Maternal Health Initiative

Final Report – A Summary of Our Work and Our Decision to Shut Down

bcswilliamson — Fri, 15 Mar 2024 16:48:59 +0000

Final Report – A Summary of Our Work and Our Decision to Shut Down

The leadership team of MHI have decided to shut down the organisation in March 2024 in the belief that MHI’s work is not the most effective use of the resources at its disposal.

The report below describes MHI’s work in detail alongside our decision to shut down.

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An Assessment of MHI’s Pilot Project

bcswilliamson — Tue, 06 Feb 2024 12:58:33 +0000

An Assessment of MHI's Pilot Project

The Maternal Health Initiative (MHI) delivered a pilot project from July 2023 to January 2024 across six hospitals in the Northern Region of Ghana. This work was conducted in partnership with Norsaac and the Ghana Health Service.

MHI would like to share the results of its internal assessment of this project based on an analysis of the baseline and endline data collected through the pilot.

Executive Summary

In this project, the Maternal Health Initiative (MHI) and Norsaac worked together to implement a programme aiming to increase contraceptive knowledge and uptake. This programme focused on training nurses and midwives on delivering an adjusted model of contraceptive counselling integrated into routine postpartum appointments.
This was a pilot project in which we aimed to compare the value of one-to-one family planning counselling during routine postnatal care sessions (PNC) against the value of short messaging and family planning referral integrated into child welfare clinic sessions (CWC)
Endline data suggests that the PNC program produced an increase in contraceptive uptake, with no clear change observed in the CWC program. Due to inconsistencies between data sources and overall data quality concerns, we have low confidence in the extent of positive impact from either program.
Research prompted by our pilot results suggests that contraceptive uptake in the early postpartum period may be significantly less valuable than expected. This is due to the high level of pregnancy prevention many women are likely gaining from unexpectedly high rates of breastfeeding and sexual abstinence.
Based on the results presented in this report alongside further research and engagement with experts, we conclude that neither project is worth further implementation or scaling at this time.

Full Report

For more detail about the project and its outcomes, please refer to the full project report below.

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Maternal Health Initiative – 1st Year in Review

bcswilliamson — Wed, 15 Nov 2023 14:08:22 +0000

Maternal Health Initiative - 1st Year in Review

The Maternal Health Initiative (MHI) works in northern Ghana delivering a light-touch programme of training integrating contraceptive counselling into routine care to increase informed choice and uptake of family planning methods. We deliver this work in partnership with two local NGOs and the Ghana Health Service, launching through the 2022 Charity Entrepreneurship Incubation Programme.

Summary

In our first year, we…

Developed and tested two evidence-based models of care with an estimated cost-effectiveness of $100/DALY on health effects alone, competitive with GiveWell’s top charities
Trained providers at 18 facilities across 2 regions of Ghana, reaching an estimated 40,000 women over the next year
Conducted in-depth on-the-ground research, surveying 836 women and 148 providers & facility directors
Successfully increased the frequency of 1:1 family planning counselling by 4.3x at postnatal care and group family planning messaging by 8x at immunisation sessions, with results for shifts in contraceptive uptake due in December 2023.

We’re currently awaiting our full results from our pilot. With strong results, we plan to scale our work through 2024 in partnership with the Ghana Health Service as we build towards government adoption of our model of care.

Who are MHI?

Maternal Health Initiative is an early-stage global health charity with a focus on healthcare worker training and access to family planning. MHI was born out of research conducted by Charity Entrepreneurship identifying postpartum (post-birth) family planning as among the most cost-effective and evidence-based approaches for improving global health.

Our team now includes Sofia Martinez Galvez as our Program Officer, Sulemana Hikimatu Tibangtaba as our Training Facilitator, and Enoch Weyori and Racheal Antwi as Project Officers through our local implementing partners, Norsaac and Savana Signatures.

What we do

We train midwives and nurses in the integration of two new models of family planning counselling developed by MHI into the standard check-ups mothers and their children receive in the months after giving birth.

In doing so, our work increases postpartum contraceptive uptake and decreases the frequency of short-spaced births. Pregnancies that occur less than two years apart are associated with a 32% higher rate of maternal mortality and 18% higher rate of infant mortality (Conde-Agudelo 2007; Kozuki 2013). Despite these risks, contraceptive use in Ghana drops by two-thirds in the early postpartum period.

Integrating high-quality counselling into routine care addresses multiple barriers to contraceptive uptake. First, mothers do not need to travel to a facility specifically for family planning. This means that they can receive confidential information and that they are spared the costs – both in time and money – of a separate visit.

Second, many women express significant concerns around side effects and health consequences from family planning. High-quality counselling ensures women receive counselling on multiple methods – helping to find a method that avoids the side effects they may be concerned about – while addressing myths and misconceptions that can drive opposition to the use of methods.

Why Ghana?

One of our first decisions was choosing which country to operate in. We conducted field visits to Sierra Leone and Ghana in January 2023 after an extensive process of research, data evaluation, and expert engagement that identified these as the best choices out of 44 countries considered.

Statistically, Ghana has a high unmet need for family planning and significant maternal and infant mortality, while having one of the highest levels of facility delivery and most robust governance structures in sub-Saharan Africa. Government integration provides a route to potentially transformative cost-effectiveness at scale, making the last two factors – level of facility delivery and governance quality – particularly crucial to our work.

Models of care

Our work is built around two models of care (program arms), targeting different points in the continuum of care after delivery. Each program is built directly off an RCT of a similar model (Asah-Opoku et al., 2023; Dulli et al., 2016), with a large body of evidence demonstrating the impact of postpartum family planning more broadly.

The postnatal care (PNC) arm integrates 10-15 minute family planning counselling into existing individual one-on-one appointments that take place 48 hours, 2 weeks, and 6 weeks post-birth. We developed a conversation guide and method cards to facilitate sessions and emphasise the delivery of client-centred care.

The child welfare clinic (CWC) arm targets the monthly sessions mothers attend from six weeks onwards with a primary focus on their child’s health and wellbeing. Our programming adds a group talk on family planning as well as brief, 1:1 counselling on family planning during vaccination into these sessions. We developed a flipchart for the group talk, as well as a card for very brief discussion during the 1:1 engagement.

For both of our program arms, we have carefully designed materials that are specifically tailored to the point of care and needs of the women we serve. Hospitals can be understaffed with providers overstretched, making it crucial to design improvements to care that are feasible and easy for providers to use. We have received consistently positive feedback from providers on the practicality of our tools.

Program Delivery

This year, MHI ran three major projects covering 18 facilities across two regions of Ghana. In total, we estimate around 40,000 women will receive MHI’s model of counselling through these projects.

Proof of Concept

In April 2023, we ran our first two training sessions at the conclusion of an extensive process of qualitative research in which we interviewed 151 clients and providers.

One key aim was to understand the feasibility of delivering single-day training sessions. Most other family planning training interventions we researched involved multi-day or even multi-week training sessions. One-day training placed significant time constraints on our program delivery with obvious and significant cost-saving benefits.

Data from two of the six facilities indicated a 15% increase in contraceptive uptake in the three months after the training sessions. This gave us confidence in the feasibility of our training delivery, while feedback from the providers and our partners helped us refine our programming models.

Mini-pilot

We launched a ‘mini-pilot’ in July 2023, training 45 providers from hospitals across two regions. Ahead of these training sessions, we shifted to the two models of care described above, more specifically tailoring the training and materials we provide to the points of care at which they will be used.

