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

描述(申请人提供)：降低发展中国家的高孕产妇和儿童死亡率是5项千年发展目标中的2项，然而，许多国家仍然远远落后于2015年的千年发展目标目标。这一缓慢的进展促使人们寻找其他战略来降低孕产妇和儿童死亡率。几个国家正在考虑的一项有争议的战略是禁止使用传统助产士(TBA)。技术性贸易协定在许多发展中国家发挥着重要作用。在撒哈拉以南非洲，57%的分娩发生在卫生机构之外，每2个家庭分娩中就有1个由TBA接生。这种禁令背后的假设是，妇女将被“推”到医院分娩，而更高质量的医院护理将降低孕产妇和儿童的健康死亡率。然而，如果妇女在没有支持的情况下在家分娩，或者如果TBA进入地下并秘密实践，禁止TBA可能会使获得机会变得更差，并导致更糟糕的结果。禁止TBA的影响尚不清楚：这种禁令是否会成功地将妇女转移到医院分娩？这样的禁令将对孕产妇和儿童死亡率产生什么影响？我们试图通过利用马拉维的一项“自然”实验来回答这些问题，马拉维政府于2007年禁止了TBA。利用马拉维2004年和2010年人口与健康调查的数据，我们比较了法律通过之前和之后的结果，在禁令本应产生更强影响的地方，相对于法律本应产生较弱影响的地方(差别无差别战略)。为了反映法律潜在效力的变化，我们利用马拉维所有卫生设施位置的独特数据集，并根据GPS坐标构建到最近医院的距离测量。我们假设，住在离医院很远的地方的女性更有可能继续在家分娩。这项研究解决了一个具有全球意义的问题，并可能直接影响正在考虑禁止TBA的国家的决定。这将是低收入国家对TBA禁令的首次严格评估。 公共卫生相关性：这项研究对公共卫生很重要，因为研究结果将提供一些初步证据，证明一项有争议的政策的影响，该政策旨在降低孕产妇和儿童死亡率，禁止使用传统助产士。

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. Public Health Relevance: This study is important to public health, as the findings will provide some of the first evidence about the impacts of a controversial policy to reduce maternal and child mortality, banning the use of traditional birth attendants.