The past two decades have brought significant increases in the availability of maternal health care services in many low- and middle-income countries, with a large increase in the number of health facilities that provide these services. However, many women still do not receive the basic services recommended by the World Health Organization. In many settings, antenatal care is associated with substantial financial cost, which means that obtaining high quality care can involve complex intrahousehold bargaining and decision-making. Women have more access to information about these services, but men generally make the financial decisions. If men are unaware of the magnitude and timing of financial needs, securing adequate financial resources may be difficult.

The investigators plan to conduct a randomized-controlled experiment of supply- and demand-side solutions to increase uptake of recommended antenatal care services in rural Côte d'Ivoire, where there are currently substantial gaps in service coverage. Despite Côte d'Ivoire's "free maternity care" policy, many recommended services - including ultrasounds and laboratory tests - continue to carry costs for patients. On the supply side, the study will evaluate the impact of providing key services (including ultrasounds, laboratory testing, and iron and folic acid supplements) for free to pregnant women (in line with Côte d'Ivoire's policy of free provision). On the demand side, the study will evaluate the impact of providing information about antenatal care recommendations to pregnant women (alone or with their partners), and of providing a financial planning session to pregnant women or their partners, or both together. The study will evaluate the impacts of these interventions on the uptake of recommended antenatal care services.

The past two decades have seen significant increases in the uptake of antenatal care (ANC) and facility-based childbirth in low- and middle-income countries (LMICs), driven by expansions in health service availability, reductions in user fees, and introductions of public insurance programs that make services accessible to a larger portion of the population. However, in many cases, expansions in service coverage have not translated into the anticipated improvements in health outcomes.

One of the primary reasons why increases in coverage have not yielded the desired improvements in health outcomes is the low quality of health care services provided in many health facilities in LMICs. These quality gaps appear to be particularly large for women of lower socioeconomic status, who not only tend to attend lower quality health facilities than wealthier or more educated women, but also tend to receive lower quality care within the same health facilities. In many settings, antenatal care is associated with substantial financial cost, which means that obtaining high quality care can involve complex intrahousehold bargaining and decision-making. Women have more access to information about these services, but men generally make the financial decisions. If men are unaware of the magnitude and timing of financial needs, securing adequate financial resources may be difficult.

In Taabo, Côte d'Ivoire, the investigators recently completed a mixed-methods pilot study examining the reasons for gaps in the quality of antenatal care. They found that, while 91% of women attended at least one antenatal care visit, only 44% had the recommended minimum 4 visits. Many also missed out on important recommended services. They found that only 79% of women received at least 1 and only 17% of women received at least 2 ultrasounds over the course of their pregnancies. Only 73% had any laboratory testing (e.g., a blood test to check for anemia). Only 60% reported taking iron and folic acid supplements 30 days per month during their pregnancy. In qualitative interviews, women identified the cost of services as a critical barrier affecting their uptake. Despite Côte d'Ivoire's "free maternity care" policy, many recommended services - including ultrasounds and laboratory tests - continue to carry costs for patients. Qualitative interviews with women raised several potential pathways through which antenatal care service costs could affect uptake. Firstly, in some cases, the services may be unaffordable for some women and their partners. Secondly, a lack of clarity around service prices - particularly in the context of a publicized "free maternity care policy" - makes it challenging for women and their partners to plan for their antenatal care expenditures. Finally, husbands (or male partners) are the main financial decision-makers in many households in the study setting, and they are not always willing to provide resources to cover the costs of antenatal care services.

The investigators plan to conduct a randomized-controlled experiment of supply- and demand-side solutions to increase uptake of recommended antenatal care services. On the supply side, the study will evaluate the impact of providing key services (including ultrasounds, laboratory testing, and iron and folic acid supplements) for free to pregnant women, in line with Côte d'Ivoire's national "free maternity care" policy. On the demand side, the study will evaluate the impact of providing information about antenatal care recommendations to pregnant women (alone or with their partners), and of providing a financial planning session to pregnant women or their partners, or both together. The study will evaluate the impacts of these interventions on the uptake of recommended antenatal care services.

Inclusion criteria for pregnant women:

• Currently pregnant
• Aged 15 years or older
• Live in the area served by the Taabo Health & Demographic Surveillance System
• Estimated gestational age of less than 6 completed months of pregnancy

Inclusion criteria for male partners:

• Aged 15 and older
• Married to or currently the main romantic partner of a woman who is enrolled in the study

De-identified data files and analytic code will be posted on public repositories at the time of publication of results.

We plan to share IPD and supporting information at the time of publication.

IPD and supporting information will be made available on public repositories.