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Assessing the effect of conditional cash transfers on pregnancy outcomes in France

Location: France
Sample: 4000 pregnant women
Timeline:
2016
Target Group: 
Mothers and pregnant women
Outcome of Interest: 
Mortality
Intervention Type: 
Incentives
Partners:

Women of lower socioeconomic status adhere to recommended prenatal care regimens at lower rates, which can have adverse effects on both maternal and newborn outcomes. Researchers conducted a randomized evaluation to measure the impact a financial incentive of € 30 ($33.89) per visit per month on rates of treatment adherence and on health outcomes.

Policy Issue 

Prenatal care is recommended for improving newborn and maternal outcomes. However, women of lower socioeconomic status1 comply less frequently to the recommended care regimen and suffer a higher risk of adverse outcomes during and after childbirth. Multiple attempts to encourage optimal care during pregnancy have shown mixed results, particularly in high-income countries. Furthermore, there is limited evidence on whether financial incentives can encourage prenatal care, and none of the existing studies primarily measure maternal or fetal outcomes. Researchers are conducting a randomized evaluation to identify the impact of financial incentives on prenatal care-seeking and ultimately on post-natal health outcomes for women of lower socioeconomic status.

Context of the Evaluation 

This study took place in 40 maternity health centers across France, a country where studies show that an estimated 12 percent of women in the general population suffer adverse pregnancy outcomes. This rate is 18 percent for low-income women.

Details of the Intervention 

Researchers randomly assigned 40 health centers to participate in the program or in the comparison group. Each center was randomly assigned either to the program or comparison group for two months at a time. After the two months, a rerandomization determined which centers would be in the program and comparison groups for the following two months. At any given time, approximately 2000 women were assigned to participate in the program and another 2000 in the comparison group.

Women were eligible for the program if they met three criteria. They must have:

  1. Been above the age of 18;
  2. Had their first pregnancy visit in one of the participating centers before the end of the 26th week after their first missed period; and
  3. Had social insurance for low-income people or illegal immigrant status.

Participants began enrolling in the program in June 2016 and will continue to do so until December 2019.

As described above, clinics were randomly assigned to the program or comparison group in two month stretches. Accordingly, half of the women were at any given time randomly assigned to participate and only received information on whether they were chosen to participate in the program or to the comparison group after agreeing to participate. Those chosen to participate in the program were given a payment card on their first visit to the prenatal care facility. It was then credited with € 30 ($33.89) after each scheduled prenatal visit. Participants were restricted to € 30 ($33.89) per month, even if they made more than one visit to the center. The other half of the women are assigned to the comparison group and receive no incentive.

Researchers used different criteria to measure outcomes for infants and mothers. For infants, criteria included the following:

  • Post-natal death
  • Premature birth
  • Small growth during pregnancy
  • Low birth weight
  • Inability to breathe at birth
  • Brain or head anomalies

For mothers, the criteria included:

  • Maternal death
  • Vein inflammation
  • Blood clots in the heart or lungs
  • High blood pressure during pregnancy or seizures
  • Post-partum bleeding that required a blood transfusion
Results and Policy Lessons 

Research ongoing; results forthcoming.

Bardou M, Crépon B, Bertaux A-C, et al. “NAITRE study on the impact of conditional cash transfer on poor pregnancy outcomes in underprivileged women: protocol for a nationwide pragmatic cluster- randomised superiority clinical trial in France.” BMJ Open 2017; 7:e017321. doi:10.1136/bmjopen-2017-017321.

1 In this study, lower socioeconomic status is defined as having healthcare insurance available only for low-income households.