Free Access to a Broad Contraceptive Method Mix and Women's Contraceptive Choice: Evidence from Sub‐Saharan Africa

Abstract

Financial barriers may restrict women's ability to use their preferred contraceptive methods, especially long-acting reversible contraceptives (LARC). Providing free access to a broad contraceptive method mix, including both LARC and short-acting reversible contraceptives (SARC), may increase contraceptive use, meet women's various fertility needs, and increase their agency in contraceptive decisions. Linking facility and individual data from eight countries in sub-Saharan Africa, we use a propensity score approach combined with machine learning techniques to examine how free access to a broad contraceptive method mix affects women's contraceptive choice. Free access to both LARC and SARC was associated with an increase of . percentage points ( percent confidence interval: ., .) in the likelihood of contraceptive use, driven by greater use of SARC. Among contraceptive users, free access did not prompt women to switch to LARC and had no effect on contraceptive decision-making. The price effects were larger among older and more educated women, but free access was associated with lower contraceptive use among adolescents. While free access to contraceptives is associated with a modest increase in contraceptive use for some women, removing user fees alone does not address all barriers women face, especially for the most vulnerable groups of women.

A cross-sectional study of women’s autonomy and modern contraception use in Zambia

“…The findings of this study highlight the importance of gender equality in decision making by affirming the evidence finding that enhancing women's autonomy improves the uptake of contraception use [24,25]. Strategies to improve women's autonomy include improving women's socioeconomic status, enhancing their education and dismantling of cultural laws that support gender inequality [14,26]. Increasing the socio-economic status of women is one of the most powerful tools that impacts significantly on reproductive choice [26].…”

“…Other cultural factors, such as those that promote men as heads of relationships, may influence decision-making in women who are educated [ 23 – 25 ]. All these issues are essential indicators of gender equality and are women’s rights issues [ 26 ].…”

“…Strategies to improve women's autonomy include improving women’s socioeconomic status, enhancing their education and dismantling of cultural laws that support gender inequality [ 14 , 26 ]. Increasing the socio-economic status of women is one of the most powerful tools that impacts significantly on reproductive choice [ 26 ].…”

Does abolishing user fees for family planning increase contraception use? An impact evaluation of the national policy in Burkina Faso

“…While a study in Colombia showed that a reduction in the price of levonorgestrel-releasing implants was immediately accompanied by an increase in demand, studies in Indonesia and Bangladesh showed that sales of different types of contraceptives were inelastic to price reductions [21][22][23]. Recent evidence gathered from eight sub-Saharan countries has suggested that rendering family planning services completely free of charge might be a promising strategy to increase access to contraception [24]; however, several systematic reviews have found no rigorous evaluations of the effects of user fee removal initiatives on contraception use [20,25].…”

Differences in contraceptive prices between and within family planning outlets in urban and semiurban Nigeria: a prospective cohort study

“…Socioeconomic gradients in the likelihood of long-acting reversible contraceptive (LARC) use in sub-Saharan Africa indicate that cost barriers may be prohibitive for the poorest women, particularly for LARC methods that may include fees for provider insertion and removal in addition to the commodity itself. 5 , 6 There is substantial regional variability in the proportion of women with unmet need for contraception who cite lack of access or high cost as a reason for nonuse: an analysis of the Demographic and Health Surveys (DHS) Program found that only 4% to 8% of women cited lack of access as a reason for nonuse overall, although this proportion was as high as 15% in Middle Africa and 10% in West Africa. 7 …”