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Maternal Mortality and the Gender Gap in Desired Fertility in Zambia

Development Challenge

Maternal mortality remains very high in many parts of the developing world, especially in sub-Saharan Africa. Limited awareness of risk factors for maternal mortality such as maternal age and birth spacing may contribute to persistently high death rates. Public health campaigns to increase awareness of risk factors could help curb maternal mortality. Data show that men, in particular, tend to underestimate maternal mortality risk, which may lead to their lower demand for contraception.

Women around the world continue to report substantial unmet need for modern contraceptives [1]. 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 conflicting 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. However, little evidence exists on what drives men’s fertility preferences and if these preferences can be changed.

Context

Relative to neighboring countries, Zambia has a high rate of maternal mortality; 1 out of 59 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 [2]. According to a recent body of literature, men’s higher demand for children can significantly reduce contraceptive adoption, even when contraceptives are easily accessible [3-8]. An initial survey found that superstitions about causes of maternal mortality are pervasive and that such beliefs impede learning about maternal health risk levels. While women tend to have more accurate information about maternal mortality because they bear the direct costs of childbirth, men may face an asymmetry in knowledge that is often seeded in cultural myths. 

Evaluation Strategy

This study is taking place in the catchment area of the Chipata and Chaisa Clinics, two government-run facilities that serve low-income areas in Lusaka. Couples of childbearing age are invited to attend a community meeting together. Upon arrival, they are split into gender-specific meetings, in which they receive information based on the group to which they have been randomly assigned (see table below). In one treatment group, women receive the family planning information and their male partners receive maternal mortality information based on a curriculum designed in collaboration with the Ministry of Health to break down cultural myths and replace them with accurate medical facts.  In the other treatment group, women receive the maternal mortality information and men receive the family planning information. In the comparison group, participants receive family planning information on available contraceptives and are encouraged to discuss their options with a nurse. Extensively trained facilitators deliver the informational content of the workshops, using visual materials and scripts designed for the study.

Treatment Conditions:

  Treatment   1 - HusMM   2 - WifeMM  3 - Comparison
  Husband   Maternal Mortality    Family Planning   Family Planning
  Wife   Family Planning    Maternal Mortality    Family Planning 

After the meeting, vouchers for free family planning services are distributed using willingness-to pay experiments. Couples that are unable to attend the community meeting receive the training directly at their residence.

From 2016 to 2017, researchers are tracking a number of important short-term and medium-term outcomes to measure the impact of providing this targeted information to different members of the household. The key outcomes include changes in knowledge and beliefs about the prevalence of maternal mortality, its risk factors, and prevention, as well as intra-household dynamics, household demand for family planning, take-up of contraception, and ultimately, realized fertility. In addition, administrative records from the two partner clinics provide information on take-up of contraception and redemption of the family planning voucher. An endline survey will examine longer term fertility outcomes, including number of children and birth spacing, as well as maternal and child health.

Results and Policy Implications

Pilot Results: The results of two small-scale pilots conducted in 2010 and 2012, baseline findings from 2015, and an immediate post-intervention survey from 2016, suggest that information about maternal mortality encourages contraception use. In 2012, 40 percent of couples in a group who had attended a community meeting on maternal mortality redeemed a voucher that granted access to free contraception, while none in the control group redeemed the voucher. This finding is consistent with results of the earlier pilot, in which 23 percent of couples who received the information redeemed the voucher, compared to 6 percent of couples in the comparison group.

Results are forthcoming from the full-scale evaluation described above.

Timeline

2013 - Ongoing

[1] “Unmet need for family planning.” World Health Organization. Accessed December 30, 2016. http://www.who.int/reproductivehealth/topics/ family_planning/unmet_need_fp/en.

[2] Zambia Demographic and Health Survey 2013-14. Rockville, Maryland, USA: Central Statistical Office [Zambia], Ministry of Health [Zambia], and ICF International, 2015.

[3] Ashraf, Nava, Erica Field, and Jean Lee. “Household Bargaining and Excess Fertility: An Experimental Study in Zambia.” The American Economic Review 104, no. 7 (2014): 2210-2237.

[4] DeRose, Laurie F., F. Nii-Amoo Dodoo, and Vrushali Patil. "Fertility Desires and Perceptions of Power in Reproductive Conflict in Ghana." Gender & Society 16, no. 1 (2002): 53-73.

[5] Dodoo, F. Nii-Amoo, and Maria Tempenis. "Gender, Power, and Reproduction: Rural-Urban Differences in the Relationship Between Fertility Goals and Contraceptive Use in Kenya." Rural Sociology 67, no. 1 (2002): 46-70.

[6] Ezeh, Alex Chika. "The Influence of Spouses over each Other's Contraceptive Attitudes in Ghana." Studies in Family Planning (1993): 163-174.

[7] Hollos, Marida, and Ulla Larsen. "Which African men promote smaller families and why? Marital relations and fertility in a Pare community in Northern Tanzania." Social Science & Medicine 58, no. 9 (2004): 1733-1749.

[8] Hollos, Marida, and Ulla Larsen. "Marriage and contraception among the Pare of northern Tanzania." Journal of Biosocial Science 36, no. 03 (2004): 255-278.

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