Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
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=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
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=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
=Transcript of the talk, from the video's captions. Auto-generated: speaker names in particular are unreliable.
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# Family Planning, Now and Later: Infertility Fears and Africa's Stalled Contraceptive Revolution

Authors: Natalie Bau, David J. Henning, Corinne Low, Bryce Steinberg  
Discussant: None  
Video: https://www.youtube.com/watch?v=0mE9GNhwdY8&t=17845s


## Talk (04:57:25 – 05:43:40)

[04:57:25] >> All right. So I am told that while Bryce Steinberg will be presenting this paper, Karen is responsible for answering all of the difficult questions.  
[04:57:32] >> Yeah, that work. No, I'm just kidding. >> Mine.  
[04:57:35] >> Yeah, the errors are all Karen. Um uh so thank you so much for for having us and for for putting together such a nice um program. I'm Bryce Steinberg.  
[04:57:46] Karen Low uh is here. Um and this is also joint with Natalie Bao and um at UCLA and and David Henning at Oxford.  
[04:57:56] Um and this is family planning now and later infertility fears and Africa's stalled contraceptive revolution.  
[04:58:03] Okay. So kind of throughout history, women's economic and social value has been intrinsically tied to their ability to conceive and bear healthy children.  
[04:58:14] This is especially true today in Africa where uh large families are really prized and infertile women can face real consequences. So divorce, polygamy, even  
[04:58:25] like accusations of witchcraft. Um, and often medical mistrust in this region takes the form of a fear that some kind of intervention is going to cause women to become infertile. So we saw this with  
[04:58:38] like the roll out of the co 19 vaccine. Um, but these rumors are nowhere more pervasive than around hormonal contraception.  
[04:58:46] Um uh the um sorry just totally lost my train of thought. Um so uh sorry [laughter]  
[04:59:00] um so there's this high demographers will claim that there's a high um unmet need for contraceptives um in in subsaran Africa.  
[04:59:11] Um and there's this wellocumented kind of pervasive belief uh that hormonal contraceptives cause infertility. And what we want to understand in this paper um is whether this belief actually causes this low take up of of  
[04:59:24] contraception. So just to give you a sense sort of across countries, this is from the PMA data. um this question uh that they they asked women um how much they agree with with a a variety of  
[04:59:37] different um statements about about uh medical things. Um and this one was if I use family planning I might have trouble getting pregnant the next time that I want to. Um as you can see like across uh these countries um there's a pretty high rate of women who agree with this  
[04:59:52] this statement and this is going to be consistent in our data as well. Um, and by the way, like if you're on social media, you might see this pop up in other areas as well. This sort of beliefs kind of actually coming back in the United States um uh as well. It's  
[05:00:04] like a little terrifying honestly. Okay. So most um researchers and NOS's uh uh that work on family planning in Africa  
[05:00:17] um really have a focus on married women who already have children and they're thinking about total fertility and they're thinking about spacing usually but um you know sometimes I have to explain this to development audiences but in this room maybe I don't. Uh we  
[05:00:32] know from evidence from the US from from Martha and Claudia and others that um the sort of pill revolution when the hormonal contraceptives became available in the US um the total fertility actually didn't  
[05:00:47] change very much at all. Um what happened was women were able to delay their first birth, finish their education and enter the labor force. So, it's really about the timing of first birth and women who didn't already have  
[05:01:01] a child. Like, that was the big impact. And yet, when we see like, you know, Marie Stoopes or Planned Parenthood International, they kind of have no focus whatsoever on women who don't already have kids. So, it seemed like a it's like a big disconnect. Um,  
[05:01:14] hormonal contraceptives are a special technology for preventing pregnancy. Um, and I think in some ways this got lost in subs here in Africa um with the push for condom use because of HIV that hormonal contraceptives are are they're  
[05:01:29] more effective than condoms. Uh they don't require any um action in the heat of the moment which is particularly important for young women who may don't have the best impulse control. Um, and the other thing that's going to be  
[05:01:43] really key in this context is that they are um they're fully female controlled, right? So you they're the only technology that doesn't require the cooperation or consent of the male partner. Okay? So if you think about condoms, if you think about withdrawal,  
[05:01:58] even abstinence to some extent requires some buyin from the partner. And so um for young women, this is going to be really important. I'm going to show you later in the talk. Hopefully I'll have time. um that in this context there's actually going to be a lot of  
[05:02:11] transactional sex relationships. So young women getting money from older partners and so this issue of bargaining power is going to be particularly important for these women. Um so young women without children might be the ones who sort of benefit the most  
[05:02:26] from hormonal contraceptives. Uh but these are exactly the women who might fear this future infertility the most because they haven't yet had a child.  
[05:02:35] And so, um, this kind of creates this interesting trade-off for these women.  
[05:02:39] They perceive this sort of intertemporal trade-off between being being able to control your fertility now and by not having a child when you don't want to and being able to control your fertility in the future by having a child when you  
[05:02:52] do want to. Um, and so because of this, we're going to focus on this key population uh, who are young women who are finishing their education. Okay. Um so particularly the women who might be most  
[05:03:06] benefited by uh using hormonal contraceptives.  
