IPA Zambia is pleased to share its final bulletin from 2017. This bulletin features updates from our Saving for Safe Delivery study and the scale-ups of the food constraints and Catch Up projects. This bulletin also highlights IPA Zambia's dissemination events for the "Making Ghanaian Girls Great!" and "Interpersonal Communication to Encourage Use of Female Condoms in Zambia" studies.
Preventing violence against women (VAW) requires witnesses to come forward, yet willingness to report is often undermined by social sanctions against those suspected of fabricating allegations. Our theory of the micro-politics of information disclosure in interdependent communities elucidates the role of social norms in preventing VAW. We present experimental evidence from a media campaign attended by over 10,000 Ugandans in 112 rural villages that featured three short videos designed to encourage reporting of VAW in the household. Results indicate a substantial reduction in VAW over a 6-month period following the campaign. Investigation of mechanisms reveals that women in the treatment group became less likely to believe that they would be labeled a gossip if they were to report an incident of VAW, and their personal willingness to speak out increased substantially. We find no evidence of a deeper change in core values pertaining to VAW.
Nearly 2.5 million mothers and babies die each year from complications in the immediate period around childbirth. Nairobi, Kenya has among the highest maternal and neonatal mortality rates in the world. Mounting evidence suggests delivering in a facility is not enough to drive mortality reductions, with utilization of poor quality facilities and delays in receiving care the major contributors to continued poor outcomes (Lozano et al. 2011). In addition to delivering in well-equipped facilities, women must arrive at the facility and be attended to in time for complications to be effectively managed. The “three delays” model attributes poor outcomes to delays in: (i) seeking care; (ii) arriving at the facility for delivery; and (iii) receiving adequate treatment once at the facility (Thaddeus 1994). These delays are strongly associated with morbidity and mortality (Pacagnella et al. 2014).
Delays could occur for many reasons including the need to travel far distances, information gaps about when to seek care in labor, or because women are away from facilities (e.g., because of overcrowding). Our preliminary work in Nairobi suggested that delays could also be occurring because of behavioral barriers to effective decision making and planning around facility delivery. Nairobi offers a very large, complex set of highly heterogeneous maternity facility options. Previous work has highlighted how choice in this type of decision context can lead to deferring decisions (Tversky and Shafir, 1992). In our preliminary work, we found that decisions about where to deliver were often made very late in pregnancy. We hypothesized that decision-making delays could lead to poor birth planning, which has been shown to increase delays in seeking care. We designed a “precommitment transfer package” which bundles a labeled cash transfer and precommitment conditional transfer (see online Appendix Section I). This intervention was designed to help women deliver where they want and to reduce delays, both by relieving financial barriers to on-time arrival and by facilitating earlier and more deliberate planning and implementation of plans for delivery. In other work, we analyze the impact of the intervention on the quality of delivery care received.
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.
- Simple growth charts, which allowed parents to see if their child had a normal height for their age, did not reduce reduce growth deficits on average among the 547 children in the study, but among malnourished children, reduced stunting by 22 percentage points.
- In contrast, inviting caregivers to quarterly meetings to learn if their children had a normal height and weight and providing food supplements to malnourished children had no impact on rates of stunting.
- Neither home-based growth charts nor community-based monitoring were found to impact children’s cognitive development.
- Home-based growth charts appear to be a cost-effective tool to reduce physical growth deficits in this context. For every dollar that was invested in growth charts, children who otherwise would have been stunted gained an estimated $22 in additional lifetime wages.
In Rwanda, we have continued our global tradition of rigorous, applicable research by building foundational research capacity and conducting evaluations in areas of pressing national concern. Examples of our work below offer promising insights into everyday issues that affect the lives of the Rwandan poor.
Maternal mortality remains very high in many parts of the developing world, especially in sub-Saharan Africa. Limited awareness of risk factors for maternal mortality such as maternal age and birth spacing may contribute to persistently high death rates, and public health campaigns to increase awareness of risk factors could help curb maternal mortality. Data shows that men, in particular, tend to underestimate maternal mortality risk, which may lead to their lower demand for contraception. Researchers are working with Zambia’s Ministry of Health and local NGOs to evaluate the impact of providing information to men and women about maternal mortality risk on knowledge of risk, demand for family planning, and maternal and child health outcomes. If the program has a positive impact, as pilot results suggest, the curriculum and its focus on men could be incorporated into existing community-based health initiatives in line with the Ministry of Health’s goal of increasing household family planning demand.
Background: Despite the continued high prevalence of faltering growth, height monitoring remains limited in many low- and middle-income countries.
Objective: The objective of this study was to test whether providing parents with information on their child’s height can improve children’s height and developmental outcomes.
