Modern contraception and family planning have substantial health benefits, helping women to manage birth spacing and thus reducing maternal and neonatal mortality and morbidity. However, access is limited in many low- and middle-income countries (LMICs), including in sub-Saharan Africa. In Mozambique, the national unmet need for modern family planning was estimated at 23% in 2015.Among girls aged 15-19, 46% already have one child or are pregnant for the first time; in this group only 14% are using contraception.
In a new study published in BMJ Global Health, we carry out a randomized control trial to analyze the efficacy of using text messaging to encourage women to visit family planning clinics in Mozambique, finding that this “nudge” approach had a modest positive effect. The study, analyzing the behavior of 3,623 women in urban and peri-urban areas in two Mozambique provinces, was conducted in collaboration with Population Services International (PSI), which leads a large community health worker program. Community health workers, known as promoters, offered women information about family planning in home visits, and referred those who requested family planning to local clinics providing free counseling and contraceptive methods.
In this project, a series of text message reminders was designed to encourage women who had received a referral to go to the clinic. Reminders with varying messages were sent on the first and fourth days following registration for the study, and then one, two, three, and four weeks following the first message. The research team then implemented a randomized controlled trial in which eligible women who had access to a phone and were provided a referral by a promoter were enrolled in the trial and randomly assigned to either receive text message follow-ups, or not. Enrollments were suspended due to Mozambique’s imposition of a COVID-19-related State of Emergency (SOE) in April 2020, leading to a modified analysis of treatment effects in the pre-SOE and post-SOE periods.
The data, collected via a mobile app used by both promoters and nurses at clinics, show that women assigned to receive the text reminders are weakly more likely to visit a clinic (2.3 percentage points) and to receive a contraceptive method at a clinic (2.2 percentage points), compared to the control group numbers of 48.0% and 46.9%, respectively. The effect on clinic visits is larger and statistically significant in the subsample of women who enrolled pre-SOE (3.2 percentage points). The estimated positive effect of the messages was larger for women 25 and younger, yet negative for those over 25 (though the latter was statistically insignificant).
The evidence suggests that text reminders can be an effective strategy to get more women to visit family planning services. The texts were particularly effective in encouraging women to visit the clinic promptly: The effect on clinic visits within 30 days was around 60% larger than the overall effect on any clinic visit; women receiving texts also visited on average one day sooner than the median of eight days between referral and visit.
Future research could also examine the effect of text reminders in addressing the problem of contraceptive discontinuation in LMICs. Women who have discontinued contraceptive use without switching to a new method constitute a substantial share of the population of women with unmet needs. Text messages encouraging rapid follow-up at clinics or with promoters may be a promising strategy to reduce discontinuation, particularly for the adolescent population shown to be more responsive to the reminders.
However, the narrowness of this study, focusing solely on Mozambique, presents a question of applying its findings in other contexts. How effective would text reminder messages for family planning services be in a country with greater access to technology compared to a country with limited access? Would the former country have more rapid follow-up at clinics? Would the reminders in a country with limited access be effective at all? This paper joins a relatively small literature that examine the effects of mHealth interventions on primary healthcare use in LMICs. More research is needed to further explore these questions.
Jessica Leight is a Research Fellow with IFPRI’s Poverty, Health, and Nutrition Division; Kyle Pico is a former IFPRI Communications Intern.
This study was supported by the U.S. Agency for International Development (USAID).
