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The Better Obstetrics in Rural Nigeria (BORN) Study

The Better Obstetrics in Rural Nigeria (BORN) Study: An Impact Evaluation of the Nigerian Midwives Service Scheme

Edward N. Okeke
Peter Glick
Isa Sadeeq Abubakar
A.V. Chari
Emma Pitchforth
Josephine Exley
Usman Bashir
Claude Messan Setodji
Kun Gu
Obinna Onwujekwe
Copyright Date: 2015
Published by: RAND Corporation
Pages: 85
Stable URL:
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  • Book Info
    The Better Obstetrics in Rural Nigeria (BORN) Study
    Book Description:

    The Midwives Service Scheme (MSS) was introduced in 2009 to increase access to skilled care for women in rural underserved areas of Nigeria. To evaluate the impact of the MSS, researchers conducted household and clinic surveys, focus group discussions and in-depth interviews, and compared changes in pregnancy and birth outcomes in MSS areas to changes in comparison areas. They found smaller than anticipated effects.

    eISBN: 978-0-8330-9366-0
    Subjects: Health Sciences, Public Health, History
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Table of Contents

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  1. Front Matter (pp. i-ii)
  2. Preface (pp. iii-iii)
  3. Table of Contents (pp. iv-iv)
  4. Summary (pp. vii-vii)
  5. Abbreviations and Acronyms (pp. viii-viii)
  6. Acknowledgments (pp. ix-ix)
  7. 1. Introduction (pp. 1-3)

    One of the major global health challenges of the 21st century is reducing the approximately 3 million newborn deaths, 7 million under-five deaths, and 300,000 maternal deaths that occur globally each year.¹ This health burden is not uniformly distributed, with most deaths occurring in the poorest regions of the world; 87 percent of maternal deaths and 37 percent of neonatal deaths, for example, occur in sub-Saharan Africa (Wang, Alva, Wang, & Fort, 2011). The startling difference in a woman’s risk of dying during pregnancy or childbirth—1 in 6 in some parts of Africa compared to about 1 in 2,400...

  8. 2. Program Description (pp. 4-7)

    Every year, more than 50,000 Nigerian women die from pregnancy-related complications (National Primary Care Development Agency (NPHCDA), 2010). The chance of a woman dying during pregnancy and childbirth in Nigeria is approximately 1 in 30 compared to about 1 in 2,400 in developed countries. In 2008, the maternal mortality ratio (MMR) was estimated at 545 per 100,000 live births, increasing to over 800 per 100,000 births in rural areas (National Population Commission (NPC) [Nigeria] and ICF Macro, 2009). Infants also experience poor health outcomes, with an estimated 250,000 newborn deaths annually and a neonatal mortality rate of about 37 per...

  9. 3. Study Design (pp. 8-10)

    Our evaluation took place in 2014. We conducted closed-ended surveys as well as semi-structured interviews and focus group discussions. The closed-ended surveys were used to collect data on outcomes in treatment and comparison areas; the in-depth interviews and focus groups provide information about program implementation and shed light on potential mechanisms of action. They also provide insight into the experiences of those providing or receiving care under the MSS. Clinic/participant selection for the interviews and focus groups was informed by preliminary survey data (see Figure 2). To identify the effects of the MSS, we compare changes in pregnancy and birth...

  10. 4. Data (pp. 11-15)

    Data collection took place between June 2014 and January 2015. Ethical review and approval for the study was provided by institutional review boards at RAND, Bayero University Kano, and the University of Nigeria, Enugu.

    Within each study community, trained interviewers visited 20 randomly sampled households having a woman who was pregnant between January 2009 and the date of interview.¹³ Since a comprehensive list of eligible households in each community was unavailable, we randomly generated 20 GPS coordinates within each community using a GPS-enabled tablet and special software and selected the dwelling nearest this point for interview. If there was no...

  11. 5. Analytical Strategy (pp. 16-18)

    To identify the impact of the MSS, we estimate difference-in-difference (DID) models that examine the relative change in outcomes in intervention relative to comparison areas. The basic econometric specification is as follows: yijt= a + β₁ Treatedj+ β₂ Postt + β₃ Treatedj* Postt+ nj+ eijtwhereyijtdenotes the outcome of interest for birthiin communityjin montht(starting in January 2009);Treatedjis an indicator that takes the value 1 if the study clinic in community j is a Wave 1 (MSS) clinic;Posttis a binary indicator that takes the...

  12. 6. Study Findings: Impacts (pp. 19-38)

    The survey sample for the impact evaluation consists of 9,475 reported births born to 7,104 women over the period 2009– 2014, of which 4,746 (50.3 percent) occurred in the intervention areas. We exclude births after the comparison group becomes exposed, leaving us with 5,295 births taking place between January 2009 and May 2012. Table 7 summarizes the variables used in the analysis at baseline and tests for balance across intervention and control areas. Even though the DID identification strategy does not require it, it is reassuring to note that the outcome variables as well as the covariates are relatively well...

  13. 7. Study Findings: Mechanisms of Action (pp. 39-51)

    It is important to understand the potential mechanisms underlying the program’s impact, or lack thereof, because these mechanisms have direct bearing on policy recommendations. Given the relatively small effect of the program, a relevant question for policymakers is: Why did the program not have larger effects? Guided by our theory of change, we examine various links in the causal chain, making use of both other quantitative data—in particular the provider surveys—and our qualitative data.

    Overall, the data suggest that the program improved access but that gains eroded over time. We begin by looking at the stock of midwives....

  14. 8. Discussion and Policy Recommendations (pp. 52-59)

    The results in the previous section show that the MSS did not have the expected impacts. The main measured effect of the program is that it increased the use of antenatal care. These gains are concentrated in the first year of the program. On average, we do not find any evidence of an increase in institutional deliveries or skilled birth attendance. However we find some heterogeneity by region with suggestive but not conclusive evidence of a small increase in skilled birth attendance in the south (the coefficient is not statistically significant at conventional levels). To put these results into context,...

  15. Appendix A: Survey Instruments (pp. 60-63)
  16. Appendix B: Pre-Analysis Plan (pp. 64-67)
  17. Appendix C: Sample Size and Power Calculations (pp. 68-70)
  18. References (pp. 71-76)