Working towards better health, education, and economic outcomes through more informed family planning and birth spacing

TL;DR

Greater adoption of contraceptives has a lot of positive benefits. Studies indicate that radio campaigns can be highly cost-effective in increasing adoption. Our new organization will implement radio campaigns where they can have the greatest impact, starting in Nigeria. If this sounds promising to you, there are several ways you can help us move from proof of concept to full rollout. 

In September, we founded Family Empowerment Media (FEM), a non-profit organization that will help people plan their families. We will provide clear, compelling, and accurate information on modern contraceptives through the radio.

We believe a well-run family planning charity focused on social and behavior change (SBC) campaigns on the radio could achieve outcomes in the realm of the most effective global health charities. Increasing access to and understanding of family planning services has been shown to have substantial positive effects on health, as well as education, income, and several other dimensions. SBC campaigns on family planning have generally been cost-effective, and a recent randomized control trial indicates that high-intensity radio-based SBC campaigns have the potential to be especially cost-effective. 

This post describes (I) the challenge we aim to solve, (II) our approach, (III), our value add, and (IV) our progress and plans. We close with a quick note on (V) how you can help FEM navigate its first year.

I. The challenge: Modern contraception’s vast benefits are not fully realized due to information gaps

In countries with developing health systems, pregnancy can be a major health risk for women. According to the Guttmacher Institute, just under 300,000 women and girls in low and middle-income countries die of pregnancy-related complications each year. Pregnancy is the most common source of mortality for adolescent girls. Pregnancy is also a source of non-fatal but serious morbidity. Conditions arising from pregnancy and childbirth include obstetric fistula - which 50,000-100,000 women experience each year - postpartum anemia, and postnatal depression.

Helping women avoid unintended pregnancies is a cost-effective means of reducing maternity-related health burdens. Almost a quarter of women in low and middle-income countries want to avoid pregnancy but are not using modern contraceptives. This “unmet need” for modern contraceptives results in 85 million unintended pregnancies per year. If all women with unmet need were provided access to and used modern contraceptives 70,000 maternal deaths per year would be averted. Guttmacher estimates, “every dollar spent on contraceptive services beyond the current level would reduce the cost of pregnancy-related and newborn care by three dollars,” while helping couples realize their family planning intentions. The Copenhagen Consensus estimates that a dollar spent on access to modern contraception leads to 120 dollars of social, economic, and environmental benefits.

In addition to reducing maternity-related health issues, helping women avoid unintended pregnancies can have positive effects on education, income generation, and children’s welfare (Figure 1). For example, a study in Indonesia found that providing access to family planning was three times more powerful than improving school quality in keeping girls in school an extra year. Research in Colombia found that girls with access to family planning clinics were 7% more likely to participate in the formal workforce as adults. More long term, a Brookings Institution study examined the effect of providing access to family planning programs to American women in the 1960s and early 1970s. It found that access led to improved college completion rates of children and higher family incomes decades later. These spillover effects are hard to measure, leading to the possibility of them being neglected in traditional cost-effectiveness analyses.

Figure 1: Benefits of improved family planning

Use of modern contraceptives has increased in recent years, but so has the unmet need (Figure 2). For example, in Nigeria (our target location), the portion of women using contraceptives rose from 11.2% to 14.2% from 2012-2019. Meanwhile, the unmet need also rose from 22.4% to 23.7%. An increasing share of Nigerian women prefer to avoid or delay pregnancy, and uptake of modern contraceptives needs to grow faster to close this intention- behavior gap.

Figure 2:  Growth in unmet need for contraceptives

Minimal or incorrect information about modern contraceptives is often a big barrier to greater use. Perhaps contrary to expectations, lack of access to contraceptive commodities is generally not a primary reason for low adoption. In Nigeria, just 5% of married women said physical access was a reason they did not use contraceptives. In contrast, 10% cited lack of knowledge on methods or sources of contraceptives; 20% cited health concerns. The latter is often connected with the former, as some women overestimate the side effects of contraceptives due to lack of knowledge. For instance, a study in two states in Nigeria found almost one in three women believed that contraceptives can make a woman permanently infertile. Unfortunately, there are countries and regions with major contraceptive stockout issues. However, by strategically picking areas where commodities are available, NGOs in this space can close information gaps and significantly increase contraception use.

II. Our approach: Radio-based campaigns to cost-effectively close information gaps

The model FEM will employ, radio-based SBC campaigns is uniquely poised to close information gaps related to modern contraceptives.

In general, family planning SBC interventions are typically effective in reducing unintended pregnancies and their associated maternal health burdens. SBC interventions seek to understand and facilitate change in behaviors and the social norms and environmental determinants that drive them. In family planning, SBC interventions use multiple channels and take diverse forms, including mass, digital and social media; interpersonal communication; and community mobilization and participation. A review drawing upon 130 studies of SBC interventions found that on average SBC increased use of modern contraceptives 30%-60% (i.e., median odds ratios achieved were 1.3-1.6). However, the cost of these interventions varied widely, with mass media interventions by far being the most efficient in reaching people. In addition, impact achieved varied by geographical location.

Radio-based SBC campaigns are especially well suited for West Africa - where the rates of fertility and unmet need are the highest in the world - including in Nigeria, where we plan to operate. Radio is both the most consumed and trusted form of media in West Africa. In Nigeria, there are more than 200 radio stations reaching a large portion of the 196 million people in the country. These stations allow for targeted geographical outreach, and at the same time they can reach up to millions of unique listeners. About three-quarters of Nigerians rely on the radio weekly for news. Moreover, radio communications are affordable. Based on previous rates obtained from production companies, we estimate that in parts of Nigeria we can reach a potential audience size of 1 million women with a one-minute advertisement for $4-8. Radio’s high reach and low cost suggest the massive potential to close contraceptive related information gaps at scale.

