Associations between introduction and withdrawal of a financial incentive and timing of attendance for antenatal care and incidence of small for gestational age: natural experimental evaluation using interrupted time series methods

OBJECTIVES: To determine whether introduction or withdrawal of a maternal financial incentive was associated with changes in timing of first attendance for antenatal care (‘booking’), or incidence of small for gestational age. DESIGN: A natural experimental evaluation using interrupted time series analysis. SETTING: A hospital-based maternity unit in the north of England. PARTICIPANTS: 34 589 women (and their live-born babies) who delivered at the study hospital and completed the 25th week of pregnancy in the 75 months before (January 2003 to March 2009), 21 months during (April 2009 to December 2010) and 36 months after (January 2011 to December 2013) the incentive was available. INTERVENTION: The Health in Pregnancy Grant was a financial incentive of £190 ($235; €211) payable to pregnant women in the UK from the 25th week of pregnancy, contingent on them receiving routine antenatal care. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was mean gestational age at booking. Secondary outcomes were proportion of women booking by 10, 18 and 25 weeks’ gestation; and proportion of babies that were small for gestational age. RESULTS: By 21 months after introduction of the grant (ie, immediately prior to withdrawal), compared with what was predicted given prior trends, there was an reduction in mean gestational age at booking of 4.8 days (95% CI 2.3 to 8.2). The comparable figure for 24 months after withdrawal was an increase of 14.0 days (95% CI 2.8 to 16.8). No changes in incidence of small for gestational age babies were seen. CONCLUSIONS: The introduction of a universal financial incentive for timely attendance at antenatal care was associated with a reduction in mean gestational age at first attendance, but not the proportion of babies that were small for gestational age. Future research should explore the effects of incentives offered at different times in pregnancy and of differing values; and how stakeholders view such incentives.