Family Planning Programs, Socioeconomic Characteristics, and Contraceptive Use in Malawi

Family Planning Programs, Socioeconomic

Characteristics, and Contraceptive Use in Malawi

BARNEY COHEN *

National Research Council, Washington, DC, USA

Summary. Ð In this paper, micro-level data from a survey of 4,849 women in Malawi are linked toinformation from a service availability questionnaire to assess the relative importance ofsocioeconomic background and various aspects of family planning provision on contraceptiveuse in one country in sub-Saharan Africa. Maximum-likelihood probit is used to assess theindependent in¯uence of four distinct dimensions of family planning e�ort on contraceptive use:mass media exposure, i.e., promotion of family planning through radio and print messages;contraceptive choice; accessibility of contraceptive services; and service quality. Results indicatethat all four components of family planning e�ort contribute to the use of modern contraceptives inMalawi, although their relative importance varies signi®cantly across di�erent segments of thepopulation. Ó 2000 Elsevier Science Ltd. All rights reserved.

Key words Ð family planning, sub-Saharan Africa, Malawi

1. INTRODUCTION

Signs of fertility decline are emerging acrosssub-Saharan Africa. Recent demographicsurveys con®rm that over the last 10 yearsfertility has been declining signi®cantly, i.e., byat least 10%, in several African countries,particularly in Kenya in eastern Africa andBotswana, Zimbabwe, and South Africa insouthern Africa. Smaller declines have beenrecorded in a variety of countries across thecontinent including Cote d'Ivoire, Ghana,Malawi, Namibia, southwest Nigeria, Rwanda,Senegal, Tanzania, and Zambia. Despite thesedeclines, fertility rates in sub-Saharan Africaare still higher than in any other major regionof the world and utilization of modern methodsof contraception remains fairly low, particu-larly in rural areas. Considerable uncertaintyexists as to the likelihood of fertility ratesdeclining still further in the near future.

One important policy question, as yet unan-swered, is whether better access to contracep-tives can increase their use, thereby acceleratingthe process of fertility decline (see, for example,Freedman & Berelson, 1976; Cutright & Kelly,1981; Lapham & Mauldin, 1987; Bongaarts,Mauldin & Phillips, 1990; Pritchett, 1994a,b;Bongaarts, 1994). Much of the empirical workon this issue focuses on cross-sectional studiesand indicates that little can be concluded from

comparing trends in family planning andfertility alone. Instead, complex multivariateanalyses, panel studies, or well-designed socialscience experiments are the preferredÐbut byno means conclusiveÐevaluation methods.

Recent attempts to test the e�ects of avail-ability, quality, and price of contraceptiveservices on contraceptive use in sub-SaharanAfrica have produced mixed results. In a studybased on the Ghanian Demographic andHealth Survey (DHS), Oliver (1995) founddistance to contraceptive services to be abinding constraint on contraceptive use in bothurban and rural areas. Furthermore, measuresof the quality of services showed no consistente�ect on either the demand for contraception oron fertility. A similar study based on the 1990Nigerian DHS, found that access, price, andquality of services were important factors in theadoption of modern contraceptives in Nigeria,but were usually not signi®cant determinants offertility in a reduced-form model (Feyisetan &Ainsworth, 1994). Furthermore, outpatient andconsultation fees appeared to have littleconstraining in¯uence on the demand formodern methods of contraception in Nigeria.Less ambiguous results were reported byThomas and Maluccio (1995) who studied the

World Development Vol. 28, No. 5, pp. 843±860, 2000Ó 2000 Elsevier Science Ltd. All rights reserved

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* Final revision accepted: 7 October 1999.

843

in¯uence of family planning characteristics andhealth services on contraceptive use in Zimba-bwe. The authors found that the availabilityand quality of family planning in the commu-nity were associated with higher rates ofadoption of modern contraceptive methods,and that these e�ects were larger for less-edu-cated women. Furthermore, the authors' anal-ysis underscored the important positive rolethat mobile family planning clinics andcommunity-based distributors have played inincreasing access to and adoption of modernmethods. Finally, studies of the e�ect of massmedia messages on reproductive behavior inKenya and Nigeria found that women exposedto mass media messages containing informa-tion about contraception have lower desiredfamily sizes and are more likely to use moderncontraceptives (Westo� & Rodriguez, 1993;Bankole, Rodriguez & Westo�, 1996). TheNigerian study is important because it alsodocuments a positive association between theintensity of exposure and reproductive behav-ior (Bankole et al., 1996).

This paper examines the impact of variouselements of family planning programs andwomen's socioeconomic characteristics oncontraceptive utilization in Malawi, one of thepoorest countries in sub-Saharan Africa. Thepaper uses data from a national-level demo-graphic and health survey conducted in 1992.These data are linked to data from a serviceavailability questionnaire that recorded thestrength of various dimensions of local familyplanning programs at the community level inorder to assess the relative contribution ofsocioeconomic factors and various measures offamily planning delivery on contraceptive use.The remainder of the paper has the followingplan. Section 2 contains a brief history offamily planning e�orts in Malawi and somedescriptive information about the data used inthis analysis. Section 3 reviews the analyticalframework that is used to guide the empiricalanalysis. The main empirical results arepresented in Sections 4 and 5. The mainconclusions from the analysis are summarizedin Section 6.

