Project Evaluation

Contraceptive Adoption, Fertility, and the Family in Zambia

Policy Issue

As much as 75% of all pregnancies worldwide are unplanned or unwanted, accounting for nearly 300,000 new pregnancies every day.1  To the extent that rapid population growth can lead to low levels of human capital investment and continued poverty for future generations, the ability to control fertility can have broad social and economic consequences. Recent evidence suggests that access to contraceptives may improve economic outcomes and reduce poverty by allowing women to optimally time births, increasing women’s investment in education and participation in the labor market at childbearing ages. There are also direct consequences for individual well-being: significant reported need for contraceptives suggests that fertility outcomes outstrip fertility desires in many parts of the developing world.

Women’s unmet need for contraceptives is commonly explained by three factors: (i) insufficient supply of appropriate contraception; (ii) lack of information or misinformation about those methods; and (iii) restrictive social norms governing fertility control. An alternative hypothesis is that excess fertility reflects the outcome of bargaining between partners with divergent fertility preferences. In many countries men dominate decisions regarding sexual relations and contraception, and spousal discordance may be a prominent factor influencing fertility outcomes.

Context of the Evaluation

Zambia currently holds one of the world’s highest maternal mortality ratios, with 729 maternal deaths per 100,000 live births,2 and a similarly high infant mortality ratio with 103 deaths per 1,000 live births.3  Family planning and reproductive health services are not uniformly available throughout the country, and 60% of currently pregnant women in Lusaka report that the pregnancy was unwanted. Although 100% of women reporting unwanted pregnancies report being familiar with at least one method of modern contraception, only 48% have ever used any modern method of contraception, and only 37% currently use modern contraceptives.

Details of the Intervention

This study evaluates the effect of male involvement on female contraceptive use through an experiment designed to remove the factors of insufficient supply, lack of information, misinformation, and divergent fertility preferences. Study participants include 1,994 married women who had given birth in the last two years living in compounds serviced by Chipata Clinic in Lusaka.

Women in the study received vouchers that granted appointments with a family planning nurse at the local government clinic, without waiting more than one hour and with guaranteed access to the modern contraceptive method of their choice. An information session explaining all methods of family planning was also given to study participants at the time of voucher distribution. Women were randomized into two treatment groups. In the “individual” arm of the study, women were given these vouchers alone. In the “couples” arm, women were given these vouchers in the presence of their husbands. In all other respects, the experimental protocol in the individual and couples arms was identical.

Results and Policy Lessons

Take up of the voucher was high at 47%, indicating that women valued the substantial reduction in the time cost of an appointment associated with the voucher.

However, evidence suggests that sharing information about family planning services with husbands reduces the couple’s propensity to utilize these services. Women who received the voucher in the presence of their husbands were 9 percentage points (18%) less likely to use the voucher to obtain an appointment at a family planning clinic. There is an even larger, 12 percentage point reduction in voucher use for couples where the husband reported wanting more children than the wife. Still a larger reduction in use is reported among younger couples, giving evidence for the hypothesis that differences in future preferences for fertility drive differences in demand for family planning services.

Male knowledge of the voucher led to a substantial reduction in use of these services, suggesting that policies or technologies that shift relative control of contraceptive methods from men to women may significantly increase contraceptive use and reduce average fertility in some contexts. This is important to note given that an increasing number of policymakers have started to promote “male involvement” in family planning. It also suggests that take up of particular modern contraceptive methods may be sensitive to the amount of control women can exercise relative to their husbands in the use of these methods.

For more information about this project, click here and here.

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1  Partners In Health, “Women’s Health – Reducing maternal mortality, improving reproductive health”, http://www.pih.org/issues/maternal.html. (Accessed September 21, 2009)
2  USAID, “Population, Health and Nutrition Issues in Zambia”,http://www.usaid.gov/zm/population/phn.htm. (Accessed September 21, 2009)
3  UNICEF, “Zambia Statistics”, http://www.unicef.org/infobycountry/zambia_statistics.html. (Accessed September 21, 2009)

Nava Ashraf, Erica Field
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