About the BORN Study

“There's not much evidence about the effect of skilled birth attendance, especially in countries like Nigeria, where it could have the greatest impact. We hope BORN can fill this gap and inform efforts to improve health for mothers and infants in the developing world.”

— Edward N. Okeke

The Better Obstetrics in Rural Nigeria (BORN) Study examined the effectiveness of the Nigerian Midwives Service Scheme (MSS) with respect to reducing maternal and infant mortality in rural, underserved areas of the country. BORN's RAND-led research team paired RAND health experts with those leading the field in Nigeria.

BORN's evaluation design took advantage of the fact that the MSS has been “phased in,” resulting in natural comparisons between groups of clinics that had adopted the program and those that had not.

Researchers used a broad range of quantitative and qualitative methods—including surveys of patient households, clinic administrators, and midwives—to understand how the program had affected access to skilled birth attendance and basic emergency obstetric care, and maternal and child health outcomes.

The BORN Study was funded by 3ie (International Initiative for Impact Evaluation).


The MSS Fell Short of Its Goals

Overall, the MSS did not have the expected large impacts. Researchers found a 12 percent increase in use of antenatal care in program clinics compared with clinics in communities not exposed to the program, and a 6 percent increase in overall use of antenatal care — both within the first year of the program. They also found weak evidence of a small increase in the proportion of births assisted by skilled attendants, although this increase was confined to the south where there were fewer challenges with maintaining the supply of midwives. The researchers did not find improvements in maternal or child health.

Why Didn't the MSS Have the Expected Effects?

The program did increase access to skilled care, but this eroded over time, in part because of challenges in retaining and recruiting midwives (this appeared to be a greater problem in the north). Such problems as difficulties associated with relocating to new areas, inadequate provision of housing accommodation, and irregular payment of salaries (which worsened over time) contributed to midwives wanting to leave the scheme. Uneven adherence by different levels of government (particularly at the state and local levels) to agreements regarding the scheme likely contributed to, and exacerbated, some of these problems.

While implementation challenges help to explain, in part, why the program was not more effective, other factors also played a role. Researchers found that other dimensions of quality that households care about did not improve, perhaps reducing women's motivation to use services. For example, in many cases clinic infrastructure, such as electricity and running water, remained poor, as did availability of drugs and supplies. Other barriers affecting the demand for services — for example, lack of transportation to clinics or women's belief that the services offered were not necessary — continued to play an important role.