Microcredit, Family Planning Programs, and Contraceptive Behavior: Evidence From a Field Experiment in Ethiopia

The causal effect of a family planning intervention on women's contraceptive use and birth spacing

SignificanceImproving access to family planning may promote contraceptive use after childbirth and reduce the likelihood of closely spaced high-risk births; however, empirical evidence for these claims is limited. We present findings from a field experiment that examines the causal impact of a broad-based family-planning intervention on postpartum contraceptive use and fertility over a 2-y period, which allows us to assess impact on high-risk short pregnancy intervals. Our findings demonstrate that the benefits of family planning extend beyond contraceptive use to improve fertility and healthy birth spacing. Evidence from this study will contribute to the design of effective family-planning programs and to informing the ongoing policy debate about how such programs impact longer-term health and development more broadly.

Birth Collapse and a Large-Scale Access Intervention with Subdermal Contraceptive Implants

Between 2016 and 2018, we observe in Uruguay a steep decline of almost 20 percent in the number of total births, leading to the collapse of the adolescent fertility rate after decades of relative stagnation. We estimate the quantitative contribution on birth rates, especially teen births, of a policy of expanded availability of subdermal contraceptive implants. We exploit the expansion schedule of a large-scale policy of free-of-charge access to subdermal implants in the country's public health system through an event study to capture causal effects. We use detailed birth administrative records for the past 20 years. We document an average reduction of 3 percent in the birth rate in public health facilities across the two years after the policy was implemented in each department. These reductions were notably higher among teens and first births. Although changes in women's fertility decisions are a multicausal phenomenon, we claim that the expanded availability of subdermal contraceptive implants accounted for one-third of the teen and young women's birth collapse.

More than credit: Exploring associations between microcredit programs and maternal and reproductive health service utilization in India

Microcredit programs are increasingly popular interventions aimed at enabling women's economic empowerment in low- and middle-income countries. Resultant improved income, and social support from co-members of microcredit programs, may lead to increased utilization of health services. But existing research is inconclusive. This study investigates the association of microcredit program awareness and participation, with maternal and postpartum reproductive health service utilization in India. We use data from a nationally representative survey, the National Family Health Survey (2015-16), and assess three indicators of maternal health service utilization: receipt of four or more antenatal check-ups, institutional delivery, and postnatal check-up among women who had a child less than 5 years of age (N = 32,880). Reproductive health service utilization is assessed via postpartum contraceptive use within 12 months of childbirth, among women who had a live birth in the 12-59 months preceding the survey (N = 24,258). We use binomial and multinomial logistic regression models to examine associations. Additionally, we use propensity score matching to account for self-selection bias. One-third of women are aware of microcredit programs in their community/village, but only 6% have ever taken a loan from these programs. Both microcredit program awareness and participation are associated with higher odds of antenatal care, postnatal check-ups, as well as use of a modern method of contraceptive within 12 months of childbirth, even after accounting for self-selection bias. Stratified analysis by household wealth show that significant associations seen in our primary analyses are significant only for the poorest women. Findings highlight the potential value of microcredit programs in improving health service utilization during and after pregnancy, particularly among poor women. Microcredit program benefits extend beyond their participants. Non-participants living close to the programs also have greater odds of maternal and reproductive health service utilization, suggesting a spillover effect of these programs at the community level.

Evaluating an MFI Community Health Worker Program: How microfinance group networks influence intervention outreach and impact

BACKGROUND

Community Health Workers (CHWs) are considered to be a cost-effective and inclusive solution to address the persistent health workforce shortage in many low and middle-income countries. In recent years, microfinance institutions (MFIs) got increasingly engaged in providing health services delivered by CHWs. Despite their growing importance, little is known about the impacts and implementation barriers of these mostly small-scale initiatives. This paper evaluates an MFI-led CHW program in the Philippines and studies the role of microfinance group networks in influencing program outreach and impact. The intervention aims at disseminating information in poor communities, improving health monitoring through increased check-ups and raising social support.

METHODS

Clustered randomized controlled trial in 70 communities in the greater area of Metro Manila, the Philippines. The main data was collected in a baseline and follow-up survey and is complemented with extensive sociometric network and geographical data. The main outcome variable is a composite health index based on 10 indicators. The role of the health worker's embeddedness and connectedness in the community for program success is tested using tools of social network analysis.

