Empowering Women to Effectively Space Pregnancies: Evidence from Malawi

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By Maria Santarelli

It is widely known that pregnancy is a critical time in a person’s life, but less frequently acknowledged is the importance of adequate timing in between pregnancies.

According to the World Health Organization (WHO), a woman should wait at least 24 months after a live birth before getting pregnant again. Poorly spaced births are associated with negative health outcomes, including increased risk of mortality and morbidity, for both women and children. In low- and middle-income countries, about 25 percent of birth intervals do not meet the WHO’s 24-month guideline.

Improving access to postpartum family planning (PPFP) may help women and couples to effectively space pregnancies and meet their desired fertility. Despite the potential, few studies, even fewer randomized controlled trials, have been conducted to assess the impact of family planning on contraceptive use in low- and middle-income settings. Thus, this study in Malawi significantly enriches the body of literature on public health interventions and women’s empowerment.

The choice of the intervention in Sub-Saharan Africa comes from the estimated  eight million women having an unmet need for spacing or limiting births. Although the total fertility rate has declined in sub-Saharan Africa over the past 30 years, from 6.5 to 4.7 births per woman, it remains much higher than in any other world region. Specifically, in Malawi, the total fertility rate is 4.2 births per woman.

When compared to the uptake of antenatal care, the use of postpartum maternal health care services remains low in Malawi: while 97.6 percent of pregnant women received antenatal care only 42.4 percent of new mothers received any postnatal care within the immediate postpartum period.Further, women in Malawi face a range of barriers that discourage them from seeking postpartum care, including lack of information or awareness of postpartum care options, long travel distances from healthcare facilities, and weak healthcare capacity.

To test the potential effectiveness of PPFP services, the Associate Director of the GDP Center’s Human Capital Initiative, Mahesh Karra launched the Malawi Family Planning Study (MFPS) in collaboration with David Canning at the Harvard School of Public Health.

The MFPS is a randomized controlled trial (RCT) that seeks to identify the effect of improved access to PPFP and reproductive health services on women’s utilization of these services (postpartum contraceptive use) and on women’s fertility outcomes, including birth spacing, in urban Malawi. As part of the trial, the MFPS provided new and expecting mothers in Lilongwe with access to a range of services between 2016-2019.

A total of 2,143 married women in the city of Lilongwe 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 who were assigned to the control arm received information about the nearest family planning clinic. Women assigned to the intervention arm received a package of services for a two-year period:

    • A brochure and up to six home visits from trained family planning counselors to received detailed information on family planning and methods. The consultations were designed to promote informed choice;
    • Free transportation from their homes to a local, high-quality family planning clinic that offered a full range of family planning services;
    • Financial reimbursement for any out of pocket expenditures that women incurred for family planning services, consultations, and referrals at the clinic.
    • Finally, women who experienced any side effects due to contraceptive use over the course of the two-year intervention received a series of services in case side effects arose.

The intervention took place between November 2016 and November 2018. A baseline survey was conducted between September 2016 and January 2017 to identify the targeted population. Participants of the study received two follow up surveys conducted from August 2017 until February 2018, and again from August 2018 until February 2019.

Key Findings

    • Women who were given the package of postpartum family planning service were more likely to be using contraception after two years of exposure to the intervention. Specifically:
      • The increase in contraceptive use was driven by an increase in long-acting method use;
      • Demand for contraceptive implants increased as a result of the intervention.
    • Women in the intervention arm had a lower risk of a subsequent pregnancy within a 24-month period;
    • The decrease in a woman’s risk of pregnancy was accompanied by a decrease in the risk of a woman having two live births within a 33-month period.

This evidence-based study suggests improving access to high quality postpartum family planning services would enable women to more effectively time and space their next births, as well as meet their desired fertility.

Following these findings, it is important to communicate with public health officials and the government of Malawi to show the benefits and propose interventions for women, families, and public health.

Malawi is one of the poorest countries in sub-Saharan Africa and remains among the lowest on key indicators of maternal and newborn mortality rates, despite the receipt of extensive amounts of overseas development funding. Improving access to postpartum healthcare services may help ameliorate human development indicators overall in the country.

The study protocol for the randomized controlled trial, “The Effect of Improved Access to Family Planning on Postpartum Women: Protocol for a Randomized Controlled Trial,” is available through the Journal of Medical Internet Research.

The various phases of the intervention were carried out in collaboration with Innovations for Poverty Action (IPA) in Malawi. In addition, Karra’s field visits to Malawi in the summer included the active participation of students from Boston University, including recipients of the Summer in the Field Fellowship.