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In Rwanda, we have continued our global tradition of rigorous, applicable research by building foundational research capacity and conducting evaluations in areas of pressing national concern. Examples of our work covered in this brief offer promising insights into everyday issues that affect the lives of the Rwandan poor.

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Brief
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November 12, 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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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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We implemented a randomised controlled trial study to measure the impact of one-on-one engagement with local religious leadership on the compliance of protocols at their mosque. Our messaging was a combination of religious appeal and public health guidelines that were interactive, involving frequent elicitation of the respondents’ reactions and agreement, as well as asking them to commit to action. Our study is different from previous strategies of COVID-19 containment as it does not rely on mass messaging but rather focuses on one-on-one engagement with focal community leaders. It aims to improve the implementation and communication of the 20-point plan that was agreed between the government and religious clergy to contain the spread of COVID-19. However, it is not novel in its approach as it is similar to previous interventions like the polio vaccination drive that disseminates knowledge and engages at the community level. Thus, the results from our study can provide valuable insights for strategies used by other public health campaigns to engage the public and build trust, such as polio vaccination and eventually the COVID-19 vaccination.

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October 07, 2021
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Objectives: Disrespectful and poor treatment of newborns such as unnecessary separation from parents or failure to obtain parental consent for medical procedures occurs at health facilities across contexts, but little research has investigated the prevalence, risk factors, or associated outcomes. This study examined these experiences and associations with healthcare satisfaction, use, and breastfeeding.

Design: Prospective cohort study

Setting: Health facilities in Nairobi and Kiambu counties in Kenya

Participants: Data were collected from women who delivered in health facilities between September 2019 and January 2020. The sample included 1,014 women surveyed at baseline and at least one follow-up at 2-4 or 10 weeks postpartum.

Primary and secondary outcome measures: 1) Outcomes related to satisfaction with care and care utilization, 2) Continuation of post-discharge newborn care practices such as breastfeeding.

Results: 17.6% of women reported being separated from their newborns at the facility after delivery, of whom 71.9% were separated over 10 minutes. 44.9% felt separation was unnecessary and 8.4% reported not knowing the reason for separation. 59.9% reported consent was not obtained for procedures on their newborn. Women separated from their newborn (>10 minutes) were 44% less likely to be exclusively breastfeeding at 2-4 weeks (aOR=0.56, 95%CI: 0.40, 0.76). Obtaining consent for newborn procedures corresponded with 2.7 times greater likelihood of satisfaction with care (aOR=2.71, 95%CI: 1.67, 4.41), 27% greater likelihood of postpartum visit attendance for self or newborn (aOR=1.27, 95%CI: 1.05, 4.41), and 33% greater likelihood of exclusive breastfeeding at 10 weeks (aOR=1.33, 95%CI: 1.10, 1.62).

Conclusions: Newborns, mothers, and families have a right to high quality, respectful care, including the ability to stay together, be informed and have proper consent for care. The implications of these practices on health outcomes a month or more after discharge illustrate the importance of a positive experience of postnatal care.

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September 05, 2021
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A randomized-trial of community-level mask promotion in rural Bangladesh during COVID-19 shows that the intervention increased mask-use and reduced symptomatic SARS-CoV-2 infections.

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Working Paper
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September 01, 2021
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The COVID-19 pandemic disproportionately threatens vulnerable populations, including women and especially pregnant and post-partum women. Early estimates suggest that maternal and child deaths could increase by 8.7-38.6% and 9.8-44.7%, respectively, across low and middle-income countries (LMIC) due to disruptions in healthcare access and food insecurity. A global systematic review of impacts on maternal health found evidence of disruptions to healthcare services, reduced use of antenatal care, decreased access to family planning, and increased stress, anxiety, and depression related in part to isolation and fear of COVID-19 infection.3 Approximately one year into the COVID-19 pandemic, there continues to be a lack of information on the social, economic, and health impacts of the pandemic on pregnant and post-partum women and their infants, particularly from LMICs. Prior to the pandemic, Kenya, in particular, reported one of the highest rates of maternal and neonatal mortality in the world. Action-oriented research is needed to identify solutions and strategies for national and local government and communities. This policy brief provides information on the experiences of pregnant and post-partum women during COVID-19, with particular attention to healthcare access, maternal and newborn healthcare utilization, and maternal and newborn health. 