These training sessions focused on refining the materials and ensuring consistent implementation of the models of care. One-month follow-up data from this project indicates a 4.3x increase in 1:1 counselling at postnatal care and an 8x increase in group counselling at immunisation sessions.

Mini-pilot

These trainings took place in October 2023 after ethical approval from the Navrongo Health Research Centre. We trained 50 providers from six hospitals in the Northern Region. These hospitals receive an estimated 20,000 clients annually.

We are currently conducting a six-week follow-up at these facilities to measure contraceptive uptake as a result of the intervention, through both in-person and phone surveying. These results will form the basis of MHI’s 2024 programming decisions and further engagement with the Ghana Health Service on next steps towards national programme adoption.

Our Impact

Estimating the impact of behaviour change interventions is tricky, especially for earlier-stage programs for which long-run data comparisons and evaluations are not possible. We estimate that our pilot programme will avert a disability-adjusted life year (DALY) for just under $100, competitive with the cost-effectiveness of GiveWell top charities such as AMF. If we are successful in achieving government adoption of the program, we estimate the cost per DALY would drop to just $34 while reaching around 800,000 mothers annually.

Beyond this, we firmly believe in the value of the non-health benefits of family planning access. Control over whether and when to have children is a fundamental marker of personal autonomy. There are robust arguments in favour of a much broader view of doing good, with prioritisation on the basis of subjective wellbeing or the capabilities approach providing two examples.

Discussing the merits of these is far beyond the scope of this post, but we believe the fundamental influence child-bearing has on people’s lives makes providing high-quality counselling for less than $2 per person highly valuable beyond its direct health implications.

Our Plans (for 2024 and beyond)

As mentioned above, we will have the results of our pilot program in December 2023, including its impact on contraceptive uptake (the rate of contraceptive use). We have mapped out three scenarios for our 2024 work based on the success of the pilot and on the level of funding we raise in the coming months.

If the results of our pilot are strong, we plan to design a final large-scale evaluation of the most promising programming model (PNC or CWC) in partnership with the Ghana Health Service. This would be explicitly designed to model a fully-integrated model of the program that the government would be open to adopting as part of the Ghana Health Service’s systems and policy should it prove successful.

With weaker results, we will focus on a smaller test of a redesigned model of care, dedicating more resources to testing potentially transformative changes to the delivery of our work, such as a Whatsapp-driven model of training delivery, that could make direct program delivery exceptionally cost-effective in its own right.

How to support us

Donate

If you would like to support our work, you can donate directly through our website. Donations are fully tax-deductible for US tax residents. For larger donations, we’d love to speak to you personally to answer any questions you may have about our work – please reach out through our contact page.

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Initial Assessment: Proof of Concept

bcswilliamson — Mon, 28 Aug 2023 11:41:49 +0000

Initial Assessment - Proof of Concept

MHI ran our first Proof of Concept in the Northern region of Ghana from April to July 2023. This provided the opportunity for MHI to test our training model in practice, learn lessons for the implementation of a larger-scale pilot later in the year, and get a preliminary understanding of our potential impact.

Written by Jemima Jones on behalf of MHI.

Overview

We’re thrilled to have passed such an important milestone in our journey to maximise the quality of information and access to family planning women receive in the post-birth period. Improving family planning services requires a deep understanding of local healthcare practices and logistical possibilities – an understanding that cannot be gained by looking at published data alone.

Our first proof of concept project has been of invaluable help in understanding how family planning information is provided in northern Ghana and allows us to better tailor our training resources. We wish to extend special thanks to our local partner Savana Signatures, who implemented the majority of our on-the-ground work.

An overview of the work we did during Proof of Concept (POC) 1. We gathered 274 data samples, including 172 surveys and interviews.

Key Terms

Clients: postpartum women attending health facilities
Providers: midwives, staff nurses and community health nurses who provide women with family planning counselling.
Supervising nurse: The most senior nurse in a department.
Baseline: First round of surveys and interviews held in April.
Endline: Second round of surveys and interviews held in May.
Northern region: the second largest of the sixteen regions of Ghana. (See picture)

Understanding where we work through facility visits and interviews

In order to better understand how women receive family planning counselling in northern Ghana, we commissioned our partner Savana Signatures to conduct qualitative work in northern Ghana, including observations of sessions, data collection, and private qualitative interviews on our behalf.

We heard from 36 local women and 24 staff members about the family planning counselling they receive or give during antenatal care and child immunisation appointments.
We also observed family planning counselling sessions and gathered data from health facilities on the numbers of women provided with family planning overall and after postnatal counselling, and the number of postnatal family counselling sessions.

Themes we investigated included existing levels of contraceptive use, the prevalence of infertility myths, barriers to contraceptive use and whether women had the chance to ask questions during counselling.

Through this we gained a more informed understanding of what information to highlight and sideline during our training session, and the many questions organically asked about family planning (10/35 participants expressed a desire to know more about it) increased our confidence in the need for improving existing family planning counselling.

How this first stage informed our work

Through analysis of data gathered we have a much deeper and up-to-date understanding of local context. This includes the percentage of women who had ever used contraception (~60-70%), the low prevalence of individual counselling, and the existing tools used by providers (overwhelmingly flipcharts).
To ensure fuller and more reliable data in future, we moved to offline digital forms after quickly discovering our previous system, giving surveyors a spreadsheet to fill in, led to problems. Whilst the offline spreadsheet format did avoid the anticipated connection issues, missed questions were a surprisingly large issue. We now use SurveyCTO, where not only are questions unskippable, but there are many other functionalities that help us monitor the reliability of our data.
After gathering data from facilities on the number of visitors they receive, we decided to shift from focusing on health centres and hospitals to solely focusing on hospitals. One of the two hospitals in our initial sample of six facilities received more visitors per month than any of the other facilities received in an entire year. We believe we can help many more women because of this shift.

Putting our training programme into action

Aunty Theodora, Regional Public Health Nurse from the Ghana Health Service and an MHI training facilitator (far left) with Ben from MHI and the participants at the end of one of our training session.

On the 26th and 28th April, MHI ran two training programmes, designed by MHI and led by facilitators from the Ghana Health Service. Each training programme consisted of four sections, with each section including a lecture and role-play in pairs. The goal of this training is to improve the quality of information shared by providers of family planning counselling, so women can make informed decisions and go on to have happier and healthier futures.

Trainings included information such as the benefits of family planning and how to respond to common concerns and misconceptions, principles of effective counselling, and information on how to conduct a session using a five-step counselling approach.

Before the session, there was an anonymous knowledge test, and we repeated the test both immediately after training and one-month later. Through the pre-training test, we found that existing knowledge levels were higher than we had been expecting – the average score was 79%!

Despite this, there was still room for our training to result in high changes – with absolute changes of over +10% in 11 questions, including two questions where absolute correct answers increased by over 30%.

Overall however, there wasn’t much room for improvement – questions that providers had answered incorrectly in the initial test were often those that were particularly difficult to remember. For example, some birth control methods can only be used at set points postpartum, and remembering which method at which point is comparatively tricky. For this reason, one of the tools we provided to participants at the session was a reference chart on this to use during counselling for this reason.

In the test immediately post-training, the average score had increased 3%, reaching 82%. Alternatively, it can be expressed as a 5% increase to 84% if you don’t include misinformation that was unfortunately shared by an attendee of the session and lowered the average answer to one question by 55 percentage points.

An additional benefit of running two training sessions was spending large amounts of time with our local partners and meeting two dozen healthcare providers. Through listening and talking to them, we learnt that facility buy-in was even more important than we had thought, and strengthened our view that individual counselling is uncommon.

