shown.

Figure 3:

Trends in Facility Births by Treatment Assignment The figure shows the proportion of births to study participants, by year, that took place in a health care institution. The sample consists of births in the ten years preceding the intervention and excludes Gombe state. The vertical dashed line marks the last pre-intervention year, 2016. We have aggregated all post births.

Figure 4:

Is there evidence of crowd-out? The figure shows smoothed local polynomial plots (with 95% confidence bands) of utilization in the intervention and control groups over the distribution of treatment saturation (top) and program pressure (bottom). Treatment saturation is the fraction of EAs in the HSA that are treated, and program pressure is the number of treated women in the HSA divided by the baseline average monthly facility patient count. The latter is truncated at 1 for visual clarity. The utilization measure in Panel A (left) is an indicator for 3 or more prenatal visits, and in Panel B (right), an indicator for a facility birth.

Figure 5:

Effect of the Conditional Cash Payment by Pregnancy Trimester at Enrollment The figure shows the effect of the conditional cash payment on (i) the number of prenatal visits, (ii) the probability of a health facility birth, and (iii) the probability of a fetal death, by pregnancy trimester at enrollment. Trimester at enrollment was imputed using month of birth and assuming a standard pregnancy duration. It cannot be imputed if the pregnancy did not result in a birth so for these women we rely on their reported pregnancy age. We plot coefficients and 95% confidence intervals from a linear regression of each outcome on the treatment indicator interacted with dummies for each trimester. The models include strata (HSA) fixed effects and the following controls: dummies for mother’s age (35 years), dummies for mother’s educational attainment (no schooling, Islamic schooling, some primary school, some secondary school, and some tertiary schooling), a dummy denoting Hausa or Fulani extraction, dummies for mother’s number of prior births, dummies indicating a prior fetal loss or a stillbirth, and household wealth quintile dummies.