Knowledge for Development Policy Brief: Malawi May 2016 Education Global Practice Beginning a Family and Health, Nutrition, and Population Global Practice Adopting a Healthy Lifestyle: A Review of the Global Evidence Corrina Moucheraud and Rifat Hasan This policy brief presents program and policy access to and generate demand for contra­ approaches that have been implemented in ception by overcoming supply- and/or different contexts to address two ­ transitions— demand-side barriers. These interventions beginning a family and adopting a healthy have been found to be effective in increasing lifestyle—that have long-term impacts on knowledge of family planning, increasing human development and thus on poverty demand for birth spacing, decreasing desired alleviation and economic development. It also family size, delaying childbirth, increasing presents programmatic lessons and offers use of modern contraception, and in some recommendations based on the global cases, reducing fertility. Increasing access to evidence. and generating demand for family planning also contribute to healthy sexual and reproductive lives of adolescents and better Beginning a Family maternal and child health. Various factors can affect the decision to begin a family either directly or indirectly. In •• Community-based distribution of the fertility literature, these factors are called contraceptive supplies has been one of proximate and distal determinants the most successful ways to increase (Bongaarts 1978). Proximate determinants of uptake of family planning. Community fertility include marriage and sexual activity, members are particularly effective at contraceptive use, and postpartum infecund- distributing contraceptive supplies and ability (the result primarily of breastfeeding information to households. When a and postpartum abstinence), and distal community-based distribution program factors include child mortality, mother’s was launched in the Matlab program education, household wealth, urbanization, in Bangladesh, there was not only an and religion. This section presents program increase in the uptake of family planning and policy approaches that have been but also improvements in maternal implemented in different contexts and shown health, women’s nutritional status, and to have an impact on two strong proximate pregnancy-related death and disability determinants (family planning and age at risks (Gribble and Voss 2009; Koenig and marriage) and two key distal determinants Keenan 2009). (child health and mother’s education) of •• Improving quality of family planning fertility. service provision (including improved Programs and policies that increase training of health workers and quality of the use of family planning can do so counseling for patients) have also been through several approaches that improve effective in Nigeria (Farooq and Adeokun 1 1976) and Uganda (Ketende, Gupta, and change campaigns, such as Bangladesh, Bessinger 2003). Some programs have the Islamic Republic of Iran, and Kenya, targeted high-risk groups, including have seen steeper declines in fertility than adolescents in Zambia (Mmari and their comparable neighbors (Bongaarts Magnani 2003), postpartum women in et al. 2012). Such comprehensive Nepal (Bolam et al. 1998), and recent approaches require budgetary resources mothers in Mali (Population Services and political commitment, but they have International 2012). A potentially effective had significant effects on contraceptive way to reach adolescents is to ensure use as well as on overall fertility rates. that services are youth-friendly—for Programs to delay marriage tackle example, training that teaches providers complex normative and economic issues, to be nonjudgmental and friendly, usually by implementing multisectoral communications targeted to adolescents, initiatives, including education and health, and supportive community activities that involve families and community mem­ (Chandra-Mouli, Lane, and Wong 2015). bers. Impact has been seen in changing the •• Programs