Economics Seminar: Does a Ban on Informal Health Providers Save Lives?

Trang Le '17

Assistant Features Editor

On April 10, the Smith College economics department welcomed Professor Susan Godlonton to present a seminar titled “Does a Ban on Informal Health Providers Save Lives? Evidence from Malawi.”

Godlonton is an assistant professor of economics at Williams College whose research interests focus on health and labor issues in developing countries, especially in Sub-Saharan Africa.

The main concern of the talk was the high mortality rate in developing countries as a result of premature births, asphyxia and infection. Globally, there are eight million children who die before the age of five, three million of which die within a month of birth. Timely intervention by skilled attendants is critical to prevent infant deaths; however, in countries where these cases are still common, skilled medical professionals facilitate only 54 percent of the deliveries. According to a story by Lauren Goodwin featured on the official Peace Corps website, “Traditional birth attendants [TBAs] fill the gap in rural, resource-deprived areas, where maternal health facilities are not accessible.”

Godlonton provided a background on TBAs and the 2007 ban against them. TBAs in developing countries are unregulated, unlicensed and possess varying skill levels. Those against the ban point out the limited access to care in resource-constrained settings, including transportation to formal healthcare providers and shortage of qualified clinics. Those in favor of the ban note the poor quality healthcare provided by TBAs and the high rate of preventable deaths, which are caused by a lack of proper facilities and staff with sufficient skills. Some traditional leaders in Malawi believe that the TBAs are related to higher rates of infant mortality, which resulted in the ban imposed on these informal birth attendants enacted in 2007. By restricting access to TBAs, the ban increased the use of the formal sector and marginally increased deliveries by relatives. However, it had a negligible effect on mortality rate. This finding is consistent with the existing literature on the state of healthcare in Malawi, which shows that returns to the formal healthcare sector is relatively low.

In Sept. 2010, the ban was lifted by President Bingu Wa Mutharika because it failed to curb Malawi’s exceptionally high maternal mortality rate attributed to the reliance on this method of birth delivery. In her study, Godlonton shows how statistical evidence demonstrates that little improvement was brought about by the ban on TBAs, and there are still issues to address with regard to formal healthcare providers. The study was a nationally representative survey with observations divided into 849 clusters in which people ages 15 to 49 were interviewed. It is a five-year retrospective on fertility history, with the data on mortality collected for all births.

The mapped data illustrates the high rate of TBA deliveries in Malawi prior to the ban and how there was a reduction in the likelihood of using TBA when the ban was enacted. To supplement her study, Godlonton provided the plotted correlation between skills of birth attendants and mortality at birth. It can be inferred that the more skilled the healthcare providers, the more infant mortality is decreased. However, richer countries are a confounding variable because they have more facilities and transportation provided to women in childbirth, which are not readily available in developing countries.

Treating prenatal care as the outcome variable, the study did not show much effect on the coefficient of interest, which is associated with the infant mortality rate that was believed to improve along with the 42 percent reduction in TBAs. The TBA ban therefore was deemed empirically ambiguous as the population of interest would either go the formal healthcare sector or resort to even more inferior methods.

Godlonton posed the question, “Why is there no impact on mortality?” One of the explanations could be related to the remoteness of households in areas with high exposure to TBA.  These villages are further from formal healthcare, thus subject to increased transportation costs and higher risk of mortality. The formal sector therefore may not provide better healthcare compared to informal ones. Godlonton concluded that the increasing demand for formal healthcare is not enough on its own to address this ongoing problem in Malawi and other African countries in general, and that there is a pressing need for  significant change in healthcare quality and efficiency.