Paying patients for prenatal care : the effect of a small cash transfer on stillbirths and survival

We study the effects of conditional cash transfers to pregnant women on stillbirths and child survival in Bolivia. Payments are conditional on compliance with medically recommended prenatal care and skilled birth attendance. At a value equivalent to just 1% of monthly household consumption, the payments are the smallest amongst national cash transfer programs in Latin America. Using multiple data sources and empirical methods, we show that the intervention reduced the average rate of stillbirths by 9.5% to 22.3%, and increased the survival rates of birth cohorts exposed to the program by 3.5% to 16.8%. The causal pathways of these effects are consistent with evidence of increased utilization of recommended health care services, including early initiation of prenatal care (17%), at least four prenatal visits (16%), and skilled birth attendance (15%). Given the modest transfer amounts and considerable effects on health care utilization, we posit that final health outcomes are likely driven by the health care conditionality, rather than an income effect. The intervention is highly cost-effective, at $184.54 per DALY averted, making the program’s pay-per-compliance design a promising policy alternative.