that lower the financial awareness, attitudes, and practice of early burden of contraception for adolescents marriage in Ethiopia (box 2), Burkina Faso have been effective, including vouchers for (Engebretsen and Kabore 2011), and the free care in Nicaragua (Meuwissen, Gorter, Republic of Yemen (Freij 2008). These ­programs and Knottnerus 2006) and program-based have taken a comprehensive community-based education and free contraceptive supplies approach with the following elements: in Ethiopia (Edmeades, Hayes, and Gaynair 2014; Erulkar and Muthengi 2009). •• Pairing individual- and community-level •• Social and behavior change interventions communication can increase demand for •• Strengthening social support systems (via family planning. Examples of strategies mentoring or peer groups) include large-scale media campaigns •• Targeting both education and health in Ethiopia (Farr et al. 2005), The •• Engaging families (formally or informally) Gambia (Valente et al. 1994), Tanzania and community and religious leaders. (Rogers et al. 1999), and, specifically for youth, Cameroon (Plautz and Meekers Zambia’s Adolescent Girls Empowerment 2007); community initiatives, which Program includes group meetings with peer can include peer educators, community educators, health care vouchers, and girl- discussions, workshops for families, friendly savings accounts (results are not yet and involvement by local organizations available). including nongovernmental organizations There is little evidence about the impact of and religious groups (Diop et al. 2004), in laws that seek to delay age at marriage Zambia (Agha and Van Rossem 2004); (Cammack, Young, and Heaton 1996; and promotion of intra-household dialogue Malhotra et al. 2011). This may be due to in Ethiopia (Terefe and Larson 1993) and insufficient implementation and accountabil- Vietnam (Ha, Jayasuriya, and Owen 2005). ity mechanisms, lack of awareness of the •• The most effective programs have legal framework, and slow-moving social combined supply- and demand-based norms and expectations. strategies, either through comprehensive Programs that improve infant and child programs and interventions or through health can also affect childbearing behav­ national family planning programs. Efforts iors through knowledge and use of family that have increased both access to and planning (especially delaying and spacing demand for contraception have performed births) as well as through desired and better than programs that have focused realized family size. These interventions on only one or the other (Debpuur et al. have delivered vaccines, vitamin A, education 2002; Gribble and Voss 2009; Koenig et about infant feeding, nutritional support, and al. 1987; Molyneaux and Gertler 2000; Pitt, treatment for respiratory infections and Rosenzweig, and Gibbons 1993; Warwick diarrhea. The following approaches have been 1986)—for example, in Bangladesh, Ghana taken to improving child health: (box 1), and Indonesia. Countries that have launched comprehensive national family •• Targeting postpartum women and peer planning programs with local distribution groups for education about infant health of contraceptives plus social and behavior care (Prost et al. 2013; Perry et al. 2015) 2 Box 1. Combining Supply- and Demand-Side Interventions to Increase Knowledge of Family Planning and Decrease Fertility in Ghana The Navrongo Community Health and Family Planning Project in Ghana conducted an evaluation in which some communities received visits from a nurse, others received services from community volunteers (chosen by the community and trained by project staff), some received both of these supply- and demand- side components, and for others nothing changed. The project provided basic health care services, including some medicines and family planning supplies, as well as information about reproductive health and outreach to men. The combined package resulted in the biggest increases in contraceptive use and the largest overall fertility effects (Debpuur