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The area of family planning is unique in that the patient, rather than the provider, is seen as the key decision-maker in determining the best course of treatment. As such, family planning programs strive to afford women and couples the greatest degree of choice over contraceptive methods, and consequently invest significant resources into providing patients with complete and accurate information. Counselors often consult with patients about their options, but little is known about how the information and contraceptive methods that are presented during counseling sessions shape the way women make informed choices about their preferred contraceptive methods. 

In a new policy brief, Mahesh Karra, Associate Director of the Human Capital Initiative (HCI) at Boston University's Global Development Policy Center, and Kexin Zhang assess the results of a 2019 study conducted with 785 married women from Lilongwe, Malawi. The study aimed to evaluate how user-centered counseling approaches to family planning would affect women’s preferences for contraceptive methods and how these preferences were realized over time. Participants received a family planning counseling session with a trained counselor at their homes and were provided with free transportation to a family planning clinic for one month. 

Key Findings:
  • The contraceptive prevalence rate in urban Malawi is high, with 87.4 percent of the women in the sample using a contraceptive method as of their consultation.
  • Injectables are the most commonly used method (44.7 percent), followed by implants (30.2 percent) and pills (7.2 percent).
  • In urban Malawi, women’s preferences for contraceptive methods are often not concordant with their actual method use. If given the choice, 36.7 percent would want to switch from their current method to another method.
  • The reasons cited by those who wanted to switch methods, but had not yet done so were: “does not know enough about the method” (32.5 percent); “costs too much” (10 percent); “fear of side effects” (9.6 percent); and “preferred method not available” (9.2 percent).
  • Notably, at the initial counseling session, 42 percent of women were using a contraceptive method that differed from their perceived ideal method, whereas at the final interview, 55 percent of women were using a method that was different from their ideal stated method. 

Based on these findings, Karra and Zhang draw several lessons to inform future policies, programs and interventions aimed at improving family planning and reproductive health services for women in Malawi and elsewhere.

Policy Lessons:
  • Women’s stated and realized preferences for family planning are malleable and sensitive to a range of factors.
  • Service providers need to be responsive to changes in women’s choice of contraceptive method, and particularly women’s desires to switch methods, even if it may come at a greater cost to them. 
  • To minimize costs associated with switching methods, service providers would benefit from conducting a more comprehensive initial counseling session with women.

This policy brief was jointly published by the Boston University Global Development Policy (GDP) Center and Innovations for Policy Action. View a full list of GDP Center publications and view a full list of IPA publications.

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October 25, 2021
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Women who become pregnant less than 24 months after giving birth face numerous risks to their own health and the health of their child. As such, postpartum family planning services can help women to better space pregnancies and mitigate health risks. However, little is known about how postpartum family planning impacts women’s contraceptive use, fertility choices and birth spacing. 

In a new policy brief, Mahesh Karra, Associate Director of the Human Capital Initiative (HCI) at Boston University's Global Development Policy Center, and four coauthors analyze their results from a randomized controlled trial that provided new and expecting mothers in Lilongwe, Malawi with access to a range of postpartum family planning services between September 2016 and February 2019. The services consisted of a combination of home visits from a family planning counselor, free transportation to a family planning clinic and financial reimbursement for purchasing services from the clinic. 

Key Findings:
  • Postpartum family planning services encourage contraceptive uptake. 
  • Women with greater access to postpartum family planning services are at lower risk of short birth spacing.

Drawing on the trial results, the researchers propose two key policy recommendations aimed at encouraging healthy birth spacing.

Key Recommendations:
  • Improving access to high quality postpartum family planning services would enable women and couples to more effectively time and space their next births.
  • In practice, the effective provision of postpartum family planning and maternal health services face multiple barriers. The study shows though, that a comprehensive postpartum intervention can help overcome some of these barriers.

The researchers note that the positive effects of family planning services extend beyond health outcomes. When women live longer and healthier lives, they are more likely to achieve higher levels of education and participate in the labor force. Policies that increase access to both pre- and postpartum family planning can empower women and girls and bring a range of economic benefits to communities as a whole.

This policy brief was jointly published by the Boston University Global Development Policy (GDP) Center and Innovations for Policy Action. View a full list of GDP Center publications and view a full list of IPA publications.

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October 25, 2021
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We study a simple savings scheme that allows workers to defer receipt of part of their wages for three months at zero interest. The scheme significantly increases savings during the deferral period, leading to higher post-disbursement spending on lumpy expenditures. Two years later, after two additional rounds of the savings scheme, we find that treated workers have made permanent improvements to their homes. The popularity of the scheme suggests a lack of good alternative savings options, and analysis of a follow-up experiment shows that demand for the scheme is also due to the scheme’s ability to address self-control issues.

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July 01, 2021
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Convincing lending institutions to provide credit to the poor can be a challenge given that poorer clients often have limited to no credit histories and are therefore deemed high risk. A pilot study in Malawi showed that using fingerprints as unique IDs to track credit histories increased repayment behavior of microfinance borrowers, holding promise as a way to help more poor borrowers access credit. With support from USAID’s Development Impact Ventures, researchers collaborated with lenders and a centralized credit data repository in Malawi to evaluate the impact of this approach prior to its transition to scale. The implementation of the scale-up faced many challenges and researchers saw relatively low adoption of fingerprint identification by local microfinance institutions. These results highlight the challenge of scaling up a complicated technology in a resource-constrained setting, and the broader importance of evaluating interventions beyond the pilot scale before expanding them to reach larger populations.

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April 07, 2021
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Globally, violence against women is a leading cause of premature death and morbidity for women and almost one-third of women report experiencing intimate partner violence (IPV) or sexual violence by a non-partner at some point in their life. Yet rigorous evidence on scalable and effective ways to reduce IPV is limited, in part because measuring IPV is challenging. Current standards of practice for reducing gender-based violence are also relatively limited in scope, focusing mainly on changing gender norms. Designing and testing new approaches has the potential to yield more effective solutions. IPA’s Intimate Partner Violence Initiative, a partnership with the International Rescue Committee, exists to address these challenges. The initiative designs and tests innovative solutions to IPV, leverages existing research to identify factors that contribute to IPV and works to address methodological and measurement challenges in violence research and related fields. With our academic and implementing partners, IPA has identified a number of effective solutions, including mass media campaigns, coupling women’s economic empowerment with gender dialogue, and teaching secondary school students soft skills. Results from several initiative-supported studies are forthcoming. Further research will be needed to validate results in new contexts and at scale, and to design and evaluate new ideas.

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October 22, 2019

We test whether the provision of multiple labeled savings accounts affects savings decisions and downstream outcomes in a field experiment with 481 entrepreneurs in urban Malawi. Treatment respondents received either one or multiple savings boxes, while a control group received nothing. Multiple accounts increased savings in treatment accounts by about 30%. Savings boxes had sizeable effects on a number of outcomes, including farming decisions, household expenditures, land purchases, credit extended to customers, and interpersonal transfers. However, we find no evidence that multiple accounts had larger downstream effects than single accounts.

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Working Paper
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May 17, 2019

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