Changes we made as a result of the proof of concept training

In response to the high levels of existing knowledge amongst the providers we trained, MHI have made two changes to our future training programmes:

The training will focus on a specific model of counselling rather than facts about family planning. In practice, this will centre around ensuring providers consistently follow important steps like asking women if they have any concerns about using family planning methods, rather than testing them on how soon after birth IUDs can be inserted.
Instead of training staff from family planning units, we are shifting our focus exclusively to frontline postnatal and child vaccination staff, who have lower knowledge levels. This will also better integrate our services within existing systems.

Participants in MHI’s training reviewing the World Health Organisation’s Medical Eligibility Criteria wheel, a tool integrated into our trainings to ensure providers consistently provide medically safe and correct guidance.

One-month follow up

Tests

For our training to have an impact, it has to be remembered! One month after the training sessions, Savana ran surveys and interviews on our behalf, to help us understand the effectiveness of our training programme and gather additional information on local family planning services. Here’s some of what we did:

We quizzed fourteen of the original training session participants to test retention and surveyed them on the usefulness of the tools we provided, like the cue cards.
Savana observed four family planning information sessions given by the healthcare workers who received our training, so that we could see the extent to which learnings were put into action.

We found that increases observed from the pre-training test to the post-training test were largely retained. Among questions where the average correct answer percentage increased, the average absolute change between the post-training test and the one month follow-up test was only -1.09%!

Counselling in practice

During our training sessions, we provided participants with two tools to improve the quality of counselling women receive. The first was a cue card with a suggested structure for family planning counselling, to ensure that women’s autonomy is fully respected through the processes. Sections in the structure include asking women about understanding the client’s needs and concerns. The second tool was a reference chart showing pictorially which family methods are safe at different points after giving birth.

We asked providers we trained about our tools at a one month follow-up survey. The cue card and reference chart were ranked as 4/5 or 5/5 for usefulness and upskilling power 100% of the time. For each of these, the percentage of people answering 5/5 ranged from 50% – 71%.

Does this reflect actual usage? In the four family-planning sessions our partners observed, one month after the tools were given out, the cue card was used in 75% of sessions and the reference chart was used in 100%.

Facility data evaluation

Has our training influenced contraceptive uptake rates in facilities where staff members underwent our training? This is the key question about the impact of our programming and one we are working hard to answer.

The Ghana Health Service gathers quarterly data on contraceptive uptake at health facilities across the country. In partnership with the Northern Region Health Directorate, MHI is working to track changes to care in the three months since our training. This will allow us to assess changes in contraceptive uptake at the six facilities from which we invited healthcare workers to the training.

At the time of writing, this data is still to be finalised but we will update this article once we have received it.

Programme design changes

Based on the proof of concept work, we've made two major changes for our future work

First, we’ve split our programming into two models. Survey data and conversations on the ground from POC 1 suggest that rates of individual counselling are lower than we expected from our engagements with other stakeholders. However, research from other countries suggests that individual counselling substantially increases family planning uptake, and this was recently corroborated by a study performed at two major hospitals in Accra, where shifting from group to individual counselling in PNC increased postpartum contraceptive uptake from 12.6% to 51% (Asah-Opoku et al 2023).

Our other programming arm will target child welfare clinic sessions specifically. These occur later in the postpartum period when the natural contraceptive benefits of breastfeeding begin to fall away and the use of family planning therefore becomes particularly salient and important. This avenue of work is based of the program implemented by Dulli et al. (2016)

Second, we’ve put an emphasis on increasing the accountability systems that we provide. We have seen how time-pressed providers are and how it is easy for best practices to fall through the cracks. We are offering small financial incentives to providers who follow best practices, selecting ‘Birth Spacing Champions’ for each facility, and increasing the rigour of our pre-post monitoring systems.

These changes are in addition to those already discussed: promoting a specific model of family planning counselling in our training sessions, and exclusively training frontline staff. Depending on our level of success with this programming, we anticipate beginning to scale one or both models across additional regions of Ghana towards the end of 2023.

Counselling in practice

Facility data evaluation

Wrapping up

Our first Proof of Concept was invaluable. It validated key aspects of our theory of change, providing evidence that participants can retain learning from training sessions for meaningful periods and that providers are willing to adopt new materials and approaches for how they deliver care. It also affirmed our fundamental assumptions, such as there being a significant unmet need for family planning amongst our target communities.

Finally, POC 1 deepened our understanding of the local context, and revealed opportunities to iterate on our model and better improve the lives of the women we hope to serve.

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The Importance of Birth Spacing

Sarah Hough — Mon, 24 Apr 2023 14:21:19 +0000

The Importance of Birth Spacing

An introduction to the value of birth spacing, highlighting the important role promoting this plays in the impact of our work. Written by Samuel Harvey on behalf of MHI. Credit for photos to the Images of Empowerment project, unless otherwise stated.

Esther and her husband Francis squeeze into the back of a taxi at 3am – her pregnant belly only just fitting behind the front seat. “Kwahu Hospital please driver”, Francis says more calmly than he feels. Esther had known this moment was coming for eight months, but something was wrong this time. Her contractions were starting weeks earlier than she’d expected and they felt different from her previous labour.

The memory of her last birth flashed back to Esther. It was just over a year ago that they’d been blessed with a daughter. Things went well for her that time, but something told her things weren’t going to be as smooth today.

The realities of maternal mortality

For many, it is easy to forget the tremendous risk that pregnancy and labour can pose to both mother and child. In the West – with our advanced sanitation and medical practices – each maternal and neonatal death is regarded as an unusual tragedy. But in some places, it is still a disturbing part of everyday life. Esther, our fictional woman from rural Ghana, has good reason to feel so frightened. In sub-Saharan Africa, one in fourteen children die before their fifth birthday [1] and one in 40 women will lose their life because of childbirth. [2]

Source: [3] Our World in Data. Child deaths by world region, 1950 to 2021 [Internet]. [cited 2022 Feb 04]. Available from: https://ourworldindata.org/child-mortality

There are many reasons why Esther and her child have the odds stacked against them. Key factors include higher rates of infectious disease, poor nutrition, and limited access to healthcare. One factor that may not immediately come to mind, however, is the short spacing between her previous pregnancy and this one.

‘Birth spacing’ is the amount of time between two consecutive pregnancies, with guidelines from the World Health Organisation recommending couples wait 24 months after a live birth before trying to become pregnant again [4]. However, a significant proportion of global births occur at much shorter intervals. A systematic review published in 2022 found that the frequency of short birth intervals in low and middle income countries (LMICs) could be as high as 66% [5].

Overall, our time in Sierra Leone was illuminating in understanding the specific successes and challenges of family provision in the country and the specific avenues along which MHI might best provide unique value. Our visit also proved fruitful in meeting with multiple potential partner organisations who can help MHI carry out preliminary research and testing work in the country, with whom we are currently finalising understandings of how we could proceed.

Why does birth spacing matter?

Lying on her hospital bed, Esther is drowsy and in a lot of pain but her thoughts are only with her newborn son. She cranes her neck to the left and sees a crowd surrounding the resuscitation trolley with her five-minute-old child in the centre.

The people surrounding her son go about their work with a calm sense of urgency. Someone is helping the tiny child breathe with a mask; another is wrapping monitor leads around his foot. Esther starts to feel light-headed. She tries to keep her eyes open but slips into a fitful sleep.