RESULTS

The intervention led to a 3.8% (95% confidence interval (CI) = 1.3, 6.4) improvement in the composite health outcome. Effects across indicators are mixed and mainly driven by changes in immediate health monitoring behavior: The probability for routine examinations increased in the treatment group by 10.6% (95% CI = 3.2, 18.1), for regular blood pressure checks by 9.6% (95% CI = 3.3, 15.9), and for having access to a health care provider by 7.2% (95% CI = 0.93, 13.5). No statistical effects on general knowledge and social support are observable. Social networks are a key driver of program outreach and impact. Close friends and acquaintances of health workers used and benefited substantially more from the program than more distant ties.

CONCLUSIONS

Despite the promising immediate behavioral impacts, it remains questionable to what extent such small-scale MFI initiatives can bring transformative and sustainable changes without external support. Microfinance group networks played an important role for the success of the health intervention and further research is needed to better understand how these affect the health care utilization decisions of the clients.

Does owning a bank account improve reproductive and maternal health services utilization and behavior in India? Evidence from the National Family Health Survey 2015-16

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Ownership of a bank account is associated with improved reproductive and maternal health services utilization and behaviour.

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Observed associations are strongest in states where the utilization of studied services is far below the national average.

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No association is found between women's ownership of a bank account and institutional delivery.

Is microfinance associated with changes in women's well-being and children's nutrition? A systematic review and meta-analysis

BACKGROUND

Microfinance is the provision of savings and small loans services, with no physical collateral. Most recipients are disadvantaged women. The social and health impacts of microfinance have not been comprehensively evaluated.

OBJECTIVE

To explore the impact of microfinance on contraceptive use, female empowerment and children's nutrition in South Asia, Sub-Saharan Africa and Latin America and the Caribbean.

DESIGN

We conducted a systematic search of published and grey literature (1990-2018), with no language restrictions. We conducted meta-analysis, where possible, to calculate pooled ORs. Where studies could not be combined, we described these qualitatively.

DATA SOURCES

EMBASE, MEDLINE, LILACS, CENTRAL and ECONLIT were searched (1990-June 2018).

ELIGIBILITY CRITERIA

We included controlled trials, observational studies and panel data analyses investigating microfinance involving women and children.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias. The methodological quality of included studies was assessed using the Cochrane risk-of-bias tool for controlled trials and quasi-experimental studies and a modified Newcastle Ottawa Scale for cross-sectional surveys and analyses of panel data. Meta-analyses were conducted using STATA V.15 (StataCorp).

RESULTS

We included 27 studies. Microfinance was associated with a 64% increase in the number of women using contraceptives (OR 1.64, 95% CI 1.45 to 1.86). We found mixed results for the association between microfinance and intimate partner violence. Some positive changes were noted in female empowerment. Improvements in children's nutrition were noted in three studies.

CONCLUSION

Microfinance has the potential to generate changes in contraceptive use, female empowerment and children's nutrition. It was not possible to compare microfinance models due to the small numbers of studies. More rigorous evidence is needed to evaluate the association between microfinance and social and health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42015026018.

Microfinance Institutions' Successful Delivery Of Micronutrient Powders: A Randomized Trial In Rural Haiti

Globally, two-thirds of child deaths could be prevented by increased provision of health interventions such as vaccines, micronutrient supplements, and water purification tablets. We report the results from a randomized controlled trial in Haiti during 2012 that tested whether microfinance institutions-which reach 200 million households worldwide-can effectively deliver health products. These institutions provide loans to underserved entrepreneurs, primarily poor women in rural areas. In the intervention group, micronutrient powders to improve the nutrition of young children were distributed at regularly occurring microfinance meetings by a trained borrower. In both the control and the intervention groups, nurses led seminars on nutrition and extended breastfeeding during microfinance meetings. At three-month follow-up, the mean difference in hemoglobin concentration between children in the intervention group and those in the control group was 0.28 grams per deciliter (g/dL)-with a subsample of younger children (under two years of age) showing greater relative improvement (0.46 g/dL)-and the odds ratio for children in the intervention group meeting the diagnostic criteria for anemia was 0.64. The results are similar to those of previous studies that evaluated micronutrient powder distribution through dedicated health institutions. Our findings suggest that microfinance institutions are a promising platform for the large-scale delivery of health products in low-income countries.