et al. 2002), with 40 percent higher odds of having knowledge of modern family planning methods and a 15 percent greater decline in the number of births than in control communities. This decline represents a full 1 birth difference between those receiving the combined package and those in control communities. Ghana’s Community-Based Efforts Show Fertility Decline (n ≈ 9,000 married women) 1.6 7 1.4 1.4 5.9 6 1.2 1.2 5.1 5.2 1.2 5.0 5 4.8 4.8 TFR (births per woman) 1.0 1.0 4.2 4.0 Odds ratio 4 0.8 3 0.6 2 0.4 0.2 1 0.0 0 Knowledge of modern FP method TFR 1995 TFR 1999 Control Nurse outreach Zurugelu Nurse outreach + Zurugelu •• Integrating service delivery across the face a lower risk of child mortality, and reproductive, maternal, newborn, and have greater self-efficacy for use of child health continuum, as in the Matlab contraceptive methods. program in Bangladesh (Gribble and Voss Different approaches to increase school 2009; Koenig and Keenan 2009) attendance and attainment at both the •• Including child health and nutrition primary and secondary level as well as to conditions for cash transfers, as in build skills for literacy and numeracy have PROGRESA (Behrman and Hoddinott 2005) been implemented globally. The impact on and Oportunidades (Gertler 2000) in Mexico educational outcomes, age at marriage or and a recent program in Burkina Faso sexual debut, and childbearing attitudes (Akresh, De Walque, and Kazianga 2013). (ideal family size) and behaviors (number of children borne) have been measured and Girls’ education has a strong effect on established. Approaches have included policy fertility and family formation, as seen changes regarding primary schooling require- across countries and time. Women who ments, offsets of the cost of primary school are more highly educated are likely to marry education, financial incentives for secondary and begin childbearing at older ages, face a school attendance and achievement, and greater opportunity cost in child rearing, skills building for out-of-school girls. 3 Box 2. Delaying Marriage Using a Comprehensive Community-Based Approach in Ethiopia The Berhane Hewan program in Ethiopia incorporated both family planning and education alongside a community-based program that provided mentoring for girls, signed compacts with families to delay their daughters’ marriages, and conducted community discussions about child marriage. Early results suggest that girls in the intervention group were 90 percent less likely to be married after the first two program years versus girls in the control group (Erulkar and Muthengi 2009). Ethiopias’ Berhane Hewan Program Decreased Early Marriage among Girls Ages 10–14 Proportion girls ever married 50 45 40 Percent 35 30 22.1 25 20 13.9 15 9.5 10 5 1.6 0 Control areas Intervention areas Baseline Follow-up (2 years) Source: Erulkar and Muthengi 2009. Adopting a Healthy Lifestyle institutional delivery but do not have any An individual’s behavior can have important significant effect on maternal mortality health impacts on the next generation via (Hatt et al. 2013), Another approach is to antenatal and intrapartum behaviors and target norms and knowledge—for example, human immunodeficiency virus (HIV) status. via birth preparedness (Soubeiga et al. This section presents evidence related to key 2014) or women’s groups. Women’s groups domains of healthy behaviors. have recently been linked to significant Younger women face higher risk of reductions in both maternal and neonatal obstetric complications and increased risk of mortality (Prost et al. 2013). abortion and abortion complications. Programs may not have a substantial Maternal mortality and morbidity are higher impact on mortality unless quality of care is among adolescent girls under the age of 20 also improved. Successfully improving than among women 20–24 (Greene and facility-based delivery requires efforts to Merrick 2015; Nove et al. 2014). strengthen the health system: Improving maternal health care around the time of childbirth can address