2. COUNTRY SETTING

According to recent World Bank estimates,per capita gross national product (GNP) inMalawi is approximately $170, making it the®fth poorest country in the world (World Bank,

1997). The vast majority of Malawian womenlive in rural areas and are engaged in farming,principally at the subsistence level. Comparedwith many of its southern African neighbors,rates of school enrollment in Malawi are rela-tively low and rates of infant and childmortality relatively high (World Bank, 1997).None of these facts make Malawi a countrythat is likely to be on the vanguard of a conti-nent-wide fertility transition. Not surprisingly,therefore, the total fertility rate in Malawiremains very high, above six children perwoman. This high level of fertility is maintainedby early and nearly universal marriage andminimal use of e�cient contraception. Never-theless, recent national-level demographicsurveys suggest that contraceptive use has risenand fertility fallen slightly in the recent past,leading to speculation about the relativecontribution of socioeconomic characteristicsand family planning e�orts in achieving thissmall fertility reduction.

Family planning programs in Malawi haveenjoyed a somewhat checkered history.Although the potentially deleterious conse-quences of closely spaced pregnancies havelong been recognized in the country, attemptsby the Ministry of Health to introduce modernfamily planning services in the 1970s quicklyran into opposition and were suspended(Ministry of Health, 1987). Widespreaddissemination of family planning services andinformation was prohibited and the Govern-ment of Malawi's o�cial position was basicallypronatalist (Nortman and Hofstatter, 1980,cited in Lucas, 1992). By the early-1980s,however, concerns about the strain of rapidpopulation growth on the country's limitednatural resources led to the establishment of aPopulation Planning Unit in the O�ce of thePresident (Population and Human ResourcesUnit, 1994). In 1982, o�cial authorization wasagain granted to include a child spacing initia-tive in the Ministry of Health's Maternal andChild Health Program. By 1987, family plan-ning services were available at approximately100 hospitals and health clinics throughout thecountry (Ministry of Health, 1987). As theprogram matured, attention focused on reduc-ing high-risk births, de®ned as high paritybirths, births to older women, and birthsoccurring within a short time of a previousbirth (Ministry of Health, 1987). Most recently,use of modern contraceptive methods has risenrapidly. In 1994, approximately 7% of marriedwomen were using a modern method, princi-

WORLD DEVELOPMENT844

pally the pill, condoms, injections (Depo-Provera), and female sterilization (NationalStatistical O�ce & Macro International Inc.,1994). By 1996, this ®gure had climbed to 14%,in part attributable to a large increase in the useof injectables (National Statistical O�ce &Macro International Inc., 1997). Part of theincrease is probably attributable to people'sheightened awareness of condoms re¯ecting thesuccess of massive condom awarenesscampaigns that were launched in response tothe worsening AIDS crisis. The highlysuccessful social marketing of ``Protector''condoms has reduced stereotypical negativeimages of condoms and dramatically increasedaccess to condoms, particularly through theprivate retail sector (Brown, 1994).

Both politicians and the general public havebecome more sensitized to the potential nega-tive consequences of rapid population growthon Malawi's development. During 1989±93, aseries of national seminars, workshops, andconferences were held on population-relatedmatters that culminated in the drafting of aNational Population Policy in May 1993. This

policy, while maintaining the rights of couplesand individuals to decide on the number ofchildren to bear, aimed to lower the growth rateof the population by improving the status ofwomen and children, lowering morbidity andmortality, and promoting information on theuse of contraceptives and the bene®ts of smallerand better spaced families (National StatisticalO�ce & Macro International Inc., 1994).

Nevertheless, fertility aspirations remain veryhigh in Malawi. Analysis of recent national-level trends in fertility indicates that the coun-try has embarked on a modest fertility decline,which probably began more or less ®ve yearsafter a renewed government commitment tofamily planning activities. Figure 1 presentseight independent estimates of the cumulativefertility rate for women aged 15±34 at variouspoints in time during the last 20 years. Despitesome di�erences across surveys, the ®gureshows very close agreement between the twomost recent surveys, conducted in 1991 and1992, both suggesting that fertility amongwomen under age 35 may have begun to declineas early as 1980. Nevertheless, given the

Figure 1. Trends in fertility among Malawian women aged 15±34, 1970±90. Note: 1971/92 PCS� 1971/72 PopulationChange Survey; 1982 DS� 1982 Demographic Survey; 1984 FFS� 1984 Family Formation Survey; 1988TMMCSS� 1988 Traditional and Modern Methods of Child Spacing Survey; 1991 FSNMS� 1991 Food Security and

Nutrition Monitoring Survey; 1992 DHS� 1992 Demographic and Health Survey.

FAMILY PLANNING PROGRAMS 845

country's low level of socioeconomic develop-ment and above average rates of infant andchild mortality, it is too early to tell whetherone should expect a continued decline infertility in Malawi similar to those recorded inseveral neighboring southern African countries.

3. THEORETICAL FRAMEWORK

This section presents the theoretical frame-work that is used to guide the empirical analysisthat follows. This framework provides themotivation for the choice of the explanatoryvariables that are used below and o�ers somepredictions about the direction of their expec-ted e�ects.

The basic framework used in this paper isborrowed from an extensive micro-economicliterature that has sought to explain householdreproductive decisionmaking as the rationaloutcome of economic considerations (Becker,1976; Schultz, 1981). There are a great manyvariants on a couple of rudimentary themes inthis literature, but the basic premise underlyingthis body of work is that parents choose thenumber of children they have in order tomaximize their well-being subject to a numberof constraints. Children are viewed as beingsimilar to other ``commodities.'' Changes in therelative price of children, changes in thecouple's income or opportunities, or changes inpreferences can in¯uence a couple's decision tohave children. This literature has stressed twoimportant ideas. First, time is scarce, so thatwomen must choose how to allocate their timebetween work and childbearing. Second, fertil-ity will decline as incomes rise if couples chooseto tradeo� the quantity for the quality ofchildren.