Design: Villages in Chipata District, Zambia (n = 127), were randomly assigned with equal probability to 1 of 3 groups: home- based growth monitoring (HBGM), community-based growth monitoring including nutritional supplementation for children with stunted growth (CBGM+NS), and control. Primary study outcomes were individual height-for-age z score (HAZ) and overall child development assessed with the International Fetal and Newborn Growth Consortium for the 21st Century Neurodevelopment Assessment tool. Secondary outcomes were weight-for-age z score (WAZ), protein consumption, breastfeeding, and general dietary diversity.
Results: We enrolled a total of 547 children with a median age of 13 mo at baseline. Estimated mean difference (b) in HAZ was 0.127 (95% CI: 20.107, 0.361) for HBGM and 20.152 (95% CI: 20.341, 0.036) for CBGM+NS. HBGM had no impact on child development [b: 20.017 (95% CI: 20.133, 0.098)]; CBGM+NS reduced overall child development scores by 20.118 SD (95% CI: 20.230, 20.006 SD). Both interventions had larger positive ef- fects among children with stunted growth at baseline, with esti- mated interaction effects of 0.503 (95% CI: 0.160, 0.846) and 0.582 (95% CI: 0.134, 1.030) for CBGM+NS and HBGM, respec- tively. HBGM increased mean WAZ [b = 0.183 (95% CI: 0.037, 0.328)]. Both interventions improved parental reports of children’s protein intake.
Conclusions: The results from this trial suggest that growth monitoring has a limited effect on children’s height and development, despite improvements in self-reported feeding practices. HBGM had modest positive effects on children with stunted growth. Given its relatively low cost, this intervention may be a cost-effective tool for increasing parental efforts toward reducing children’s physical growth deficits.
IPA Zambia is pleased to share its second quarter bulletin of 2017. This bulletin features updates on our research projects on improving public services by improving staff allocation; trust, spontaneous clusters, and the growth of urban small- and medium-sized enterprises; and interpersonal communication to encourage use of the Maximum Diva Woman's Condom. This bulletin also highlights IPA Zambia's presentation of preliminary results from the Girls Negotiation study in early May.
In Sierra Leone, we have continued our global tradition of rigorous, applicable research by building foundational research capacity and conducting evaluations in areas of pressing national concern. Examples of our work described in this brief offer promising insights into everyday issues that affect the lives of the poor in Sierra Leone.
In Liberia, we have continued our global tradition of rigorous, applicable research by building foundational research capacity and conducting evaluations in areas of pressing national concern. Examples of our work described in this brief offer promising insights into everyday issues that affect the lives of the Liberian poor.
Research on intrahousehold decision making often finds that fathers have more decision-making power than mothers, but mothers put more weight on children’s well-being. One policy response has been to try to shift decision-making power toward mothers, for example by making mothers the recipient of transfers aimed at improving children’s welfare (Lundberg, Pollak, and Wales 1997). However, changing decision making in the family is not always feasible or advisable. In such cases, the divergent preferences and decision making of parents suggest a trade-off when targeting policies to improve children’s well-being. On the one hand, fathers have more power to change household behavior in ways that help children. On the other hand, mothers might have a stronger desire to do so. This trade-off might be especially stark in developing countries where women have especially low bargaining power (Jayachandran 2015).
We study this trade-off in the context of classes that teach parents low-cost ways to improve child health. Our setting is Uganda. Many simple, inexpensive behaviors that promote child health such as boiling drinking water, exclusively breastfeeding newborns, spacing births, and using antimalarial bed nets have low take-up, and increasing their adoption could reduce child malnutrition and mortality (Bhutta et al. 2013). We compare village-level parenting classes for mothers, which were held over the course of a year and encouraged these health-promoting behaviors, to similar classes for fathers. For the reasons discussed above, it is ambiguous whether targeting the classes to mothers or fathers will be more effective. In addition to contributing to the literature on intrahousehold decision making, this paper is one of the first to rigorously study whether mothers’ and fathers’ knowledge have different
impacts on child health.
In Burkina Faso, Côte d'Ivoire, and Mali, we have continued our global tradition of rigorous, applicable research by building foundational research capacity and conducting evaluations in areas of pressing national concern. Examples of our work below offer promising insights into everyday issues that affect the lives of the Francophone West African poor.
IPA Zambia is pleased to share its first quarter bulletin of 2017. This bulletin highlights our research projects on the impact of teaching girls negotiation skills and the challenges of water provision, including policy dissemination events co-hosted with the International Growth Centre on results from these two studies. This bulletin also features our project on maternal mortality risk and the gender gap in desired fertility.
Distributing subsidized health products through existing health infrastructure could substantially and cost-effectively improve health in sub-Saharan Africa. There is, however, widespread concern that poor governance – in particular, limited health worker accountability – seriously undermines the effectiveness of subsidy programs. We audit targeted bednet distribution programs to quantify the extent of agency problems. We find that around 80% of the eligible receive the subsidy as intended, and up to 15% of subsidies are leaked to ineligible people. Supplementing the program with simple financial or monitoring incentives for health workers does not improve performance further and is thus not cost-effective in this context.