Dan Maggio is a PhD candidate at Cornell University and the Editor of Economics that Really Matters; Co-authors include Mahesh Karra (Boston University), David Canning (Harvard University), Muqi Guo (Harvard University), and Bagrey Ngwira (University of Malawi).
In low- and middle-income countries, an estimated one out of four pregnancies do not meet the World Health Organization’s guidelines for adequate birth spacing of at least 24 months between pregnancies.[1] Poorly spaced births can contribute to higher rates of mortality for both mothers and children, and have been associated with increased risks of low birth weight, premature births, and anemia (and other poor health outcomes) for women.
Family planning may allow women and couples to more effectively space and time pregnancies to meet their desired fertility goals. Postpartum family planning interventions, which introduce family planning services to women immediately following their pregnancy, may be particularly important for improving birth intervals. Postpartum family planning services aim to promote healthy inter-birth intervals by encouraging women to supplement lactational amenorrhea, where women are protected from pregnancy for a short term by intensive and exclusive breastfeeding, with modern contraceptive methods.
In a new working paper [2], we study the impact of postpartum family planning services on contraceptive use and inter-birth intervals through a randomized control trial in Lilongwe, Malawi. As part of the trial, 2,143 immediate postpartum [3] or pregnant women aged 18-35 were randomly assigned to either an intervention or control arm. A woman who was assigned to the intervention arm received a two-year long family planning intervention that included:
- a family planning information package and up to six private counseling visits at her home with trained family planning counselors;
- free transportation (taxi) to a high-quality family planning clinic with low waiting times; and
- financial reimbursement for family planning services, which covered out of pocket expenditures related to family planning care and treatments that she may receive at the family planning clinic (e.g. medications, contraceptive methods, consultation fees, exam fees, treatment of contraceptive-related side effects), and free over-the-phone consultations and referral services from a doctor in the event that she experienced contraindications or side effects related to her use of family planning.
The trial was conducted between November 2016 and February 2019 and aimed to reduce key cost barriers and increase financial and geographic accessibility of family planning services.
At the time of our endline survey (November 2018 – February 2019), we observe a 5.9 percentage point increase in contraceptive prevalence among women assigned to the intervention arm. Further, this increase seems to be larger in women who were immediate postpartum at the beginning of the intervention (7.2 percentage point) than those who were pregnant (for whom we do not find a significant effect) at baseline. This finding suggests that the rollout of the family planning intervention was more effective when women were in a position to act on that information. Digging deeper, we find that the increase in contraceptive use among women in the intervention arm is largely driven by an increase (4.6 percentage points) in contraceptive implants, which are long-acting and reversible methods. The shift to implants we observe provides evidence that family planning services help women better act on their demand for control over birth spacing.
To test the effect of our intervention on inter-birth intervals, we conduct a survival analysis using a Cox proportional hazards model. Our results show that women assigned to the intervention arm were 43 percent less likely to have a second pregnancy within 24 months of their birth at baseline. In the accompanying figure, we plot the measured probability that a woman had conceived a second child, by treatment group, given the timing since the index birth.
There is a growing demand among policy makers and practitioners for evidence-based family planning policy programs. This creates the need for high-quality evidence – in particular from experimental studies – on which interventions work in family planning, why they work, and how family planning can contribute to wider health and development goals. Our study meets this need by identifying the causal impact of increased access to family planning services on contraceptive use and birth intervals. We will continue to study longer-term impacts of this intervention, and the longer birth intervals it induced, on the health and economic well-being of both mothers and children. These future analyses will help inform cost-benefit analyses (CBA) of family planning services. One recent CBA [4] suggests that the benefit-cost ratio of postpartum family planning services may be as high as 61.2, which implies an estimated gain of 61.2 dollars for every dollar spent on family planning. The true benefit ratio may be even higher if there are positive downstream effects of family planning interventions on women’s agency, labor force participation, child health, and educational outcomes. However, even in the absence of evidence on downstream impacts, our results tell a clear story that postpartum family planning services help women better control their reproductive health.
[1] Rutstein SO. Effects of preceding birth intervals on neonatal, infant and under-five years mortality and nutritional status in developing countries: Evidence from the Demographic and Health Surveys. Int J Gynecol Obstet 2006; 89: S7–24.
[2] Karra, M., Maggio, D., Guo, M., Ngwira, B., & Canning, D. 2020. The Causal Effect of Improved Access to Postpartum Family Planning: Evidence from a Single-Blind, Randomized Controlled Trial in Urban Malawi. Working Paper.
[3] Immediate postpartum women are those who had recently given birth within the past six months from the time of their baseline interview.
[4] Radin, M. and M. Karra. A Cost-Benefit Analysis of Postpartum Family Planning Counseling in Malawi. Copenhagen Consensus Center Policy Brief (In preparation).