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August 02, 2021
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In a collective effort bringing together 15 studies, researchers from over 30 institutions surveyed over 20,000 individuals between June 2020 and January 2021 on questions regarding respondents’ vaccine acceptance and hesitancy and their most trusted sources for vaccination advice. During some surveys, results from COVID-19 vaccine clinical trials had yet to be announced, and during later surveys, governments had started approving vaccines for use. The fast-moving nature of COVID-19 information may change people’s perceptions about vaccines by the time they are widely available in low- and middle-income countries (LMICs). Over the past six months, the body of evidence demonstrating the safety and efficacy of available COVID-19 vaccines, which have been given to millions of people, has become clearer. At the same time, severe, but rare, side effects may have undermined public confidence.

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July 19, 2021
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Widespread acceptance of COVID-19 vaccines is crucial for achieving sufficient immunization coverage to end the global pandemic, yet few studies have investigated COVID-19 vaccination attitudes in lower-income countries, where large-scale vaccination is just beginning. We analyze COVID-19 vaccine acceptance across 15 survey samples covering 10 low- and middle-income countries (LMICs) in Asia, Africa and South America, Russia (an upper-middle-income country) and the United States, including a total of 44,260 individuals. We find considerably higher willingness to take a COVID-19 vaccine in our LMIC samples (mean 80.3%; median 78%; range 30.1 percentage points) compared with the United States (mean 64.6%) and Russia (mean 30.4%). Vaccine acceptance in LMICs is primarily explained by an interest in personal protection against COVID-19, while concern about side effects is the most common reason for hesitancy. Health workers are the most trusted sources of guidance about COVID-19 vaccines. Evidence from this sample of LMICs suggests that prioritizing vaccine distribution to the Global South should yield high returns in advancing global immunization coverage. Vaccination campaigns should focus on translating the high levels of stated acceptance into actual uptake. Messages highlighting vaccine efficacy and safety, delivered by healthcare workers, could be effective for addressing any remaining hesitancy in the analyzed LMICs.

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Published Paper
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July 16, 2021
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Mass media reaches a large and growing share of the population in developing countries, but can it be used to tackle poverty and change behaviors, such as the adoption of modern contraception? Given the low marginal costs of mass media campaigns, even small effects could be highly cost-effective. IPA partnered with researchers and Development Media International to evaluate the impact and cost-effectiveness of an intensive, 2.5-year mass media radio campaign in Burkina Faso that promoted family planning and aimed to dispel myths and misinformation about modern contraception.

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June 30, 2021
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Childhood immunization is one of the most successful and cost-effective public health interventions to date, preventing an estimated 2 to 3 million deaths every year and severe morbidity for millions more children from devastating diseases such as polio and the hepatitis B virus. Although there have been substantial gains in childhood immunization globally, coverage still lags in many countries, leaving millions vulnerable to disease. A particular challenge is on the demand side—low acceptance and uptake despite availability of vaccine supplies and services. Demand-side interventions target the barriers to acceptance and uptake, such as lack of awareness about the schedule and benefits, low prioritization of immunization, financial obstacles, or distrust in immunization. These interventions will only move the needle in the context of a functioning vaccine supply chain and effective health services. In this brief, Innovations for Poverty Action’s Path-to-Scale Research team has compiled the evidence for demand-side interventions to increase child immunization in low and middle-income countries (LMICs).

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June 24, 2021
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Empirical social sciences rely heavily on surveys to measure human behavior. Previous studies show that such data are prone to random errors and systematic biases caused by social desirability, recall challenges, and the Hawthorne effect. Moreover, collecting high frequency survey data is often impossible, which is important for outcomes that fluctuate. Innovation in sensor technology might address these challenges. In this study, we use sensors to describe solar light adoption in Kenya and analyze the extent to which survey data are limited by systematic and random error. Sensor data reveal that households used lights for about 4 h per day. Frequent surveyor visits for a random sub-sample increased light use in the short term, but had no long-term effects. Despite large measurement errors in survey data, self-reported use does not differ from sensor measurements on average and differences are not correlated with household characteristics. However, mean-reverting measurement error stands out: households that used the light a lot tend to underreport, while households that used it little tend to overreport use. Last, general usage questions provide more accurate information than asking about each hour of the day. Sensor data can serve as a benchmark to test survey questions and seem especially useful for small-sample analyses.