the •• Interventions that improve the quality so-called “three delays” in seeking care, ­ of care, as in India (Spector et al. 2012) reaching the health facility, and receiving and in Senegal and Mali (Dumont et al. quality care at the facility (Thaddeus and 2013)—for example, health worker training Maine 1994). Targeting these delays could and knowledge and use of checklists and disproportionately improve the maternal audits health of adolescents in places where a •• Training for traditional birth attendants, substantial proportion of births are to which may have a stronger effect on adolescent mothers. To increase demand for neonatal mortality, as in Argentina, care, some programs offer vouchers or fee Bangladesh, Brazil, the Democratic Republic exemptions for institutional childbirth. of Congo, The Gambia, Guatemala, India, However, a recent review found that such Indonesia, Mozambique, Pakistan, and financial incentives may increase rates of Zambia (Wilson et al. 2011). 4 Box 3. Reducing Risky Behavior in Zambia A program in Zambia that used peer educators to facilitate discussion about sexual health, demonstrate skills, and perform dramatic skits was associated with increased knowledge and approval of both abstinence and condom use as well as decreased incidence of multiple regular partners in the short term (Agha and Van Rossem 2004). Nutritional status has important implica- transmitted infections (De Walque et al. tions for the health of adolescent girls and 2014), but in Malawi it had no effect on their children. Adolescent and women’s HIV status (Kohler and Thornton 2012). nutrition can be improved through nutrition supplementation during pregnancy, fortifi­ Conclusions cation of foods, cash transfer programs, The global evidence indicates that interven- and community-based programs with local tions focused on increasing access to and implementation by health care workers or demand for family planning, addressing community members (Bhutta et al. 2013). early marriage through multisectoral As supported by the Copenhagen consen- approaches at the community level, com- sus, fortification is one the most cost-­effective prehensively improving infant and child strategies for improving nutritional status, but health, improving girls’ education, improving it is most effective when implemented within access to quality maternal health care, a comprehensive nutrition strategy. There is addressing adolescent undernutrition, and increasing evidence that large-scale nutrition providing comprehensive sexuality educa- supplementation can be effective. tion and incentives to avoid risky behaviors Reducing risky behavior during adoles­ can have positive impacts on adolescents’ cence is very important, not only for healthy health behaviors and outcomes. These sexual and reproductive health in the short interventions provide an enabling environ- term but also for human capital accumula­ ment for adolescents and their communi- tion and productivity in the longer term. ties to make informed decisions about beginning a family and adopting a healthy •• Comprehensive sexuality education lifestyle. Because youth transitions are programs (Kirby, Laris, and Rolleri 2007), influenced by many factors within and including those focused on HIV and those outside the health sector, they must be implemented in school settings (Paul- addressed using a multisectoral approach. Ebhohimhen, Poobalan, and Van Teijlingen Improved adolescent transitions can help a 2008), may change sexual behavior, country to achieve the full demographic including delayed sexual initiation, fewer transition and its accompanying economic sexual partners, and increased use of benefits, but requires strong political condoms. Evidence indicates little change, commitment and considerable resources to however, in health outcomes (pregnancy or remove potential economic, logistic, or rates of sexually transmitted infections). social barriers. •• Peer education programs, however, have not been found to consistently References change sexual behavior (Medley et al. Agha, Sohail, and Ronan Van Rossem. 