Constrained Provider Choice: The Effect of a TBA Ban on Morality

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DESCRIPTION (provided by applicant): Reducing the high rates of maternal and child mortality in developing countries are 2 out of the 5 Millennium Development Goals (MDG), yet, many countries continue to lag well behind 2015 MDG targets. This slow progress has led to a search for alternative strategies to reduce maternal and child mortality. A controversial strategy that is being considered in several countries is a ban on the use of traditional birth attendants (TBA). TBAs play an important role in many developing countries. In sub-Saharan Africa, 57% of births take place outside a health facility, and a TBA attends 1 in 2 home births. The assumption underlying such a ban is that women will be "pushed" to deliver in a hospital, and the higher quality of hospital care will reduce maternal and child health mortality. Banning TBAs may however, worsen access and result in worse outcomes if women deliver at home with no support or if TBAs go "underground" and practice in secret. The impacts of a ban on TBAs are unknown: will such bans succeed in shifting women into hospital deliveries? What impacts will such a ban have on maternal and child mortality? We attempt to answer these questions by leveraging a "natural" experiment in Malawi where the government banned TBAs in 2007. Using data from the 2004 and 2010 waves of the Demographic and Health Surveys for Malawi, we compare outcomes before and after the law was passed, in places where the ban should have had a stronger effect relative to places where the law should have had a weaker effect (a difference-indifference strategy). To proxy for variation in the potential effectiveness of the law we exploit a unique dataset on the location of all health facilities in Malawi and construct measures of distance to the nearest hospital based on GPS coordinates. We hypothesize that women who live far away from a hospital will be more likely to continue to have births at home. This study addresses a question of global significance and could directly impact the decisions of countries that are considering a TBA ban. This will be the first rigorous evaluation of a TBA ban in a low income country.