The Politics and Impact of Perinatal Health Interventions in Nigeria

Abstract

Nigeria accounts for 14 percent of maternal deaths worldwide. The risk of mortality peaks during the perinatal period, at delivery and following childbirth, reducing with skilled care, facilitated by supplies needed for complication management. Less than 4 in 10 Nigerian mothers receive skilled care at birth or postnatally. A 2015 review of maternal health interventions in Nigeria found only one study focused on skilled postnatal care use, and all the studies of delivery care use lacked a counterfactual. This dissertation contributes to the evidence base on increasing skilled perinatal care access. The first paper (authored with Marcos Vera-Hernandez, Marcus Holmlund, and Pedro Rosa Dias) evaluates the impact of the Subsidy Reinvestment and Empowerment Program (SURE-P) Maternal and Child Health (MCH) Intervention, using difference-in-difference models. We find that improving the staffing and supplies in facilities was associated with an increase in the probability of giving birth with skilled assistance and in facilities. We also show that benefits of the intervention were concentrated among women that lived in urban areas. The second paper examines the political returns to the Nigerian President who championed the SURE-P MCH intervention. We show that there were positive returns to the Nigerian President, in terms of approval of overall performance and of provision of health services, trust, and intentions to vote, among voters overall and voters outside the President’s region of origin. The third and fourth papers examine how traditional birth attendants (TBAs) can be engaged in promoting postnatal care use. We show that educating TBAs may be insufficient to encourage postnatal referrals given potential negative implications in the event of complications. Suggested means of increasing referral rates included rewards for referrals and cordial relationships with and support from skilled health workers. We thus conducted a randomized controlled trial of the effectiveness of monetary incentives for TBA referrals in increasing postnatal care use among TBA clients and found that referral incentives increased the proportion of maternal and neonatal clients that attended postnatal care within 48 hours of delivery. Together these four papers provide policy-relevant evidence on interventions to increase the use of skilled perinatal care in Nigeria.