2004. “Impact of a School-Based Peer Sexual Health Intervention on 2009). A meta-analysis of HIV prevention Normative Beliefs, Risk Perceptions, and Sexual strategies targeting youth in Sub-Saharan Behavior of Zambian Adolescents.” Journal of Africa found that condom use increased, Adolescent Health 34 (5): 441–52. but health outcomes did not change Akresh, Richard, Damien De Walque, and Harounan (Michielsen et al. 2010); an exception to Kazianga. 2013. “Cash Transfers and Child Schooling: Evidence from a Randomized Evaluation of the Role this is a program in Zambia (box 3). of Conditionality.” Policy Research Working Paper •• Other programs have used financial 6340, World Bank, Washington, DC. incentives to reduce risky behaviors, but Behrman, Jere, and John Hoddinott. 2005. “Programme results have also been mixed. In Malawi Evaluation with Unobserved Heterogeneity and and Tanzania, projects offered monetary Selective Implementation: The Mexican PROGRESA Impact on Child Nutrition.” Oxford Bulletin of payments to adolescents if they remained Economics and Statistics 67 (4): 547–69. free of HIV or sexually transmitted Bhutta, Zulfiqar, Jal K. Das, Arjumand Rizvi, Michelle infections, respectively. In Tanzania, Gaffey, Neff Walker, Susan Horton, Patrick Webb, this reduced the incidence of sexually Anna Lartey, and Robert Black. 2013. 5 “Evidence-Based Interventions for Improvement of Health Education: Evaluation of an HIV/AIDS Radio Maternal and Child Nutrition: What Can Be Done and Campaign in Ethiopia.” Journal of Health at What Cost?” The Lancet 382 (9890): 452–77. Communication 10 (3): 225–35. Bolam, Alison, Dharma Manandhar, Purna Shrestha, Freij, Leah. 2008. “Safe Age of Marriage in Yemen: Matthew Ellis, and Anthony M. de L. Costello. 1998. Fostering Change in Social Norms.” U.S. Agency for “The Effects of Postnatal Health Education for International Development, Washington, DC. Mothers on Infant Care and Family Planning Gertler, Paul. 2000. “Final Report: The Impact of Practices in Nepal: A Randomised Controlled Trial.” PROGESA on Health.” International Food Policy BMJ 316 (7134): 805–11. Research Institute, Washington, DC. Bongaarts, John. 1978. “A Framework for Analyzing the Greene, M. E., and T. Merrick. 2015. “The Case for Proximate Determinants of Fertility.” Population and Investing in Research to Increase Access to and Use Development Review 4 (1): 105–32. of Contraception among Adolescents.” Alliance for Bongaarts, John, John Cleland, John Townsend, Jane Reproductive, Maternal, and Newborn Health, Bertrand, and Monica Das Gupta. 2012. “Family Seattle WA. Planning Programs for the 21st Century: Rationale Gribble, James, and Maj-Lis Voss. 2009. “Family and Design.” Population Council, New York. Planning and Economic Well-Being: New Evidence Cammack, Mark, Lawrence Young, and Tim Heaton. from Bangladesh.” Population Reference Bureau, 1996. “Legislating Social Change in an Islamic Washington, DC. Society: Indonesia’s Marriage Law.” American Journal Ha, Bui T. T., Rohan Jayasuriya, and Neville Owen. 2005. of Comparative Law 44 (1): 45–73. “Increasing Male Involvement in Family Planning Chandra-Mouli, Venkatraman, Catherine Lane, and Decision Making: Trial of a Social-Cognitive Sylvia Wong. 2015. “What Does Not Work in Intervention in Rural Vietnam.” Health Education Adolescent Sexual and Reproductive Health: A Research 20 (5): 548–56. Review of Evidence on Interventions Commonly Hatt, Laurel, Marty Makinen, Supriya Madhavan, and Accepted as Best Practices.” Global Health: Science Claudia Conlon. 2013. “Effects of User Fee and Practice 3 (3): 333–40. Exemptions on the Provision and Use of Maternal Debpuur, Cornelius, James Phillips, Elizabeth Jackson, Health Services: A Review of Literature.” Journal of Alex Nazzar, Pierre Ngom, and Fred Binka. 2002. Health, Population, and Nutrition 31 (4, suppl. 