Maternal Mortality Risk and the Gender Gap in Desired Fertility
Nava Ashraf
Women in Rural Zambia
Short Description
This RCT tests whether a maternal mortality curriculum designed to break down cultural myths about pregnancy can increase contraceptive uptake. Couples will attend community workshops, where they learn about contraceptives and receive vouchers for family planning.
Development Challenge
High fertility rates and inadequate family planning undermine economic growth and contribute to infant and maternal mortality, justifying hundreds of millions of dollars of international donor support every year. However, evidence on the effect of providing access to contraceptive supplies is mixed. In fact, some research has even shown that access alone may not decrease fertility.[i] Fertility demand has slowly decreased in sub-Saharan Africa over the past half century, but only a small portion of the decline can be attributed to the increased provision of contraceptive supplies.[ii] While women’s fertility demand has steadily decreased throughout sub-Saharan Africa in recent years, men’s fertility demand has remained relatively constant. In cases where men have more intra-household bargaining power, this gap in fertility preferences results in lower contraceptive use and higher fertility. Despite this problem, there has been little research on what drives men’s fertility demand and how to align the preference gap for children.
Context
The primary gender difference from which such a gap is likely to originate is the fact that women directly bear the cost of childbearing. In Zambia, cultural myths around maternal mortality are common and men are shielded from many of the complications and maternal risks during delivery. However, such lack of knowledge has never been linked to a gender gap in desired fertility, a connection which arose often in the investigators’ previous work with men, women, and family planning nurses. Despite growing policy emphasis to involve men in family planning, little rigorous evidence exists on how to make such involvement effective. 13 of 16 published randomized evaluations on male involvement show no effect on fertility. Previous work by the investigators has shown that even when contraceptives are readily available, men’s demand for children can significantly impact contraceptive adoption and fertility (Ashraf, Field and Lee, 2012).
Evaluation Strategy
This study will evaluate whether and how increasing maternal mortality awareness changes men’s fertility demand. In Lusaka, 2,000 couples will attend a community workshop at which they will be randomly assigned to a “husband focused” or “wife focused” group. In the “husband focused” group, the wives will attend a neutral health meeting and in the “wife focused” group, the husband will attend a neutral health meeting. Husbands in the “husband-focused” group and wives in the “wife-focused” group will be randomized into either a treatment or comparison group. In the comparison group, participants will receive information on available contraceptives and be encouraged to discuss their options with a nurse. Treatment group participants will receive the same information in addition to a maternal mortality curriculum designed with the Ministry of Health to break down cultural myths and replace them with accurate medical facts. All participants will receive a voucher for free planning services at a local clinic. Data collected from the local clinics will be used to compare voucher uptake among the different groups. Additionally, a panel survey will be administered to measure short and medium term outcomes. Outcomes to be measured include knowledge on maternal mortality, individual and household behaviors, superstitious beliefs about maternal mortality, and intra-household dynamics. Health outcomes, which include use of family planning services, contraception adoption and pregnancy, will also be measured. Researchers will then determine the extent to which adding information on maternal mortality to family planning services changes men’s fertility demands. The results will be incorporated into Zambia’s community health education program and could have important implications for other countries facing similar problems.
Results and Policy Implications
Project ongoing, results forthcoming
Timeline
2013-Ongoing
BERI 