Stories like this play out in hospitals, birthing units, and homes throughout the world every day. Each terrible outcome is influenced by a combination of lifestyle factors, genetics, and bad luck. Compared with risks like smoking or malnutrition, something like birth spacing seems innocuous enough to hardly seem relevant. But the fact is this: short birth spacing kills mothers and children every day.

There is strong evidence that short birth spacing effectively doubles the risk of childhood mortality and stillbirths compared to adequately spaced births [5]. This contributes to a significant burden of preventable premature death in LMICs. In fact, a report from the World Health Organisation estimates that in less developed countries, almost 900,000 deaths of children under 5 years old could be prevented by spacing births at least 24 months apart, with a further 940,000 prevented with a spacing of 36 months. [6]

Source: [7] Rutstein SO. Further evidence of the effects of preceding birth intervals on neonatal, infant and under-five-years mortality and nutritional status in developing countries: evidence from the Demographic and Health Surveys. DHS Working Papers, Demographic and Health Research (41), 2008.

Short-spaced births also put an incredible amount of physiological stress on the mother. Without sufficient time to recover from a previous pregnancy, women are at increased risk of death and disease. This is mainly through increased rates of anaemia, postpartum haemorrhage, uterine rupture, and obstetric fistula. [8]

Adequate birth spacing can have a multitude of benefits beyond just preventing infant and maternal deaths. In the simplest terms, birth spacing can improve quality of life as a whole for both parents and children, while bringing significant benefit to women’s autonomy.

Parenting is challenging to begin with, and this challenge is compounded when juggling the needs of multiple children. People in developing countries likely face additional hurdles, such as financial insecurity, poorer health, and overstretched government support. Imagine you are Esther six months after the birth of her second child. Assuming a traditional family set up (as is common in Ghana), she is likely to be given the primary responsibility of looking after the children in these early years. Every day she will face many small decisions about where to put her time and money. 18 months is a very social age for a toddler, a time where they probably just want to play with mum, but Esther will also have a hungry infant who needs to be fed and therefore have less time to play. Maybe Esther would prefer to breastfeed the older child for longer but she doesn’t have the physical energy to feed both at the same time.

The financial decisions are also difficult. Perhaps they can only afford to send one child to school, afford fewer doctor visits between the two children, and have to ration food between the children at times to feed them both. Longer birth spacing gives breathing room to families, making these tough choices less common. Parents can allocate more time, energy, and attention to each child, resulting in improved wellbeing, health, education, and happiness.

Furthermore, adequate birth spacing can allow women additional time and energy to pursue activities outside of childrearing. Instead of being solely responsible for raising children, women have the choice to pursue other interests, such as furthering their education, starting a business, or advancing their careers. This can lead to increased economic independence and self-esteem, which benefits not only women but also their families and communities.

Why does short birth spacing negatively impact health?

After a while, Esther wakes up feeling groggy but relieved to see her son by her side. He is noticeably smaller than the other newborns in the room, but is breathing on his own and seems peaceful. She lets out a sigh of relief as she recalls the urgency in the room and the need for medical intervention. A nurse explains that Esther was anaemic and needed a blood transfusion, while her son required some help with breathing.

Happily, the nurse assures Esther that both she and her baby are stable now. Esther is grateful to have received the necessary care, but wonders how this could have happened, especially because her last pregnancy a year ago had gone so smoothly.

The health of a mother and her baby are intimately linked. In Esther’s case, research suggests that short birth spacing could have had a direct impact on her own health and the health of her new child. While the exact causes of these negative effects are not fully understood, observational studies have identified several possible mechanisms.

A potential cause of the negative effects associated with short birth spacing is maternal nutrition depletion. When a mother’s body is unable to fully recover from the demands of a previous pregnancy before starting a new one, there may not be enough nutrients for both the mother and the foetus. This creates a state of biological competition that puts both at risk [8]. This effect is even more significant in areas where nutrition is often inadequate. Interestingly, one study has found that the negative impacts of short birth spacing become less pronounced as the development level of the country increases [9]. This could provide further support for the hypothesis of nutritional depletion, as women in higher-income countries are less likely to experience malnourishment.

Another potential mechanism is sibling competition, where siblings that are close in age may compete for resources, parental care, and attention. This point about resource sharing is quite tangible in areas where access to food is legitimately limited and there may be significant rationing between children. The second point is less obvious but plausibly can increase stress levels for both the parents and the children, leading to adverse outcomes. In a similar vein, another suggested mechanism is that having more children around increases the chances of children spreading infectious disease between one another, therefore increasing childhood mortality.

Source: Hanna Morris on Unsplash

Birth spacing as a cultural norm

In our story, Esther had given birth within a year of having her last child. As we have seen, this is quite a common occurrence in some LMICs. This is not the story everywhere, however. The concept of birth spacing is certainly not new, and already a cultural norm in some parts of West Africa. One example is the concept of “Nef” in Senegal, which highlights a traditional emphasis on ensuring significant spacing between births.

A 2019 article explored the relationship between Nef, birth spacing and family planning by interviewing Senegalese men and women [10]. Nef was described most commonly as becoming pregnant while still breastfeeding, with the ideal length of breastfeeding being two years. Interestingly, this aligns with the WHO recommendation for birth spacing (24 months).

The overarching theme from the paper was that Nef is viewed quite negatively and carries a strong social stigma. One reason for this stigma is the poor health outcomes that Nef can inflict on a woman. Some of the beliefs discussed about birth spacing touch on the mechanisms discussed earlier in this post.

For example, interviewees often emphasised the importance of resting and regaining strength after childbirth:

“If a woman does not respect birth spacing it will cause health issues for her and she will have problems to take care of her children, she can develop anaemia because if we give birth each year we can develop blood problems.” [10]

In terms of why birth spacing is valued In the Senegalese context, it appears to be based on the way in which it strengthens her ability to adhere to the traditional role of mother by giving her more energy and time to better care for children and family. [10]

While this study focused on Senegal, it suggested positive attitudes towards longer birth spacing are widespread in West Africa, making it a natural fit for organisations to work with communities to promote positive change in this area. It is important to note that the local values and motivations behind birth spacing may differ from Western ones, and it is crucial to understand these differences when working in the region.

Barriers to birth spacing

There are a number of reasons why adequate birth spacing isn’t widely practised despite being beneficial and aligned with cultural values.

One factor is a lack of knowledge about its importance. In many places in Sub-Saharan Africa, good health information is hard to come by. Many women only interact with the health system very infrequently (often only when they give birth) and schools do not provide reproductive health information reliably. The health services that they can access may also be of poor quality and be inconsistent in providing family planning information.

There is also a general lack of understanding around modern contraceptives, leading to harmful misconceptions that drive hesitation in the use of family planning methods [11].

Finally, there is the problem of accessing contraceptives. Contraceptive availability varies based on the region and can be subject to supply issues. On top of this, while most contraceptives are relatively cheap, they are not entirely free. In a part of the world home to many of the poorest people on the planet, this barrier may be significant.

How MHI addresses this problem

At the Maternal Health Initiative, we’re working to promote birth spacing by training health workers to provide family planning counselling in both the antenatal and postpartum period. The postpartum period is a particularly important touchpoint because contraceptive use is typically very low at this time.

One driver of this is an incorrect belief that it is impossible to become pregnant soon after childbirth when in fact fertility can return as early as four weeks after giving birth [12]. Beyond this, the only time many women interact with the healthcare system is when they give birth, which makes these sessions a unique opportunity to provide individuals with information and access to family planning solutions.