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Published Paper
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May 18, 2021
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Evidence suggests that face masks can slow the spread of COVID-19 and save lives, but getting people to consistently and properly wear masks has been a public health challenge. In Bangladesh, researchers partnered with policymakers to design and evaluate strategies to increase mask uptake. Masks were distributed to households and in public places. Mask use was promoted through role-modeling, messages by prominent Bangladeshi leaders and personalities, informational brochures, and in-person reinforcement. The researchers also tested a number of incentives and behavioral nudges, including public commitment devices and text message reminders.

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May 13, 2021
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BACKGROUND: Limited evidence exists on how women’s experiences of care, specifically person-centered maternity care during childbirth, influence maternal and newborn health outcomes.

OBJECTIVE: This study aimed to examine the associations between person-centered maternity care and maternal and newborn health outcomes.

STUDY DESIGN: Longitudinal data were collected with 1014 women who completed baseline at a health facility and followed up at 2 weeks and 10 weeks after birth. A validated 30-item person-centered maternity care scale was administered to postpartum women within 48 hours after childbirth. The person-centered maternity care scale has 3 subscales: dignity and respect, communication and autonomy, and supportive care. Bivariate and multivariable log Poisson regressions were used to examine the relationship between person-centered maternity care and reported maternal complications, newborn complications, postpartum depression, postpartum family planning uptake, exclusive breastfeeding, and newborn immunizations.

RESULTS: Controlling for demographic characteristics, women with high total person-centered maternity care score at baseline had significantly lower risk of reporting maternal complications (adjusted relative risk, 0.63; 95% confidence interval, 0.42−0.95), screening positive for depression (adjusted relative risk, 0.55; 95% confidence interval, 0.38−0.81), and reporting newborn complications (adjusted relative risk, 0.74; 95% confidence interval, 0.56−0.97), respectively, than women with low total person-centered maternity care scores. Women with high scores on the supportive care subscale had significantly lower risk of reporting maternal and newborn complications than women with low scores on these subscales (adjusted relative risk, 0.52 [95% confidence interval, 0.42−0.65] and 0.74 [95% confidence interval, 0.60−0.91], respectively). Significant associations were found between all 3 subscale scores and screening positive for depression. Women with high total personcentered maternity care scores were also more likely to adopt a family planning method than those with low scores (adjusted relative risk, 1.25; 95% confidence interval, 1.02−1.52). In particular, women with high scores on the communication and autonomy subscale had significantly higher odds of adopting a family planning method than women with low scores (risk ratio, 1.15; 95% confidence interval, 1.08−1.23).

CONCLUSION: Improving person-centered maternity care may improve maternal and newborn health outcomes. Specifically, improving supportive care may decrease the risk of maternal and newborn complications, whereas improving communication and autonomy may increase postpartum family planning uptake.

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May 06, 2021
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Mass media can spread information and disinformation, but its impact is hard to rigorously measure. Using a two-level randomized evaluation covering 5 million people, we test both exposure to mass media (with 1,500 women receiving radios) and the impact of a high-quality, intensive 2.5 year, family planning mass media campaign in Burkina Faso (8 of 16 local radio stations received the campaign). We find women who received a radio in noncampaign areas reduced contraception use by 5.2 percentage points (p=0.039) and had more conservative gender attitudes. In contrast, modern contraceptive use rose 5.9 percentage points (p=0.046) in campaign areas and 5.8 percentage points (p=0.030) among those given radios in campaign areas. Births fell 10%. The campaign changed beliefs about contraception but not preferences, and encouraged existing users to use more consistently. We estimate the nationwide campaign scale-up led to 225,000 additional women using modern contraception, at a cost of US$7.7 per additional user.

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Working Paper
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May 05, 2021

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