Pictured Above: A traditional birth attendant in Ebonyi State, Nigeria
Elizabeth had built a career supporting women and their newborns through childbirth, delivering over 400 healthy babies. As a reflection of her standing in the community, she had been appointed the head of the women’s association. A client had returned one day after delivery. The newborn and mother were febrile, and she did not have the medical supplies to help. In the local clinic, there was a doctor with supplies and equipment to treat the baby and mother. Complications after delivery could be harmful to Elizabeth’s reputation, threatening her standing and livelihood. Regardless, she decided to refer her clients immediately, potentially at a personal and social cost. 
The time of birth and the day after are critical to the health of newborns and their mothers. Within 48 hours of childbirth, maternal deaths tend to be caused by bleeding, infections, and hypertension, while neonatal deaths tend to result from infections, prematurity, and asphyxia. Every mother and newborn should receive postnatal care within 48 hours of delivery to facilitate early diagnosis, treatment, and referral in the event of complications. More than six out of ten childbirths in Nigeria are not supported by a skilled health care provider. In most cases, these women turn to a traditional birth attendant (TBA), an informally-trained and community-based provider of pregnancy-related care who works independently of the health system. About 20% of these mothers and newborns receive postnatal care, compared to up to 80% following childbirth in health facilities.
We published findings from qualitative interviews indicating that a TBA’s advice influences decision-making by his/her clients, including the choice to visit a health facility. Many TBAs voiced concerns about the reputational risk and potential for client loss if a TBA referred a client to a skilled health worker postnatally, particularly if there were complications following delivery. Our interviews suggested that monetary rewards could potentially offset these reputational costs to the TBA and increase referrals for postnatal care. In the absence of rigorous studies of the effectiveness of this intervention, we conducted a randomized controlled trial to estimate the impact of individual cash rewards for maternal referrals on postnatal care use among both mothers and their newborns within 48 hours of delivery.
This month, we published findings from our trial which randomized 207 TBAs in Nigeria to receive US$ 2.00 for every maternal client that attended postnatal care within 48 hours of delivery within the intervention group. Irrespective of their group, all TBAs were informed of the benefits of postnatal care within 48 hours of delivery for maternal and neonatal survival, encouraged to refer their clients within this time window. The probability that a maternal client in the intervention group attended postnatal care within 48 hours of delivery was 15.4 percentage points higher than for maternal clients in the control group. Our intervention only rewarded TBAs in the intervention group for referring mothers to postnatal care, however, the intervention also increased postnatal care checks for newborns. The TBA’s advice was an important motivation for attending postnatal care for themselves or their newborns (Figure 1).
Figure 1: Why did you choose to attend postnatal care?
Fewer than 20% of mothers or newborns in the intervention group received postnatal care within 48 hours of delivery, leaving most clients of TBAs vulnerable to complications within this critical window. Furthermore, obtaining postnatal care in a health facility from a skilled provider did not guarantee that mothers or their newborns were assessed appropriately, as health providers addressed only 42% of recommended actions from the postnatal care guidelines developed by the World Health Organization.
Every mother and her newborn should be supported before, during, and after delivery by a skilled and equipped provider. Where mothers continue to patronize informal providers like Elizabeth, our study shows that monetary rewards for referrals can link these mothers to skilled care during the postnatal period. Postnatal care can be particularly consequential and lifesaving for these mothers and newborns that do not receive skilled support during pregnancy and delivery. However, for postnatal care to save lives, skilled health care providers must deliver high-quality care. Cash incentives for referrals should be complemented with interventions that address other demand- and supply-side barriers to high-quality, skilled health care.
 A fictional case based on qualitative research conducted by the study team. The subject of the picture granted informed consent for its use as part of the study protocol.