What Works in Family Planning Interventions: A Systematic Review of the Evidence

"To revitalize political will and funding for a new era in the promotion of family planning and reproductive health (FP/RH) services, robust evidence-based strategies must continue to demonstrate research-driven best practices and outline the logistics of implementation."

This study presents findings from a systematic review of evaluations of family planning (FP) interventions published between 1995 and 2008. In particular, it (i) synthesises recent research on FP programme effectiveness, focusing on experimental and quasi-experimental impact evaluation studies; (ii) discusses programme approaches that are successful (and those that are less successful); (iii) identifies gaps in FP evaluation research; and (iv) recommends future research and evaluation directions.

Studies that used an experimental or quasi-experimental design or had another way to attribute programme exposure to observed changes in fertility or FP outcomes at the individual or population levels were included and ranked by strength of evidence: (i) high - e.g., randomised cluster designs; (ii) medium - e.g., pre-post test with comparison group design that had a follow-up period of at least 6 months; and (iii) low - e.g., quasi-experimental designs that often included a pre-post test control group design with no control for differences between the groups and/or a very short follow-up period.

The findings are summarised in tabular format by the type of intervention (classified as supply-side or demand-side). About two-thirds of the studies found were on demand generation type-programmes - e.g., mass media programmes such as a radio soap opera in Tanzania; mass media and social marketing initiatives in various African countries; mass media and interpersonal communication (IPC) approaches in Paraguay and Nepal; peer education in various countries; health education programmes featuring use of information, education, and communication (IEC) materials; community-based projects; and development approaches such as conditional cash transfer programmes and a savings and credit programme. Among the 63 studies that met the inclusion criteria, the strength of the evidence varies widely. In particular, among the 42 studies that were in the demand category, 7 were of low quality, 27 were of medium quality, and 8 were considered to be of high quality.

Generally speaking, the available evidence over the period of time under study suggests that FP programmes have positively impacted individuals' FP knowledge, attitudes, discussion, intentions, and to a smaller degree, contraceptive use. Seventy-five percent of the studies that measured contraceptive use as an outcome reported positive findings for increased contraceptive use or reduced unmet need, while the outcomes of knowledge, attitudes, discussion, and intentions were more commonly found to be significant. These impacts are often a result of programmes that have taken into account the importance of various approaches to reaching women and couples with FP products and services, providing quality information and service delivery, addressing cultural norms and barriers to contraceptive use, and seeking community support. Increased service use and changes in fertility-related outcomes were less consistently evident, and less than half of the studies that measured fertility or pregnancy-related outcomes found an impact.

More specifically, the researchers cull out findings by type of intervention that may help practitioners choose which approach to pursue - though there is no one-size-fits-all approach. For instance, the examination of mass media interventions illustrated positive results on contraceptive use and/or unmet need, while IPC interventions less consistently demonstrated these effects. (A notable example is the quasi-experimental study by Rogers and colleagues (1999) that showed a significant effect of exposure to an entertainment-education radio soap opera on contraceptive use by married women, which led to the scale-up of the programme nationwide throughout Tanzania.) Only 2 (Askew et al. 2004; Cabezon et al. 2005) out of the 4 studies from the IPC category that measured fertility-related outcomes found significant reductions in unintended pregnancies.

Remaining within the category of demand-side approaches, some specific strategies emerge and are explored here. For instance, Cabezon and colleagues (2005) revealed a protective effect in preventing unintended pregnancies from a school-based intervention taught by teachers. The authors reported that the success of their teacher-led programme was due to the accurate and comprehensive information provided and the focus on developing assertiveness and negotiation skills. This example along with an example provided by Askew highlight the importance of the programme facilitators' comfort with the subject matter and their commitment to the programme.

The review found that supply-side interventions that addressed access to FP led to positive effects on FP use, whereas improved quality less consistently showed positive effects on FP behaviours. The supply-side intervention studies that did measure fertility showed the most consistent and positive findings, generally using the strongest study designs (Khan et al. 2008; Debpuur et al. 2002; Rahman et al. 2001; Sherwood-Fabre et al. 2002).

The researchers offer several other observations in the discussion section of the paper. For instance, even in some places where the findings were positive, results were not necessarily consistent across different locations or intended groups. Also, although the findings presented in this review categorised studies as demand-side and supply-side interventions, a small number of studies explicitly included a multi-component approach; these studies generally found positive FP outcomes and, when measured, positive fertility outcomes as well. They indicate that it is also worth noting where the evidence was weak or non-existent in this review. For instance, there is limited evidence on the effectiveness of male involvement programmes on population-based fertility and FP outcomes; studies with medium to low quality of quasi-experimental design, however, have shown mixed results in regards to behavioural outcomes such as contraceptive use and unintended pregnancies.

Based on the review findings, the researchers propose directions for future evaluation research of FP interventions. In part, they say, "there is a need to undertake evaluations of broader development approaches and supply-side interventions measuring population-level outcomes (beyond operations research) and their long-term impacts on family planning and fertility. Likewise, there is a need for more research around the impact of male involvement, integrated services, public-private partnerships, and voucher programs, especially in light of the recent push and funding for these approaches. There is also a need for information on the effectiveness and cost-effectiveness of alternative implementation approaches for both demand and supply-side interventions. For example, there are gaps in our understanding of the impact of a peer-led versus instructor or facilitator led program as well as gaps in the understanding of intervention costs and the comparison of costs for alternative implementation approaches."

In conclusion: "As interventions are designed, it is imperative that planning goes into monitoring and evaluating the activities, so that programs can be refined and lessons learned can be shared widely. Particular attention needs to be paid to undertaking rigorous impact evaluations that can attribute program activities to changes in outcomes of interest. Randomized controlled trials will not be feasible for most FP program activities; thus evaluators need to identify alternative study designs (quasi-experimental; longitudinal) that are appropriate for the varying settings where programs are being implemented....This attention to rigor of family planning evaluations will increase accountability, improve program decision making, and in the end, improve maternal and infant health outcomes."