[05:03:11] Okay. So we are gonna um the the population that we're going to focus on are undergraduates at the University of Zambia. So this is the like flagship institution in Zambia. Um uh  
[05:03:26] at baseline 64% of them believe that contraceptives can cause infertility.  
[05:03:30] This is like even higher than the averages we saw before. Um, they have a really high access to hormonal contraception. You can get it for free on campus. There's not like a cost issue here. The vast majority of them are living apart from parents and partners,  
[05:03:45] so there's less stigma than you might think in other contexts. They're having lots and lots of unprotected sex, so uh, don't worry about that. Um, and yet none of them report wanting to have a child right now. So we we try to ask this in a  
[05:03:59] variety of ways. Um and it just doesn't uh almost none of them report like any desire for children. Um and yet only 5% of them are using a a hormonal contraception at baseline. And if you did this in the US it would be something  
[05:04:14] like 60%. In Northern Europe it's like closer to 70 or 80 in some places. So this is pretty low. Um and perhaps unsurprisingly given all of this pregnancies are fairly common in this  
[05:04:25] population. So, in our data, um, 5.3 report a pregnancy over a six-month period. Um, which, you know, hopefully I don't have to do the math, uh, for you  
[05:04:37] guys, but, uh, that's 10% per year. So, if you think about over the course of four years, that's a really high hazard rate of pregnancy for women who tell us that they do not want to be pregnant and have a very high cost of pregnancy. Um  
[05:04:51] and and abortions are fairly common in this setting. But remember, this is a setting where healthcare is not great.  
[05:04:57] And so both births and abortions are pretty costly in this setting. You shouldn't think of this as like there's like you can get abortions, but they are they tend to be um much less safe than they would be in in a developed country.  
[05:05:10] >> Is there any sense that abortions could lead to infertility?  
[05:05:14] >> So, it's a good question. I think that they do. there's there is some of that perception. Um but they often when you  
[05:05:24] talk to them about this um it's like if they have this sort of exanti expost thing. So emergency contraceptives are also incredibly like used a lot. So they  
[05:05:37] sort of are like well if you're using preventative contraception you're sort of like asking for trouble in a way that like once you're in trouble like I don't know you just got to do what you got to do to get out of it. So, um, so we haven't asked them that specifically  
[05:05:50] like in a survey setting, but in focus groups, I do think they have some of that belief, but they just kind of like their preferences change a lot like once they're already pregnant.  
[05:05:59] Um, okay. So, this is um at at baseline in our sample. Um, just to sort of hammer the point home, uh, there's very low use of hormonal contraception. So, the um  
[05:06:12] this is women who are sexually active. So they're taking out the about half the women report being sexually active um at baseline. Um and so you know the most common uh thing that they're using is the pill, but it's just the vast majority of them are not on any kind of  
[05:06:26] hormonal contraception. Um we asked them why in the survey you're not using contraception. This I'm limiting to women who've had sex in the last two weeks just to sort of make sure they're kind of having high frequency sex.  
[05:06:41] Interestingly, still 36% of them tell them tell us that they're not having sex frequently enough even though in the survey they they just told us that they had sex in the last two weeks. Um so there might be a little bit of cognitive dissonance there. Um  
[05:06:55] uh some of them report using like condoms or withdrawal. Um there's very little uh who report like stigma or expense or like time. like it seems like this issue of access is just  
[05:07:09] not that big of a deal for these women. Um, but many of them report uh sort of like they're afraid of the side effects or they're afraid of infertility specifically. And if you look into the kind of qualitative work when they talk about side effects, it's not like weight  
[05:07:24] gain and acne. They're talking about like harm to your reproductive tract in various ways. And so we're going to kind of lump side effects and fear of infertility together when we do some stuff later on because mostly when they  
[05:07:38] talk about side effects it's it they really mean like something going wrong with your reproductive tract basically.  
[05:07:45] Okay. So what did we do? We recruited uh 1500 female undergraduates uh on the campus at the University of Zambia. Uh and we randomized them into three groups. So we had a control group um a  
[05:07:59] voucher treatment and then this an infertility information treatment. Um and basically what we did was you know we came and found you on campus. Uh we sort of consented you in and then if you agreed to be part of this study we  
[05:08:12] invited you to a workshop. And so we randomized them right on the spot. We invited them to a workshop. They didn't know which kind of workshop they were being invited to but they were kind of given like a menu of times to come based on their group. So, everybody gets invited to this workshop, but you kind  
[05:08:26] of don't know. They knew it had something to do with women's health, but like not much more than that.  
