Why do we still see low use of contraceptives in Tanzania? The answer might be found within the household

Understanding household decision-making is crucial in ensuring effective implementation of anti-poverty programmes. If we do not understand the dynamics of household decision-making and resource allocation, many projects and policies will not achieve their intended goals. Increasing women's bargaining power within the household is advocated as a prominent and important channel for improving children’s welfare and reducing gender disparities and poverty, as emphasised by sustainable development goal five. 

Women in low- and middle-income countries tend to have less bargaining power than their husbands. In simple terms, this can make women unable to do what they want. As an example, Benhassine et al. (2016) found that if women were given a cash transfer, only 33% would pick it up alone (as opposed to 70% of men if the cash transfers were given to them). Similarly, Bobonis et al. (2013) show that female beneficiaries of Oportunidades, the government social assistance programme in Mexico, are more likely to receive violent threats than non-beneficiaries. They attribute this to men using threats to extract money from them. 

Family planning services

An important area of household decision-making is the use of family planning services. In many low-income countries, and certainly sub-Saharan Africa, the ‘unmet need’ for family planning remains high, especially in rural areas (United Nations Department of Economic and Social Affairs 2015, Adamou et al. 2017). As family planning services have now been made widely available in most areas (United Nations Populations Fund 2010), this large ‘unmet need’ indicates that there are important demand constraints within the household. 

In analysing the source of this demand constraint, a prominent study by Ashraf et al. (2014) distributed vouchers to women in Zambia that gave them free access to contraceptives at a local health facility. They found that if the husband needed to sign the voucher for the women to redeem them, the uptake of contraceptives was significantly lower than if the women did not need their husband’s signature. 

Several mechanisms can explain this finding. Men might disapprove of contraceptives and refuse to give their consent. On the other hand, women might (incorrectly or not) believe that their husband disapproves of contraceptives and decide not to approach him to avoid conflict. Several studies have shown that in most couples there is little communication around family planning and contraceptive use (e.g. Shattuck et al. 2011, Hartmann et al. 2012). Little or no communication implies that women do not necessarily know whether their husband approves of contraceptive use. In our experiment, we show that women’s beliefs about their husband’s approval explain their decision whether to receive family planning services (D’Exelle and Ringdal 2019).

Looking at established couples in rural Tanzania

We conducted an experiment in northern rural Tanzania with established couples. In the experiment, the participants were asked to choose between two types of payments. One of the payments was given to the participants one month after the experiment. The other payment was also paid out to participants one month after the experiment, but only if the woman had attended a family planning meeting at a local health facility. The two types of payments vary in size, with the family planning meetings taking place every day and free to attend. 

If the participants chose the payment conditional on attending a family planning meeting, they were given a voucher to be signed by the nurse to confirm their attendance. In the following, we refer to choosing the ‘family planning voucher’ as the proportion of participants choosing this payment.

We varied who made the decision. Specifically, the wife, the husband, or the couple jointly made the decision. By comparing the decisions in each of these, we can identify the causal effect of involving the husband in the decision.

The effect of involving the husband

Figure 1 shows the overall effect of involving the husband. Once the husband is involved in the decision-making, either by making it with his wife or alone, the likelihood that participants choose to receive the family planning voucher is higher. Specifically, involving the husband increases the likelihood by approximately 10 percentage points. 

Figure 1 Effect of involving the husband

Note: This figure shows the proportion of participants choosing the family planning voucher in each treatment with standard error bars.

This finding is arguably puzzling. In previous literature, the husband is often considered as an obstacle to women using family planning services. However, in our study it seems that the husband can enhance the uptake. Given that only 40% of the couples in our sample had discussed family planning in the past year, we look into whether women’s beliefs about their husband’s approval can drive the treatment effects.

Women’s beliefs about their husbands are key

Figure 2 shows that the treatment differences displayed in Figure 1 are entirely driven by whether the wife believes that the husband approves of contraceptives. Specifically, if she believes that the husband approves of contraceptives, there are no treatment differences. Therefore, involving the husband does not affect the likelihood of the couple choosing the voucher.

On the other hand, if the wife thinks that the husband disapproves of contraceptives, then involving the husband increases the likelihood of choosing the family planning voucher by approximately 20 percentage points.

Figure 2 The effect of the wife's beliefs

Note: This figure shows the proportion of participants choosing the family planning voucher in each treatment with standard error bars. 

But did couples actually attend the family planning meeting?

Of the couples that chose the payment conditional on attending a family planning meeting, 82% did so. Moreover, 78% of the couples that attended a family planning meeting received some type of contraceptives and 70% received a modern contraceptive (including injectables, the pill, and intrauterine devices). 

Whether a couple attended the family planning meeting or received contraceptives did not depend on whether the husband was involved in the decision. This suggests that as long as a decision to attend a family planning meeting has been made, they will go and that once at the meeting, they will start using a contraceptive method. 

Policy implications: Correcting false beliefs

An important question to ask is whether women’s beliefs about their husbands’ approval of contraceptives are correct and whether communication can help solve any inaccuracy. Our analysis suggests that women who believe that their husband disapproves of contraceptives are incorrect. Moreover, as the ‘joint decision’ treatment forces couples to discuss the decision together, our results indicate that initiating communication among spouses is a sufficient condition to increase the likelihood that the family planning voucher is chosen. 

In sum, our study has provided experimental evidence that supports the policy advice from studies such as Shattuck et al. (2011) and Hartmann et al. (2012) to stimulate communication among spouses. It has also provided new insights into why and when it could increase the uptake of contraceptives. In particular, our study suggests that lack of communication might lead women to have inaccurate beliefs about their husband’s preferences, which in turn could make them reluctant to use contraceptives. Similarly, our study suggests that a policy that stimulates communication among spouses would only be effective where spouses do not have substantially different preferences about family planning services.

References

Adamou, B, B Iskarpatyoti, C Agala and C Meija (2017), “Male engagement in family planning. Gaps in monitoring and evaluation", MEASURE Evaluation.

Ashraf, N, E Field and J Lee (2014), “Household bargaining and excess fertility: An experimental study in Zambia", American Economic Review 104(7): 2210-2237.

Benhassine, N, F Devoto, E Duflo, P Dupas and V Pouliquen (2015), “Turning a shove into a nudge? A labelled cash transfer for education”, American Economic Journal: Economic Policy 7(3): 86–125.

Bobonis, G, M Gonzalez-Brenes and R Castro (2013), “Public transfers and domestic violence: The roles of private information and spousal Control”, American Economic Journal: Economic Policy 5(1): 179–205.

D’Exelle, B and C Ringdal (2019), “Uptake of family planning services: An experiment on the husband’s involvement”, Unpublished.

Hartmann, M, K Gilles, D Shattuck, B Kerner and G Guest (2012), “Changes in couples' communication as a result of a male-involvement family planning intervention", Journal of Health Communication 17(7): 802-819.

Shattuck, D, B Kerner, K Gilles, M Hartmann, T Ng'ombe and G Guest (2011), “Encouraging contraceptive uptake by motivating men to communicate about family planning: The Malawi male motivator project", American Journal of Public Health 101(6): 1089-1095.

United Nations Department of Economic and Social Affairs (2015), “Trends in contraceptive use worldwide 2015", United Nations Department of Economic and Social Affairs.

United Nations Population Fund (2010), “How universal is access to reproductive health? A review of the evidence", United Nations Population Fund.

Family planning Tanzania Contraceptives Beliefs Household decision-making