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Research Questions

  1. Did the Midwives Service Scheme (MSS) increase use of antenatal care?
  2. Did the MSS increase institutional delivery or skilled birth attendance?
  3. Did the MSS improve maternal and child health outcomes?
  4. What were key barriers and facilitators to implementation?

Pregnancy-related morbidity and mortality have serious economic and social consequences. The Midwives Service Scheme (MSS) was introduced in 2009 to provide round-the-clock access to skilled care in rural underserved areas of Nigeria. At rollout, the MSS deployed nearly 2,500 midwives to 652 primary health care centers across 36 states. To evaluate the impact of the program, the researchers surveyed 7,104 women in 386 communities across 12 states and conducted in-depth interviews and focus group discussions with policymakers, providers, childbearing women, and community stakeholder groups in three states. They compared changes in pregnancy and birth outcomes in MSS areas to changes in comparison areas over the same period. They found a 12 percent increase in antenatal care use in program clinics and a 6 percent increase in overall use of antenatal care, both in the first year of the program. They also found suggestive but not conclusive evidence of a small increase in skilled birth attendance that was largely confined to the south where there were fewer challenges with maintaining supply of midwives. They found no improvements in maternal or child health. The researchers found that while the deployment of midwives initially increased access to skilled care, this eroded over time, potentially explaining why initial improvements were not sustained. 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.


  • Engage with state and local-level policymakers, in addition to the federal government.
  • Ensure adequate compensation for midwives.
  • Create a "career ladder" for midwives and opportunities for professional development.
  • Consider local recruitment and hiring of midwives where possible.
  • Address supply-side factors, such as physical infrastructure and availability of drugs and equipment.
  • Integrate interventions that address demand-side barriers such as low perceived need for services.

This work was supported by the International Initiative for Impact Evaluation (3ie) and within RAND Health, a division of the RAND Corporation.

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