[05:08:33] Um, so for the control group, when they get to the workshop, we introduce them to the survey. So, we're going to um we're going to follow these women for six months or with a sort of uh bi-weekly survey. And so, the control workshop was mostly like about the  
[05:08:47] survey. It was like introducing them to the survey. We had them fill out the baseline right there so that we could like help them. These were all the survey was self-administered on smartphones and we did this because in piloting um and this is consistent with  
[05:09:01] evidence from the US for sensitive questions people are more likely to tell the truth when there's not like an actual person surveying them. Um and so and these women all have smartphones because they need them for school basically. So we sent them the  
[05:09:15] survey on their phone. They sort of did it right there. Um so that we could answer any technical questions or any survey based questions. Um and then uh subsequently we sort of sent them surveys again every two weeks. Um so we  
[05:09:29] told them about the survey. We sort of told them kind of you know uh that we were interested in women's lives and their health. Um and then we told them about our partner clinic uh which was a public clinic near the university called  
[05:09:42] Kolingalinga clinic. Um and we gave them a what we called a guaranteed no waiting card. Um, and the reason we did this is we wanted to be able to track them if they went to the clinic. So, if they turned in the card, then we sort of know  
[05:09:55] that they were there. Um, we, you know, you could think of this as a pretty active control. You can think of this as an access treatment kind of in and of itself. We told them where you can get contraception off campus, so maybe a little less stigmatized. Um, and  
[05:10:10] we gave them this card so they wouldn't have to wait. We sort of paid a nurse to work extra time. Um and then uh uh and then we sort of sent them on their way.  
[05:10:22] So uh the voucher group got basically that exact same workshop, but instead of just giving them this no weight card, we paid them $4 to turn that card in at the  
[05:10:34] clinic. So we basically we we um we wanted to design something that would sort of reduce the access costs to basically zero. So, we wanted to get them in the door of the clinic and then it's like once you're there, it's like  
[05:10:48] incredibly low cost to actually like get the contraception. So, we wanted to just make sure that there was no lingering like even behavioral things about I I keep meaning to go and I'm procrastinating or whatever. We wanted  
[05:10:58] to kind of get them in the door. Yeah. >> In order to be prescribed contraception for the first time, did they have to have a physical exam?  
[05:11:11] >> No. And no >> return visit.  
[05:11:15] >> No, no. So the return visit, so for certain things they do. So for the pill, um >> a pill or a shot, uh typically no. For the implant, you it was typically it was like only given on certain days. Um we  
[05:11:29] we're going to include IUD here. Nobody took up an IUD. So um but people did take up the implant. And for that sometimes it was like, oh, you have to come back on Thursday because that's when the nurse is here who like does the implants. And then just a couple other  
[05:11:42] details. Um could they collect how for what duration of supply? How much could they collect it at once from the clinic?  
[05:11:49] >> So they typically would get like a month like a month for the pill. Um you can so one thing to be clear like you can buy the pill over the counter in Zambia at a pharmacy. So like it's not um you know you can ask the nurse questions in this cases and and I think it's like some  
[05:12:04] subsidized the clinic etc. But like um but yeah typically they were not given like a three-month pack. they were given like one pack of pills. Um the shot lasts for three months. Um the implant obviously much longer, but for the um for the pill it was typically like one  
[05:12:18] pack of pills. And you'll you'll see when we get there um there may have been some people who took one pack of pill and then sort of never came back.  
[05:12:27] >> And then for access to plan B or to the morning after pill, um is that also available aties or did that have to be obtained from? Uh it's even better than that actually which is that uh you can get it atarmacies and one common  
[05:12:41] entrepreneurial practice at the University of Zambia is women will go and buy a bunch of these and then sell them to their classmates and so you can actually go around I don't think I have it on these slides we have a picture somewhere of like uh there are sign flyers on campus that are like we'll  
[05:12:54] come and deliver plan B to your they don't call it plan B they call it like the emergency bill um we'll come and like deliver it to your call this number or like what's this number and we'll like deliver plan B to your room Um, so if you're willing to pay, you can have  
[05:13:07] it like door dash to you basically. >> Have you administered a question to these women about how you get pregnant and the change in hormones in a woman's  
[05:13:22] body? Exactly what's going on? What what do you think they would say? And what fraction do you think have any idea? So if they have this fear, the fear may be illfounded  
[05:13:37] or they may know a lot and the fear may in fact be wellfounded.  
[05:13:44] Was there any sense that you thought that teaching them our bodies ourselves would help?  
[05:13:53] >> Yeah. So we actually did a little bit of that. So I'll tell you what we do in the information treatment because we sort of explained a little bit about how uh they work. Um the I will tell you one thing I have asked them is so one thing I don't know  
[05:14:08] if it came up on here or whatever. Um I think it's under withdrawal. It's like also they use what they call safe days which is basically like timing methods.  
[05:14:17] So a lot of them talked about using safe days and then I asked them like what are the safe days and mostly they're not correct about what they are.  
[05:14:26] So I think there is some misunderstanding of the mechanics. To be fair, I'm not sure I totally knew what the safe days were like when I was in my 20s. Um so I think there's some uh a little bit of  
[05:14:39] lack of understanding. Um there's also I think I want to be fair like there is a history you know these fears this fear of infertility does not come from nowhere. So there is a history in this region and in many parts of the world of like sterilization campaigns. There was  
[05:14:53] the Dalcon shield which was like a terrible IUD that got discontinued in the US and then they just like sent it all abroad um that gave people pelvic inflammatory disease and actually did cause infertility. So I think some of  
[05:15:05] this is rooted in like actual historical experience. Um uh we I'll tell you like sort of what we told we told them basically like a little bit about how ovulation works to  
[05:15:18] be able to like explain um what the pill was. So, we did a little bit of that.  
