Women around the world continue to report a substantial unmet need for modern contraceptives. Limited physical access to reliable contraception in low-income or rural areas is only partially responsible. Even where contraceptive resources are available, family planning decisions often involve two individuals with different fertility preferences. Evidence from Zambia shows that men on average want to have more children than their wives and that this preference hinders contraception use, but little evidence exists on the drivers of men’s fertility preferences.
Studies from across Africa have documented men’s lack of knowledge, compared to women, about maternal mortality and the misconceptions they hold about its causes. This study was designed to inform the Zambian government on effective policies to align men and women’s fertility goals and improve maternal health. The study tested whether the difference in men and women’s demand for children is driven by women having more accurate information about the maternal mortality risk of high parity and low birth spacing, given they bear the physical burden. If providing reliable maternal health information to men can bridge the gender gap in demand for family planning, researchers expected it to serve as an effective tool for increasing households’ demand for family planning.
Zambia has a high rate of maternal mortality, even relative to neighboring countries; 1 out of 79 women die in childbirth during their lifetime. Men and women’s different fertility preferences and, therefore, different demands for family planning services may play a role in maternal health outcomes. Zambian women have, on average, a desired number of 4.5 children, compared to men’s reported ideal family size of 5.0 children and the actual fertility rate of 5.3. An initial survey in peri-urban Lusaka found that superstitions about causes of maternal mortality are pervasive and that such beliefs might impede learning about maternal health risk levels.
This study took place in the catchment areas of the Chipata and Chaisa Clinics, two government-run facilities that serve low-income areas in Lusaka.
Researchers partnered with Zambia’s Ministry of Health and local NGOs to conduct a randomized evaluation that measured the impact of providing information to men and women about maternal mortality risk on their knowledge of risk, contraceptive use, demand for family planning, marital well-being, maternal and child health outcomes, and other outcomes.
The research team invited 772 couples of childbearing age to attend a community meeting together and 562 couples attended. Each married couple was randomly assigned to one of three groups.
- Maternal mortality information to husbands: Husbands received information on women’s health during pregnancy and the risk of maternal mortality and morbidity in addition to family planning information, while the wife meeting provided family planning education only.
- Maternal mortality information to wives: Wives received the additional maternal health information, while husbands received family planning education only.
- Comparison: Both spouses attended a gender-specific meeting that relayed information about family planning only.
During family planning workshops, two trained educators (a male and a female in each workshop) showed participants the types of contraceptives available at the clinic, discussed common misconceptions about family planning, and referred the participants to a nurse in the public clinic.
During maternal mortality informational workshops, the educators delivered the same information, but also added information about maternal health. They went over the magnitude of the risk of maternal mortality in Zambia, the primary medical causes of maternal mortality and morbidity, and the risk factors by birth spacing, parity, and age. The content of the workshops was developed in close collaboration with clinic nurses, the Zambian Ministry of Health, and local NGOs, such as the Society for Family Health.
After the meetings, vouchers for free family planning services were distributed.
Approximately one year after the program ended, researchers found that providing targeted information to men on maternal health risk through gender-specific community meetings narrowed the gender gap in fertility goals between men and women and increased uptake of family planning. Specific results are as follows:
Realized fertility: Couples in which the husband was offered information about maternal mortality at community meetings (“program husbands”) experienced a 6 percentage point decrease both in the probability of the wife being pregnant at the end of the study and in the probability of her giving birth after the program ended. The latter corresponds to a 32 percent decrease relative to the comparison group. Offering the wife the information had no impact on realized fertility.
Desired fertility: Program husbands were 7 percentage points less likely to report to want another child, relative to the comparison group, and were 13 percentage points less likely to believe that their wife wanted another child. Husbands whose wives were offered the information did not exhibit any change in their desired fertility or in their belief about their wife's desired fertility.
Contraceptive use: Offering husbands the information about maternal mortality led to a 4 percentage point increase in any contraceptive pill usage and a 5 percentage point increase in regular contraceptive pill usage. No impact on contraceptive use was found when the wife was offered the information.
Communication between spouses: Offering husbands the information about maternal mortality led to changes in several measures of intra-household communication, including a 10 percentage point decrease in the probability of agreement on using contraceptives, a 7 percentage point increase in the probability that the husband reports trying to convince his wife to use contraceptives, together with an increase in the probability that the husband reports changing his wife's mind or his own mind. Similar changes were found among wives of husbands who were offered the information. However, no change was found in measures of intra-household communication among husbands of wives who were offered the information or by wives who did.
Maternal health knowledge: Program husbands were 14 percentage points more likely to be able to identify key risk factors for maternal mortality, compared to husbands in the comparison group. Wives who were offered the information were 10 percentage points more likely to identify key risk factors in their reports, relative to the comparison group. However, wives of men who were offered the information exhibited small and imprecise changes in their understanding of risk factors.
Marital wellbeing: Program husbands reported higher marital satisfaction, as did their wives. For instance, both program husbands and their wives were about 7 percentage points more likely to report being happy with their own marriage, relative to the comparison group. Husbands of treated wives also report comparable increases in marital satisfaction; while the treated wives themselves report no detectable change in marital satisfaction.
Demand for family planning voucher: Willingness to pay for a voucher for contraception was not significantly different between programs husbands as compared to either the husbands of program wives or comparison wives. However, program husbands were almost 6 percentage points more likely to get the voucher right after community meetings as compared to the comparison group.
Maternal and child health outcomes: Analysis ongoing; results forthcoming.
Overall, these preliminary results suggest that providing targeted information to men on maternal health risk through gender-specific community meetings can narrow the gender gap in fertility goals between men and women and increase uptake of family planning.
*Results are preliminary and may change after further data collection and/or analysis.