While fertility in Sub-Saharan Africa has declined in recent decades, the region continues to have one of the highest fertility rates in the world, with an average total fertility rate of 4.9 children per woman as compared to South Asia (2.7 children per woman) and Latin America (2.2 children per woman). There are several reasons for this trend in Sub-Saharan Africa, including extended household structures (which allows for other family members and members of the community to share childcare responsibilities) and a greater flexibility for women to couple childcare with work. Taken together, these factors contribute to a lower opportunity cost of childbearing and childrearing in the region. Nonetheless, the rate of unintended pregnancies, both unwanted and mistimed, remains high in Sub-Saharan Africa, where many couples have a preference for better spacing and timing of births. Family planning interventions may therefore provide an important means for women to achieve better timing and spacing of pregnancies, thereby allowing women to have better health and long-term development outcomes.
The evidence of the effects of family planning and reproductive health interventions on contraceptive use, fertility, and intermediate and longer-term health and socio-economic outcomes is, however, quite limited. In a research seminar on March 13, Prof. Mahesh Karra from the Frederick S. Pardee School of Global Studies at Boston University presented preliminary findings from a 3-year field experiment that was conducted in Lilongwe, Malawi which aimed to identify the causal impacts of a family planning intervention.
The study population comprised of 2,143 married women aged 18 to 35 years old from urban Lilongwe and who were either pregnant or up to 6 months postpartum at the time the study began in 2016. After conducting a comprehensive baseline survey, each woman was randomly assigned to either the intervention or the control group. Women assigned to the intervention group received: 1) a family planning intervention package and up to six private counselling sessions from a trained family planning counselor over a two year intervention period; 2) free transportation to a private family planning clinic; and 3) financial reimbursement for family planning services, side effects management, and other related reproductive health services for the two year intervention period. The control group received a small information package of available family planning services in the area.
Preliminary findings from the first year of the study show that use of contraceptives increased after one year. Compared to women in the control group, women in the treatment group had an estimated four percent increase in the use of contraceptives after one year. While the effect of the study intervention was positive in terms of contraceptive use, the study also showed that family planning uptake and access have been increasing over time independently of the intervention. This is because access to family planning and reproductive health services in is relatively high in Lilongwe and has been substantially increasing in recent years as a result of ongoing international investments, donor support, and access to such programs in Malawi. In spite of these trends, the study finds that women in the treatment group are even more likely to take up family planning relative to women in the control group. Findings from the study suggest that the increase in uptake as a result of the intervention might be larger in areas with less access to family planning than Lilongwe.
Finally, preliminary results from the study found that after two years, the likelihood of being pregnant was lower in the treatment group by 3.8-percentage point when compared to women in the control group. This reduction in the pregnancy rate translates to a 58 percent decline in pregnancy due to exposure to the family planning intervention. This implies that women in the treatment group were more likely to successfully adhere to the World Health Organization's recommendation for a minimum two-year interval between births.
Prof. Karra concluded the presentation by comparing the Malawi study’s main findings to other country studies, such as the Matlab study in Bangladesh. He pointed out that it is hard to compare these studies because treatments, samples, and length of time for follow up are very different. However, he noted that the Matlab study had an estimated 10-percentage point increase in contraceptive uptake in two years, compared to the current study’s uptake of 4 percentage points in two years. This difference is likely to persist because just one percent of women in Matlab were using contraceptives, compared to 58 percent of women in Lilongwe.
