Monetary Incentives and Early Initiation of Antenatal Care: A Matched-pair, Parallel-cluster Randomized Trial in Zambia

Monetary incentives are often used to increase the motivation and output of health service providers. However, the focus has generally been on frontline health service providers. Using a cluster randomized trial, we evaluate the effect of monetary incentives provided to community-based volunteers on early initiation of antenatal care visits and deliveries in health facilities in communities in Zambia. Monetary incentives were assigned to community-based volunteers in treatment sites, and payments were made for every woman referred or accompanied in the first trimester of pregnancy during January-June 2020. We found a significant increase of about thirty-two percentage points in the number of women seeking antenatal care visits in the first trimester but no effect on coverage rates (the percentage of women who deliver at a health facility and are assisted by skilled birth attendants). The number of women accompanied by community-based volunteers for antenatal care in the first trimester increased by thirty-three percentage points. Deliveries in health facilities also increased by twenty-two percentage points. These findings suggest that the use of health facilities during the first trimester of pregnancy can be improved by providing community-based volunteers with monetary incentives and that such incentives can also increase deliveries in health facilities, which are key to improving the survival of women and newborns.