Association for Public Policy Analysis & Management

Background:Fifty years after independence in 1964, the population of Malawi grew by more than 500%, significantly outpacing economic growth during the same period. To slow the population growth, the Malawi government introduced a community-based intervention to distribute family planning methods in the country’s rural communities, in 2005. Effect of the intervention on contraceptive use has, however, not been established.

Objectives:First, to evaluate the effect of a community-based distribution (CBD) of family planning methods on contraceptive use among women in Malawi. Second, because CBD agents of family planning methods also disseminate family planning information, to examine if maternal education affects the association between CBD of family planning methods and contraceptive use.

Methods:We used 4 waves of data for years 2000, 2004, 2010 and 2015 of the Malawi Demographic and Health Surveys (MDHS) and difference-in-differences (DD) methods to estimate effects of the intervention in a sample of 54,764 women aged 15–49 years. Since the intervention was implemented only in rural communities, we designated rural communities as the treatment group and urban communities as controls; because there are no geographic areas defined as communities in MDHS, we used primary sampling units as a proxy for communities. As the intervention was introduced in 2005, data collected before 2005—MDHS2000 and MDHS2004—represented the pre-intervention period while MDHS2010 and MDHS2015 represented the post- intervention period. Contraceptive use was defined as current use of any modern contraceptive method—e.g., pills and condoms—and was modelled as a binary variable in a 2-level random intercept logistic regression. All analyses were performed in Stata 14.

Findings: We estimated that before CBD of family planning methods was introduced, the probability of using contraceptives was 25.1% in rural communities and 27.6% in urban communities. After the intervention, however, the probability of using contraceptives increased in both rural and urban communities but the increase was greater in rural communities (35.7% vs. 34.3%). The DD estimator—the increase in probability of using contraceptives among rural women attributable to the intervention—was about 3.9 percentage points. In terms of odds ratios, CBD of family planning methods significantly increased the odds of using modern contraceptives among rural women by about 26% [OR=1.26, 95% CI=1.08-1.47]. We also found that the effect of CBD of family planning methods on contraceptive use was stronger among women with higher levels of education.

Conclusion: The introduction of CBD of family planning methods increased the probability that rural women would use contraceptives; the effect, however, increased with more maternal education.

Policy implications: CBD of family planning methods has positive effects on contraceptive use and should be continued, as well as strengthened, as it can help to control population growth which is important if the country is to achieve its target of reducing poverty and achieving sustainable economic development by 2030. The country should also invest in girl child education if various interventions in reproductive health, including CBD of family planning methods, are to produce optimal results.