[05:15:23] Um, but it wasn't the main focus of what we did. Um, but I don't know if you ask them to understand like the mechanics of ovulation, like how much they actually know. It's a good question.  
[05:15:35] >> Yes. >> Bryce, relatedly, and maybe this is about to show I've fallen victim to the Tik Tok influencers, but I thought even with like a good IED that like there's some period right after you have it taken out when you actually harder to get pregnant.  
[05:15:47] >> Okay. So, yeah, I've learned a ton about this in this uh process. So different methods have different returns to fertility. That's true. Um and typically uh the implant has the quickest return to fertility. It tends to be a dose response. So if you think about the shot  
[05:16:01] like it's a huge dose of hormones and the 3-month period is the period for which it's 99% effective. And so it's like 70% effective for like six months.  
[05:16:12] You know what I mean? And different people have different reactions to it.  
[05:16:14] So and the pill is sort of somewhere in between where you're giving yourself a larger dose. the implant, even though it's in your body, is like actually the smallest dose. Um, and IUDs are also quite a low dose. Um, and so IUDs and implants actually have a quicker return  
[05:16:28] to fertility than pills and shots, even though they sort of feel more invasive.  
[05:16:33] But so there is a period. We're not talking about like, you know, you stop the pill and is it harder to get pregnant for the next 3 or 6 months?  
[05:16:40] Usually what these women are talking about when you kind of like dive in with them, they're like, "No, no, no. I'm going to take this now and then in six years when I'm married and trying to have a kid, I'm going to be infertile.  
[05:16:50] Like that's usually the story that they're telling. It's not like I might want to get pregnant next year. It's like they're thinking pretty far out into the future.  
[05:16:58] >> But I'll just add that that's we do think the shot and that longer return to fertility is like part of what people are hearing about that makes them nervous. And so that's part of the intervention is that we explain like exactly that return to fertility and  
[05:17:11] that like if you heard a friend say I had the shot and it took me like and then I couldn't get pregnant for six months like that's actually a normal part of using the shot. That might not be the right method for you.  
[05:17:23] >> Yeah. Exactly. Okay. So then so these were sort of Oh, sorry. Go ahead. Um so you said typically when they come and try to collect a um pack of of pills they're given one pack of pills. Do you  
[05:17:37] know I mean I maybe I should know I don't know but uh what happens to if you take a peel for for a month and then you stop for like say like two months and then you do it again. Do you have a  
[05:17:50] sense medically of what it does to your body?  
[05:17:55] >> No. Well, I mean, my sense is not super harm. I I don't know of any specific harm to doing that. I don't think it's a great way to prevent pregnancy is my sense like um but you know, I think it's like I don't think that it's like particularly harmful. Lots of people  
[05:18:09] sort of go on and off various contraceptives or like try one and then try a different one and they're off for a little while. Like I think it's fairly common. Um okay. So, so our information treatment, the thing we were actually really interested in, um, these guys got  
[05:18:24] sort of everything in the voucher treatment. So, they got introduced to the survey, they got told about the clinic, they um, were given the same voucher. They were sort of paid to go to the clinic in the same way. Um but in addition we had this so we had the same facilitators  
[05:18:37] um but they basically told a story about how they um they had used a long-acting contraceptive and then they had gotten pregnant. They actually showed pictures of their children. This is Kathy. She was one of the one of the facilitators.  
[05:18:52] Um and then we did this sort of demonstration about um how these things work in the body. And this is actually I should like give Karen credit for this because this was her brainchild.  
[05:19:00] Um, we tried [clears throat] a we thought of a bunch of stuff. We tried a bunch of things to try to find something that would be very salient. Um, and so what we did was we had somebody come forward and said um and we blindfolded them and uh we held an orange up in front of them and said, "What do you  
[05:19:15] smell?" And they would say, "Oh, I smell orange." And then uh the facilitator would put like some mint oil in front of the orange. So she'd sort of hold it like this and she'd say, "Now, what do you smell?" And she'd say, "Oh, I smell mint." But the audience could see that  
[05:19:28] like the orange was still there. And so then she'd take the mint away and she said like okay like give it a minute and like now what do you smell again? And she's like oh I smell the orange. And she's like see the orange was there the whole time. The orange was like your fertility. It was just temporarily  
[05:19:42] blocked by the oil. And so like this was the metaphor that we had of like you know this thing is always here.  
[05:19:48] It like lives in the background but we're just blocking it temporarily while we were taking the contraception. So this was uh and that and you know we explained a little bit about like ovulation as like part of this but it wasn't super detailed. There were not  
[05:20:02] like pictures of uteruses or anything. Um and the whole thing was like so the the these two workshops took about half an hour. Um the infertility information treatment lasted about an hour. So it's like altogether about an extra 30  
[05:20:16] minutes. And that was it. Like that's the entire treatment. Okay.  
