Family Planning, Now and Later: Infertility Fears and Contraceptive Take-Up

Early fertility is thought to be one of the key barriers to female human capital attainment in sub-Saharan Africa, yet contraceptive take-up remains puzzlingly low among women in critical periods for human capital investment. We study a barrier to hormonal contraceptive uptake among young, nulliparious women that, while recognized in the qualitative literature, has not been causally tested: the persistent (incorrect) belief — grounded in medical mistrust and an adverse history of population control policies — that these contraceptives cause later infertility. This belief creates a perceived tradeoff between current and future reproductive control. We use a randomized controlled trial with female undergraduates at the flagship university in Zambia to test two interventions to increase contraceptive use. Despite high rates of sexual activity, low rates of condom-use, and near zero desire for current pregnancy, only 5% of this population uses hormonal contraceptives at baseline. Providing a voucher to visit a local clinic — greatly reducing access costs — only temporarily increases contraceptive use. However, pairing this transfer with a carefully-designed treatment to change persistent incorrect beliefs that contraceptives cause infertility doubles the initial effect, persistently increases contraceptive take-up over 6 months, and reduces reported pregnancies by as much as 71%. This treatment reduces self-reports that contraceptives cause infertility, and compliers are more likely to cite fear of infertility as the reason for not using contraceptives at baseline. IV estimates indicate that eliminating the belief that contraceptives cause infertility would more than triple contraceptive use.