Source: Source: [13] Track 20. Trends in the Uptake of Postpartum Family Planning [Internet] [cited 2023 May 09] Available from: https://www.track20.org/pages/data_analysis/in_depth/PPFP/trends.php

MHI trains providers at health facilities to give up-to-date, evidence-based family planning advice so women like Esther can make informed decisions about the future of their families. By empowering healthcare providers with the knowledge and tools to provide effective counselling, we can support them in offering consistent information tailored to the needs and understandings of the women who they counsel.

Our current partnerships in the Northern Region of Ghana are helping us to test the best approaches to providing this training before we begin to scale this support across the country.

Inspired by MHI’s work? Please follow our work through our newsletter, reach out to us directly through our contact form, or consider donating to help us expand our work. Thank you for your support.

References

[1] Child mortality [Internet]. UNICEF DATA. 2023 . Available from: https://data.unicef.org/topic/child-survival/under-five-mortality/

[2] Maternal mortality rates and statistics [Internet]. UNICEF DATA. 2023. Available from: https://data.unicef.org/topic/maternal-health/maternal-mortality/

[3] Our World in Data. Child deaths by world region, 1950 to 2021 [Internet]. [cited 2023 Feb 04]. Available from: https://ourworldindata.org/child-mortality

[4] World Health Organization. Reproductive Health and Research. Geneva: WHO; 2007. [cited 2023 Feb 04]. Available from: https://web.archive.org/web/20170202023531/http://apps.who.int/iris/bitstream/10665/69855/1/WHO_RHR_07.1_eng.pdf

[5] Islam MZ, Billah A, Islam MM, Rahman M, Khan N. Negative effects of short birth interval on child mortality in low- and middle-income countries: A systematic review and meta-analysis. J Glob Health. 2022 Sep 3;12:04070. doi: 10.7189/jogh.12.04070. PMID: 36057919; PMCID: PMC9441110. [cited 2023 Feb 04] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9441110/

[6] Bakamjian LCS, Cianci S, Malandrino C, et al. Programming strategies for postpartum family planning. Eur J Obstet Gynecol Reprod Biol. 2013;13:23. Available from: https://apps.who.int/iris/bitstream/handle/10665/93680/9789241506496_eng.pdf

[7] Rutstein SO. Further evidence of the effects of preceding birth intervals on neonatal, infant and under-five-years mortality and nutritional status in developing countries: evidence from the Demographic and Health Surveys. DHS Working Papers, Demographic and Health Research (41), 2008.

[8] Conde-Agudelo, A., Rosas-Bermudez, A., Castaño, F., & Norton, M. H. (2012). Effects of birth spacing on maternal, perinatal, infant, and child health: a systematic review of causal mechanisms. Studies in Family Planning, 43(2), 93-114. doi:10.1111/j.1728-4465.2012.00308.x. PMID:23175949.

[9] Joseph Molitoris, Kieron Barclay, Martin Kolk; When and Where Birth Spacing Matters for Child Survival: An International Comparison Using the DHS. Demography 1 August 2019; 56 (4): 1349–1370. doi: https://doi.org/10.1007/s13524-019-00798-y

[10] Duclos, D., Cavallaro, F. L., Ndoye, T., Faye, S. L., Diallo, I., Lynch, C. A., … Penn-Kekana, L. (2019). Critical insights on the demographic concept of “birth spacing”: locating Nef in family well-being, bodies, and relationships in Senegal. Sexual and Reproductive Health Matters, 27(1), 136-145. https://doi.org/10.1080/26410397.2019.1581533

[11] Hindin, D. J., McGough, L. J., & Adanu, R. M. (2012). Misperceptions, misinformation and myths about modern contraceptive use in Ghana. Journal of Family Planning and Reproductive Health Care, 38(4), 251-255. https://doi.org/10.1136/jfprhc-2012-100464

[12] Jackson E, Glasier A. Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol. 2011;117:657–662. https://doi.org/10.1097/AOG.0b013e31820ce18c.

[13] Track 20. Trends in the Uptake of Postpartum Family Planning [Internet] [cited 2023 Feb 05] Available from: https://www.track20.org/pages/data_analysis/in_depth/PPFP/trends.php

The post The Importance of Birth Spacing appeared first on Maternal Health Initiative.

Stakeholder Engagement Visits: Jan-Feb 2023

bcswilliamson — Fri, 31 Mar 2023 12:37:28 +0000

Stakeholder Engagement Visits: Jan-Feb 2023

The Maternal Health Initiative’s (MHI) team had the pleasure of conducting a month-long visit to Sierra Leone and Ghana across January and February 2023. This trip provided the opportunity for MHI to engage with a broad range of key stakeholders as the team lays the groundwork for a program of preliminary research and initial pilot testing of our contraceptive counselling training through March and April.

Sierra Leone

The trip began with around 10 days in Freetown, a city with beautiful coastal views and the capital of Sierra Leone. Freetown is the hub of much of the international development work across Sierra Leone, providing a convenient opportunity to meet with the leadership teams of multiple major international NGOs. Meeting with the United Nations Population Fund (UNFPA) and Planned Parenthood Sierra Leone (PPASL) gave us clear insight into the challenges of ensuring comprehensive access to family planning across the country.

A visit to the Aberdeen Women’s Centre, a dedicated maternal hospital funded by the Fistula Foundation, was a fantastic opportunity to speak to providers of family planning services directly. Here, we were able to witness the complexity of providing high-quality service to a continual flow of clients and the strategies healthcare workers employ to overcome these difficulties.

While in Freetown, we were also kindly invited to speak to the Program Manager for Reproductive Health work for the Government of Sierra Leone. This initial meeting lays the foundation for future collaboration and helps MHI ensure that our work is truly providing additional value, addressing gaps in existing work by the government and other actors.

Venturing beyond Freetown, we travelled to the regional city of Bo to continue engaging with a variety of key stakeholders. In Bo, we had the pleasure of engaging with the regional team for Marie Stopes International, researchers from Njala University, and the fantastic team delivering high quality care at the Haikal clinic. Learning directly from midwives and clinicians here about the approaches they take to providing family planning services was particularly insightful.

Travelling around Bo also brought the team our first experience of the bright, three-wheeled keke’s that from an integral part of transport in the country. The open sides offer a welcome breeze in the humidity and heat of Sierra Leone’s dry season.

Ghana

With a firm intention of maximising the value of our trip, we also spent the best part of two weeks in Ghana. This provided the opportunity to build on the connections and understanding from an initial scoping visit to the country in October 2022.

Thanks to an enhanced understanding of the Ghanaian healthcare system and work of key organisations from that trip, we were able to focus our efforts on engaging local NGOs who we may be able to partner with.

Based initially in Osu, a busy suburb towards the west of Accra’s city centre, we met with some of the leading organisations implementing work to improve the quality and reach of reproductive health services across Ghana. Engaging in detailed discussion with these organisations provided fantastic insight around how best to implement an initial program of work, and how to design it with a view to scaling its value in partnership with the national government.

We are particularly excited about carrying out work in the north of Ghana and were also able to travel to Tamale, capital of the Northern Region, for four or five days. Here, we met with some fantastic local organisations and were able to set in motion plans to conduct preliminary work across several regional clinics and hospitals in the coming weeks.

Our time in Ghana has left us feeling energised about the prospects of delivering a truly impactful and scalable counselling training. We’re now hard at work building on this momentum and carrying it through into designing and running our first training workshops in the coming weeks.