Within this framework, the demand forfamily planning services arises when the bio-logical supply of children (i.e., the number ofchildren that couples would have if they madeno deliberate attempt to limit family size)exceeds the demand for children. Whethercouples choose to regulate their fertility,however, will depend on how couples weigh thecosts and bene®ts of additional children againstthe costs of regulation. Conceptually, the priceof contraception includes all monetary, timeand psychological factors associated withobtaining and using contraception. The latterinclude such factors as the mental distressassociated with worrying about the potentialside-e�ects of particular methods of contra-

ception. The objective of this study is to assessthe role that particular attributes of familyplanning programs, which may be manipulatedby government policy, play in determiningcontraceptive use.

Note that in Africa this demand-orientedapproach is often viewed as overly simplisticbecause it ignores many features of Africansocial organization and family formation. Forexample, child fostering is commonplace inmany parts of the region, but the neoclassicaleconomic model assumes that individualcouples act alone and ignores the role thatextended family members play as child rearers.Furthermore, because female labor forceparticipation is assumed to take place outsideof the home, the model views childrearing andwork as largely incompatible with one another.In largely subsistence economies however, as isthe case in much of sub-Saharan Africa, a largefraction of female labor force participationtakes place on family farms so that work maynot be particularly incompatible with child careactivities. In addition, siblings, grandparents,and other relatives are often available to act assubstitutes in child care, reducing the impor-tance of this potential con¯ict. Furthermore,the contribution of children to farm work andchild-minding activities is largely ignored inmost neoclassical formulations, yet theeconomic contribution of children to familyoutput can be considerable from a very earlyage. Finally, in many African societies, childrenconfer status on their parents and the familypatriarch, and provide both a form of riskinsurance in an uncertain environment and aninvestment in old-age security. All of thesefactors provide additional important incentivesfor high fertility.

In the analysis of contraceptive use below, alarge number of potential determinants offertility that the theory of household decision-making suggests may be important are consid-ered. Greater education is usually associatedwith lower fertility because education tends todelay marriage, increase the value of women'stime and increase the likelihood that they areengaged in paid employment. Greater educa-tion also may empower women with moredecisionmaking authority in their householdand improve their ability to practice e�cientcontraception. The e�ect of other variables oncontraceptive use, such as income, is moreambiguous. If children are viewed by parents as``normal'' goods then an increase in incomewould imply that parents would want more


children. But, because couples can choose totradeo� the quantity and the quality of theirchildren, it is theoretically possible (and indeedquite likely) that an increase in income maylead to couples deciding to have fewer, butperhaps higher ``quality'' children. In the ®rstscenario, contraceptive use would fall withincome, while in the latter scenario, contra-ceptive use would rise with income.

Lower prices (broadly de®ned) or improvedquality of services are expected to be associatedwith higher use of contraceptives, and higherprices and poorer services with lower use.Apart from reducing the price of contracep-tives, lowering the ``price'' of contraceptiveservices also can be accomplished by suchinterventions as: (a) increasing the general levelof knowledge about contraception and break-ing down social barriers to using moderncontraceptives through information, education,and communication campaigns; (b) increasingcontraceptive choice; (c) alleviating concernsabout adverse medical side-e�ects associatedwith use of certain methods; (d) increasing theaccessibility of contraceptives, which can lowerthe time cost of obtaining them; and (e)improving the quality of services by, forexample, providing better counseling or a moresupportive environment that is responsive toindividual clients' needs.

In summary, the function describing contra-ceptive usage may be written in reduced formas:

pij � a0Xij � b0Zj � eij;

where pij represents the probability that the ithwoman in the jth community uses a modernmethod of contraception, expressed as a func-tion of a vector of exogenous individual andhousehold factors (Xij) a�ecting the demand forchildren, and a vector of community-levelfactors (Zj) associated with the supply andprice of contraception. The ®nal term, eij,represents unobserved individual speci®cheterogeneity, such as a woman's individualfecundity, which is assumed to be independentand identically distributed across observations.

Before presenting the empirical results, it isimportant to note that a number of potentialeconometric problems plague the estimation ofa contraceptive use function of the sort descri-bed above. As is often the case in the socialsciences, the theoretical debate concerning theplacement of family planning programs andcontraceptive use far exceeds the availability of

data with which to model it. This is certainlytrue in sub-Saharan Africa where micro-levelstudies on this topic are still very rare. Conse-quently, in order to lend mathematical tract-ability to the problem, it is assumed that: familyplanning programs are distributed randomly,not according to the likely demand for services(Rosenzweig & Wolpin, 1986); there is nocorrelation between program placement andpotential migration of heterogeneous programbene®ciaries (Rosenzweig & Wolpin, 1988); andknowledge about contraceptive use is measuredaccurately and is not correlated with women'sunobserved level of underlying fecundity orwomen's desire to use contraception. Theseassumptions appear plausible in the case ofMalawi where levels of modern contraceptiveuse are currently very low. Nevertheless, thepaper's conclusions should be interpreted withthese caveats in mind.

4. DATA AND VARIABLE DEFINITIONS

Data for this study are drawn from the 1992Malawi Demographic and Health Survey(DHS), a nationally-representative samplesurvey designed to provide information onlevels and trends in fertility, family planningknowledge and use, and early childhoodmortality and morbidity in Malawi. Full detailsof the sampling methodology employed incollecting the data are described in a report ofthe National Statistical O�ce and MacroInternational Inc. (1994). In addition to anindividual-level questionnaire, the MalawiDHS administered a community-level ques-tionnaire to community-leaders, recordinginformation on nearby health facilities andlocal availability of family planning services. Intotal, the Malawi DHS collected informationon 4,849 women aged 15±49 living in 225clusters.

