Experimental studies demonstrating the effectiveness of nonclinical distribution of contraceptives are typically conducted in settings where contraceptive use is low and unmet need is extensive. Determining the long-term role of active outreach programs after initial demand is met represents an increasingly important policy issue in Asia, where contraceptive prevalence is high and fixed service points are conveniently available. This article examines the long-term rationale for household family planning in Bangladesh-where growing use of contraceptives, rapid fertility decline, and normative change in reproductive preferences are in progress, bringing into question the rationale for large-scale deployment of paid outreach workers. Longitudinal data are analyzed that record outreach encounters and contraceptive use dynamics in a large rural population. Findings demonstrate that outreach has a continuing impact on program effectiveness, even after a decade of household visitation. The policy implications of this finding are reviewed.
PIP: Longitudinal data were analyzed to determine the long-term impact of community-based distribution of contraception in rural Bangladesh. Since 1978, the Family Welfare Assistant initiative has grown to involve more than 40,000 nonclinical outreach workers and supervisors. Debate has focused on the sheer scope of this undertaking and on its potential, permanent impact on demographic transition, especially with the advent of less expensive supply depots, satellite clinics, and social marketing outlets that now blanket the country. This study provides an analytical framework for interpreting the long-term role of service outreach as a determinant of contraceptive use. The framework has pathways that connect to demographic, socioeconomic, and programmatic factors. A typology is also developed to explain the interface of the costs of fertility regulation and the demand for contraception. The Maternal and Child Health-Family Planning Extension Project monitoring activities provided data for this analysis through a Sample Registration System covering a 10-year period. A statistical model was developed to analyze changes in the reproductive behavior and motives of 4236 respondents arising from exposure to outreach activities. Results of the analysis indicate that 1) outreach generates incremental contraceptive use that would not arise if underlying demand were the sole determinant of use; 2) the outreach activities of male workers have no role in maintaining use; 3) outreach continues to foster contraceptive use because of the high frequency of encounters; 4) the outreach program is the single most important component of program exposure in the study population; 5) outreach generates a small but significant demand for contraception; and 6) sex preferences for offspring are weakened, but not eliminated, by outreach. These results suggest that the outreach program should be continued and that the male health assistant role should be revised or phased-out. Without outreach, contraceptive prevalence would be 15 points lower than the observed level of 40%. Even though outreach has a continuing demographic role, this role should be reevaluated periodically, especially to determine how to employ supporting communication strategies. These findings may also be extrapolated to similar settings in other countries.