We’re excited to continue this journey and to share it with you as we look to maximise the value MHI can bring to women and children across sub-Saharan Africa. As ever, if you have any thoughts or questions about our work, please don’t hesitate to reach out to us.

The post Stakeholder Engagement Visits: Jan-Feb 2023 appeared first on Maternal Health Initiative.

Family Planning: A Significant Opportunity for Impact

bcswilliamson — Thu, 12 Jan 2023 10:10:06 +0000

Family Planning: A Significant Opportunity for Impact

This post was written as MHI was being founded in August 2022 as part of our research into the potential impact of family planning work and the best opportunities in this area of work. It provides an overview of our reasoning for pursuing work in family planning, and postpartum family planning specifically.

This was submitted to Open Philanthropy’s Cause Exploration Prize and originally published on the EA Forum.

Summary

218 million women in low- and middle-income countries (LMICs) lack access to modern contraceptives.
Lack of contraceptive access resulted in 85 million unintended pregnancies in 2019. Pregnancy-related complications are a major cause of death and disability in LMICs, with around 300,000 women and girls dying of pregnancy-related complications each year. Other negative outcomes of unwanted pregnancies include health risks for newborns, decreased autonomy, and negative economic impacts for families and communities.
There are several highly cost-effective existing interventions in this space, such as radio messaging and integrating family planning services into postpartum care, that are comparable or even more cost-effective than existing GiveWell top charities.
While there is substantial investment in this space by non-EA actors, there remain highly neglected geographies and significant outstanding opportunities, particularly for a funder focused on maximising impact and cost-effectiveness.

Importance

1 in 10 women of reproductive age worldwide want to postpone or avert a pregnancy but are not using modern contraception (UN DESA, 2020). This unmet need for family planning means that an estimated 218 million women in low- and middle-income countries (LMICs) lack access to modern contraceptives (Guttmacher, 2020). Unmet need results from a range of reasons, including limited access to services, particularly among young, poor, and unmarried women; misinformation concerning side effects; and cultural or religious opposition (WHO, 2020).

Lack of contraceptive access resulted in 85 million unintended pregnancies in 2019 (Sedgh et al., 2014). Unintended pregnancies lead to a number of negative effects. They are associated with higher maternal and neonatal death and disability from pregnancy and childbirth (Dehingia et al., 2020), as well as higher rates of unsafe abortions (Kantorová, 2020). Unintended pregnancies also lead to significant losses in autonomy for women who are unable to exert control over their lives. This has a knock-on effect on their income due to decreased earnings and increased expenses (Schultz, 2009), with consequent negative effects on national economies (Canning et al., 2012).

Maternal and Neonatal Health Impacts

Pregnancy-related complications continue to be a leading cause of preventable death among both mothers and children, with almost 300,000 women and girls dying due to pregnancy and childbirth in 2017 (WHO, 2017). The risk is particularly concentrated in sub-Saharan Africa, which accounts for more than 2/3 of global maternal deaths (Our World in Data, 2013).

Contraceptive use reduces the DALYs lost through pregnancy-related complications by reducing the total number of births, allowing adolescents to delay births, and allowing for birth spacing. Pregnancy and childbirth are more dangerous for those aged 10-19, with particular dangers for girls under 15 years old. However, pregnancy remains common among adolescents in LMICs, with complications from pregnancy and childbirth constituting the leading cause of death for women aged 15 to 19 (Chandra-Mouli et al., 2014). These pregnancies also pose risks to newborns, as rates of preterm birth and low birth weight are much higher among babies born to young mothers (Neal et al., 2018). Contraceptive access mitigates these risks by allowing young women to delay births until the risks are lower (WHO, 2017).

Short-spaced pregnancies – when women give birth within 2 years of their most recent birth – present substantial health risks to both mother and child, yet are fairly common in LMICs. Although the exact mechanisms aren’t clear, giving birth within a shorter timeframe compromises the mother and child’s nutrition (Wendt et al., 2012) and increases the riskiness of the pregnancy. Short-spaced births are strongly associated with increased risk of low birthweight, stillbirth, and neonatal death (Schummers et al., 2018; Gemmill and Lindberg, 2014).

Cleland et al. (2006) estimate that comprehensive access to family planning could avert more than 30% of maternal deaths and 10% of child mortality. Despite this, birth spacing is often underutilised. Misconceptions concerning postpartum fertility, lack of awareness of the health benefits of birth spacing, and lack access to preferred methods of contraception all contribute to the continued prevalence of short-spaced pregnancies (Dev et al., 2019).

Despite legal barriers and social stigma, more than a third of unintended pregnancies in sub-Saharan Africa end in abortion. The bulk of such abortions are unsafe, carrying with them serious threats to women’s health (Guttmacher, 2020). Recent analysis suggests that unsafe abortions are the cause of 5-13% of all maternal deaths globally (UNFPA, 2022). Increased contraceptive access would reduce uptake of unsafe abortions and the corresponding threats to women’s health.

Decreased Autonomy

More broadly speaking, unintended pregnancies compromise women’s autonomy. The decision of whether to have a child has wide-ranging effects on women’s lives, bearing on questions of health, education, and employment. Providing women with the tools to delay or avert a pregnancy empowers them with a greater level of control over their bodies and their lives. The fact that so many unintended pregnancies in LMICs end in abortion despite the associated dangers and social stigma suggests that many women have strong preferences against additional births that are currently being undermined due to lack of access to contraception.

The autonomy effects of family planning are difficult to quantify but clearly significant, given as they relate to women’s control over fundamental aspects of their bodies and their lives, with a similarly wide range of hard-to-measure benefits as interventions such as unconditional cash transfers.

Income and Economic Development Impacts

Unintended pregnancies have negative economic effects on both individual families and on national economies more broadly. Modelling the economic benefits of a reduction in total fertility rate by one child per woman in Nigeria, Canning et al. (2012) found this would increase GDP per person by 13.2% above baseline forecasts after 20 years, and 25.4% after 50 years factoring in long-term effects. On an individual level, the 19-year Matlab family planning study in Bangladesh raised women’s average wages by a third (Schultz, 2009).

Broadly speaking, a reduction in fertility rates produces a ‘demographic dividend’ of a high working population relative to the number of dependents. This can provide “a window of opportunity for rapid economic growth and a boost in per capita income” (Guttmacher, 2019).

Environmental Impacts

“[P]oor reproductive health outcomes and population growth exist hand-in-hand with poverty and unsustainable natural resource use” (Yavinsky, 2015). Providing universal choice over family size would likely lead to reduced population growth, with significant flowthrough benefits for the environment (Starbird et al., 2016).

Project Drawdown (n.d.), which evaluates leading environmental solutions, lists ‘Family Planning and Education’ as the 3rd most effective solution available for reducing CO2 emissions out of 90 reviewed.

Tractability

There is strong evidence that family planning programmes produce large increases in contraceptive uptake, alongside decreases in fertility rate, unmet need, and maternal mortality rates. This suggests that family planning is a highly tractable area in which to work.

In 2015, 64% of women of reproductive age used contraception globally, with family planning charities playing ‘a key part in raising the prevalence of contraceptive practice from less than 10% to [more than] 60%’ over the last 40 years (Grant, 2016). To take one example, total fertility in East Asia fell by more than three children per woman between 1970 and 2019 (OECD, 2022) while contraceptive prevalence rose by 33% over the same period (Haakenstad et al., 2022).

