Madagascar Trial - How a Simple Pregnancy Test Can Change Lives

A community health worker explains different methods for family planning to a woman in Madagascar .
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Not having access to affordable pregnancy tests profoundly affects women's lives. Without access to these tests, women are not able to confirm if they are pregnant. This leads to delays in getting prenatal care services.

Complications related to pregnancy as well as mother and infant deaths are all too common in low-resource countries like Madagascar. That is why it's important to seek prenatal care early and frequently.

The World Health Organisation recommends that women start seeking prenatal care as early as possible in the pregnancy. Yet only one third of pregnant women in Madagascar receive prenatal care during the first trimester.

Our new research shows that providing affordable pregnancy tests to women in low-resource countries is a critical, yet under-appreciated, way to improve their health.

What we found

In our research, we set out to test whether offering these tests for free through community health workers could be a solution to prompt women to seek prenatal care earlier. Community health workers are lay health workers trained to provide health services such as birth control as well as counselling on different health issues. They have been used as an effective way to increase access to health services, especially for women in more remote and rural areas.

We conducted our study in rural Madagascar using a randomised controlled trial. This study design is considered the gold standard. It allows researchers to attribute any improvements in outcomes to the intervention, rather than to other confounding factors. In our trial, we randomly allocated community health workers to receive (or not) free pregnancy tests for distribution in their community.

We followed these health workers for a period of four months. We found that offering free pregnancy tests through community health workers led to more women seeking general health services from these health workers. In addition, we found that more women were able to confirm they were pregnant by the end of their visit with the community health worker.

Importantly, this intervention also led to significantly more women receiving antenatal care counselling. Learning from a community health worker about the importance of early and frequent prenatal care is not the same as going to the health centre to receive that care. But it is a critical first step towards ensuring early prenatal care seeking for women who want to continue their pregnancy.

Even women who are not pregnant could benefit from access to these tests. For example, community health workers would be more likely to offer hormonal contraceptives if they were able to reliably rule out pregnancy.

In an earlier study we found that community health workers provided significantly more women with hormonal contraception when they also offered free home pregnancy tests. Both these studies were funded by the United States Agency for International Development (USAID) through the Strengthening Health Outcomes through the Private Sector project.

Other studies have shown that health providers deny women hormonal contraceptives if they can't reliably rule out if a woman is pregnant or not. And for women who want to terminate their pregnancy, finding out earlier that they are pregnant could enable them to have safer procedures.

What next

Pregnancy tests now cost only 10 cents wholesale. But in low-resource countries, they are not widely available outside clinics or pharmacies. When they are available, their prices tend to be significantly marked up.

Urine pregnancy tests are one example of a hugely under-appreciated health technology for improving women's health. When considering where to invest resources to improve women's and children's health, funding community-based provision of low-cost pregnancy tests in low-resource countries might just be the best idea. It has bang for the buck.

Providing pregnancy tests through community-based programs is cost-effective compared to other programs to support mothers, newborns and children. Introducing free home pregnancy tests as part of community-based health services can improve pregnancy care by attracting more women to services at the community level. In turn, this enables women to confirm they are pregnant and receive antenatal counselling if they want to continue the pregnancy.

Let's not under-estimate the impact of such a simple technology. Donors, implementing partners and policy-makers should invest in expanding provision of free pregnancy tests in sub-Saharan African countries to ensure that women - and their children - can survive and lead healthy lives.

Alison B. Comfort, Health Economist, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco

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