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Study Overview

Title:
Examining the Impact of Family Planning on Fertility, Maternal and Child Health, and Economic Well-Being: Evidence from a Field Experiment in Urban Malawi
Change History for Title
Changed On Previous Value
04/27/2016 Examining the Impact of Family Planning on Fertility, Maternal and Child Health, and Economic Well-Being: Evidence from a Field Experiment in Urban Burundi
Study is 3ie funded:
No
Study ID:
RIDIE-STUDY-ID-556784ed86956
Initial Registration Date:
05/28/2015
Last Update Date:
02/16/2020
Study Status:
Completed
Change History for Status
Changed On Previous Value
02/16/2020 Ongoing
12/31/2018 In Development
Location(s):
Malawi
Change History for Location(s)
Changed On Previous Value
04/27/2016 Burundi
Abstract:

This study seeks to identify the causal impact of a family planning intervention on fertility, maternal and child health outcomes, and downstream economic outcomes by means of a randomized control trial. The trial will be conducted in Lilongwe, Malawi. As part of the intervention, women in the study sample who are randomly assigned to the treatment arm will receive a multicomponent family planning package that includes: 1) a family planning information package and private counseling sessions; 2) free private transportation to a family planning clinic with low waiting times; and 3) financial reimbursement for family planning services, including out of pocket expenditures related to family planning care and treatments received at the family planning clinic. Short-term outcomes of interest include modern contraceptive use, intention to use, and knowledge of family planning. Intermediate outcomes include fertility outcomes and outcomes associated with maternal and child health, including safe pregnancy, child birth height and weight, and nutritional status. Longer-term outcomes include educational attainment, labor market and employment outcomes, income, and household expenditure.

Change History for Abstract
Changed On Previous Value
02/16/2020 This study seeks to identify the causal impact of a family planning intervention on fertility, maternal and child health outcomes, and downstream economic outcomes by means of a randomized control trial. The trial will be conducted in Lilongwe, Malawi. As part of the intervention, women in the study sample who are randomly assigned to the treatment arm will receive a multicomponent family planning package that includes: 1) a family planning information package and private counseling sessions; 2) free private transportation to a family planning clinic with low waiting times; and 3) financial reimbursement for family planning services, including out of pocket expenditures related to family planning care and treatments received at the family planning clinic. Short-term outcomes of interest include modern contraceptive use, intention to use, and knowledge of family planning. Intermediate outcomes include fertility outcomes and outcomes associated with maternal and child health, including safe pregnancy, child birth height and weight, and nutritional status. Longer-term outcomes include educational attainment, labor market and employment outcomes, income, and household expenditure.
04/27/2016 This study seeks to identify the causal impact of a family planning intervention on fertility, maternal and child health outcomes, and downstream economic outcomes by means of a randomized control trial. The trial will be conducted in Bujumbura, Burundi. As part of the intervention, women in the study sample who are randomly assigned to the treatment arm will receive a multicomponent family planning package that includes: 1) a family planning information package and private counseling sessions; 2) free private transportation to a family planning clinic with low waiting times; and 3) free medical telephone consultations and reimbursement of out of pocket expenditures related to the treatment of contraceptive-related side effects. Short-term outcomes of interest include modern contraceptive use, intention to use, and knowledge of family planning. Intermediate outcomes include fertility outcomes and outcomes associated with maternal and child health, including safe pregnancy, child birth height and weight, and nutritional status. Longer-term outcomes include educational attainment, labor market and employment outcomes, income, and household expenditure.
Registration Citation:
Categories:
Health, Nutrition, and Population
Additional Keywords:
Secondary ID Number(s):
AEA Social Science Registry Number: AEARCTR-0000697

Principal Investigator(s)

Name of First PI:
Mahesh Karra
Affiliation:
Harvard University
Name of Second PI:
David Canning
Affiliation:
Harvard University

Study Sponsor

Name:
The William and Flora Hewlett Foundation
Study Sponsor Location:
United States