2): S67. “The Impact of the Navrongo Project on Contraceptive Ketende, Charles, Neeru Gupta, and Ruth Bessinger. Knowledge and Use, Reproductive Preferences, 2003. “Facility-Level Reproductive Health and Fertility.” Studies in Family Planning 33 (2): Interventions and Contraceptive Use in Uganda.” 141–64. International Family Planning Perspectives 29 (3): De Walque, Damien, William Dow, Carol Medlin, and 130–37. Rose Nathan. 2014. “Stimulating Demand for AIDS Kirby, Douglas, B. Laris, and Lori Rolleri. 2007. “Sex and Prevention: Lessons from the RESPECT Trial.” In HIV Education Programs: Their Impact on Sexual African Successes: Human Capital, edited by Sebastian Behaviors of Young People throughout the World.” Edwards, Simon Johnson, and David N. Weil. Chicago: Journal of Adolescent Health 40 (3): 206–17. University of Chicago Press. Koenig, Joyce, and William Keenan. 2009. “Group B Diop, Nafissatou, Modou Faye, Amadou Moreau, Streptococcus and Early-Onset Sepsis in the Era of Jacqueline Cabral, Hélène Benga, Fatou Cissé, Maternal Prophylaxis.” Pediatric Clinics of North Babacar Mané, Inge Baumgarten, and Molly America 56 (3): 689–708. Melching. 2004. The TOSTAN Program: Evaluation of a Koenig, Michael, James Phillips, Ruth Simmons, and Community-Based Education Program in Senegal. Mehrab Ali Khan. 1987. “Trends in Family Size Washington, DC: Population Council. Preferences and Contraceptive Use in Matlab, Dumont, Alexandre, Pierre Fournier, Michel Abrahamowicz, Bangladesh.” Studies in Family Planning 18 (3): 117–27. Mamadou Traoré, Slim Haddad, and William Fraser. Kohler, Hanspeter, and Rebecca Thornton. 2012. 2013. “Quality of Care, Risk Management, and “Conditional Cash Transfers and HIV/AIDS Prevention: Technology in Obstetrics to Reduce Hospital-Based Unconditionally Promising?” World Bank Economic Maternal Mortality in Senegal and Mali (QUARITE): Review 26 (2): 165–90. A Cluster-Randomised Trial.” The Lancet 382 Malhotra, Anju, Ann Warner, Allison McGonagle, and (9887): 146–57. Susan Lee-Rife. 2011. “Solutions to End Edmeades, Jeffrey, and Robin Hayes, with Gil Gaynair. Child Marriage.” International Center for Research on 2014. “Improving the Lives of Married Adolescent Women, Washington, DC. Girls in Amhara Ethiopia: A Summary of the Evidence.” Medley, Amy, Caitlin Kennedy, Karen O’Reilly, and International Center for Research on Women, Michael Sweat. 2009. “Effectiveness of Peer Washington, DC. Education Interventions for HIV Prevention in Engebretsen, S., and G. Kabore. 2011. “Addressing the Developing Countries: A Systematic Review and Needs of Girls at Risk of Early Marriage and Married Meta-Analysis.” AIDS Education and Prevention Adolescent Girls in Burkina Faso.” Population Council, 21 (3): 181. Washington, DC. Meuwissen, Liesbeth, Anna Gorter, and Andre Erulkar, Annabel, and Eunice Muthengi. 2009. Knottnerus. 2006. “Impact of Accessible Sexual and “Evaluation of Berhane Hewan: A Program to Delay Reproductive Health Care on Poor and Underserved Child Marriage in Rural Ethiopia.” International Adolescents in Managua, Nicaragua: A Quasi- Perspectives on Sexual and Reproductive Health 35 (1): Experimental Intervention Study.” Journal of 6–14. Adolescent Health 38 (1): 56. Farooq, Ghazi, and Lawrence Adeokun. 1976. “Impact of Michielsen, Kristien, Matthew F. Chersich, Stanley a Rural Family Planning Program in Ishan, Nigeria, Luchters, Petra De Koker, Ronan Van Rossem, and 1969–72.” Studies in Family Planning 7 (6): 158–69. Marlene Temmerman. 2010. “Effectiveness of HIV Farr, A. Celeste, Kim Witte, Kassa Jarato, and Tiffany Prevention for Youth in Sub-Saharan Africa: Menard. 2005. “The Effectiveness of Media Use in Systematic Review and Meta-Analysis of 6 Randomized and Nonrandomized Trials.” Aids 24 (8): Saville, Neena Shah More, Bhim Shrestha, Prasanta 1193–202. Tripathy, Amie Wilson, and Anthony Costello. 2013. Mmari, Kristin, and Robert Magnani. 2003. “Does “Women’s Groups Practising Participatory Learning Making Clinic-Based Reproductive Health Services and Action to Improve Maternal and Newborn More Youth-Friendly Increase Service Use by Health in Low-Resource Settings: A Systematic Adolescents? Evidence from Lusaka, Zambia.” Journal Review and Meta-Analysis.” The Lancet 381 (9879): of Adolescent Health 33 (4): 259–70. 