Supply and Demand-Side Interventions to Improve Uptake of Antenatal Care Services: a Randomized Controlled Trial in Rural Côte d’Ivoire

This study involves three interventions:
1) Information video – In this video, participants will be shown a short video that describes key recommendations for antenatal care and health during pregnancy, based on national guidelines in Cote d’Ivoire. In intervention groups (1) and (2), this video will be shown only to the pregnant woman. In intervention group (3), this video will be shown to the pregnant woman together with her partner.
2) Financial planning session – In this intervention, a member of the study team will facilitate a structured discussion about planning for the expenses of health care services and related transportation costs over the course of pregnancy. The discussion will follow a series of questions and prompts set up as a survey form in ODK (attached to this protocol). The study team member will also share a list of the local prices of recommended antenatal care services. In intervention group (2), this intervention is delivered only to pregnant women. In intervention group (3), this intervention is delivered to pregnant women together with their partners.
3) Vouchers for antenatal care services – This intervention consists of vouchers for a pre-defined set of antenatal care services. Pregnant women who are randomized to receive this intervention will be given vouchers for one ultrasound, one “bilan prenatal” (a recommended set of prenatal laboratory tests in Cote d’Ivoire), and a 6-month supply of iron & folic acid supplements (with dosage based on her health care provider’s recommendation). The study team will establish agreements with local health facilities to provide services in exchange for these vouchers, with reimbursement by the study team.

2026-01-14

2026-09-30

Proportion of women receiving recommended antenatal care services

The primary endpoint is the portion of women receiving the following recommended antenatal care services during their pregnancy, as measured through recall during endline surveys with pregnant women:
• At least four antenatal care visits with a skilled provider AND
• At least one ultrasound AND
• At least one laboratory assessment.

1. Proportion of participants receiving the recommended number of malaria chemoprophylaxis doses during pregnancy
2. Proportion of participants receiving high-quality antenatal care measured using antenatal care booklets
3. Average antenatal care knowledge scores among pregnant women and their partners
4. Portion of women who delayed or missed care for financial reasons
5. Proortion of women who are satisfied with the antenatal care health services that they received
Portion of women responding “Excellent” or “Very good” to the question, “How would you rate the overall quality of care you received during your most recent pregnancy? Excellent, Very good, Good, Fair, Poor.”
6. Proportion of fathers involved in early care-giving activities
7. Perinatal mortality as reported by women during endline surveys
8. Birthweight as reported by women during endline surveys

1. Portion of participants who receive at least three doses of malaria chemoprophylaxis during pregnancy as reported by study participants during endline interviews
[Time Frame: During pregnancy (measured 4-8 weeks after the end of pregnancy)]
2. High-quality antenatal care (defined as at least 4 antenatal care visits with a skilled provider, at least one ultrasound, and at least one laboratory assessment) as measured through review of antenatal care booklets (as opposed to measurement by maternal recall). This secondary endpoint will only be measured in cases when women have an ANC book available at the time of the endline interview.
[Time Frame: During pregnancy (measured 4-8 weeks after the end of pregnancy)]
3. Average scores (among pregnant women and among their partners) on assessments of knowledge of antenatal care recommendations, as measured using the following questions during endline surveys with pregnant women and their partners:
1. During antenatal care visits, health care providers conduct some examinations and tests. Can you tell me which examinations and tests they should conduct?
2. During antenatal care visits, health care providers also sometimes give medications or treatments. Can you tell me which medications they should provide to all pregnant women?

Participants receive 1 point for each correct test or examination they mention in response to Q1 and 1 point for each correct medication or treatment they mention in response to Q2.
[Time Frame: Measured 4-8 weeks after the end of pregnancy]
4. Proportion of women who respond “yes” to one or both of the following questions during endline surveys:
• During your most recent pregnancy, did you ever delay your visit to the hospital because of financial issues?
• During your most recent pregnancy, did you ever skip recommended care - like an ultrasound or a blood test - because of money problems?
[Time Frame: Measured 4-8 weeks after the end of pregnancy]
5. Proportion of women responding “Excellent” or “Very good” to the question, “How would you rate the overall quality of care you received during your most recent pregnancy? Excellent, Very good, Good, Fair, Poor.”
[Time Frame: Measured 4-8 weeks after the end of pregnancy]
6. Proportion of mothers who respond “everyday” or “most days” to the following question during endline surveys: “How often does the father of the child participate in daily care activities such as feeding, bathing, or changing diapers? Every day, most days, some days, or never.”
[Time Frame: Measured 4-8 weeks after the end of pregnancy]
7. Mortality between 28 weeks of pregnancy and 7 days after birth, as reported by women during endline surveys
[Time Frame: Measured 4-8 weeks after the end of pregnancy]
8. Birthweight in grams, as reported by women during endline surveys

Women will be randomized to one of the three study groups: In group 1, the information video will only be shown to the pregnant women, not to their partners. In group 2, the information video AND the financial planning intervention will only be given to pregnant women, not to their partners. In group 3, the information video will be shown to the pregnant woman and her partner, and the financial planning session will be done with both partners together. Within these three intervention groups, each woman will be randomized to intervention version (a) with no vouchers for antenatal care services or version (b) with vouchers for antenatal care services. Randomization to vouchers (or no vouchers) will be done after the information video and financial planning interventions are completed. The vouchers will be explained directly to the pregnant woman.

Not available

Random number draw on tablet (ODK).

Woman (individual level).

No

NA

1290

We anticipate enrolling 1290 pregnant women.

Enrolling 430 women in each intervention arm provides 81% power to detect a 10 percentage point change in antenatal service coverage (from 36% to 46%) assuming 90% follow-up, comparing each intervention arm to the control arm and comparing the two intervention arms to each other. We anticipate cross-randomizing the voucher intervention so that 43 women in each study arm receive vouchers. Assuming 10% attrition, we will have 87% power to detect a 15 percentage point change in antenatal care service coverage (from 36% to 51%) comparing the vouchers recipients to non-vouchers recipients.