Maternal and Child Health Journal

, Volume 23, Issue 5, pp 633–640 | Cite as

An Incentive-Based and Community Health Worker Package Intervention to Improve Early Utilization of Antenatal Care: Evidence from a Pilot Randomised Controlled Trial

  • Laura RossouwEmail author
  • Rulof Petrus Burger
  • Ronelle Burger


Objectives One of the factors linked to South Africa’s relatively high maternal mortality ratio is late utilization of antenatal care (ANC). Early utilization is especially important in South Africa due to the high HIV prevalence amongst pregnant women. This study examined the impact of a package intervention, consisting of an incentive called the Thula Baba Box (TBB) and a community health worker (CHW) programme, on early utilization of ANC. Methods A pilot randomised controlled trial consisting of 72 women aged 18 and older was conducted in an urban area in South Africa to evaluate the impact of the package intervention. Women were recruited and randomised into either intervention (n = 39) or control group (n = 33). The intervention group received both the TBB and monthly CHW visits, while the control group followed standard clinical practice. Both groups were interviewed at recruitment and once again after giving birth. The outcomes measured are the timing of first ANC visit and whether they attended more than four times. It is anticipated that the box will also have a beneficial impact on infant health outcomes, but these fall out of the scope of this study. Results Women in the intervention groups sought care on average 1.35 months earlier than the control group. They were also significantly more likely to attend at least four antenatal clinic visits. Conclusions for practice Given the South African context and the importance of early care-seeking behaviour to improve health outcomes of HIV-positive pregnant women, the intervention can help to improve maternal and neonatal health outcomes. Further research is needed to investigate the impact of the two interventions separately, and to see if these findings hold in other communities.


Maternal health Maternal mortality Antenatal care Incentives Community health worker South Africa 



We would like to thank several people for their assistance and inputs in designing the interventions. These are Dr. Miemie du Preez, Dr. Lungiswa Nkonki, Professor Mark Tomlinson, the Philani Health and Nutrition project (specifically Kwanie Mbewu and Dr. Ingrid le Roux), Masincedane Community Service, Masikhule and members of the Western Cape Department of Health, especially members of the PICH group. A special thank you to the team who assisted with fieldwork, Busisiwe Sokutu, Koleka Sibeko, Ntombizukile Marhobobo and Thabisa Peter. We would also like to thank Ernst Hertzog and Frans de Villiers for their original idea, contribution and assistance with the Thula Baba Box.

Author Contributions

LR, RPB and RB all contributed to the study design. Implementation, fieldwork, project management and statistical analysis were performed by LR. Manuscript drafting was performed by LR, RB and RPB. All the authors read and approved the final manuscript.


Funding for the project was received from the Abdul Latif Jameel Poverty Action Lab (JPAL), Broadreach Healthcare and REDI3x3. Several smaller sponsorships were also obtained from Ackermanns, Agrimark SA and Jonsson.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no competing interests.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Economics DepartmentStellenbosch UniversityMatielandSouth Africa

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