Research Partner

Name of Partner Institution:
Innovations for Poverty Action Malawi (IPA Malawi
Change History for Name of Partner Institution
Changed On Previous Value
04/27/2016 Health Systems and Development Consult
Type of Organization:
NGO-international
Change History for Type of Organization
Changed On Previous Value
04/27/2016 Private firm
Location:
Malawi
Change History for Location
Changed On Previous Value
04/27/2016 Burundi
Intervention

Intervention Overview

Intervention:

For the study, we will recruit women who: are married; are either currently pregnant or have gave birth within 6 months from the time of the initial screening; are between the ages of 18 to 35; live in the city of Lilongwe. As part of the intervention, women who are recruited in the study sample will be randomly assigned to one of two experimental arms, a treatment arm or a control arm, following the baseline survey. Women assigned to the treatment arm will receive a multicomponent family planning package that includes: 1) a family planning information package and private counseling sessions; 2) free private transportation to a family planning clinic with low waiting times; and 3) financial reimbursement for family planning services, including out of pocket expenditures related to family planning care and treatment. Women assigned to the control arm will receive a package of publicly available literature and information on the benefits of family planning as well as information about their nearest family planning clinic. This information package will be delivered to all women at the time of the baseline interview. Women in the control arm will only be re-contacted at follow-up.

Change History for Intervention
Changed On Previous Value
02/16/2020 For the study, we will recruit women who: are married; are either currently pregnant or have gave birth within 6 months from the time of the initial screening; are between the ages of 18 to 35; live in the city of Lilongwe. As part of the intervention, women who are recruited in the study sample will be randomly assigned to one of two experimental arms, a treatment arm or a control arm, following the baseline survey. Women assigned to the treatment arm will receive a multicomponent family planning package that includes: 1) a family planning information package and private counseling sessions; 2) free private transportation to a family planning clinic with low waiting times; and 3) financial reimbursement for family planning services, including out of pocket expenditures related to family planning care and treatment. Women assigned to the control arm will receive a package of publicly available literature and information on the benefits of family planning as well as information about their nearest family planning clinic. This information package will be delivered to all women at the time of the baseline interview. Women in the control arm will only be re-contacted at follow-up.
04/27/2016 For the study, we will recruit women who: are married; are either currently pregnant or have gave birth within 6 months from the time of the initial screening; are between the ages of 18 to 35; live in the city of Bujumbura. As part of the intervention, women who are recruited in the study sample will be randomly assigned to one of two experimental arms, a treatment arm or a control arm, following the baseline survey. Women assigned to the treatment arm will receive a multicomponent family planning package that includes: 1) a family planning information package and private counseling sessions; 2) free private transportation to a family planning clinic with low waiting times; and 3) free medical telephone consultations and reimbursement of expenditures related to the treatment of contraceptive-related side effects. Women assigned to the control arm will receive a package of publicly available literature and information on the benefits of family planning as well as information about their nearest family planning clinic. This information package will be delivered to all women at the time of the baseline interview. Women in the control arm will only be re-contacted at follow-up.
Private Intervention Details:

Please refer to attached experiment proposal for additional details.

Change History for Private Intervention Details
Changed On Previous Value
02/16/2020 Please refer to attached experiment proposal for additional details.
Theory of Change:

Based on the theory and model specifications that were outlined previously, we expect to observe one of four outcome paths when assessing the impact of the family planning intervention. For three of these outcome paths, we can use the reduced-form framework (see Figure 3 in the research proposal) to provide some key explanations as to why each outcome path below is plausible. The four expected outcomes are:

  1. Outcome Path 1-to-3: Family planning reduces fertility, which leads to increases in female labor supply and educational attainment and improvements in health. This outcome reflects the standard theoretic predictions of the household models that are outlined above, where parity declines as a result of family planning.
  2. Outcome Path 2-to-3: Family planning does not change parity, but leads to increases in birth spacing, which in turn impacts female labor supply and other downstream outcomes. This outcome reflects the expectation that parity does not change but birth spacing and age at first birth increases, which in turn affect female labor supply, improve employment outcomes, and contribute to longer-term welfare.
  3. Family planning reduces fertility but does not affect female labor market outcomes, employment, or educational attainment. Here, it is likely that we do not have the capacity within our study to measure these downstream effects. Alternatively, it may be that women face other barriers to entering the labor market that are orthogonal to family planning and fertility.
  4. Family planning affects neither fertility nor female labor supply, or affects these outcomes in a countertheoretic manner. In this case, further examination of both the empirical and theoretical predictions need to be undertaken before any reasonable explanations for these observed outcomes are proposed.
Multiple Treatment Arms Evaluated?
No