[05:20:22] Um, so then we got data from two sources. So first we're going to have data from the clinic. So those cards that they got, we could sort of see who turned in those cards at the clinic. Um, and then measure what services they took up. Uh, that's going to be nice in some  
[05:20:36] ways. It's going to have no attrition, no like reporting bias or anything like that. Um, but it's also going to have some downsides. So one is that we're only going to see this one clinic. So if people are sort of substituting where they're getting their contraception,  
[05:20:48] like that's not great. Um, and you know, if they come back from the for the implant later, we're not going to see that. Um, and uh, so, and we're also not going to know if they take one pack of pills and then they never take it again.  
[05:21:03] That's not super great for preventing pregnancy. And so, we want to be able to measure like actual usage over time. And so, for that, we're going to use this survey. Question.  
[05:21:13] >> Did you also mention any of the STDs and related issues when you were having your information.  
[05:21:20] >> So if you want to get anything by IRB in these contexts and you talk about sex, you have to talk about HIV. So like we did talk about HIV in all three of these um sort of in a preuncter way, but we're like, you know, like condoms and abstinence prevent HIV or like there was  
[05:21:33] something sort of like that, but we didn't talk a lot about um that. We did do another add-on experiment um that I don't have in the slides today uh that was sort of kind of worked but was a little bit  
[05:21:47] underpowered where we tried to we told them actually that uh ganorrhea and chlamydia actually do cause infertility and that that is actually one of the big causes of infertility in subs Africa. Um  
[05:21:59] and we measured the effect on take up of STI testing and actually did have an effect on STI testing. Um, but it was sort of like a text message treatment and it was like a bit underpowered. Um, so I don't want to like rely too heavily on it.  
[05:22:12] >> I I wonder whether that can cause some conservative estimate on your end if you're working against you. If I think that I will use some form of birth control and I want to also protect myself for STDs. I would rather go to  
[05:22:26] the nonormal ways than >> Yeah. I mean, so I'll come back to the condom use a little bit in the end, but like what they're what they're doing, what we observe is a lot of them are using condoms sometimes. So like they're  
[05:22:40] using them intermittently. A lot of them kind of mean to use condoms. If you go back, like some people tell us, I don't use hormonal contraception because I use condoms. Like that's this group. But you can even look at those people and they don't use it 100% of the time. So it's  
[05:22:53] like most of them are using it sometimes.  
[05:22:58] Um so they're very aware of HIV. I mean you walk around campus there's like billboards about preventing HIV. Like no one is not aware that this is a thing and that condoms help prevent it. It's just like they're either not using it in the heat of the moment or they're like  
[05:23:12] not in a position to bargain for using those condoms. Think >> I was wonder doing the information campaign if you're informing them in that particular group. Yeah, we do look at the impact on condom use and we don't find anything. So, that's reassuring because we were somewhat worried about  
[05:23:26] that. Okay. So, um so then we're going to supplement this admin data with bi-weekly smartphone data um that uh is going to give us data on usage uh for 6 months  
[05:23:39] after treatment. Um this is nice because it's going to be overall usage, so not just at the partner clinic. Um, and then we're also gonna be able to ask a bunch of questions about like pregnancy and sexual behavior and beliefs and you know  
[05:23:52] whatever else. Okay. Um, so first let me show you uh the admin data. So on the left is um uh whether people actually showed up to the clinic. So this is sort of like did we get them in the door? Um and so  
[05:24:07] you'll see that like you know 18 almost 19% of the control group came and used that no wait card. Um, so it wasn't nothing. Uh, but in the groups that we paid to go to the clinic that we gave  
[05:24:19] them the the voucher, um, around 70% in both the voucher only and the in information group um, turned in that voucher at the clinic. So, we think it worked fairly well. Like it was enough money to kind of get them to take the  
[05:24:34] walk to the clinic. Um, and lots of those people just like turned in the voucher and turned around and left basically. Could you give us a sense of how much the $4 is like in terms of >> Yeah, so this context I mean we have a bunch of other papers about how poor  
[05:24:45] these women are, but they um this uh many of them are paying around like $40 a month for rent. So it's not nothing.  
[05:24:54] >> Okay. >> Um I mean rent is like you share a twin bed and you're in a room with like eight other girls. So it's not like you could rent a flat for that, but like >> but like a nice meal costs >> you could buy like Nando maybe for that.  
[05:25:06] Um, so it's like, you know, but again, like their their total living expenses when we measure their consumption are like on the order of like $80 to $100 a month.  
[05:25:15] >> So it's an it's it's a good amount of money for them.  
[05:25:17] >> Okay. >> Yeah.  
[05:25:19] >> Um uh and then on the right you can see the contraceptive uptake at the clinic. So this is just hormonal contraception. Um they do actually take up I don't think I have it in the slides here, but they do actually take up you can get condoms at  
[05:25:33] the clinic also. So they some of them do uh take up condoms. Um but we see sort of some women in the control group do take up contraception when they get there. Um  
[05:25:45] uh these are unconditional but about 4% in the voucher group take up some kind of hormonal contraception. Um and it's about 6.8% in the information group.  
[05:25:56] Okay. So you see like getting them in the door does seem to do something. Um but already it's considerably higher in the information group. Yes.  
[05:26:04] >> How much did they have to pay at that point of service if they wanted to get a month supply?  
[05:26:09] >> Nothing. >> Okay.  