Evaluating the impact of integrated development: are we asking the right questions? A systematic review

Background: Emerging global transformations - including a new Sustainable Development Agenda - are revealing increasingly interrelated goals and challenges, poised to be addressed by similarly integrated, multi-faceted solutions. Research to date has focused on determining the effectiveness of these approaches, yet a key question remains: are synergistic effects produced by integrating two or more sectors?  We systematically reviewed impact evaluations on integrated development interventions to assess whether synergistic, amplified impacts are being measured and evaluated.

Methods: The International Initiative for Impact Evaluation’s (3ie) Impact Evaluation Repository comprised our sampling frame (n = 4,339). Following PRISMA guidelines, we employed a three-stage screening and review process.

Results: We identified 601 journal articles that evaluated integrated interventions. Seventy percent used a randomized design to assess impact with regard to whether the intervention achieved its desired outcomes. Only 26 of these evaluations, however, used a full factorial design to statistically detect any synergistic effects produced by integrating sectors. Of those, seven showed synergistic effects.

Conclusions: To date, evaluations of integrated development approaches have demonstrated positive impacts in numerous contexts, but gaps remain with regard to documenting whether integrated programming produces synergistic, amplified outcomes. Research on these program models needs to extend beyond impact only, and more explicitly examine and measure the synergies and efficiencies associated with linking two or more sectors. Doing so will be critical for identifying effective integrated development strategies that will help achieve the multi-sector SDG agenda.

Do Targeted Reproductive Health Services Matter? - The Impact of a Midwife Program in Indonesia

This paper examines empirically whether midwives, as an integral part of the reproductive health and family planning programs in Indonesia, are effective in advising young women to delay their first birth and also influence the decision on post-primary school attendance. Using the Indonesian Family Life Survey, I investigate the extent to which the expansion of a midwife program affects the age at first birth and the number of school years of women. My findings suggest that women who were exposed to a midwife when they have to decide on further school attendance (aged 13-20 years) delay their first birth and also stay longer in school. According to the average returns of education in Indonesia, I conclude that reproductive health services provided by midwives can generate large socioeconomic benefits by allowing young women to postpone their first birth. Copyright © 2017 John Wiley & Sons, Ltd.

Evaluating integrated development: are we asking the right questions? A systematic review

Background: Emerging global transformations - including a new Sustainable Development Agenda - are revealing increasingly interrelated goals and challenges, poised to be addressed by similarly integrated, multi-faceted solutions. Research to date has focused on determining the effectiveness of these approaches, yet a key question remains: are synergistic effects produced by integrating two or more sectors?  We systematically reviewed impact evaluations on integrated development interventions to assess whether synergistic, amplified impacts are being measured and evaluated. Methods: The International Initiative for Impact Evaluation’s (3ie) Impact Evaluation Repository comprised our sampling frame (n = 4,339). Following PRISMA guidelines, we employed a three-stage screening and review process. Results: We identified 601 journal articles that evaluated integrated interventions. Seventy percent used a randomized design to assess impact with regard to whether the intervention achieved its desired outcomes. Only 26 of these evaluations, however, used a full factorial design, the only design capable of statistically detecting synergistic effects produced by integrating sectors. Of those, seven showed synergistic effects. Conclusions: To date, evaluations of integrated development approaches have demonstrated positive impacts in numerous contexts, but gaps remain with regard to documenting whether integrated programming produces synergistic, amplified outcomes. Research on these program models needs to extend beyond impact only, and more explicitly examine and measure the synergies and efficiencies associated with linking two or more sectors. Doing so will be critical for identifying effective integrated development strategies that will help achieve the multi-sector SDG agenda.

Evaluating the effect of integrated microfinance and health interventions: an updated review of the evidence

BACKGROUND

Solutions delivered within firm sectoral boundaries are inadequate in achieving income security and better health for poor populations. Integrated microfinance and health interventions leverage networks of women to promote financial inclusion, build livelihoods, and safeguard against high cost illnesses. Our understanding of the effect of integrated interventions has been limited by variability in intervention, outcome, design, and methodological rigour. This systematic review synthesises the literature through 2015 to understand the effect of integrated microfinance and health programs.

METHODS

We searched PubMed, Scopus, Embase, EconLit, and Global Health databases and sourced bibliographies, identifying 964 articles exclusive of duplicates. Title, abstract, and full text review yielded 35 articles. Articles evaluated the effect of intentionally integrated microfinance and health programs on client outcomes. We rated the quality of evidence for each article.

