Every year, more than 300,000 women and 2.5 million babies die from complications related to pregnancy and childbirth. The majority of these deaths occur in low-resource settings and, in most cases, could be prevented (WHO, 2016). In rural areas of Guatemala there is little acceptance of medical services, which reduces the chances of women receiving adequate prenatal care.

In the mid-1990s, the Guatemalan government established the Coverage Extension Program (PEC), a program providing free basic health care services to children under the age of five and women of reproductive age, with a focus on preventive care. The Ministry of Health then hired local NGOs to operate a network of rural basic clinics in which health workers are expected to track individual families and inform them when they should attend the monthly mobile medical team’s visit. However, there are no clear guidelines and communication depends on health workers’ initiative.

A sample of 130 clinics were randomly allocated to an intervention and control group. For those communities in the intervention group, community health workers received accurate and up-to-date information about women who were pregnant and would need prenatal care during the medical team’s upcoming visit to their clinic. Health workers were trained to use these lists to go house to house giving specific and timely in-person reminders to women so that they would go to the clinic during the monthly visit days. In the control group, the community health workers did not have the precise information of the program and had to rely on their own records.

The reminders had a positive and statistically significant effect on prenatal check-ups six months before delivery, increasing their probability by 6.6 percentage points. The first trimester of pregnancy is significant to the development of the fetus and so these prenatal check-ups are particularly important. We also find positive and statistically significant effects on prenatal assessments one and two months before delivery (7.8 and 7.2 percentage points, respectively)

Intervention effects increase with age. While the effect for women between 14 and 24 years old was small and statistically insignificant, the intervention increases the probability of women aged 25 to 35 years attending a prenatal check-up one month before delivery by 11.4 percentage points. The effect is even larger for women between 36 and 49 years of age (47.9 percentage points). Intervention effects are also larger and statistically significant for women that had one previous miscarriage and for women who are pregnant for the first time. In sum, the intervention seems to be more effective for the group of women who would benefit most from having regular prenatal check-ups.

Inspired to implement this design in your own work? Here are some things to think about before you get started:

• Are the behavioral drivers to the problem you are trying to solve similar to the ones described in the challenge section of this project?
• Is it feasible to adapt the design to address your problem?
• Could there be structural barriers at play that might keep the design from having the desired effect?
• Finally, we encourage you to make sure you monitor, test and take steps to iterate on designs often when either adapting them to a new context or scaling up to make sure they’re effective.

Additionally, consider the following insights from the design’s researchers:

• For the implementation of the intervention, a software program was developed that generated the lists of patients from PEC’s medical record system, which were delivered to the community health workers during their monthly meeting with the NGO.
• Pregnant women received a prenatal checkup that included measuring their weight, blood pressure and abdominal circumference, taking urine samples, and providing them with vitamins and food supplements. A smaller proportion of the population within the intervention group received tetanus vaccines and ultrasounds to assess the baby’s health.