Can cash transfers increase women’s modern contraceptive use? This was the question that researchers recently set out to answer through a systematic review of existing studies on conditional and unconditional cash transfers published in Studies in Family Planning. As the authors of the study noted, extensive evidence has demonstrated that cash transfers (CT) can improve a broad range of health-related outcomes, including use of preventive services, antenatal care, immunization coverage, nutritional status (though the evidence on this one is mixed) and reductions in HIV-related risks. However, far fewer studies have examined whether cash transfer programs have impacts on family planning. This is indeed a major oversight, given that so many programmes have explicit aims around improving child health and nutritional status and reducing poverty, and the evidence is overwhelming that women’s contraceptive use is good not only for women’s health but also for child survival. Thus, increased contraceptive use may be one possible pathway through which cash transfer can improve child health. Further, access to family planning can increase economic growth. Given these powerful benefits of contraception, it is important to understand whether policies such as cash transfer programs can improve its use.
In their systematic review, Khan and colleagues did find evidence that CTs can increase contraceptive use, increase birth spacing, and reduce unwanted pregnancy. However, while the majority of evidence suggests that cash transfers do not increase fertility, the authors do highlight two studies which demonstrate fertility increases related to CCT programs—one using quasi-experimental evidence from Mexico’s Oportunidades program and a second from Nicaragua, where initial implementation of the CCT program allowed for transfer amounts to increase if additional children were born or moved into the household (this loophole was subsequently closed). Still, the authors were able to include only ten studies in their systematic review and conclude that more rigorous research is needed to definitively conclude whether cash transfers can increase contraceptive use.
We commend Khan and colleagues’ efforts to summarize this important literature and second their call for more research on the topic, however we strongly disagree with their concluding recommendation to condition transfers on having no more than two children. This undermines women’s and couples’ rights to autonomy and reproductive freedom and may translate into dangerous unintended consequences, including hiding children, not seeking necessary preventive care and health check-ups for these children, or, at an extreme, infanticide. A much more suitable and less harmful approach would be to cap the benefits at a maximum number of children, to be determined at the country level and informed by contextual factors. In this way, couples may choose to have more children but would not see their transfer amounts increased for doing so nor would they incur any penalties.
Further, it may not make sense to condition transfers on such specific objectives. Government-run CT programs largely fall under social protection strategies, where objectives are broad and related to poverty reduction and improving food security in the short term and resiliency and human capital development in the medium- and longer terms. While studies have shown how CT programs can have wide-ranging benefits on outcomes related to multiple sectors, it is counterproductive to condition payments on too many sector-specific outcomes. This increases costs and administrative burden and dilutes programs’ ability to reduce poverty and increase families’ resiliency through allowing them to spend and invest the transfers as they deem most appropriate for themselves. For these reasons, most government-run CT programs in Africa are unconditional. Indeed, many of the wide-ranging positive benefits of CT programs stem from the fact that poverty is an underlying cause of many poor outcomes, and maintaining the focus on poverty reduction while strengthening systems and scaling up programs will continue to impact outcomes multi-sectorally.
We do, however, agree with the authors’ recommendation to simultaneously address supply factors for better outcomes. There are several such initiatives (sometimes called “cash plus”) currently underway, not specifically related to family planning, but often related to health and nutrition. CT participants are often among the poorest and most vulnerable populations and linking these individuals and families to strengthened services will likely have positive, synergistic impacts. More initiatives and research in this area is also needed.