RESULTS

Most interventions combined microfinance with health education, which demonstrated positive effects on health knowledge and behaviours, though not health status. Among programs that integrated microfinance with other health components ( i.e. health micro-insurance, linkages to health providers, and access to health products), results were generally positive but mixed due to the smaller number and quality of studies. Interventions combining multiple health components in a given study demonstrated positive effects, though it was unclear which component was driving the effect. Most articles (57%) were moderate in quality.

DISCUSSION

Integrated microfinance and health education programs were effective, though longer intervention periods are necessary to measure more complex pathways to health status. The effect of microfinance combined with other health components was less clear. Stronger randomized research designs with multiple study arms are required to improve evidence and disentangle the effects of multiple component microfinance and health interventions. Few studies attempted to understand changes in economic outcomes, limiting our understanding of the relationship between health and income effects.

Credit with Health Education in Benin: A Cluster Randomized Trial Examining Impacts on Knowledge and Behavior

We evaluate whether health education integrated into microcredit lending groups reduces health risks by improving health knowledge and self-reported behaviors among urban and rural borrowers in eastern Benin. In 2007, we randomly assigned 138 villages in the Plateau region of Benin to one of four variations of a group liability credit product, varying lending groups' gender composition and/or inclusion of health education using a 2 × 2 design. Women in villages receiving health education, regardless of gender composition of the groups, showed improved knowledge of malaria and of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), but not of childhood illness danger signs. No significant changes in health behavior were observed except an increase in HIV/AIDS prevention behavior, a result predominantly driven by an increase in respondents' self-reported ability to procure a condom, likely an indicator of increased perceived access rather than improved preventative behavior. Women in villages assigned to mixed-gender groups had significantly lower levels of social capital, compared with villages assigned to female-only groups. This suggests there may be an important trade-off to consider for interventions seeking improved health outcomes and social capital through provision of services to mixed-gender groups. Although bundling health education with microcredit can expand health education coverage and lower service-delivery costs, the approach may not be sufficient to improve health behaviors.

Community-Based Financing of Family Planning in Developing Countries: A Systematic Review

In this systematic review, we gather evidence on community financing schemes and insurance programs for family planning in developing countries, and we assess the impact of these programs on primary outcomes related to contraceptive use. To identify and evaluate the research findings, we adopt a four‐stage review process that employs a weight‐of‐evidence and risk‐of‐bias analytic approach. Out of 19,138 references that were identified, only four studies were included in our final analysis, and only one study was determined to be of high quality. In the four studies, the evidence on the impact of community‐based financing on family planning and fertility outcomes is inconclusive. These limited and mixed findings suggest that either: 1) more high‐quality evidence on community‐based financing for family planning is needed before any conclusions can be made; or 2) community‐based financing for family planning may, in fact, have little or no effect on family planning outcomes.

Group-based microfinance for collective empowerment: a systematic review of health impacts

Objective

To assess the impact on health-related outcomes, of group microfinance schemes based on collective empowerment.

Methods

We searched the databases Social Sciences Citation Index, Embase, MEDLINE, MEDLINE In-Process, PsycINFO, Social Policy & Practice and Conference Proceedings Citation Index for articles published between 1 January 1980 and 29 February 2016. Articles reporting on health impacts associated with group-based microfinance were included in a narrative synthesis.

Findings

We identified one cluster-randomized control trial and 22 quasi-experimental studies. All of the included interventions targeted poor women living in low- or middle-income countries. Some included a health-promotion component. The results of the higher quality studies indicated an association between membership of a microfinance scheme and improvements in the health of women and their children. The observed improvements included reduced maternal and infant mortality, better sexual health and, in some cases, lower levels of interpersonal violence. According to the results of the few studies in which changes in empowerment were measured, membership of the relatively large and well-established microfinance schemes generally led to increased empowerment but this did not necessarily translate into improved health outcomes. Qualitative evidence suggested that increased empowerment may have contributed to observed improvements in contraceptive use and mental well-being and reductions in the risk of violence from an intimate partner.

Conclusion

Membership of the larger, well-established group-based microfinance schemes is associated with improvements in some health outcomes. Future studies need to be designed to cope better with bias and to assess negative as well as positive social and health impacts.