Implementing Agency

Name of Organization:
Innovations for Poverty Action Malawi (IPA Malawi)
Change History for Name of Organization
Changed On Previous Value
04/27/2016 Health Systems and Development Consult
Type of Organization:
NGO (International)
Change History for Type of Organization
Changed On Previous Value
04/27/2016 Private for profit organization

Program Funder

Name of Organization:
The William and Flora Hewlett Foundation
Type of Organization:
Private for profit organization

Intervention Timing

Intervention or Program Started at time of Registration?
Yes
Change History for Intervention Timeline
Changed On Previous Value
12/31/2018 No
Start Date:
12/01/2016
Change History for Start Date
Changed On Previous Value
04/27/2016 12/01/2015
End Date:
03/31/2019
Change History for End Date
Changed On Previous Value
02/16/2020 01/31/2019
12/31/2018 11/30/2017
04/27/2016 11/30/2016
Evaluation Method

Evaluation Method Overview

Primary (or First) Evaluation Method:
Randomized control trial
Other (not Listed) Method:
Additional Evaluation Method (If Any):
Instrumental variables
Other (not Listed) Method:

Method Details

Details of Evaluation Approach:

We will exploit the randomized assignment to treatment arms and a pre-/post-intervention design to identify the impact of the multicomponent family planning intervention on our outcomes of interest. The main econometric specification for estimating the intent-to-treat (ITT) effect of our family planning intervention. Here, outcome variables of interest include immediate, intermediate, and long-term outcomes mentioned in the previous sections. We will also decompose the reduced-form ITT regression into the two stages of the causal chain, instrumenting fertility in the second stage with the family planning intervention treatment arms. I will conduct several sub-group analyses in order to examine how the family planning intervention effects vary across particular subpopulations. Subgroups of interest include: pregnant women, new mothers, women who have previously used of family planning, women who expressed a desire to space or limit births at baseline, poorer women, and women with low educational attainment. In addition, we will estimate heterogeneous treatment effects for girls, older children, and high parity households.

Change History for Details of Evaluation Approach
Changed On Previous Value
02/16/2020 We will exploit the randomized assignment to treatment arms and a pre-/post-intervention design to identify the impact of the multicomponent family planning intervention on our outcomes of interest. The main econometric specification for estimating the intent-to-treat (ITT) effect of our family planning intervention. Here, outcome variables of interest include immediate, intermediate, and long-term outcomes mentioned in the previous sections. We will also decompose the reduced-form ITT regression into the two stages of the causal chain, instrumenting fertility in the second stage with the family planning intervention treatment arms. I will conduct several sub-group analyses in order to examine how the family planning intervention effects vary across particular subpopulations. Subgroups of interest include: pregnant women, new mothers, women who have previously used of family planning, women who expressed a desire to space or limit births at baseline, poorer women, and women with low educational attainment. In addition, we will estimate heterogeneous treatment effects for girls, older children, and high parity households.
Private Details of Evaluation Approach:

Please refer to attached experiment proposal for additional details.

Change History for Private Details of Evaluation Approach
Changed On Previous Value
02/16/2020 Please refer to attached experiment proposal for additional details.
Outcomes (Endpoints):

Primary outcomes include: knowledge of family planning, including knowledge of birth spacing and timing and perceptions toward contraception (intentions to use); contraceptive use, including changes in contraceptive prevalence; changes in method mix; and adherence to methods; pregnancy status at 24 months; parity within 24 months; delivery in a facility; months since last birth; wantedness of last birth; and intentions to become pregnant in future. Secondary intermediate outcomes include: child anthropometric outcomes (child height, weight, and anemia status) for all children born after the start of the intervention; women’s anthropometric outcomes, including height, weight, and anemia status; women's completed fertility; women’s and children’s educational attainment. Secondary longer- term outcomes include: women's labor force participation, income, and employment, including women’s time use (time spent on childcare versus household and income-generating activities); changes in household wealth; household consumption; and expenditures.

