Over the last two decades, tremendous gains have been made in improving women's access to prenatal, obstetric, and postnatal care. Yet challenges remain, with many women in northern Ghana still not starting prenatal care until second (and in some cases third) trimester. The most commonly cited reasons for not seeking maternal health services include lack of money, the perception that obstetric care is not necessary, and transportation problems. Additional obstacles include lack of financial and moral support from partners and mothers-in-law, cultural factors related to performance of traditional rites that delay ANC onset and stigma felt by young women who become pregnant (especially if pregnancy is out of wedlock).

Our intervention is designed to test whether the implementation of community meetings (or durbars) to communicate the importance of obstetric care, combined with phone messages and household visits to discuss birth preparedness plans with pregnant women, their partners, and mothers-in-law, increases the use of maternal health services and improves health outcomes in northern Ghana. The intervention involves cross-randomized interventions: 1) community education at durbars, 2) phone calls to reinforce key messages and monitor pregnancy, and 3) home visits to check on the pregnant woman and prepare birth plans together with husbands and mothers-in-law.

This study was developed in close partnership with the local health policy experts and health providers, who identified traditional and cultural beliefs that still loom large in the local context as issues that undermine national policy interventions designed to address maternal health issues. By testing interventions that are aligned closely with the local context and feasible to implement, we are ensuring that the tested interventions are scalable. Since cost is a crucial question for expanding the intervention, we will gather cost data to inform policy decision makers.

Impact of expanded access to antiretroviral therapy on economic functioning in low-income settings

with Harsha Thirumurthy and the SEARCH team

The Sustainable East Africa Research in Community Health (SEARCH) trial evaluated the impact of universal HIV testing, immediate initiation of antiretroviral treatment (ART), and streamlined approach to HIV care on community health in rural East Africa. The SEARCH intervention led to significant improvements in health, including significantly higher rates of viral load suppression, reduced incidence of tuberculosis, and lower death rates due to illness by year 3. Our most recent work tests whether such improvements in health translate to better socio-economic functioning of working-age adults and their children three years after implementation of the SEARCH intervention.

with Dennis Egger, Pius Akankwasa, Ronald Mulebeke, Rhoda Wanyenze, Noah Kiwanuka

COVID-19 continues to pose a major threat to countries around the world, and may have an especially devastating impact on low- and middle-income countries where fragile health systems would have difficulty accommodating a large number of COVID patients. For example, Uganda has only 12 functioning ICUs (55 ICU beds), or the equivalent of 1.3 ICU beds per 1million people, nearly all of which are in the capital city of Kampala. Although confirmed cases remain low, at 657 confirmed cases and 0 deaths as of 11 June 2020, the limited testing capacity may be understating the true spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within Ugandan communities. At this time no known treatments or vaccines exist for COVID-19; efforts to limit the spread of SARS-CoV-2 are limited to non-pharmaceutical interventions including emergency lockdowns, social distancing, frequent hand washing, and face coverings. Although conflicting recommendations have been issued over time regarding face coverings, the most recent evidence suggests that face masks may significantly reduce the spread of SARS-CoV-2. These recommendations are based on mathematical models and observational studies, with no randomized controlled trials on masks conducted to date. Given the enormous toll lockdowns have had on African countries, widespread use of face coverings may offer an important mitigation strategy as societies consider opening up. In Uganda, an unprecedented effort to provide a face mask to each citizen of the country is currently underway. Given the tremendous scale and logistical challenge of this ambitious effort, we propose to incorporate a randomized schedule of which communities receive face masks first to study the impact of face coverings on the spread of SARS-CoV-2 in Uganda. The distribution of masks will be paired with education campaigns about COVID-19 and proper use of masks. Effectiveness of the masks and information about the virus will be evaluated using phone surveys and antibody tests in a random subset of the target population.

with Ted Miguel, Dan Posner, Pius Akankwasa, Elizeus Rutebemberwa

Health worker absenteeism impedes Uganda’s progress towards the sustainable development goals (SDGs) and reduces trust in healthcare system quality and dependability, two factors crucial during difficult times such as the COVID-19 pandemic. Using a randomized design developed in close collaboration with the Prime Minister’s Office Delivery Unit (PMDU), our project proposes to test whether biometric tracking of attendance (fingerprint scans to mark the beginning and end of a shift), combined with behavioral interventions, cost-effectively improves health worker attendance. The behavioral interventions—both positive (financial bonuses for exemplary attendance) and negative (personalized letters of reprimand for poor attendance signed by a senior government official)—aim to reinforce the impact of the biometric monitoring by providing evidence that data collected by the biometric devices are being monitored and used to evaluate the workers’ performance.

Adolescent pregnancy and education attainment

with Ketki Sheth and Elizabeth Wall-Weiler

What is the impact of adolescent pregnancy on education? Is adolescent pregnancy a choice given limited economic prospects of some girls? Or is the pregnancy itself interruptive to education trajectories? These questions are difficult to disentangle given the endogenous nature of socio-economic circumstances, sexual risk behaviors, and fertility preferences. I am working on two projects related to adolescent prenancy to help untangle this puzzle.

In sub-Saharan Africa, multiple countries have adopted school policies related to adolescent pregnancy that expel girls from school during pregnancy and, in some more severe cases, forbid the girl from returning to school once she is an adolescent mother. We are aiming to use the variation in the time of these policy implementations to assess how the policies affected girls' education and fertility outcomes. (with Ketki Sheth)

In Canada, we are using rich administrative data from Manitoba to trace impact of adolescent pregnancy on education and income assistance. Using population-representative administrative data on education, income assistance, and family structure, we assess the probability of women dropping out of high school and using income assistance while controlling for a rich set of women’s characteristics from before a teen pregnancy, including school performance, family characteristics, and community characteristics. Our models includes propensity score weights to enable stronger inference about adolescent pregnancy and school attainment and receipt of income assistance. (with Elizabeth Wall-Weiler)