A complete list of variables used in theanalysis is provided in Table 1. Contraceptiveuse was measured by a dummy variable indi-cating whether the woman was currently usinga modern method of contraception. Womenalso were asked if they had ever used anymethod of modern contraception; but it wasfelt that because of the cross-sectional nature ofthe data, there was little to be gained fromattempting to explain patterns of ever-use ofcontraception with variables that describedeither the current strength of family planningprograms in a particular district or the current


characteristics of a woman's nearest source offamily planning services. Traditional methodsof contraception have been ignored in thisanalysis. The two most popular methods oftraditional contraception in Malawi are the use

of beads or string tied around the waist and thedrinking of potions made from local herbs orother medicines (Kalipeni & Zulu, 1993;Madise & Diamond, 1993). These methods areunlikely to be very e�ective forms of contra-

Table 1. Variable de®nitions, means and standard deviationsa

Variable De®nition Means and standard deviations

Urban Rural Total

Dependent variablesCURRENTUSE DV: 1 if currently using modern method

of contraception0.13 (0.34) 0.05 (0.22) 0.07 (0.26)

EVERUSE DV: 1 if ever used a method ofcontraception

0.32 (0.47) 0.15 (0.35) 0.19 (0.40)

Independent variablesIndividual-levelAGE Age of the female respondent in years 27.16 (8.59) 28.43 (9.72) 28.08 (9.44)NOSCHOOL DV: 1 if respondent had never attended

primary school0.20 (0.40) 0.46 (0.50) 0.39 (0.49)

PRIMARY14 DV: 1 if respondent has 1±4 years ofprimary education

0.16 (0.37) 0.24 (0.43) 0.22 (0.41)

PRIMARY58 DV: 1 if respondent has 5±8 years ofprimary education

0.43 (0.49) 0.27 (0.45) 0.31 (0.46)

SECONDARY+ DV: 1 if respondent attended secondaryschool or above

0.21 (0.41) 0.03 (0.16) 0.08 (0.27)

Household-levelHUSBAND DV: 1 if husband present 0.65 (0.48) 0.64 (0.48) 0.65 (0.48)HUSED0 DV: 1 if husband has no formal education 0.06 (0.25) 0.21 (0.41) 0.17 (0.37)HUSED1 DV: 1 if husband has 1±4 years of school 0.09 (0.28) 0.22 (0.41) 0.18 (0.39)HUSED2 DV: 1 if husband has 5±8 years of school 0.47 (0.50) 0.47 (0.50) 0.47 (0.50)HUSED3 DV: 1 if husband has 9+ years of school 0.37 (0.48) 0.10 (0.30) 0.17 (0.38)RADIO DV: 1 if household owes a radio 0.72 (0.45) 0.35 (0.48) 0.45 (0.50)LAMP DV: 1 if household owes a lamp 0.86 (0.35) 0.87 (0.33) 0.87 (0.34)BICYCLE DV: 1 if household owes a bicycle 0.20 (0.40) 0.25 (0.43) 0.23 (0.42)ASSETS DV: 1 if household owes other assets 0.11 (0.31) 0.05 (0.21) 0.06 (0.24)

Community-levelURBAN DV: 1 if respondent lives in urban area ± ± 0.27 (0.44)NORTHERN DV: 1 if resides in Northern region 0.29 (0.45) 0.30 (0.46) 0.30 (0.46)CENTRAL DV: 1 if resides in Central region 0.36 (0.48) 0.32 (0.47) 0.33 (0.47)SOUTHERN DV: 1 if resides in Southern region 0.35 (0.48) 0.38 (0.49) 0.37 (0.48)HEARDFP DV: 1 if heard family planning message

on the radio within the last month0.48 (0.50) 0.24 (0.43) 0.31 (0.46)

SEENADVERT DV: 1 if heard or seen message aboutcondoms within the last month

0.58 (0.49) 0.33 (0.47) 0.40 (0.49)

AIDSIEC DV: 1 if AIDS awareness campaign ran incommunity in last 12 months

0.19 (0.39) 0.41 (0.49) 0.35 (0.48)

DISTTOFP Distance to nearest source of familyplanning (miles)

1.80 (1.39) 7.67 (10.20) 6.05 (9.09)

CHOICES Number of family planning methods thata woman knows where to obtain

4.07 (2.30) 2.97 (2.30) 3.27 (2.35)

HOSPITAL DV: 1 if nearest source of family planning(f.p.) is a hospital

0.49 (0.50) 0.43 (0.50) 0.45 (0.50)

CLINIC DV: 1 if nearest source of f.p. is a clinic 0.30 (0.46) 0.47 (0.50) 0.42 (0.49)MOBILE DV: 1 if nearest source of f.p. is a mobile

health unit/other0.21 (0.39) 0.10 (0.27) 0.13 (0.31)

PUBLIC DV: 1 if nearest source of f.p. is run by thepublic sector

0.79 (0.41) 0.72 (0.45) 0.73 (0.44)

a DV� (1,0) Dummy variable.


ception except perhaps when potions are usedto induce an abortion.

The list of explanatory variables includescharacteristics of women and their husbands aswell as community-level data obtained from thesupplemental service availability questionnaire.The list of women's characteristics include age,education, place and region of residence, andmarital status. In the absence of a directmeasure of wealth, dummy variables denotingasset holdings have been used as proxies. Whenavailable, information on husband's educationalso is included as an additional proxy forhousehold wealth.

Descriptive statistics for all the explanatoryvariables are provided in Table 1. The samplehas been strati®ed into separate urban andrural subsamples, in order to highlight the largeurban-rural di�erences that exist for certain keyvariables. For example, there is considerablevariability in educational attainment betweenthe urban and the rural subsamples. Forty-sixpercent of women in the rural subsample neverattended school and only 3% attended second-ary school or higher. By contrast, only 20% ofwomen in the urban subsample never attendedschool and 21% attended secondary school orhigher.

Not surprisingly, access and use of moderncontraception also varies considerably betweenurban and rural areas. In urban areas, thenearest source of family planning is approxi-mately 1.25 miles away and takes an average of30 min to reach. In rural areas, averagedistance to the nearest source of family plan-ning is 4.4 miles and it takes approximately anhour and a half to reach. Urban women are alittle over twice as likely to have ever used amodern contraceptive and approximately twoand a half times more likely to be currentlyusing a modern method of contraceptioncompared to their rural counterparts.

The main purpose of this paper is to improveour understanding of the relative importance ofvarious elements of a reproductive healthprogram as an important ®rst step towardsidentifying policies aimed at increasing theoverall quality of family planning programsand raising contraceptive use in Malawi. Table2 presents the percentage of women currentlyusing or having ever used modern contracep-tives strati®ed according to various dimensionsof family planning characteristics and urban/rural residence.

The most direct way to in¯uence people'sbehavior is through information, education,

and communication (IEC) campaigns. Suchcampaigns are an essential way of informingpeople why family planning is important, whereto obtain contraceptive supplies, and how touse them correctly. Well-designed family plan-ning campaigns have been shown to increasenot only awareness but also contraceptive use(Westo� & Bankole, 1997). For example, arecent analysis of the role of mass media andfamily planning in Kenya documented a strongstatistical association between reports of havingheard or seen messages about family planningand various measures of reproductive behavior(Westo� & Rodriguez, 1993). In Malawi,because of past opposition to family planning,producers of family planning messages tend toappeal to traditional values related to appro-priate birth interval length, emphasizing therole that modern contraceptives can play inhelping families better space their children(Marshall, 1989). In addition, a large socialmarketing project began marketing ``Protec-tor'' condoms in July 1991, running a barrageof print and radio advertising designed toincrease general awareness of condoms andimprove their image (Brown, 1994).

There are a number of di�erent measures ofthe perceived and actual strength of advertisingcampaigns available in the DHS data. Womenwere asked whether in the last month theyheard any message about childspacing on theradio or whether they had seen or heard anyadvertisement about condoms either on theradio or in newspapers, magazines or on bill-boards. In addition, the supplemental serviceavailability questionnaire recorded fromcommunity leaders whether there had been anyspecial educational campaigns designed toincrease awareness about AIDS in each samplecluster.

Table 2 reveals that exposure to mass mediamessages, either through hearing family plan-ning messages on the radio, or reading aboutcondoms in newspapers or magazines appearsto be highly correlated with the use of moderncontraceptives. Note, however, that to someextent women's recall is in¯uenced by theirinterest in using contraception. In contrast, theresponses of community leaders in the samesample cluster should be a relatively un-contaminated measure of local mass mediaactivity.

A second potential option for policymakerswishing to promote contraceptive use is toincrease method choice. Previous research hasshown that greater contraceptive choice can be


associated with higher use. For example, inIndia, the government's nearly exclusive reli-ance on sterilization as the family planningmethod of choice in the 1970s prevented manycouples from altering their reproductivebehavior in response to changing mortalityenvironments (Bhat, 1998). Table 2 suggeststhat women who know where to obtain four ormore methods of contraception are far morelikely to be currently using contraceptioncompared with women who know where toobtain less than three methods. Here again, the

possibility of reverse causality exists. Further-more, to the extent that the information isderived from clients rather than serviceproviders, one perhaps could view it as merely ameasure of the success of past information andeducation campaigns. This complication will beaddressed below.

There is a large operations research literaturewithin the study of family planning whichpoints to a third policy option to promotecontraceptive use: increase access to contra-ceptive services (see, for example, Foreit &

Table 2. Percentage of women using modern contraception by various socioeconomic characteristics

Ever use Current use

Urban (%) Rural (%) Urban (%) Rural (%)

Exposure to mass media messagesHeard family planning message onradio

Yes 42.4 23.5 18.4 9.4No 22.6 11.9 8.3 3.8p-value <0.001 <0.001 <0.001 <0.001

Seen advertisement for condoms innewspaper

Yes 40.7 24.2 17.0 9.7No 20.5 10.0 7.9 2.9p-value <0.001 <0.001 <0.001 <0.001

AIDS awareness campaign in last12 months

Yes 28.9 15.4 11.2 5.5No 34.0 14.3 13.9 4.9p-value 0.130 0.339 0.260 0.494

Contraceptive choiceNumber of methods known where toobtain

0±1 5.3 3.1 1.9 1.12±3 13.9 12.2 3.8 3.94+ 45.0 25.0 18.9 8.9p-value <0.001 <0.001 <0.001 <0.001

AccessibilityFamily planning obtainable fromprimary health care facility locatedwithin 3 miles

Yes 34.6 17.6 14.2 7.2No 27.1 13.2 10.4 4.1p-value 0.020 <0.001 0.108 <0.001

Family planning obtainable fromhospital located within 15 miles

Yes 35.2 15.9 14.4 5.4No 31.2 14.0 12.5 5.0p-value 0.130 0.125 0.324 0.538

Service provider characteristicsNearest source of family planning is:

Hospital 31.5 14.5 13.1 5.5Health Clinic 34.6 15.3 12.3 4.8Mobile Unit/Other 35.4 12.0 15.8 4.2p-value 0.429 0.333 0.434 0.511


Frejka, 1998, and references therein). In thispaper, access to reproductive health services ismeasured by distance or travel time to thenearest family planning outlet taken from thesupplemental service availability questionnaire,acknowledging that the nearest outlet may notalways be the preferred choice. For example,the desire for anonymity among certainsubgroups of the population (e.g., unmarriedschoolgirls) may cause them to prefer outletsfurther away from their own neighborhoods.Nevertheless, it is easier to argue that distanceand time to the nearest source of family plan-ning should be treated as exogenous than it isto argue that self-reported data on contracep-tive knowledge should be, although someauthors have cautioned that endogenousprogram placementÐwhere demand for familyplanning outlets determines their locationÐcanlead one to false inferences (Rosenzweig &Wolpin, 1986). Furthermore, distance may notbe the best proxy for the total cost or time ofobtaining contraceptives without additionalinformation about available transport to thesite or whether the woman travels near to thesite regularly for other purposes. These caveatsaside, Table 2 shows that, at the bivariate levelat least, there appears to be some evidence thatproximity to a primary health care facility inrural areas is associated with greater use ofmodern contraception. In urban areas theassociation also appears to be in the expecteddirection, but it is insigni®cant.

A ®nal important potential strategy topromote greater contraceptive use is to improveprogram quality. Studies devoted to problemsof the quality of services have increased rapidlyin the 1990s, following a call at the 1994International Conference on Population andDevelopment for greater attention to thequality of reproductive health services and thereproductive rights of individual women (Kols& Sherman, 1998). Successful programs areusually those that are responsive to clientneeds, that o�er a good choice of methods, andthat provide informed counselling in asupportive, clean, private, and friendly envi-ronment. For example, recent data from Perusuggest that current contraceptive use is a�ec-ted by the family planning service environmentin which a woman resides (Mensch, Arends-Kuenning & Jain, 1996). Moreover, in ruralBangladesh, Koenig, Hossain, and Whittaker(1997) found that perceptions of womenregarding the quality of ®eld-worker care weresigni®cantly related to the probability of

subsequent adoption of a family planningmethod. While it was not possible to constructa detailed index of the quality of serviceso�ered at each clinic using this dataset, a set ofdummy variables denoting various character-istics of nearby providers have been included asproxies of various aspects of quality of care.These include whether the nearest source offamily planning is a hospital, a primary healthclinic, or a mobile outreach point and whetheris it government-or church-operated. Thesevariables are likely to be related to such indi-cators of quality as the nature of provider-clientinteractions, the extent of training and super-vision of professional sta�, and the probabilitythat a particular contraceptive method mightbe o�ered. Table 2 shows, however, that at thebivariate level, these crude measures of thelikely quality of services o�er little in the way ofexplanatory power.

5. MULTIVARIATE RESULTS

The procedure used to analyze the determi-nants of contraceptive use in a multivariatesetting is very straightforward. First, contra-ceptive use is modeled as a function of varioushousehold characteristics, placing particularemphasis on the role of female and male edu-cation and measures of household wealth. Thenvarious measures of the strength and variousdimensions of family planning programs areadded and their e�ects on the probability ofusing a modern method of contraception areobserved.

Table 3 shows the results of a maximum-likelihood probit model of contraceptive usecontrolling for selected individual and house-hold characteristics. To make the interpretationeasier, all the coe�cients have been trans-formed into changes in derivatives. For dummyvariables, dF/dx represents the change from thevariable being 0 to the variable being 1.Because of the nature of the sample, the stan-dard errors reported under the coe�cients arerobust for clustering e�ects (StataCorp, 1997).

The model is estimated for the full sample ofwomen. Contraceptive use is modeled as afunction of a woman's age, her education, theeducation of her husband, and proxies for theirhousehold wealth. These variables make up thestandard set of exogenous variables in micro-economic models of human behavior. Othervariables such as age at marriage, parity, ordesired family size are usually treated as


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endogenous and, consequently, are not inclu-ded in a reduced form speci®cation.

In the ®rst speci®cation, current contracep-tive use increases with age, but at a decreasingrate. Given di�erences in fecundity over thelife-cycle and given that as women age they aremore likely to approach their desired familysizes, it is not surprising to ®nd strong agee�ects in the data, a point that requires nogreater elaboration.

Female education beyond primary schoolappears to be an important determinant ofcurrent contraceptive use, perhaps becausemore educated women are more likely toappreciate the advantages of having fewer,better educated, children. Small amounts ofeducation have been found to sometimes raise,rather than lower, fertility because it breaksdown traditional birth-spacing practices suchas prolonged breastfeeding or postpartumabstinence without lowering fertility desires orincreasing age at marriage. Furthermore, moreeducated women are less likely to be fatalistictoward the use of family planning and morelikely to be knowledgeable about alternativemethods of family planning and their potentialside-e�ects. Finally, educationÐtogether withthe coe�cient on residence which is also highlysigni®cantÐserves as a proxy for the value ofwomen's time and the likelihood of her ®ndingpaid employment.

From a theoretical standpoint, the e�ect ofmale education on contraceptive use is ambig-uous. It can be either positive or negativedepending upon parents' preferences. In Table3, we see that male education has little e�ect onthe determinants of contraceptive use when onecontrols for female education. Only the coe�-cient on whether the husband has secondaryeducation is signi®cant at the 5% level in therural and the older subsamples, a result thatcarries over to the total sample. Here, ahusband's higher level of education tends toincrease the likelihood of a woman currentlyusing a contraceptive as opposed to lowering it,perhaps an indication that male and femalepreferences are very similar.

Regrettably, the DHS did not attempt tomeasure household income or wealth. In theabsence of better measures, various measures ofasset holdings have been included to indicate(albeit somewhat crudely) household wealthcontrolling for the presence of a husband andthe husband's education. Three of the fourvariables measuring asset holdings were signif-icant, and always in the same directionÐim-

plying that contraceptive use rises as incomerises. At the bottom of Table 3, chi-squaredtests of the joint signi®cance of the educationand wealth variables are provided. The resultsshow that jointly, these measures of educationand wealth are highly signi®cant.

The remaining columns in Table 3 presentthe same model estimated for various subsam-ples of the population. By and large, thesecoe�cients con®rm the importance of femaleeducation and household wealth as determi-nants of contraceptive use. The results indicatethat, ceteris paribus, greater female educationand larger household wealth increase theprobability that a woman uses moderncontraception. One noteworthy feature of thisanalysis is the interaction between female edu-cation and place of residence, suggesting thatthe positive relationship between education andcontraceptive use is stronger in urban areas.Recall that these two variables are proxies forthe value of women's time and the likelihood ofher ®nding a job o� the family farm.

Having now modeled contraceptive use asparsimoniously as possible, measures of variousdimensions of family planning e�ort are intro-duced. Table 4 shows selected statistics frommaximum-likelihood probit models of contra-ceptive use using both household and commu-nity-level variables. Again, the coe�cients havebeen transformed into changes in derivatives.The results show that mass media exposure,contraceptive choice, and accessibility of servi-ces all are associated with higher contraceptiveuse. The coe�cients on mass media andcontraceptive choice are positive, indicating themore exposure to media messages or the morechoice provided, the greater the likelihood ofuse of modern contraception. Similarly, as onewould expect, the coe�cient on accessibility isnegative. As distance from the nearest source offamily planning increases, contraceptive usedeclines.

Table 4 also provides some weak evidencethat the characteristics of the nearest availablesource of family planning services a�ectscurrent contraceptive use. Adding a set ofdummy variables denoting various character-istics of the nearest source of family planningdid not improve the explanatory power of themodel (see column 8). But, when all the variousdimensions of family planning program e�ortwere included in the model, the dummy vari-ables indicating whether the nearest source offamily planning was a hospital or a health clinicwere both signi®cant. Furthermore, as a block,


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the service provider dummies just pass a chi-square test implying that one can reject the nullhypothesis of no e�ect.

As discussed above, one of the majorpotential criticisms of the above analysis is thatinformation about family planning messagesand availability of methods is self-reported.Overall, 31% of women in the sample (48% ofurban women and 24% of rural women) hearda family planning message on the radio withinthe past month. Only 7% of women in thesample (13% in urban areas, 5% in rural areas)are currently using a modern method ofcontraception. It is quite possible that womenwho are using contraceptives are more cogni-zant of local mass media messages or moreaware of locations where one can obtaincontraceptives than women who have nointerest in using modern contraception. Oneway to avoid this problem is to use theresponses of the other women in the samesampling cluster to construct an independentcommunity-based measure of the strength ofmass media e�orts within a particular samplingcluster. When this is done for exposure to massmedia messages, the coe�cient on familyplanning messages e�ectively evaporates,although it still operates in the correct directionand is signi®cant at the 10% level (see column 2of Table 4). This suggests a positive errorcorrelation between contraceptive use andcontraceptive knowledge. Similarly, one canconstruct a measure of the degree of contra-ceptive choice within a particular cluster basedon the responses of other women in the cluster.When this variable is used to replace the orig-inal contraceptive choice variable, the size ofthe coe�cient is reduced, but is still signi®cant(see column 5 in Table 4).

A second common strategy for dealing withpotential endogeneity is to use instrumentalvariables (IV) estimation, using ``instrumental''variables that are thought to be correlated withthe potential endogenous explanatory variablebut not associated directly with currentcontraceptive use. For this method to workwell, one must have good instruments. If thedegree of identi®cation is low, the correctedestimates will have large standard errors,diminishing the precision with which one canmeasure the ``true'' e�ect of the explanatoryvariables in question (Bound, Jaeger & Baker,1995). Unfortunately, the list of defensibleinstruments in the current data set is quiteshort. Identi®cation was achieved using adummy variable denoting whether the house-

hold owns a radio and using the responses toquestions about whether the respondent usuallylistens to a radio or reads a newspaper ormagazine at least once a week. The r-squaredfrom the ®rst-stage equations range from 0.06to 0.20. Not surprisingly, therefore, IV estima-tion leads to fairly imprecise estimates of thee�ect of mass media messages on contraceptiveuse that are larger but not statistically di�erentfrom those reported earlier (see column 1 versuscolumn 3 in Table 4). In such cases, it may bebetter to ignore the issue of potential endoge-neity and simply accept the fact that the esti-mated coe�cient may contain a positive bias.

To choose between alternative speci®cations,a speci®cation test was performed to determinewhether there is any evidence of a statisticaloverlap between unobservable variables thata�ect both contraceptive knowledge andcontraceptive use. The test, suggested byBollen, Guilkey and Mroz (1995), is reasonablystraightforward and involves predictingcontraceptive knowledge using ordinary leastsquares and then including the estimated errorterms from the contraceptive knowledge equa-tions as additional regressors into the contra-ceptive use equation. (To a large extent, ofcourse, the power of this test again relies onceagain on having good instrumental variables.)Jointly, the residuals were not signi®cant,suggesting that one cannot reject the nullhypothesis that unobservables in the equationfor contraceptive knowledge do not help toexplain variation in the propensity for contra-ceptive use, controlling for the observableexplanatory variables. (The value of the ®nalchi-squared test statistic was 5.36, with aprobability value of 0.15.) Because the infor-mation about accessibility and service providercharacteristics was obtained separately fromthe community questionnaire, the issue ofendogeneity did not arise.

Identifying the characteristics of women whowant and use family planning services enablespolicymakers to evaluate the e�ectiveness ofcurrent programs and to estimate the likelyfuture market for services. For this reason, theanalysis was repeated for various subsamples ofthe population strati®ed by age, residence, andeducation. The results from the chi-squaredtests reported in Table 5 show the joint e�ectsof various dimensions of family planningprograms on contraceptive use. These resultsgenerally con®rm the strong positive associa-tion between media messages and current use ofcontraception and contraceptive choice and


current use of contraception. The results for theaccessibility and service provider characteristicsare somewhat weaker although accessibility(proximity) appears to be particularly impor-tant for rural and for younger women. Distanceto the nearest source of family planning doesnot appear to be a signi®cant constraint on theuse of modern contraceptives for urban resi-dents, who may know several places where theycan obtain contraceptives with the nearestsource not necessarily being their preferredchoice. Indeed, married women may prefer touse clinics on the other side of town to avoidbeing recognized.

The characteristics of the nearest serviceprovider generally appear insigni®cant in themodels. Undoubtedly, quality of servicesmatters, but the impact of factors such as betterprovider-client interactions cannot be capturedin our low level measures.

6. DISCUSSION

Very few studies have been published on thedegree to which family planning programs canstimulate demand for contraceptives in sub-Saharan Africa. Nevertheless, from a policyperspective, increasing access to contraceptionis the most direct intervention available forlowering fertility, so the topic continues towarrant careful study. Furthermore, identifyingthe characteristics of women who want or usefamily planning services enables policymakersto evaluate the e�ectiveness of currentprograms and to estimate the likely futuremarket for services.

In this paper, micro-level data from ademographic and health survey of almost 5,000women in Malawi have been linked to infor-mation about health service availability inorder to assess the relative importance ofsocioeconomic background characteristics andvarious aspects of family planning provision oncontraceptive use in one country in sub-Saha-ran Africa. Maximum-likelihood probit modelshave been used to assess the independentin¯uence of four dimensions of family planninge�ort on contraceptive use: mass media expo-sure (i.e. promoting family planning throughradio and print messages), increasing contra-ceptive choice, improving the accessibility ofcontraceptive services, and improving servicequality (to the extent that it can be proxied by aweak set of characteristics about the nearestservice provider). Results indicate that all fourcomponents of family planning e�ort contrib-ute to the use of modern contraceptives inMalawi, although their relative importancevaries substantially across di�erent segments ofthe population.

The analysis strongly suggests that massmedia messages have a powerful e�ect onmodern contraceptive use. As discussed above,however, given the cross-sectional nature of thedata, one cannot be completely certain of thetemporal order of events and these results donot necessarily establish causality. Neverthe-less, they are entirely consistent with recent®ndings of Westo� and Rodriguez (1993) andBankole et al. (1996) who found that mediamessages in¯uence women's motivation to limitfertility and increase their knowledge about theavailability of supplies.

Table 5. v2 tests of the e�ects of various dimensions of family planning programs on the probability of currently using amodern method of contraception: alternative sub-samples

Sub-sample Mass mediaexposure

Contraceptivechoice

Accessibility Serviceprovider

characteristics

All communitycharacteristics

All womena 14.42�� 47.31�� 6.57�� 7.46� 88.19��

Age < 25 6.99� 7.12�� 5.63�� 2.66 24.35��

25 < Age < 35 9.06�� 13.65�� 2.86� 2.05 28.28��

Age > 35 4.69 28.48�� 0.11� 4.78 43.50��

Urban women 14.67�� 11.98�� 2.49 5.03 34.88��

Rural women 7.59�� 39.88�� 6.80�� 5.37 66.22��

No education 4.80 24.16�� 3.93�� 7.60� 47.38��

Some education 16.62�� 16.57�� 3.97�� 5.13 51.28��

a All regressions also include controls for woman's age, education, urban/rural residence, region of residence, pres-ence of husband, husband's education, and household assets.* p < 0:10.** p < 0:05.*** p < 0:01.


Rapid population growth in Malawi hascreated a situation in which large numbers ofwomen are about to enter reproductive age.Recent demographic surveys in Malawi havedocumented the need to increase the level offamily planning services throughout the coun-try. In such a setting, it is particularly impor-tant for the government to be able to use thelimited resources that it has at its disposal ase�ectively as possible. Probably the mostimmediate need is to continue to increase thesupply of reversible methods of moderncontraception that can be used to either delaychildbearing or to better space pregnancies.Judging from women's self-reported answers toquestions regarding the timing and size of theirfamilies, a signi®cant proportion of women inneed of family planning services want to betterspace their children rather than to stop child-

bearing completely (National Statistical O�ce& Macro International, 1994). In all likeli-hood, family planning providers can expectwomen to be quite receptive to the idea ofusing modern family planning methods forspacing purposes since the advantages of well-spaced births long have been appreciated inMalawi.

In the absence of proper experimentaldesigns, it is very hard, if not impossible, forpolicymakers to determine the likely merits ofalternative policy options. Ultimately, the typeof cross-sectional survey data currently avail-able is not well-suited to answering policyquestions of this sort. Greater e�ort needs to bemade to design demonstration projects thatcontain a careful experimental design thatwould allow researchers to better evaluatealternative policy options.

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Family Planning Programs, Socioeconomic Characteristics, and Contraceptive Use in Malawi

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