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<p>After the 2012 London Summit on Family Planning, there have been major strides
in advancing the family planning agenda for low and middle-income countries worldwide.
Much of the existing infrastructure and funding for family planning access is in the
form of supplying free contraceptives to countries. While the average yearly value
of donations since 2000 was over 170 million dollars for contraceptives procured for
developing countries, an ongoing debate in the empirical literature is whether increases
in contraceptive access and supply drive declines in fertility (UNFPA 2014). </p><p>This
dissertation explores the fertility and behavioral effects of an increase in contraceptive
supply donated to Zambia. Zambia, a high-fertility developing country, receives over
80 percent of its contraceptives from multilateral donors and aid agencies. Most contraceptives
are donated and provided to women for free at government clinics (DELIVER 2015). I
chose Zambia as a case study to measure the relationship between contraceptive supply
and fertility because of two donor-driven events that led to an increase in both the
quantity and frequency of contraceptives starting in 2008 (UNFPA 2014). Donations
increased because donors and the Zambian government started a systematic method of
forecasting contraceptive need on December 2007, and the Mexico City Policy was lifted
in January 2009. </p><p>In Chapter 1, I investigate whether a large change in quantity
and frequency of donated contraceptives affected fertility, using available data on
contraceptive donations to Zambia, and birth records from the 2007 and 2013 Demographic
and Health Surveys. I use a difference-in-difference framework to estimate the fertility
effects of a supply chain improvement program that started in 2011, and was designed
to ensure more regularity of contraceptive supply. The increase in total contraceptive
supply after the Mexico City Policy was rescinded is associated with a 12 percent
reduction in fertility relative to the before period, after controlling for demographic
characteristics and time controls. There is evidence that a supply chain improvement
program led to significant fertility declines for regions that received the program
after the Mexico City Policy was rescinded. </p><p>In Chapter 2, I explore the effects
of the large increase in donated contraceptives on modern contraceptive uptake. According
to the 2007 and 2013 Demographic and Health Surveys, there was a dramatic increase
in current use of injectables, implants, and IUDs. Simultaneously, declines occurred
in usage of condoms, lactational amenorrhea method (LAM), and traditional methods.
In this chapter, I estimate the effect of the increase in donations on uptake, composition
of contraceptive usage, and usage of methods based on distance to contraceptive access
points. The results show the post-2007 period is associated with an increase in usage
of injectables and the pill among women living further away from access points. </p><p>In
Chapter 3, I explore attitudes towards the contraceptive supply system, and identify
areas for improvement, based on qualitative interviews with 14 experts and 61 Zambian
users and non-users of contraceptives. The interviews uncover systemic barriers that
prevent women from consistently accessing methods, and individual barriers that exacerbate
the deficiencies in supply chain procedures. I find that 39 out of 61 women interviewed,
both users and non-users, had personal experiences with stock out. The qualitative
results suggest that the increase in contraceptives brought to the country after 2007
may have not contributed to as large of a decline in fertility because of bottlenecks
in the supply chain, and problems in maintaining stock levels at clinics. I end the
chapter with a series of four recommendations for improvements in the supply chain
going forward, in light of recent commitments by the Zambian government during the
2012 London Summit on Family Planning.</p>
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