Poor women want contraceptives they can hide

by Rhona Mahony. Many women in developing countries tell surveyors that they want to have no more children or that they would like to space the births of their future children. Yet, in some countries, over half of those women have never used modern contraception. Private clinics, pharmacies, and public clinics in many developing countries now sell birth control cheaply. Why aren’t women taking advantage of it? A cleverly designed experiment in Lusaka, the capital of Zambia, has found one reason. Husbands want more children than their wives do. When wives in Lusaka had a chance to get contraceptives that their husbands didn’t know about, 23 percent more went to the public clinic’s family planning nurse and 38 percent more chose a form of birth control that could be hidden from their husbands, such as an injectable contraceptive. The result: those women had 57 percent fewer unwanted births.

Family planning staff members in many countries have been experimenting with programs to reduce the number of unwanted births. Some are including husbands with their wives in meetings to explain contraceptive methods. The Lusaka experiment suggests that as long as husbands want more children than their wives do, and can get their way, increasing the participation of husbands–and therefore their knowledge of their wives’ birth control plans–may backfire.

Three economists from Harvard University–Nava Ashraf, Erica Field, and a graduate student, Jean Lee–designed and ran the experiment in Lusaka, with funding from the National Science Foundation, the Hewlett Foundation, and the Women and Public Policy Program at Harvard’s Kennedy School. Field workers identified 836 married women in the Chipata district of Lusaka willing to participate. The economists randomly assigned the women to an individual group or a couples group. Field workers gave a colorful voucher to each wife entitling her to free contraception at the Chipata government health clinic with a guaranteed waiting time of one hour or less. In the couples group, field workers handed the voucher to the women in the presence of their husbands. In the individual group, they gave the voucher to the women without revealing the offer to the husband. It was up to the wives in the individual group whether or not to let their husbands know about it.

The voucher was valuable. The experiment’s funding made it possible to stock the Chipata Clinic with plenty of injectable Depo-Provera (by Pfizer, Inc.) or implantable Jadelle (manufactured by Bayer Schering Pharma Oy), both eminently hideable inside its user living in a tiny, meagerly furnished house, and both normally out of stock at the clinic. The funding also paid for a nurse dedicated to participating women, so that their waiting time could be kept unusually short. Women who got a secret voucher made their aspirations clear; they queued up to reduce their births and deceive their husbands.

Why might husbands want large families? Economists suspect that husbands don’t take into account how much time and effort child raising requires, since it is their wives’ time and effort, not their own. Most likely, also, few husbands understand that spacing births several years apart results in healthier wives and brighter children. Ashraf, Field, and Alessandra Voena, a Stanford University economics graduate student, are now experimenting in Lusaka with ways to change men’s notions of the ideal number of children. They must also work to update the religious scruples of pharmacists and nurses who refuse to provide contraceptives to women who lack their husbands’ permission, or husbands entirely, for fear of encouraging fornication, infidelity, or battering. According to Field, such paternalism is widespread in Africa.

In Brazil and India, social scientists have found that television soap operas featuring stylish and small middle-class families made millions of poor couples want fewer children. Could the soap operas be dubbed? Or refilmed round the world for new viewers?

“Household Bargaining and Excess Fertility: An Experimental Study in Zambia,” Nava Ashraf, Erica Field, and Jean Lee; November 10, 2009 (unpublished)
Society for Family Health, Lusaka, Zambia