[05:26:12] >> Yeah. It's free. >> Can you to interpret these? These are not sort of the ITTs or they are the IT.  
[05:26:17] >> These are the ITTs. They're just like unconditional. Yeah. Yeah. Yeah.  
[05:26:21] >> And sorry, how much do they have to pay if they go to a pharmacy?  
[05:26:25] >> Uh it's a good question. It's not super high. Um, but it's not nothing. Do you know, Karen? It's like >> It's like $2. Yeah, that's what I was gonna say. Like $2 a pack, something like that.  
[05:26:37] >> Um, it's really heavily subsidized uh by the government. Um, yeah, and as we said, like almost none of them said that cost was like a significant factor for them. Okay, so now I'm going to show you  
[05:26:50] the data from the survey. So this [snorts] is um this is not relative control. This is just sort of like what happened in the data. Um this is just relative to baseline. Um and and the outcome here is usage of any of uh the  
[05:27:05] hormonal methods. So pills, shots, implants, etc. Um you can see in the voucher only group, you see this increase. So these first two surveys are about the time period we gave them to go to the clinic. So sort of matches up with the clinic data. And you see there's this increase over time in  
[05:27:20] overall usage. That's already somewhat reassuring that they weren't just switching where they were getting their uh contraception. Um, but you can see it kind of like peters out over time. You know, it's like by the end of the survey, it's like a little higher than  
[05:27:33] it was at baseline, but not much. If you look at the information group, you see an almost identical increase in those first two weeks. So, it looks like really similar. But then the big difference comes over time. So, there's this big uh this increase if anything  
[05:27:48] kind of grows over time and by the end of the survey they look quite different from the voucher only group.  
[05:27:55] >> Yes. So can you help? I would have thought that the effect of misinformation would have constrained initial takeup.  
[05:28:04] So it suggests something about the particular nature of the misinformation.  
[05:28:08] It's not that you bought taking it. >> Yeah. So I wish I had this slide here on a button, but I don't, which is that I think part of this is about the method.  
[05:28:15] So the voucher girls were much more likely to take up a pill and they were much more likely to like take a pack of pills I think and never go back. this infertility group, infertility information group, they were more likely, especially over time, to take  
[05:28:28] out shots and implants, which both have like kind of a mechanical effect. They just, you know, if you're if you're if you have an implant at week three, you have an implant at week 12. Um, but uh often what you actually see is they would like take up a pill in the first  
[05:28:42] month and then like a month later instead of re-upping the pill, they would go back and like get the implant or something. And so we think actually in talking to them, we don't really have the power to distinguish this, but the more invasive the method, the more they  
[05:28:56] were afraid of it causing infertility. And so we think we kind of had bigger belief impacts on these like longer acting methods. So I think part of what's going on here is that like these guys are willing to like try a pack of  
[05:29:10] pills, but they're still kind of nervous. Um, and our information group is sort of willing to dive into the longer acting methods. That's what I think is going on basically.  
[05:29:20] >> Do you have data then that would cover the decision to reup the longer acting method? So like do you get a second depo shot?  
[05:29:29] >> Yeah. So we this is a long enough period of time. So we don't literally ask them did you get a second depo shot but it's a long enough period of time that like the oneo shot won't cover you because this is these are 12 surveys but they're every two weeks. So this is six months.  
[05:29:42] Um and so we do see even by the end here they would have had to take a second depo shot.  
[05:29:50] Um and the shot is the majority of the takeup in that group. So that's the most common.  
[05:29:59] Um so we also had a very active control. Um so you might be interested in sort of like what happened to those guys like they just had an access treatment in and of themselves. Um, and so I'll show you that like there was, you know, if you  
[05:30:12] squint there's like a small increase in control the control usage over time. Um, but we don't see much. And so when you look sort of relative to control, you see like really the voucher treatment looks pretty bad. Um, and it's only really this in uh infertility  
[05:30:27] information group that has like a significant difference over time relative to these other two relative to control. So this is really consistent with other studies in this area that like access to contraception does not seem to be the barrier in this group.  
[05:30:41] There's like lots and lots of studies doing now. Sorry, there's some questions.  
[05:30:45] >> U so just wanted to understand since these were college students uh since these were college students in the same college um did the control know the other >> Yeah. Um >> they had friends.  
[05:30:59] >> Yeah. One of the reasons we wanted to look at control here is you can imagine there were like spillovers like this is important information. This is new information you're telling me I'm going to tell my friends and like they're also going to take up these methods. We didn't see a ton of that. We weren't superpowered to see like you know if you went in certain groups or went with your  
[05:31:14] friends etc. Um but but yeah, we don't see a ton of evidence for spillovers. If you want to see this control going up and sort of interpret it that way, I think it's possible. Um but we didn't see a ton of it. Yeah. Are you measuring  
[05:31:28] their fertility preferences? Is like their preference for total fertility also changing over over the intervention?  
[05:31:33] >> Uh we asked them their preference for total number of children. Um it's in line with the what's typical in this population which is like fourish. Um I I do not remember if we asked that  
[05:31:48] question more than once. Um, but we do ask them at various points like do we we ask them a bunch of different ways like do you want to have kids now? Are you indifferent to having kids now? What would h like how bad would it be if you had a kid now? And  
[05:32:02] they really really are very insistent that they do not want to have a kid now.  
