Thirty-five years later: Long-term effects of the Matlab maternal and child health/family planning program on older women’s well-being

Family planning programs are believed to have substantial long-term benefits for women’s health and well-being, yet few studies have established either extent or direction of long-term effects. The Matlab, Bangladesh, maternal and child health/family planning (MCH/FP) program afforded a 12-y period of well-documented differential access to services. We evaluate its impacts on women’s lifetime fertility, adult health, and economic outcomes 35 y after program initiation. We followed 1,820 women who were of reproductive age during the differential access period (born 1938–1973) from 1978 to 2012 using prospectively collected data from the Matlab Health and Demographic Surveillance System and the 1996 and 2012 Matlab Health and Socioeconomic Surveys. We estimated intent-to-treat single-difference models comparing treatment and comparison area women. MCH/FP significantly increased contraceptive use, reduced completed fertility, lengthened birth intervals, and reduced age at last birth, but had no significant positive impacts on health or economic outcomes. Treatment area women had modestly poorer overall health (+0.07 SD) and respiratory health (+0.12 SD), and those born 1950–1961 had significantly higher body mass index (BMI) in 1996 (0.76 kg/m²) and 2012 (0.57 kg/m²); fewer were underweight in 1996, but more were overweight or obese in 2012. Overall, there was a +2.5 kg/m² secular increase in BMI. We found substantial changes in lifetime contraceptive and fertility behavior but no long-term health or economic benefits of the program. We observed modest negative health impacts that likely result from an accelerated nutritional transition among treated women, a transition that would, in an earlier context, have been beneficial.

The case for global scale-up of family planning programs rests, in part, on the potential long-term benefits of family planning programs for women’s health and economic empowerment (1, 2). A counterpoint to this assumption suggests that smaller families may actually have negative consequences for women in societies where old-age support and women’s status are tied to childbearing (3). Yet, few studies have established either the extent or direction of long-term effects.Much of our existing understanding of family planning program effects comes from the Matlab maternal and child health/family planning (MCH/FP) program (4–6). The program was implemented by icddr,b (formerly known as the International Centre for Diarrhoeal Disease Research, Bangladesh) starting in 1977 in the rural Matlab area of Bangladesh. MCH/FP revolutionized the field by using a home-based delivery model, integrating family planning with mother-and-child health services, and collecting extensive data that facilitate evaluation. MCH/FP yielded immediate and enduring effects. While fertility levels were similar in treatment and comparison areas at baseline, the MCH/FP treatment area subsequently experienced increased contraceptive use, reduced fertility (6–8), and reductions in maternal and child mortality (9). By 1989, MCH/FP services were scaled up to the rest of Bangladesh, including the comparison area, creating a well-documented period of differential treatment exposure from 1977 to 1989. Using the 1996 Matlab Health and Socioeconomic Survey (MHSS1), Barham (5) assessed the medium-term effects of MCH/FP on beneficiary children in a representative sample of Matlab. Joshi and Schultz (4) found that adult women living in the treatment area compared to comparison area villages had a body mass index (BMI) more than 1 kg/m² higher and concomitant reductions in the proportion with BMI of <18 kg/m². They found no differences in self-rated health or self-reported activities of daily living (ADLs); however, the targeted women were still relatively young in 1996, and these measures of health typically show variation later in life.Relatively few other studies have demonstrated long-term effects of family planning programs, in part due to the difficulties of longitudinal follow-up, biased self-selection into treatment, and the lack of appropriate comparison groups. Family planning may affect long-term well-being through a multiplicity of mediating pathways, including via effects on age at first birth, spacing between births, age at last birth, and completed fertility (2). Canning and Schultz (1) recently highlighted similar pathways of later benefit of family planning as potentially freeing up resources and women’s time. Miller (10) showed that early access to family planning in Colombia led to delayed fertility, higher schooling, and greater labor force participation. Yet, to our knowledge, only Matlab offers the potential to apply a prospective intervention design to look at long-term health effects.This study examined the consequences of the Matlab MCH/FP on women’s lifetime fertility, adult health, and economic outcomes using the second Matlab Health and Socioeconomic Survey (MHSS2), conducted in 2012, ∼35 y after initial rollout of services. We focused on women who were of reproductive age during the period of differential treatment exposure—those born 1938–1973 (aged 40 y to 75 y in 2012). We measured impacts on three domains of health—metabolic, functional, and respiratory health—using a mix of directly observed physical tests (i.e., anthropometry, blood pressure, and grip strength) and indirectly diagnosed morbidity. The rich integrated database of the icddr,b Matlab Health and Demographic Surveillance System (HDSS) combined with MHSS1 and MHSS2 allowed us to address causal considerations related to assignment of intent-to-treat (ITT) status before program introduction, to selective attrition, and to potential confounders. We also examined take-up of modern contraception as well as underlying mechanisms related to later health, including family size, birth spacing, and BMI. In addition, we measured the effect of the program on economic outcomes such as consumption, savings, and employment.