Contraceptive Adoption, Fertility, and the Family in Zambia
Rates of unwanted births and unmet demand for contraception remain high in many countries where men report larger ideal family sizes than their wives. Researchers used an evaluation that varied whether women were given access to contraceptives alone or with their husbands to examine the effect of male involvement in family planning on fertility outcomes. Results suggest that women who received private access to vouchers for contraceptives were more likely to take up and use contraception, compared to women whose husbands were involved in the voucher program.
The ability to control fertility through modern contraception holds potentially broad social and economic consequences for women and society. However, many countries still report substantial unmet need for contraception and high rates of unwanted births. In addition to insufficient supply and restrictive social norms, low contraceptive use may reflect the outcome of bargaining between partners with different fertility preferences. In many countries, men report larger ideal family sizes than their wives. If men dominate decisions regarding sexual relations and contraceptive use, women who wish to delay pregnancy may have an incentive to adopt concealable forms of contraception when available. However, the opportunity to conceal contraceptive use may increase suspicion and mistrust within the household.
Many family planning programs target women directly and privately, providing them with opportunity for greater reproductive control, while others promote male involvement in family planning. However, there is little evidence on how household bargaining and the opportunity to conceal contraceptives affect either fertility outcomes or intrahousehold dynamics.
Fertility and unplanned birth rates are high in Zambia: an estimated 41 percent of births in Lusaka between 2002 and 2007 were unwanted at the time of conception. However, it is likely that most were unwanted only by the wife: on average, Zambian men want 0.8 more children than their wives. Although contraceptives can be obtained in public and private clinics, the price fluctuates widely and popular forms are often out of stock. Injectables, one of the easiest methods to conceal, are particularly difficult to obtain. Although the legislation changed in 2005 so that the law no longer requires spousal consent for contraception, some providers continue to deny contraceptives without a husband’s explicit approval. However, women use contraception more frequently than men know: 89 percent of the study sample had used a modern form of contraception. Among the 23 percent of men who claim they are “not doing anything to prevent pregnancy,” 59 percent had wives who reported using some form of birth control. Although relatively few women have used injectables, men are generally aware of their existence, and anecdotal evidence indicates that suspicion over hidden contraception may increase marital tension.
This study evaluated the effect of male involvement on female contraceptive use. Study participants included 749 married women aged 18-40 who had given birth in the last two years and lived in compounds serviced by Chipata Clinic in Lusaka.
Community health workers visited all participating women in their homes twice. During the first visit, husbands were not present. Wives were administered a baseline survey and provided with health information about condom use, prevention of sexually transmitted diseases, and benefits of and options for family planning.
During the second visit, women received a voucher guaranteeing free and immediate access to modern contraceptives through a private appointment with a family planning nurse. Prior to this visit, women were randomly assigned to either the Couple or Individual treatment group. Women in the Individual treatment were given the voucher alone. In the Couple treatment, the voucher was given to the husband in the wife’s presence.
Nurses at the family planning clinic kept daily visit logs to track voucher redemption and contraceptive take-up. Two years later, researchers conducted a follow-up survey to study the impact of contraceptive access on fertility and well-being.
Overall, 48 percent of women redeemed the voucher for family planning services, but those who received the voucher privately were more likely to redeem it.
Women who received the voucher privately were ten percentage points more likely to redeem it, from a baseline of 43 percent (a 23 percent increase), and were six percentage points more likely to take up injectable contraception when they did redeem the voucher, from a baseline of 18 percent (a 33 percent increase). For the subset of women who believed their husbands wanted more children than they did at the onset of the study, private access further increased the likelihood of voucher redemption and the take-up of injectable contraception.
Among women who did not want children in the next two years, those who received the voucher privately delayed their next pregnancy by an average of three to five months more than women who received the voucher with their husband, and were 27 percent less likely to give birth in the next year, when contraception from the voucher would have been active. They were also more likely to give birth in the fourteen to eighteen months after the program.
Among women who believed their husbands desired more children than they did at the onset of the study, women who received the voucher with their husband reported being significantly happier and healthier than those who received the voucher privately.
These results suggest that private access to contraception can enable women to make welfare-enhancing family planning choices that they otherwise might not be able to make. However, concealing contraceptive use may carry a psychological cost for women. Policymakers should be mindful of this potential trade-off when designing a family planning program.
Ashraf, Nava, Erica Field, and Jean Lee. 2014. "Household Bargaining and Excess Fertility: An Experimental Study in Zambia." American Economic Review 104(7): 2210-37.