JMIR Publications

ABSTRACT

Background:

The World Health Organization (WHO) guidelines recommend that a woman wait at least 24 months after a live birth before getting pregnant again; however, an estimated 25 percent of birth intervals do not meet this recommended guideline for adequate birth spacing, and unmet need for postpartum family planning services, particularly in Sub-Saharan Africa, is high. Few randomized control trials have been conducted to assess the causal impact of increased access to postpartum family planning in low-income countries, and even fewer impact evaluations have been conducted to determine the extent to which such family planning interventions may affect postpartum contraceptive use, birth spacing, and other measures of health and well-being.

Objective:

We conduct a randomized controlled trial that identifies the causal impact of a comprehensive intervention to improve access to postpartum family planning and reproductive health care on postpartum contraceptive use, pregnancy, and birth spacing in urban Malawi.

Methods:

A total of 2,143 married women aged 18-35 and who were either pregnant or had recently given birth were randomly assigned to either an intervention arm or a control arm. Women assigned to the intervention arm received a package of services over a two-year intervention period. Services included: 1) a brochure and up to six home visits from trained family planning counselors; 2) free transportation to a high-quality family planning clinic; and 3) financial reimbursement for family planning services, consultations, and referrals for services. Two follow-up surveys were conducted one and two years after the baseline survey, respectively. Data collection for the first follow-up survey began in August 2017 and was completed in February 2018, and data collection for the second follow-up survey began in August 2018 and was completed in February 2019.

Results:

The project was funded in August 2014 and was approved by the Harvard University Institutional Review Board (IRB) on July 2, 2016 and by the Malawi National Health Sciences Research Committee (NHSRC) on August 2, 2016. Data collection for the baseline survey began on September 5, 2016, and a total of 2,143 women were enrolled into the study. Women were randomized into intervention and control groups starting in October 2016. Intervention activities with the first women who were randomly assigned to the intervention group began on November 7, 2016. Data collection for the endline (second year follow-up) survey and intervention activities ended on January 31, 2019. At this time, recruitment, data collection and monitoring, intervention activities and implementation, and follow up have been completed. Data cleaning and preliminary analyses began in May 2019, and analysis of the primary outcomes is expected to be completed by December 2019. Results from the analysis of primary outcomes are expected to be published by the summer of 2020.

Conclusions:

Results from this trial seek to fill the current knowledge gaps on the effectiveness of family planning interventions on improving fertility and health outcomes. More generally, the study findings may also provide evidence to show that the benefits of improving access to family planning are likely to extend beyond the fertility and health domain by also improving other measures of women’s well-being. Clinical Trial: This trial was registered at the American Economics Association Registry for randomized controlled trials (https://www.socialscienceregistry.org/) on May 7, 2015 (AEARCTR-0000697) and at the Registry for International Development Impact Evaluations (RIDIE, https://ridie.3ieimpact.org/) on May 28, 2015 (RIDIE-STUDY-ID-556784ed86956).