Change History for Outcomes (Endpoints)
Changed On Previous Value
02/16/2020 Primary outcomes include: knowledge of family planning, including knowledge of birth spacing and timing and perceptions toward contraception (intentions to use); contraceptive use, including changes in contraceptive prevalence; changes in method mix; and adherence to methods; pregnancy status at 24 months; parity within 24 months; delivery in a facility; months since last birth; wantedness of last birth; and intentions to become pregnant in future. Secondary intermediate outcomes include: child anthropometric outcomes (child height, weight, and anemia status) for all children born after the start of the intervention; women’s anthropometric outcomes, including height, weight, and anemia status; women's completed fertility; women’s and children’s educational attainment. Secondary longer- term outcomes include: women's labor force participation, income, and employment, including women’s time use (time spent on childcare versus household and income-generating activities); changes in household wealth; household consumption; and expenditures.
05/19/2016 Attitude/Knowledge of Family Planning, including: knowledge of family planning; knowledge of birth spacing and timing; and perceptions toward contraception (including intentions to use). Contraceptive Use, including: changes in contraceptive prevalence; changes in method mix; and adherence to methods (compliance, discontinuation). Pregnancy and Fertility Outcomes, including: pregnancy status; parity; delivery in a facility; months since last birth; wantedness of last birth; and intentions to become pregnant in future. Child Anthropometric Outcomes, including child height, weight, and anemia status for all children born after the start of the intervention. Women’s Anthropometric Outcomes, including height, weight, and anemia status. Women’s and Children’s Educational Attainment, including time spent in school; type of school (public or private) attended, and the highest educational qualification achieved Weeks Worked, Income, and Women’s Employment, including women’s time use (time spent on childcare versus household and income-generating activities) and sources of household income. Household Assets, Wealth, Consumption, and Expenditure
Unit of Analysis:
women
Hypotheses:

Based on the theory and model specifications that were outline, we expect to observe one of four outcome paths when assessing the impact of the family planning intervention. The four expected outcomes are: 1. Family planning reduces fertility, which leads to increases in female labor supply and educational attainment and improvements in health. This outcome reflects the standard theoretic predictions of the household models, where parity declines as a result of family planning. 2. Family planning does not change parity, but leads to increases in birth spacing, which in turn impacts female labor supply and other downstream outcomes. 3. Family planning reduces fertility but does not affect female labor market outcomes,employment, or educational attainment. 4. Family planning affects neither fertility nor female labor supply, or affects these outcomes in a countertheoretic manner. In this case, further examination of both the empirical and theoretical predictions need to be undertaken before any reasonable explanations for these observed outcomes are proposed.

Change History for Hypotheses
Changed On Previous Value
02/16/2020 Based on the theory and model specifications that were outline, we expect to observe one of four outcome paths when assessing the impact of the family planning intervention. The four expected outcomes are: 1. Family planning reduces fertility, which leads to increases in female labor supply and educational attainment and improvements in health. This outcome reflects the standard theoretic predictions of the household models, where parity declines as a result of family planning. 2. Family planning does not change parity, but leads to increases in birth spacing, which in turn impacts female labor supply and other downstream outcomes. 3. Family planning reduces fertility but does not affect female labor market outcomes,employment, or educational attainment. 4. Family planning affects neither fertility nor female labor supply, or affects these outcomes in a countertheoretic manner. In this case, further examination of both the empirical and theoretical predictions need to be undertaken before any reasonable explanations for these observed outcomes are proposed.
Unit of Intervention or Assignment:
Individual women
Number of Clusters in Sample:
2,000 women
Number of Individuals in Sample:
2,000 women
Size of Treatment, Control, or Comparison Subsamples:
1,000 women in treatment arm; 1,000 women in control arm