1736–46. Molyneaux, John, and Paul Gertler. 2000. “The Impact of Rogers, Everett, Peter Vaughan, Ramadhan Swalehe, Targeted Family Planning Programs in Indonesia.” Nagesh Rao, Peer Svenkerud, and Suruchi Sood. Population and Development Review 26 (suppl.): 61–85. 1999. “Effects of an Entertainment-Education Radio Nove, Andrea, Zoe Matthews, Sarah Neal, and Alma Soap Opera on Family Planning Behavior in Tanzania.” Camacho. 2014. “Maternal Mortality in Adolescents Studies in Family Planning 30 (3): 193–211. Compared with Women of Other Ages: Evidence from Soubeiga, Dieudonne, Lise Gauvin, Marie Hatem, and 144 Countries.” The Lancet Global Health 2 (3): Mira Johri. 2014. “Birth Preparedness and e155–e64. Complication Readiness (BPCR) Interventions to Paul-Ebhohimhen, Virginia, Amudha Poobalan, and Reduce Maternal and Neonatal Mortality in Edwin Van Teijlingen. 2008. “A Systematic Review of Developing Countries: Systematic Review and School-Based Sexual Health Interventions to Prevent Meta-Analysis.” BMC Pregnancy and Childbirth 14 STI/HIV in Sub-Saharan Africa.” BMC Public Health (1): 129. 8 (1): 4. Spector, Jonathan, P. K. Agrawal, Bhala Kodkany, Stuart Perry, Henry, Melanie Morrow, Sarah Borger, Jennifer Lipsitz, Angela Lashoher, Gerald Dziekan, Rajiv Bahl, Weiss, Mary DeCoster, Thomas Davis, and Pieter Mario Merialdi, Matthews Mathai, Claire Lemer, and Ernst. 2015. “Care Groups II: A Summary of the Child Atul Gawande. 2012. “Improving Quality of Care for Survival Outcomes Achieved Using Volunteer Maternal and Newborn Health: Prospective Pilot Community Health Workers in Resource-Constrained Study of the WHO Safe Childbirth Checklist Settings.” Global Health: Science and Practice 3 (3): Program.” PLoS ONE 7 (5): e35151. 370–81. Terefe, Ashenafi, and Charles Larson. 1993. “Modern Pitt, Mark, Mark Rosenzweig, and Donna Gibbons. 1993. Contraception Use in Ethiopia: Does Involving “The Determinants and Consequences of the Husbands Make a Difference?” American Journal of Placement of Government Programs in Indonesia.” Public Health 83 (11): 1567–71. World Bank Economic Review 7 (3): 319–48. Thaddeus, Sereen, and Deborah Maine. 1994. “Too Far to Plautz, Andrea, and Dominique Meekers. 2007. Walk: Maternal Mortality in Context.” Social Science “Evaluation of the Reach and Impact of the 100% and Medicine 38 (8): 1091–10. Jeune Youth Social Marketing Program in Cameroon: Valente, Thomas, Young Min Kim, Cheryl Lettenmaier, Findings from Three Cross-Sectional Surveys.” William Glass, and Yankuba Dibba. 1994. “Radio Reproductive Health 4 (1): 1. Promotion of Family Planning in The Gambia.” Population Services International. 2012. “ProFam International Family Planning Perspectives 20 (3): Urban Outreach: A High-Impact Model for 96–100. Family Planning.” Population Services International, Warwick, Donald. 1986. “The Indonesian Family Planning Washington DC. Program: Government Influence and Client Choice.” Prost, Audrey, Tim Colbourn, Nadine Seward, Kishwar Population and Development Review 12 (3): 453–90. Azad, Arri Coomarasamy, Andrew Copas, Tanja Wilson, Arnie, Ioannis Gallos, Nieves Plana, David Houweling, Edward Fottrell, Abdul Kuddus, Sonia Lissauer, Khalid Khan, and Javier Zamora. 2011. Lewycka, Christine MacArthur, Dharma Manandhar, “Effectiveness of Strategies Incorporating Training Joanna Morrison, Charles Mwansambo, Nirmala and Support of Traditional Birth Attendants on Nair, Bejoy Nambiar, David Osrin, Christina Pagel, Perinatal and Maternal Mortality: Meta-Analysis.” Tambosi Phiri, Anni-Maria Pulkki-Brännström, BMJ 343d: 702. doi: http://dx.doi.org/10.1136/bmj​ Mikey Rosato, Jolene Skordis-Worrall, Naomi .d7102. © 2016 International Bank for Reconstruction and Development / The World Bank. Some rights reserved. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. 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