Improving the Effectiveness of Vouchers for Free Family Planning after Childbirth in Kenya
- Mothers and pregnant women
- Women and girls
- Sexual and reproductive health
- Nudges and reminders
- Preventive health
Pregnancy and childbirth pose major risks to those who lack access to basic health care. In particular, short birth intervals are a major risk factor and something that can be addressed through the use of modern contraceptive methods during the postpartum period. In partnership with Jacaranda Health, researchers evaluated a family planning program that provided pregnant women with varying combinations of vouchers for free modern contraception and reminders of the importance of family planning. While none of the combinations increased self-reported use of modern contraception in the short term, the combination of the voucher and reminder did increase its use in the medium term.
As much as 41 percent of all pregnancies worldwide in 2012 were unplanned or unwanted, accounting for nearly 85 million pregnancies.1 Moreover, pregnancy and childbirth pose major risks of disability or death for millions of women in low- and middle-income countries who lack access to basic health care.2 Access to modern contraceptive methods such as condoms, injectables, implants, IUDs, and others allows women to optimally time births, providing greater opportunity to invest in education or participate in the labor market during childbearing years.3 In contrast, households experiencing unwanted or unanticipated pregnancies may find it harder to pay for their children’s education, healthcare, and other needs. Can vouchers for free family planning methods—coupled with reminders and deadlines for redemption—increase take up of contraception among new mothers?
Context of the evaluation
According to the Kenya Demographic and Health Survey 2014, a Kenyan woman could expect to bear four children during her lifetime, one more than the ideal family size reported by women in the country. That same year, among all currently married individuals, 47 percent of women and 41 percent of men stated that they did not wish to have another child. Moreover, 32 percent of women and 37 percent of men asserted that they would like to wait at least two years before their next birth.
Participants in this evaluation were all pregnant women. Sixty-seven percent of participants reported having used modern contraceptive methods in the past. Thirty percent of participants reported not wanting any more children, while 21 percent reported that their male partners did not want more children. Thirty-two percent of study participants reported wanting to start using modern contraceptive methods shortly (nine weeks) after delivery.
This study took place between April 2014 and December 2015 in two private maternity clinics in Nairobi’s informal settlements (Kiambu County). These densely populated areas are characterized by high poverty rates, poor access to water and sanitation and food insecurity. Women’s fertility rates in Nairobi’s urban poor regions are slightly higher than that of Nairobi as a whole, but lower than the fertility rates in rural areas and the national average. Jacaranda Health aims to improve the safety of pregnancy and childbirth by providing affordable care at private maternity hospitals in peri-urban areas of Nairobi.4 In 2015, Jacaranda conducted 18,860 outpatient visits and delivered 923 babies.
Details of the intervention
In partnership with Jacaranda Health, researchers conducted a randomized evaluation with prenatal patients at Jacaranda’s maternity hospitals. Patients eligible to participate were between 18 years and 40 years old and were at least seven months pregnant at the time of enrolment. In total, 686 women enrolled in the program. Each patient received basic information about family planning, and was assigned to one of six groups:
- Reminder Only: Women received a reminder five weeks after delivery to use contraceptives or practice abstinence.
- Voucher Only: Women received a voucher redeemable for their choice of method of contraception at no cost and could redeem their voucher at any time.
- Voucher + Reminder: In addition to a family planning voucher, women received a reminder five weeks after delivery encouraging them to use contraceptives or practice abstinence.
- Voucher + Deadline: To reduce potential procrastination, women received a free contraceptive voucher that expired eight weeks after their expected due date.
- Voucher + Deadline + Reminder: In addition to a voucher with an eight-week deadline, women also received the reminder.
- Comparison: Women did not receive a voucher or a reminder.
Contraceptive methods and services available through vouchers included condoms, injectables, implants, IUDs, oral contraceptives, and counseling. The main outcome of interest was self-reported current use of a modern contraceptive method in the short and medium term after delivery of a woman’s first child. To gather this data, participants were asked nine and 22 weeks after delivery whether and how long after delivery they sought means of family planning and whether they actively adopted it.
Results and policy lessons
None of the interventions impacted the likelihood of using modern contraception in the short term, or nine weeks after delivery. In the medium term, or 22 weeks after delivery, the probability of using modern contraception for those who received a standard voucher with SMS was 25 percentage points higher than the comparison group, in which 58 percent of women used a modern method of contraception. None of the other program groups experienced impacts on the likelihood of modern contraceptive use in the medium term.
Researchers found that participants assigned to receive any SMS were 19 percentage points more likely to report using contraception in the medium term than those who did not. Additionally, participants who reported an intention to start family planning in the short term were 16 percentage points more likely to report using family planning in the medium term and participants who had been pregnant for the first time were 10 percentage points less likely to report contraceptive use.
Researchers speculated that the combination of the voucher and the SMS nudge was effective because it addressed both cost and behavioral barriers to take-up. The likelihood of redeeming the voucher for free contraception was higher among participants who used a long-acting reversible method of contraception (LARC) compared with other methods, suggesting that the voucher may have been especially helpful among women interested in using LARC.