However, contraceptive uptake remains low in many countries, presenting a significant opportunity for further success and action. This investment can be highly cost-effective. For example, Kennedy et al. (2013) estimated that a $9 million investment in contraceptive access in Vanuatu and the Solomon Islands could meet family planning needs across the two countries. This would produce $112 million in economic benefit while averting 2,500 maternal and child deaths – a cost of $3,600 per death prevented.

There are well-evidenced programmes for increasing contraceptive uptake with demonstrable results. One example comes from the ‘Matlab’ study across 140 villages in Bangladesh over a 20-year period. Through a mixed-method approach, child-to-woman ratios were 16% lower in villages with an outreach programme than in those that had access only to standard government family planning clinic services, after adjustment for village and year fixed effects (Canning et al., 2012). Further evidence for effective family planning interventions is summarised in the ‘Family Planning: High Impact Practices’ briefs compiled by a panel of leading stakeholders, including the WHO, Bill and Melinda Gates Foundation, and USAID.

Sub-Saharan Africa is a particularly promising geography for family planning, as it has the highest fertility rate in the world as well as the highest unmet need for family planning. Contraceptive rates across Africa are less than half of the global average (Grant, 2016), and by 2030, over half of young women with unmet need for family planning will live in the region (Gahungu et al, 2021).

The most promising family planning interventions target the root causes of unmet need for family planning, including lack of accurate information, limited access to services, low-quality services, and cultural opposition. A full exploration of all possible avenues for family planning interventions is beyond the scope of this writeup, but we will now briefly explore two of the central drivers of low family planning uptake–lack of accurate information and limited access to services–and investigate possible interventions in these areas.

Problem: Lack of Accurate Information around Family Planning

Lack of accurate information concerning family planning methods is a key driver of unmet need for family planning. Numerous studies have indicated a substantial knowledge gap concerning family planning in many LMICs (Family Planning: High Impact Practices, n.d.). Misconceptions surrounding contraceptives are often common, such as beliefs that contraceptives cause infertility and cancer (Adongo et al., 2014). Such misconceptions lead to decreased contraceptive uptake.

A range of interventions dedicated to disseminating accurate information concerning family planning have been tested, to varying results. The most promising interventions include mass media, interventions promoting healthy couples’ communication, social norm-based interventions, and interventions targeting individual knowledge, beliefs, and self-efficacy (Family Planning: High Impact Practices, n.d.).

Example Solution: Mass Media Campaigns

Of these interventions, mass media stands out for its cost-effectiveness and scalability. Other interventions in this space involve the costs of running individual or group counselling sessions, or training peer educators who can reach a limited number of clients per week. In contrast, mass media interventions can reach hundreds of thousands to millions of people at a set, low cost. Furthermore, mass media campaigns can be scaled to reach multiple regions or entire countries much more easily than other interventions, greatly increasing their potential impact.

Strong evidence suggests that well-run mass media campaigns increase contraceptive uptake and decrease birth rates. Across 9 studies included in a systematic review that reported change in modern contraceptive use, the effect size ranged from 5-27% increase in uptake (Family Planning: High Impact Practices, n.d.). For example, Glennester et al. (2021) found that a 2.5 year mass media campaign reaching 5 million people led to a 5.8% increase in modern contraceptive uptake and 10% decrease in birth rate.

Example Organisation: Family Empowerment Media

Family Empowerment Media (FEM) launched in September 2020 through the Charity Entrepreneurship Incubation Program (Charity Entrepreneurship, 2022). They work to help couples in LMICs plan their families by implementing radio-based social and behavioural change campaigns, leading to higher uptake of contraceptives, fewer unintended pregnancies and improved maternal and child health.

Through their work in Kano in Northern Nigeria, FEM reach more than 5 million listeners more than 10 times a day, with ads and longer format shows, including stories, testimonial shows and serial dramas. A one-minute long ad provides contraceptive information to this audience base for just $14.40 (Family Empowerment Media, 2022).

Early evidence indicates that FEM’s radio programs are highly effective. In the time period overlapping with their pilot campaign, the contraceptive uptake in Kano increased by 75%, from 8pp to 14pp, corresponding to ∼250,000 new contraceptive users (PMAdata, 2022). This is twice the increase measured in the last 5 years combined. This work was conducted in a region where around 1% of all pregnancies cause a maternal death (Meh et al., 2019). FEM is aiming to conduct an RCT to validate their impact further, using a new technology they have invented.

Scaling their programming over the next four years, FEM expects to avert a maternal death for ∼ $2,600 while operating in 10 Nigerian states and reaching 16 million people (Charity Entrepreneurship, 2022). This would make FEM’s cost effectiveness comparable with other Givewell recommended organisations, solely on the basis of cost per life saved (Giving What We Can, 2016).

FEM has closed their 2022 funding gap and is now raising $1.1 million to scale their programmes to three new regions in 2023 (Charity Entrepreneurship, 2022). A commitment of $7.0 million would fund FEM’s ambitious scaling plans over the next four years, preventing ∼3100 maternal deaths and ∼340,000 unintended pregnancies. FEM is doing proof of concepts (short campaigns) in three new regions by the end of 2022, and will have an even better understanding of the potential and cost effectiveness of the intervention at scale then.

Problem: Limited Access to Services

Another key driver of unmet need for family planning is that many women simply lack physical access to contraceptives. This results in part from the reality that healthcare systems in many LMICs are generally under-resourced. However, challenges specific to family planning abound, some of which are tractable through targeted interventions.

Given the complex breadth of reasons why access to contraceptives is lacking in many LMICs, the range of potential interventions is similarly broad. Some of the most promising interventions include expanding family planning coverage by community health workers, integrating family planning into postpartum and post-abortion services, mobile outreach services, advocating for domestic public financing of contraceptives, and addressing supply-chain issues in order to reduce contraceptive stock-outs (Family Planning: High Impact Practices, n.d.; Family Planning: High Impact Practices, n.d.).

Depending on the execution approach taken, many of these interventions could be highly cost-effective and impactful. For example, Advance Family Planning has successfully advocated for the expansion of family planning programs across several LMICs. Meanwhile, IntraHealth International has strengthened supply chains in countries such as Senegal in order to reduce contraceptive stock-outs.

This writeup will briefly explore one intervention targeting limited access to family planning services in greater depth, postpartum family planning, as Charity Entrepreneurship has identified it as a highly impactful intervention with strong cost-effectiveness.

Example Solution: Postpartum Family Planning

Postpartum family planning (PPFP) is the provision of contraceptive information and access during the period of care a mother receives at a health facility when giving birth (Family Planning: High Impact Practices, n.d.). This can be both in the immediate aftermath of childbirth and in the subsequent 12 months in conjunction with maternal and child health check-ups.

PPFP is considered a ‘proven’ family planning intervention by a panel of leading development organisations, including USAID, WHO and the Gates Foundation (Family Planning: High Impact Practices, n.d.). In a 2017 report evaluating immediate postpartum family planning, USAID found a 33% increase in contraceptive uptake across five programmes evaluated (Family Planning: High Impact Practices, n.d.).

Postpartum family planning is a particularly promising opportunity for several key reasons. First, it is effective in preventing short-spaced pregnancies by providing mothers with contraceptive access in the immediate aftermath of a birth.

As discussed previously, short-spaced pregnancies lead to higher mortality rates, with wide-ranging negative health consequences for both the mother and child (DaVanzo et al., 2007). Delaying all births until 24 months after a previous pregnancy could avert 893,000 child deaths across 52 LMICs (Rutstein, 2008).