Community Health Workers' Provision of Family Planning Services in Low- and Middle-Income Countries: A Systematic Review of Effectiveness

This systematic review evaluates the strength of the evidence that community health workers' (CHW) provision of family planning (FP) services in low- and middle-income countries is effective. In a search of eight databases, articles were screened by study design and outcome measure and ranked by strength of evidence. Only randomized trials, longitudinal studies with a comparison group, and pre-test/post-test studies met inclusion criteria. A total of 56 studies were included. Of those studies with relevant data, approximately 93 percent indicated that CHW FP programs effectively increased the use of modern contraception, while 83 percent reported an improvement in knowledge and attitudes concerning contraceptives. Based on these findings, strong evidence exists for promoting CHW programs to improve access to FP services. We recommend a set of best practice guidelines that researchers and program managers can use to report on CHW FP programs to facilitate the translation of research to practice across a wide range of settings.

Meeting rural demand: a case for combining community-based distribution and social marketing of injectable contraceptives in Tigray, Ethiopia

Background

In Sub-Saharan Africa, policy changes have begun to pave the way for community distribution of injectable contraceptives but sustaining such efforts remains challenging. Combining social marketing with community-based distribution provides an opportunity to recover some program costs and compensate workers with proceeds from contraceptive sales. This paper proposes a model for increasing access to injectable contraceptives in rural settings by using community-based distributers as social marketing agents and incorporating financing systems to improve sustainability.

Methods

This intervention was implemented in three districts of the Central Zone of Tigray, Ethiopia and program data has been collected from November 2011 through October 2012. A total of 137 Community Based Reproductive Health Agents (CBRHAs) were trained to provide injectable contraceptives and were provided with a loan of 25 injectable contraceptives from a drug revolving fund, created with project funds. The price of a single dose credited to a CBRHA was 3 birr ($0.17) and they provide injections to women for 5 birr ($0.29), determined with willingness-to-pay data. Social marketing was used to create awareness and generate demand. Both quantitative and qualitative methods were used to examine important feasibility aspects of the intervention.

Results

Forty-four percent of CBRHAs were providing family planning methods at the time of the training and 96% believed providing injectable contraceptives would improve their services. By October 2012, 137 CBRHAs had successfully completed training and provided 2541 injections. Of total injections, 47% were provided to new users of injectable contraceptives. Approximately 31% of injections were given for free to the poorest women, including adolescents.

Conclusions

Insights gained from the first year of implementation of the model provide a framework for further expansion in Tigray, Ethiopia. Our experience highlights how program planners can tailor interventions to match family planning preferences and create more sustainable contraceptive service provision with greater impact.

Determinants of better health: a cross-sectional assessment of positive deviants among women in West Bengal

Background

Rural women in West Bengal have been found to have low rates of formal education, poor health knowledge, high rates of malnutrition and anemia, and low levels of empowerment. Despite these difficult circumstances, some women have positive health outcomes compared to women with similarly disadvantaged backgrounds. The purpose of this study is to identify factors associated with positive health outcomes among women with primary education or less.

Methods

Multivariable regression models were built for outcomes of positive deviance to better characterize the factors in a woman’s life that most impact her ability to deviate from the status quo.

Results

Positive deviants in this context are shown to be women who are able to earn an income, who have access to information through media sources, and who, despite little schooling, have marginally higher levels of formal education that lead to improved health outcomes.

Conclusions

Study findings indicate that positive deviant women in disadvantaged circumstances can achieve positive outcomes amidst a host of contextual barriers that would predict poor health outcomes. Focusing on areas such as enhancing access to media sources, facilitating self-help groups for married women, and promoting prolonged education and delayed marriage for girls may improve health knowledge and behavior among married women with low levels of education.

The economic consequences of reproductive health and family planning

We consider the evidence for the effect of access to reproductive health services on the achievement of Millennium Development Goals 1, 2, and 3, which aim to eradicate extreme poverty and hunger, achieve universal primary education, and promote gender equality and empower women. At the household level, controlled trials in Matlab, Bangladesh, and Navrongo, Ghana, have shown that increasing access to family planning services reduces fertility and improves birth spacing. In the Matlab study, findings from long-term follow-up showed that women's earnings, assets, and body-mass indexes, and children's schooling and body-mass indexes, substantially improved in areas with improved access to family planning services compared with outcomes in control areas. At the macroeconomic level, reductions in fertility enhance economic growth as a result of reduced youth dependency and an increased number of women participating in paid labour.