[05:32:06] I don't know about their sort of like whether their future preferences are changing. Yeah.  
[05:32:11] >> Do you ask them about any side effects that they experience during this during this period?  
[05:32:17] >> I don't think we did. That was a That's a good question. We did not um No, we didn't ask them about side effects.  
[05:32:25] Yes. >> I don't know if there's a mic like >> Sorry.  
[05:32:35] Thank you. I I was wondering if you are verifying in any way um the survey data if you work at all that this might be demand effects that you're asking the same questions like self report use of  
[05:32:48] contraception to a group that received that information treatment and they felt compelled to say that they are um is there any way like are you checking in like is there any way to besides the first  
[05:33:02] >> yeah I mean I'm going to show you results on pregnancy >> so yes okay um and then also you know this this the stuff from the clinic is also like not self-reported this is like what they took up so um so yeah I mean  
[05:33:17] we can't rolled out rule it out entirely, but we think it's not what's driving the results. Okay, so I'm just going to show you that we didn't uh we were very we're worried about this and we were happy to find that we like didn't really seem to have much effect on people's sexual behavior. Um this is  
[05:33:31] also somewhat reassuring with demand effects or whatever. Um they didn't report like using condoms more or less, any sex, partners, partner age, etc. We just didn't see much going on there. Um, okay.  
[05:33:45] So, um, you might be interested. Uh, these women are taking up pretty effective contraception. Um, did this actually reduce pregnancies? So, I'm going to show you, but I'm also going to caveat it a little bit. Um, we were not powered to detect differences in  
[05:33:59] pregnancies. We're following these women for 6 months. Um and uh if you think about the timing of this, right, if you're taking up something like the implant, it's like we're not there's no possibility of seeing pregnancy differences before like two months  
[05:34:13] basically because you have to sort of get on it. Often many of these methods you have to start on day one of your cycle and then it would be like a whole another month before you would see a pregnancy. So it's just sort of a long um we don't have a great time horizon for seeing this and there's a bunch of women who are trying not to get  
[05:34:27] pregnant. So like you know a 5% rate of pregnancies over this time is high in terms of like welfare cost but it's not necessarily high in terms of like statistical power. Um so what we're going to do is we're going to pull the voucher and control treatments for this  
[05:34:41] because we don't see changes in usage over time in the voucher group. So we're going to use them both. We're going to compare the infertility information group to those two combined. Um and we're going to use two measures of pregnancy. Um, at Endline we asked, did  
[05:34:55] you have any pregnancy in the last 6 months? We think this is under reportported for a variety of reasons.  
[05:35:01] One, there's like good evidence that the longer time horizon you do, the more people forget things that they would prefer not to have happened. And so things like abortions um are almost really going to be under reportported here. Um,  
[05:35:15] on the other hand, in the bi-weekly survey, we asked every two weeks, have you had a positive pregnancy test in the last two weeks? We think this might be a little over reported if anything. Um there may like people might have like sort of thought they might be pregnant  
[05:35:28] and not or whatever. Um they could have just made a mistake you know one week in the in the survey. Um, so we're going to show you both of these things. Uh, just, you know, to be as transparent as possible sort of and we're going to find  
[05:35:42] actually the the there are more pregnancies reported in the bi-weekly survey than at NLine, but the overall effect size is very similar across the two. Yeah.  
[05:35:52] >> Do you collect any data about whether they've had their period?  
[05:35:56] >> We wanted to do that, but I don't know that it would have gotten through IRB.  
[05:36:00] Yeah. [clears throat] We had this whole idea of having like a period calculator like in the thing and it just like never it never took off. Yeah. Yes.  
[05:36:10] >> Do you ask the bi-weekly survey and the endline to the same people and like >> Oh yeah. Yeah. These are the same people.  
[05:36:15] >> Okay. How often are they >> everybody who reports a pregnancy in the at endline reported one in the bi-weekly. There are some people who report them in the bi-weekly and particularly people who report that they either had a miscarriage or had an abortion that do not then report a  
[05:36:29] pregnancy at 10 deadline. And I genuinely I think like if we may have asked it differently if we could do it again because I think some of them genuinely have the thought of like well I wasn't really pregnant. I was pregnant for like a week, you know, and you know,  
[05:36:42] um, okay, so um, in the endline measure, um, we find a 73% reduction in pregnancies across this group. Um, and so, uh, so we take this as as kind of  
[05:36:57] reassuring that like the people who we induced onto these contraceptive methods were the people who might have been particularly at risk of having an unwanted pregnancy in this time. If you look in the bi-weekly measure, you can  
[05:37:10] see kind of reassuringly in the first two months, you don't see any difference. And again, if you're worried about kind of reporting bias or something, it should be somewhat reassuring that like they're not because like mechanically, we couldn't do anything during that time. We wouldn't  
[05:37:23] expect to see it. But after 2 months, we start to see the infertility information group have like sort of a lower reported rate of pregnancy every two weeks. Um, and it sort of grows over time, if  
[05:37:34] anything, much like the usage did. question.  