Supplementary Files

Analysis Plan:
Research Proposal - Malawi FP Experiment 4-27-16.pdf
Change History for Analysis Plan
Changed On Previous Value
04/27/2016 Research Proposal - Burundi FP Experiment 2-15-15.pdf
Other Documents:
: Appendix 1 - HLMA Research Protocol - FP Intervention 8-11-17.pdf
Change History for Other Documents
Changed On Previous Value
02/16/2020 Description: IRB Research Protocol - Malawi FP Field Experiment
Filename: Appendix 1 - HLMA Research Protocol - FP Intervention 3-25-16.doc
04/27/2016 Description: HLMA - Harvard IRB Protocols
Filename: HLMA Research Protocol - FP Intervention 2-20-2015.doc
Data

Outcomes Data

Description:
3 household surveys: 1. Baseline survey, collected before intervention implementation (intervention period of 1 year) 2. One-year follow-up survey 3. Two-year follow-up survey
Data Already Collected?
Yes
Change History for Data Collection Status
Changed On Previous Value
05/20/2019 No
Data Previously Used?
No
Data Access:
Restricted -- Access requires a formal approval process
Data Obtained by the Study Researchers?
Data Approval Process:
Following completion and analysis of the primary and secondary outcomes, the MFPS study team will create a public use data set. Data requests for the public use data set can be made through an online application submission process (to be developed) and will be reviewed by the MFPS study team.
Approval Status:
Yes-obtained approval and have received the data

Treatment Assignment Data

Participation or Assignment Information:
Yes
Description:
Data Obtained by the Study Researchers?
Data Previously Used?
Data Access:
Data Obtained by the Study Researchers?
Data Approval Process:
Approval Status:

Data Analysis

Data Analysis Status:
Yes
Change History for Data Analysis Status
Changed On Previous Value
02/16/2020 No
05/20/2019 Yes

Study Materials

Upload Study Materials:
Full Baseline Survey Instrument - Malawi FP Experiment: Appendix F - COMPLETE SURVEY - ENGLISH 3-18-16.pdf
Change History for Upload Study Materials
Changed On Previous Value
04/27/2016 Description: Full Survey Instrument - Burundi FP Experiment
Filename: COMPLETE SURVEY - ENGLISH 2-20-15.pdf
Link: http://

Registration Category

Registration Category:
Non-Prospective, Category 4: Data for measuring impacts have been obtained/collected by the research team and analysis for this evaluation has started
Change History for Registration Category
Changed On Previous Value
02/16/2020 Prospective, Category 3: Data for measuring impacts have been obtained/collected by the research team but analysis for this evaluation has not started
05/20/2019 Non-Prospective, Category 4: Data for measuring impacts have been obtained/collected by the research team and analysis for this evaluation has started
05/20/2019 Prospective, Category 1: Data for measuring impacts have not been collected
Completion

Completion Overview

Intervention Completion Date:
03/31/2019
Data Collection Completion Date:
03/31/2019
Unit of Analysis:
The primary unit of analysis for primary endpoints was a woman.
Clusters in Final Sample:
N/A - the intervention was randomly assigned at the individual woman level.
Total Observations in Final Sample:
2,143 women (N = 1,026 women in the treatment group, N = 1,117 in the control group)
Size of Treatment, Control, or Comparison Subsamples:
2,143 women (N = 1,026 women in the treatment group, N = 1,117 in the control group)

Findings

Preliminary Report:
No
Preliminary Report URL:
Summary of Findings:

Our preliminary findings show a 5.62 to 5.83 percentage point increase in postpartum contraceptive use in the treatment group after two years of exposure to the intervention and a 5.47 percentage point increase in long-acting contraceptive use after two years of exposure to the intervention. Upon further decomposition of the contraceptive method mix, we find a 4.02 to 4.19 percentage point increase in implant use. At the same time, we do not find evidence of a significant change in injectable use. We also find that the odds of short birth spacing among women in the treatment group was up to 32 percent lower after two years of exposure to the intervention (OR: 0.681) than women in the control group.

Paper:
No
Paper Summary:
Paper Citation:

Data Availability

Data Availability (Primary Data):
No--Data not expected to be available
Date of Data Availability:
Data URL or Contact:
Access procedure:

Other Materials

Survey:
Yes
Survey Instrument Links or Contact:
Program Files:
No
Program Files Links or Contact:
N/A
External Link:
External Link Description:
Description of Changes:

Study Stopped

Date:
Reason: