My favorite academic paper was finally published, in American Economic Review, no less. Nava Ashraf, Erica Field and Jean Lee explore the effect of husbands on fertility decisions in urban Zambia. This is very similar to my own dissertation research project in Tanzania (aka, my life for the past five years), so I'm quite interested in their work.

Similar to my study, the authors use a randomized control trial to measure the impact of husbands involvement in decisions about whether or not to adopt contraceptives. In contrast to my study, the Zambian health worker only visits homes a single time and gives a voucher for free injectable contraceptives (my intervention is longer and contraceptives are already free Tanzania). Women who receive the voucher alone (without their husbands) have the option of adopting contraceptives discretely; women who receive the voucher together with their husbands have a clearer path towards some form of family planning communication. Men in the Couples treatment (e.g. receive together) are essentially given veto power: they are a part of the discussion about the availability of contraceptives and can choose to express their approval, be part of the contraceptive adoption process, prohibit the stuff or be a stick in the mud (among other options). And because men in these samples typically have more bargaining power within the household (economist speak for women not empowered), this sort of inclusion of husbands translates into the power to obstruct.

A somewhat unsurprising discussion in this paper is about the trade-offs between privately improving a woman's set of choices (and gaining utility), while possibly lowering the value of the marriage by the addition of secrecy (the "conjugal value of the marriage"). And in my own study, I've heard some women admit to the short-term benefits of concealed used of contraceptives while bemoaning the risks of secrecy and poor communication in their marriage. In other news, these women tend to have inattentive and unhelpful husbands.

One thing that Ashraf et al. seem to overlook, however, is the possibility of changing the psycho-social cost (economist speak for anxiety) of using contraceptives. 

We do find that [women in the Individual treatment, who had an opportunity to use contraceptives without their husband's approval] experienced a significant reduction in happiness, health and ease of mind compared to those in the Couple treatment. This suggests a longer-term psycho-social cost to concealable contraceptives that can be mitigated by spousal involvement.

While involving husbands in the dialogue over family planning is one way to reduce the burden of secrecy, the elephant in the journal article is that birth control carries this weight of anxiety because it is not socially acceptable in these places. The type of husband whose wife is seriously considering concealed contraceptives is not exactly a well-educated progressive male feminist. He resides in the space where social acceptance matters, traditional gender and tribal roles dominate and mis-education (especially with regards to medicine and healthcare) is rampant. 

In fact, in their large sample, some men who even expressively did not want to have a child in the next two years simultaneously discouraged their wives from using contraceptives, thereby increasing inefficient outcomes (which, in this case, is economist speak for unwanted births). This is not just miscalculated costs or utility, this is something bigger.

Despite my training as an economist, I cannot deny that the psycho-social cost of adopting contraceptives (concealed or not) can be reduced by fuzzy things like social change. Of course, I also acknowledge the standard fertility determinants of microeconomics. But, my work with community health workers in rural Tanzania has given me renewed hope in training, education and development as vehicles to adjust gender norms and create institutional social change. Social change is hard to measure and harder to implement, but when it is done well, the change is undeniable. Poor people's fertility choices may be easier to digest through a simple microeconomic lens, but to study these decisions without at least some acknowledgement of the larger social factors dominating individual action like sexism, culture and social norms is to overlook the greater implications of this research.

Economics takes such a quantitative approach to research; we excel at measuring effects, not at explaining why those effects exist. So, I understand the value of focus group discussions. Allowing people the opportunity to openly explain why, and have responses that include more than a 0 or 1, is a small pittance to that effort.

It’s also useful to have a few anecdotes. There was the woman whose in-laws intervened after she and her husband had decided to use contraceptives.  Or a family planning worker who swears people listen to her public health message more when her she carries her official work bag. Even if my quantitative analysis is extremely rigorous, people remember these stories.

However, I mostly find focus groups to be an unpredictable, methodologically imprecise and difficult to analyze.

Last Tuesday, we conducted a focus group in one of the nearby study villages that was included in the intervention educating local family planning workers.  My field assistant liked this village; the village officer was very helpful, and this often made a big difference on how smoothly the household data was collected.

I was also impressed as a group of eight men were waiting at the village office for the meeting to start. Family planning discussions with men in Meatu can send off a flurry of debate, as many in these villages are firmly pro-natalist.   However, this focus group discussion went extremely smooth.  Yes, family planning would be useful for families in this village. Yes, I discuss contraceptive use with my wife. No, we don’t find it difficult to discuss.  So, conclusively positive reactions to family planning?

Not exactly. If I were to simply analyze the discourse during this discussion, I would miss the entire story.   With a little subjective judgment, I saw that the village leader officer had put on a nice show. The sample of this focus group discussion was clearly biased in favor of family planning. These men were mostly well educated and had mostly been screened to be appropriate for our discussion. 

However, there was one older gentleman in the corner who added two things to the discussion. His initial response to questions about the cost of children was that they are not expensive. And his conclusive statement about family planning was that  “it’s complicated.”

This guy was clearly not on the family planning train, had more-or-less gotten the message that the conversation should stay positive for the American guest and he was keeping his opinions to himself.

Meanwhile, my other beef with qualitative research analysis is the Worldes trend (see below). Apparently, this has become a hip and acceptable as a form of analysis. I could be the old man in the corner and just say the word “think" over and over, and this deep insight would make its way into some analysis in a presentation. 

Great for a t-shirt, I think, not for a conference.

Hat tip: ALD, LN

I have the following table from my preliminary Meatu district health data. It still blows my mind because it basically contradicts all my previously held thoughts about religion, Tanzania and contraceptives.

First of all, 67% of households interviewed did not identify with any religion, not even traditional beliefs. This contradicts everything my Swahili teacher told us about being a good East African ("one should always at least identify as a major religion, even if one never prays"). I guess not so in Meatu? People do report being largely fatalistic, though. 35% of women report that their fertility decisions (do you want another child?) are "up to God" and this group is made up of only one quarter of those that identify with a religion.

The real kicker, though, is the fact that couples who identified with a religion were more likely to use contraceptives. You can see from the number of households and the number of women reporting contraceptive use that the sample size is small. However, Catholics (88 households) have almost twice the overall rate of contraceptive use! Someone tell Paul Ryan?

My hypothesis on this second observation is that affiliation with a larger religion in these extremely rural villages is actually a signal of being more cosmopolitan. There's also a good chance that official doctrine in the Catechism of the Catholic Church isn't making its way all the way to Mwajidalala and Longalonhiga. I'm not complaining.

As for any explanation for the dearth of reported religious identification, my only hypothesis is that I asked the wrong person. I asked men. This time around, I'm asking women. I'm otherwise extremely surprised that individuals don't identify as more religious.

I'm accepting any and all theories, hypotheses and shots in the dark as to why.

From @CBlatts:

We investigate whether the show [16 and Pregnant] influenced teens’ interest in contraceptive use or abortion, and whether it ultimately altered teen childbearing outcomes. …We find that 16 and Pregnant led to more searches and tweets regarding birth control and abortion, and ultimately led to a 5.7 percent reduction in teen births in the 18 months following its introduction. This accounts for around one-third of the overall decline in teen births in the United States during that period.

One third?? Wow.

I'm hoping for a 20% increase in the uptake of contraceptives in my research district in Tanzania, which may not even translate into a reduction in teen births at all.  And my intervention includes real people visiting homes, an attempt at solidifying the impact of the intervention with a very clear and personal message. 16 and Pregnant, on the other hand was a) optional b) could be turned off at any point c) is interrupted with commercials and d) may have included unclear and varying messages that affect fertility behavior in different directions.

The effect of TV shows on fertility behavior is not new, however, Brazil's soap operas had the effect of reducing fertility by showing happy families than are much smaller than the realistic size in Brazil at the time. How does one show send a positive message about smaller families and one show send a negative message about teen pregnancy? Artistic choice, I suppose, and probably something economists won't ever know.

Bongaarts and Casterline in Population and Development Review explore whether sub-Saharan Africa's fertility is systematically different from the rest of the world, a theory first posited by Caldwell (1992). The authors reject Caldwell's hypothesis that these countries are experiencing a different type of transition in which declines in fertility are occurring at older ages. However, they do confirm some unique characteristics of sub-Saharan Africa's fertility experience. First of all, in many regions, the decrease in Total Fertility Rate (TFR) has stalled, in contrast to the pattern of steep TFR decline in the earliest stages of demographic transitions in Latin American and Asia. And secondly, the small decreases in TFR are mostly driven by larger birth intervals rather than a desire for smaller families.

Except Rwanda. The Rwandan DHS shows an unusual pattern in which unmet need (as defined by women who do not want to get pregnant and are not using contraception) declined by nearly a half between 2005 and 2010, to which the authors credit the invigoration of a national family planning program. Contraceptives use more than doubled between 2005 and 2010. This stands in stark contrast to other sub-Saharan countries (e.g. Ghana, Burkina Faso, Kenya and Nigeria) where use of contraceptives has basically stalled since the mid-1990s.

What this paper doesn't answer is how the drivers of unmet need (e.g. lack of knowledge of contraceptive methods and supply; low quality and limited availability of family planning services; cost of methods in travel and time; familial objections and concerns about acceptability) that are propping up that green curve, can be fixed.

To clarify, this graph shows frequency of previous contraceptives used for women who have hidden contraceptive use in the past across twelve villages in Meatu, Tanzania. So, while hiding a condom is obviously difficult, women who have hidden the pill from their partner have also used condoms in the past. Injections are extremely popular in this rural district, notably for their effective duration.

Easily the most interesting graph I've made in a while.

Some thoughts from the Breakthrough Institute and the Washington Post on the world's survival of the supposed population bomb. Some interesting points here (and fantastic images), but I turn to David Lam's 2011 presidential address at the Population Association of America conference for more.

He justifies the 1960s era fear of the population bomb and his explanation is more robust than cultural exposure such as television. Namely 1) economic factors: Market responses, innovation (especially the green revolution), globalization and 2) demographic factors: urbanization, fertility decline and investment in children.

When we see growth rates of food output or GDP of 7% and 10% per year we can see how countries like Vietnam, China, and India outraced the Malthusian devil in recent decades. The point is not that population growth does not create challenges for economic development, but that these challenges can be overcome when forces like market liberalization lead to this kind of rapid economic growth.

It may seem that fertility decline alone is a simple explanation for surviving the population bomb, but this would undermine the effect of economic factors and incentives on fertility. Even as someone who studies the effect of simple access to family planning on fertility, I know they're all related.

Hat tip: NAJ, DL

Having spoken to a lot of women who seem legitimately interested in family planning (although I have also developed a strong social bias detector), I'm more aware of the logistical challenges that Mama from Mwajidalala village might actually face in adopting contraceptives. Dispensaries are fairly well stocked and family planning is almost entirely free. For the most part, the Ministry of Health staff appears well-trained and dedicated to their work.

The big hold up to access is combination between timing and distance. It's Ministry of Health policy that women cannot start on a contraceptive unless 1) they've had a check-up to ensure that the method is the right one and 2) the big logistical challenge, that they are on their period on the day they visit the clinic. Both of these policies are standard health procedures and fairly consistent with my experiences in the states. The methodology behind timing adoption with current menstruation is to be absolutely sure that Mama from Mwajidalala isn't pregnant.

However, the crucial information of 1) and 2) from above are not very well-known (although the CBDs in my study are very hopefully spreading the word). If Mama from Mwajidalala, who works up the gumption to leave her work in the cotton fields for a day and walk to the closest dispensary, four hours away, she might finally arrive and be told that she hasn't come on the right day of the month. This is obviously frustrating and time consuming for Mama from Mwajidalala, so she might gives up there.

There's hope with the mobile clinics- the Ministry of Health's way of addressing the fact that villages and subvillages are so spread out in Meatu. The health center and district hospital operate a schedule of visits to each village every month for outreach. But for Mama from Mwajidalala, the timing is again a challenge since the mobile clinic schedule likely does not coincide with her menstrual schedule.  The probability of Mama being able to adopt contraceptives from the mobile clinic, is about 5/30, or 1/6.

All this timing and access challenge makes me grateful that my intervention lasts a full year. But even this feels too short.

I arrived in Tanzania on Monday and by lunch on Wednesday, I was in Swahili Sexual Education. For my dissertation research, I’m evaluating the effect of a community-based distributor family planning program in a rural northern district called Meatu. Three dynamic facilitators from the Ministry of Health are leading this two-week training session for community distributors (all women) from eight different villages.  It’s only been a couple of days, but this training is an awesome way to jump right into my research. 

I’m completely immersed in the language and it basically feels like I never left this town, so my Swahili is coming back and expanding with health vocabulary and sexual jokes. Sadly, I still don’t get the sexual jokes, but I pretend to. This usually makes everyone laugh even more.

The training is extremely comprehensive. In addition to photos and explanation about each method, there are demonstrations as well. The women (who will shortly become distributors of family planning education) can hold a dose of Depo Provera in their hand and see what the injection needle looks like. I’m learning more about the methods and mechanics of family planning than I ever did in school (and I didn’t even go to a Catholic school).

In addition to the humor and practical knowledge, this training actually seems to be serving as much of a role in empowering these young women as educating them. I never entirely sold this family planning program as empowerment, it’s a lofty concept and very difficult to teach. However, one of the trainers is incredible and I would be selling her short to say that she is not empowering. She led a participatory conversation about women taking control of their bodies, in terms of child-bearing and sexuality.  By the end of it, the distributors were chanting, “Tunaweza! Tunaweza!” (we can!). I got chills.

With widespread intimate partner violence in Tanzania (39% according to DHS) and in Meatu district (35% according to my sample), there is likely a   relationship between contraceptive use and violence. It's hard to say what exactly that relationship is, especially with the difficulty of establishing causality when these things are all related to the personal intricacies of an intimate relationship. This study in the Journal of Biosocial Science, however, finds a strong relationship between covert contraceptive use and violence.

But again, does that mean using the pill in secret increases violence, or is it the case that women who experience violence are more likely to hide the pill? Researchers wanted.