A recently conducted randomized controlled trial on a radio-based SBC campaign in Burkina Faso bears out this potential. From 2016-2018, Development Media International (DMI), a pioneer in conducting mass media SBC interventions, worked with Innovations for Poverty Action to test its campaign in Burkina Faso. DMI broadcasted ten family planning ads per day and three longer interactive programs per week on local radio stations. The results were dramatic. In treatment areas, use of modern contraceptives increased by 5 percentage points (pp), with belief that contraceptives make women infertile dropping 9 pp and belief they cause disease dropping 8 pp.

FEM plans to adapt this proven model to the Nigerian context. In Nigeria, the total fertility level (the average number of children a woman will have in our lifetime) is 5.4. As noted earlier, almost one quarter of sexually active women in Nigeria have an unmet need for family planning. Meanwhile, the Government of Nigeria has demonstrated a strong commitment to family planning. Modern contraceptives are freely available at public clinics and stockouts are relatively infrequent in many states. And as mentioned, radio airtime rates are reasonably priced. Due to the high (and relatively homogeneous) population in the north of Nigeria, we expect to be able to scale up our programs comparatively easily as we progress. In many (though not all) respects, conditions are ideal to execute a radio-based SBC campaign in this environment.

III. Our value-add

FEM plans to extend radio- SBC campaigns to fill in gaps in coverage by existing actors. Radio-SBC campaigns are neglected relative to their potential for impact. DMI, the Johns Hopkins Center for Communications Programs, and BBC Media Action are three notable organizations that implement high quality radio-SBC campaigns. Yet, in many locations with high unmet need for contraceptives and low stockouts, there are little to no efforts to provide family planning information over the radio. After extensive research and helpful conversations with these organisations, we selected as FEM’s launch point a state in Northern Nigeria (Kano) where radio-SBC campaigns are underutilized.

FEM is also different from other family planning organizations in our narrow focus. Many organisations expand into multiple aspects of improving reproductive health, like distribution, advocacy and demand generation. We aim to be hyper focused on providing effective family planning radio campaigns at scale, which we believe is a particularly evidence based, and cost effective intervention within the cause area. In doing so, our plan is to remain a lean organisation with a small effectiveness minded staff.

FEM may also be distinct in that we use common tools from the effective altruism community to make decisions. For example, we often weigh major decisions through a cluster thinking approach that leverages, among other mechanisms, cost-effectiveness analysis, weighted factor models, and expert opinions. We also think closely about counterfactuals before making decisions.

Finally, we believe that family planning could be an underexplored and neglected cause area in the EA community. We believe that it is worthwhile to have EAs exploring this cause area and its potential. We aim to do rigorous evaluations of all our programming and therefore contribute to the literature on the effectiveness of radio SBC family planning programs.

IV. Our progress and plans

FEM was conceived during the Charity Entrepreneurship Incubation Program in July and August and officially launched in September. Since then, we developed our strategy and work plan, selected Kano state in Nigeria as our launch point, selected a media production partner, and built a relationship with a local implementation support partner. We have also interacted with a number of key governmental and NGO and civil society stakeholders within the state who are aware and supportive of our plans.

In the next six months we will conduct small scale operational experiments to test the feasibility of working in our target location and with chosen partners. The first experiment is a one week proof of concept which we aim to have on air within two months. If the proof of concept is successful, and we are able to raise sufficient funding, we will next conduct a longer pilot of our model. While the proof of concept is a feasibility test, we will conduct M&E on our pilot in order to measure early predictors of longer term behaviour change. Depending on results we may pivot our work to a new location or shut down completely. In any case, we will be transparent in our decision-making process and share what we learn.

V. How you can help

There are various ways supporters can help FEM in this make-or-break year. High priority needs include:

Technical advice. We seek expert academics and practitioners on family planning, SBC interventions, qualitative research to inform script writing, radio, monitoring and evaluation, and Nigeria to test out our ideas and gather feedback.

Volunteering. We’ve identified numerous opportunities for volunteers from anywhere in the world to support us, even if they can dedicate just a few hours of time as advisors.

Funding. We are currently seeking to close a $40,000 funding gap to complete baseline data collection and a pilot study. Individual donors may contribute to FEM on our website . We also plan to engage more risk-tolerant institutional donors.

We think FEM has a chance to make an important contribution to the family planning space, and be a high impact and efficient organization. We look forward to reviewing any feedback you may have here - and please feel free to reach out to us directly.

Kenneth Scheffler and Anna Christina Thorsheim (Anna_Christina) incubated Family Empowerment Media during the Charity Entrepreneurship (CE) Incubation Program in July and August 2020. CE has provided FEM a $75,000 seed grant. Ken is a former Dalberg and Deloitte consultant, and program manager at USAID. Anna Christina co-founded Fornix, a mental health startup, and led the Effective Altruism chapter of the Norwegian University of Science and Technology.

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1. “Need” is inferred based on a whether a woman “wishes to have a child (or another child) soon or ever,” (Guttmacher Institute, “Unmet Need for Contraception in Developing Countries,” Jun. 2016)

2. Based on FEM’s analysis of data provided through the Federal Ministry of Health’s “Family Planning Dashboard,” as of 15 Nov. 2020