Opinion: In Uttar Pradesh, women know about contraception options. Why aren't they using them?

Family planning is by far the most effective public health intervention to reduce deaths of women and children. If a woman can space out her pregnancies and have fewer children, she and each baby will have fewer complications and are more likely to survive.

There is encouraging momentum to increase the uptake of family planning. More than 30 countries have now committed to FP2020, a global partnership that includes a set of strategies and goals to reach millions more women. Most of the current initiatives are focused on improving supply-side problems, such as better access to contraception.

Yet our research is showing that a strategy limited to raising awareness and providing products will never succeed in reaching these goals. The state of Uttar Pradesh, for example, has one of the highest fertility rates in India and contraceptive use is not growing, despite a decade of investment in access to family planning programs.

Clearly access is not enough to explain why women who know about contraception don’t use it. If we crack the barriers couples face between knowledge and action, we solve the family planning challenge.  

This overemphasis on the supply of products and services is exactly what we have seen in voluntary medical male circumcision to reduce the spread of HIV/AIDS. Our work in Zimbabwe and Zambia has shown that demand among men for the procedure can be lacking for a variety of reasons, some of which are easier to address, and others more difficult. To reveal these diverse barriers to behavior, we used decision-making games and other novel methods inspired by principles of behavioral science.

We are now applying these insights to family planning as we dig into the data in Uttar Pradesh, and coming up with clear guidelines to a successful approach.

First, development professionals need to look at family planning from a behavioral angle. Women and men who know about modern contraception will choose to use it when they are motivated to act. What are the social norms and core beliefs that hinder women and their husbands from taking that step? If they do not feel the need to limit family size, for example, or their communities frown on contraception, then optimizing supply alone will not bridge that gap.

Second, taking this demand-side approach will also require better methodologies to capture data. Asking people directly to state their emotions and beliefs is quite different from asking them about access to contraception, and prone to many biases. The field should therefore refine its approach to generating data and incorporate mixed methods: from small, in-depth qualitative research to large-scale quantitative studies, experimentation, and segmentation. Adopting techniques from fields such as psychology and behavioral economics can prove useful.

Third, we need to apply a systems lens to address the problem of insufficient use. Reaching global family planning goals has the greatest chance of success when both supply-side and demand-side barriers to using contraception are solved in parallel.

Above all, a successful demand generation strategy requires a sophisticated marketing strategy with techniques borrowed from the private sector. We need to drill down to differences within markets and then adopt a product portfolio approach that ensures the right product gets delivered to the right people at the right time.

For example, different women may want to use different methods depending on their reasons for family planning, or at different times of their lives. Marketing therefore needs to account for differences at the individual level. Instead of segmenting the target market by age, income, or education, this can be more accurately achieved using psychographic-behavioral segmentation based on attitudes, values, or lifestyles. Demand-based forecasting can estimate the future market size for different products, and, as in the private sector, a staged market launch that actively stimulates uptake can be used to match appropriate products to suitable customers.

While this approach is largely missing in promoting family planning, all the ingredients could be adopted with relative ease, as we have piloted in persuading men to get circumcised. Marketing segmentation and demand-based forecasting are not things that public health professionals often think about. But with family planning under threat in the current political climate, we need to squeeze out the most of each dollar we have. We need to know our customers deeply and address the barriers that they face so they can plan their families with confidence.

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