Second, the postpartum period is one of the only points at which many women in LMICs will interact with the formal healthcare system. This period is one of the few opportunities for women to safely access a wide range of contraceptive options. Despite this, contraceptive uptake in the postpartum period is consistently lower than average national rates (Pasha et al., 2015; Track20, n.d.).

Partnering with governments in LMICs to integrate family planning into postpartum care is a highly cost-effective way to increase uptake of family planning services (Zakiyah et al., 2016). By providing both information and access to services, it addresses multiple root causes of unmet need for family planning. By targeting women in the postpartum period, it reaches women at higher risk of short-spaced pregnancies. Furthermore, partnering with governments creates the opportunity for an organisation to shape policy at a regional or national scale, greatly increasing potential impact.

Charity Entrepreneurship modelled the cost-effectiveness of a PPFP charity operating in Ghana. They estimate that this charity could reach 2.5 million women across 8 years at a cost of $39 per additional contraceptive user and $67 per unintended birth averted. The low costs per additional user and birth averted suggests that postpartum family planning is a cost-effective way of improving health, increasing autonomy over fundamental choices, and improving income for families and communities.

Existing organisations–such as Jhpiego and IntraHealth International–have engaged in advocacy and technical assistance in order to promote postpartum family planning in a number of LMICs, but substantial gaps remain.

Charity Entrepreneurship is launching a postpartum family planning charity through their Summer 2022 Incubation Programme to address this gap. Starting with a pilot programme in sub-Saharan Africa in late 2022, this charity will aim to partner with governments to scale PPFP training and support for community health workers nationally.

Neglectedness

Family planning has not received philanthropic resources commensurate with its massive scale (Grollman et al., 2018). Recent investments in the sector have helped to make the gap less severe, but the mismatch between the problem and the resources dedicated to addressing it remains substantial, and a range of cost-effective interventions remain untapped.

Historically, only limited resources have been allocated to family planning interventions, with one estimate suggesting that donor assistance amounted to only $0.17 per woman of childbearing age in developing countries in 2008 (Tsui, 2010). The Family Planning 2020 Partnership – subsequently retooled as FP 2030 – has led to increased resources dedicated to family planning. However, these resources remain insufficient to address the need present (Guttmacher, 2019).

The need for further investment in family planning is underlined by the fact that the number of women with an unmet need for family planning is growing rather than shrinking (UN DESA, 2020). Though the percentage of women with an unmet need is slowly decreasing, the total number of such women is growing due to global population trends, with an increasing proportion of people living in areas with high levels of unmet need for family planning.

Funding in the family planning space is not consistently oriented towards the most cost-effective interventions nor the most neglected geographies. Cost-effectiveness is only one of many considerations for major funders within the space, and this is reflected in the programs receiving funding (Fan et al., 2017). Condoms and other short-term contraceptives have received substantially more investment than longer-acting contraceptives (UNFPA, 2022) despite the likely greater cost-effectiveness and longevity of the latter (Ngacha and Ayah, 2022; Trussell et al., 2009). Additionally, the most cost-effective interventions have not received substantial funding, with only minimal funding going to interventions such as mass media and postpartum family planning.

Geographically speaking, funding has not been as targeted toward sub-Saharan Africa as the distribution of unmet family planning need would suggest, with major donors – such as the UN Population Fund – dedicating a surprising amount of resources to other geographies (UNFPA, 2021).

These factors mean that there is significant low-hanging fruit remaining in the family planning space; that is, there are a number of areas where an effectiveness-minded funder could catalyse significant impact.

Finally, it’s worth noting that non-governmental funders are particularly important within the family planning space due to the politicisation of abortion and family planning services. Some national governments are unwilling to fund family planning or provide funding with substantial strings attached, meaning that non-governmental funders are particularly important in this space (Grollman et al., 2018).

Uncertainties & Downside Risks

To what extent will contraceptive use increase without targeted interventions?

Some may argue that family planning interventions shouldn’t be a priority given that demographic and development trends have led to increased contraceptive use and corresponding decreases in fertility rate even in the absence of targeted family planning efforts. And, indeed, historical trends suggest that increased education and economic growth make a significant contribution to higher contraceptive uptake and decreased family size.

However, family planning interventions appear to produce significant additional effects, notably accelerating and extending progress. A historical analysis by DaVanzo and Adamson (1998) found that family planning programs have been responsible for around 43 percent of the decline in global fertility from 1965 to 1990.

Additionally, contraceptive uptake in certain geographies lags far behind global trends. Most notably, this is the case for many parts of sub-Saharan Africa where contraceptive uptake remains far lower than global averages (Grant, 2016). This presents a significant opportunity for influence that is likely to be robust to global trends.

Existing evidence for benefits of family planning may undersell its value

It is hard to quantify some of the most significant benefits of family planning. Increased

autonomy is among the strongest benefits of expanded access to family planning, yet we found very little measurement of autonomy in health and development research. The Relative Autonomy Index (RAI) provides one recent example of the kind of measure that may better illustrate the full extent of benefits arising from family planning (Vaz et al., 2016; Gram et al., 2017).

Similarly, control over one’s fertility is likely to produce significant effects on subjective wellbeing. At a minimum, we can expect a reduction in unintended pregnancies to produce a decrease in postpartum depression and consequent increase in subjective wellbeing. However, we could not find robust measurement of the subjective wellbeing effects of contraceptive access in the literature.

These benefits make it more challenging to fairly compare family planning against other interventions. How can the autonomy effects of family planning be measured against those of other autonomy-improving interventions, such as cash transfers? How can the overall effects of family planning be compared against other interventions with little to no autonomy effects? Answers to these questions, however provisional, would allow comparisons across cause areas to be made more fairly and consistently.

Further investigation

While we think this report offers a solid introduction to the opportunities within family planning as a cause area, there are additional questions that would be worth investigating. A more thorough evaluation of how current funding is allocated by large grantmakers would help to identify a wider range of particularly promising programmes.

Similarly, a longer research process assessing the cost-effectiveness of a range of existing organisations would be likely to produce a longer list of specific grants that Open Philanthropy could disperse. Family planning is a large area, with both significant room for additional funding and a large number of existing actors. As such, we believe it is likely that there are more organisations than those we have highlighted in this report whose work would be highly impactful if given the funding to scale up.

Finally, it fell beyond the scope of this report to fully explore the evidence for the benefits of family planning in less-researched areas. In particular, we think that further study and measurement of increases to subjective well-being and autonomy from contraceptive access may provide additional compelling evidence for the value of family planning as a cause area.

Conclusion

Unmet need for family planning services is a substantial problem, leading to significant death and disability for mothers and children, decreases in autonomy, and negative economic effects on families and national economies. Cost-effective interventions such as radio-based messaging and postpartum family planning, among many others, offer the possibility of addressing the harms created by unmet need for family planning.

Progress in family planning appears highly tractable yet comparatively neglected by the EA movement compared to many other large-scale global health and development investment programmes. On a global scale, expanding contraceptive access could prevent 2.5 million maternal deaths, 73 million child deaths, and 16 million stillbirths by 2035 (Stenberg, 2014).

By investing in cost-effective and scalable family planning solutions, Open Philanthropy could lead this work and have a transformative positive impact.

Note: The authors of this report plan to launch a postpartum family planning charity after evaluating several promising charities through the 2022 Charity Entrepreneurship Incubation Programme. We think that family planning is a strong cause area that includes a number of highly promising interventions, including but certainly not limited to PPFP. Additionally, the section on Family Empowerment Media was edited by their staff for accuracy.

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