During the first two years of Mexico's Oportunidades cash transfer program, contraceptive use increased to a greater degree among titulares (women who are the head female of the household) living in communities where the program was offered than it did among their counterparts in communities where the program was not yet available, according to a recent analysis.1 In addition, during the program's first year, greater improvements in titulares' household autonomy occurred in participating communities than in those where implementation had been delayed. However, the program had no apparent effect on birth spacing.
The Oportunidades program, launched in 1997 under the name Progresa, pioneered the approach of using conditional cash payments as a means of improving public health, particularly in poorer, rural communities. To receive monthly payments, participants must meet specified conditions (e.g., children have to attend school regularly, and family members must get routine checkups). When it initiated the program, the Mexican government, for financial reasons, could not enroll all of the eligible communities. Thus, the government scheduled 320 communities to begin receiving benefits in 1998, and another 186 communities to begin participation in 2000. This approach created a randomized trial of sorts: The program's effects can be evaluated by comparing outcomes in communities where the program was launched in 1998 ("early recipients") with those in communities that started receiving benefits in 2000 ("delayed recipients"), with the latter serving as a de facto control group.
Prior studies of the program's impact on contraceptive use have shown mixed results. In the current analysis, researchers examined reproductive health outcomes among titulares, reasoning that any benefits might be particularly apparent among this group because the cash payments are given directly to the head female of the household, perhaps increasing her autonomy—and thus her ability to control her fertility. Women aged 15–49 who identified themselves as the head of the household or who were married to the head of the household were included in the analysis, which used data from five surveys conducted between 1997 and 2003. Information about demographic and social variables, including women's age, education, literacy, monthly expenditures, number of children and employment, were obtained in two baseline surveys conducted in 1997 and 1998. Information was collected in 1998 and 1999 on women's autonomy, classified as lowest, low, medium or high on the basis of whether decisions about children's school attendance, their doctor visits and various types of household spending were made by the woman, her husband or jointly. Finally, reproductive health outcomes were assessed in two follow-up surveys: Current use of a modern contraceptive method and current use of any method were measured at baseline and in early 2000 and late 2003, while spacing between births was assessed in the latter survey. (Reproductive outcomes were assessed among only a fraction of respondents in 2003, as part of a special survey module.) At the time of the 2000 survey, early recipients had been receiving payments for two years, but delayed recipients had not yet received any benefits; by the 2003 survey, the two cohorts had been receiving payments for nearly six and four years, respectively.
In each survey, a member of every household in the 506 communities was surveyed, regardless of whether the program had been initiated in the community or whether the household itself was receiving benefits. More than three-fourths of households in the communities were eligible for the program, and 97% of eligible households enrolled. Overall, 8,568 titulares completed the two baseline surveys, 6,157 completed the 2000 follow-up survey, and 1,737 completed the 2003 reproductive health module.
Early and delayed recipients had similar characteristics: At baseline, about 60% were 30 or older, two-thirds were literate, 40% were indigenous and 99% lived with a husband. Only about half of titulares lived in homes with indoor bathrooms, and about 40% had no electricity. One-third said they wanted to have at least one child in the future, and nearly three in 10 already had five or more children.
In 1998, the prevalence of modern contraceptive use was similar in the early recipient (37%) and delayed recipient (39%) groups. Two years later, the prevalence had risen slightly among titulares in the early group (41%), but not among those in the delayed group (39%); the difference between the two groups in the change in prevalence was statistically significant. By 2003, prevalence of modern contraceptive use had increased in both groups, to 55% among early recipients and 49% among delayed recipients, but in this case the difference in the change was not statistically significant. In addition, the two groups did not differ in overall contraceptive use (i.e., use of any modern or traditional method).
Nearly half (48%) of titulares had a birth between 1998 and 2003; of these women, 41% had at least one additional birth. However, the mean interval between births did not differ between early recipients (29 months) and delayed recipients (28 months).
Between 1998 and 1999, autonomy levels increased to a greater degree in the early recipient group than among delayed recipients. The increase in autonomy did not influence the relationship between exposure to the Oportunidades program and contraceptive use. However, among titulares with the lowest level of autonomy at baseline, early recipients showed greater increases in contraceptive use during the program's first two years than did delayed recipients.
Overall, the results suggest that the Oportunidades program had a small but measurable effect on contraceptive use among titulares. "Our findings suggest that conditional cash transfers to women have a role in increasing their contraceptive use, especially among women who enter the program with low levels of autonomy," the authors conclude. However, they add that additional innovations, such as new methods of conveying family planning information, "may be necessary to maintain and increase program affiliation that eventually leads to changes in fertility in this population."—P. Doskoch
REFERENCE
1. Feldman BS et al., Contraceptive use, birth spacing, and autonomy: an analysis of the Oportunidades program in rural Mexico, Studies in Family Planning, 2009, 40(1):51–62.