[05:37:41] >> So, so it looked like your control mean was also higher than I'm sorry, lower than the 5.3%. Do you think that there was effect on the control group too?  
[05:37:51] >> No, no, no. Sorry. So, the 5.3% is from this bi-weekly mother. So, 5.3% of women at some point over the survey report a pregnancy. At endline, it's closer to 2% report a pregnancy. Um, and so that's what I'm saying that we think there's  
[05:38:05] kind of like under reporting in one, maybe some over reporting in the other, and like the truth lies somewhere in between. Um, so that's kind of why we show both. Yeah.  
[05:38:17] Do you know if they so do you know anything about whether this is coming from preventing conception or whether this is coming from increased use of plan B or abortion  
[05:38:32] or other kind of expost measures? >> I mean we we consider an abortion a pregnancy like so if they're if they and we ask every time we ask about a pregnancy >> it's not like are you pregnant it's like did you become pregnant? We ask did you have a positive pregnancy test at any  
[05:38:46] point in the last 2 weeks? And then we ask like um do you uh like if so like what happened >> if her policy plan B prevents conception it doesn't terminate it there.  
[05:38:56] >> Thank you. >> Can you measure the the outcomes of the pregnancy?  
[05:39:01] >> Yeah, we do. We're not super powered to like see differences but like yeah the majority I don't think I have it in the slides here. The majority of pregnancies I think this is right. the majority of pregnancies end in abortion in this population. Um there's also a lot of  
[05:39:15] miscarriages, more than you would predict for women this age. So you think maybe like they're miscarriages. Um uh so yeah, but we we can't detect like the differences and we can barely detect pregnancies overall.  
[05:39:28] >> One of the things we find in the MCAR study is that there's almost perfect substitution between preventative contraception and abortion.  
[05:39:35] >> So there's very little difference in birth outcomes.  
[05:39:39] >> Yeah. >> And birth outcomes.  
[05:39:40] >> Yeah. But there's a big reduction in abortion rates um in the treatment group.  
[05:39:44] >> I would not be surprised if that were true in this case. We just can't we just we just aren't empowered to measure it.  
[05:39:50] I'm just going to push because I only have like a couple of minutes. Um but I'll if there's any time I promise I will take questions at the end. Okay. So um I want to in the paper we have a couple of different tests about sort of whether this belief change is actually kind of  
[05:40:05] what's causing this change in behavior. Um, I'm just going to show you one here which I think is sort of the most straightforward which is like we just asked them do you believe that contra that any of these methods of  
[05:40:17] contraception can cause infertility. Um this was sort of two weeks after so kind of right after the first survey after the um treatment. Uh and we find that  
[05:40:29] the fertility information group has um a 13 percentage point reduction in their belief um that any of these methods cause infertility. Um to be clear, that is not going to zero. So the control  
[05:40:43] mean is 65%. And so we get it down to like a little more than half, but we're not eliminating this belief entirely by a long shot. Um what I find interesting is we ask this question again and after  
[05:40:55] 6 months and we find almost identical sized effects. So unlike you know I don't know I teach development economics and usually we have a whole class it's like information treatments never work.  
[05:41:07] Um so I was sort of surprised by this. So I think it was this a particularly salient piece of information. we kind of drilled it into them and you know maybe there's some of this is reporting bias but we do find like even after 6 months  
[05:41:20] they're still reporting um that they don't have this belief. Um okay uh you might think okay we increase contraceptive use by 3.5 percentage points over like the the average over  
[05:41:35] that time period that I showed you. Um and reduce pregnancies by like 1.2 percentage points. Um you might think that these are kind of small effects overall. Um they are in line. So there are many contraceptive interventions in  
[05:41:49] Africa. The majority of them do nothing. Uh it's very very hard to move these outcomes. There are a few that have been successful in moving behavior. They tend to have pretty similar size effects in  
[05:42:02] terms of percentage points in both usage and births.  
[05:42:06] um we're measuring pregnancies and they're measuring births which is different. Uh and in percent terms are because we have such low usage at baseline uh we actually have much higher much bigger results in that case. Um and the other  
[05:42:21] thing we like to say um is that we this was a pretty light touch intervention.  
[05:42:25] So we changed beliefs but not uh not entirely. Okay. So um one thing I just want to say very quickly before I have to conclude um we uh as I said condoms require the consent of male partners and  
[05:42:39] in this uh setting we see a lot of sex that's driven by financial need. So we ran another experiment two years later um we recruited a new sample of women and we paid them a monthly stipend um of  
[05:42:53] $40 a month. We measured sexual activity in the same way and we found that sexual activity decreased sharply in the treatment group. So sexual debut reduced by 40%. Um so it's like entry into sexual activity and condom use went up  
[05:43:07] with those who are having sex by about 25%. So the background here kind of floating around is that a lot of this sex is financially [music] driven. Okay.  
[05:43:15] So that's it. I just wanted so if you want to see that paper you should read it. It's interesting. Um but otherwise I'll leave you with the conclusion. SO THANK YOU.  
[05:43:26] >> [applause] >> I lost 15inut.