Innovative strategies reduce fertility in Ghana. (Experimental Programs).
The study team comprises investigators from the NHRC, Council staff members James F. Phillips and Elizabeth F. Jackson, and two Council fellows assigned to the NHRC, Cornelius Debpuur and Bawah Ayaga Agula. The experiment tests the relative effects of two strategies for delivering primary health care services to rural residents in the Kassena-Nankana District.
In one strategy, Ministry of Health nurses live and work in community-constructed health centers and provide health and family planning services door to door. In the other strategy--known as zurugelu, which means "togetherness" in the local language--door-to-door services are provided by local volunteers and supported by community leaders. These leaders also host community gatherings, known as durbars, that foster community dialogue about health and reproductive matters.
The study is being conducted in four geographic regions in the Kassena-Nankana District. People in Area 1 are exposed to the zurugelu strategy. Residents of Area 2 receive care from nurses. In Area 3, people benefit from contact with both the zurugelu and nurse outreach strategies. In these three experimental areas and in Area 4, the comparison area, residents have access to Ministry of Health fixed-location clinics.
The NHRC's central scientific resource is the Navrongo Demographic Surveillance System, which registers all demographic events--including births, deaths, migrations, marriages, and pregnancies--that occur in the lives of all 142,000 individuals residing in Kassena-Nankana District. The system also provides continuous estimates of fertility rates for approximately 43,000 women of reproductive age.
"The initial results of the experiment suggest that in a traditional African society provision of primary health services in the local community and intensive social mobilization can make a difference in fertility and ideas and beliefs about reproduction," says Phillips.
Phillips and his colleagues examined the effect of the experiment on knowledge of contraceptives, desire to limit childbearing, reported contraceptive use, and fertility. Controlling for several potential biases, the researchers found that when nurse outreach and zurugelu were combined, married women's knowledge of contraceptives improved significantly more than it did in areas where either the zurugelu or the nurse outreach strategy was implemented separately.
Outreach by nurses, meanwhile, had the strongest influence on women's desire to limit childbearing. The researchers found that after one year of nurse outreach activities, women in that study group were 40 percent more likely to want to limit fertility than women in the comparison group. Women's fertility preferences in the zurugelu-only area were not significantly different from those of women in the comparison area. Women who experienced both nurse outreach and zurugelu were 20 percent more likely than women in the comparison group to want to limit their childbearing. "By emphasizing exchanges between nurses and individual women, the nurse outreach approach may introduce women to new ideas about childbearing that do not immediately arise from zurugelu activities in the community," says Jackson.
Does the desire to limit childbearing translate into contraceptive use? A statistical analysis showed that one year of exposure to nurse outreach and zurugelu implemented together increased reported modern contraceptive use among currently married women by 24 percent, a significant change. In the two areas where each of the strategies was implemented separately, no significant change was reported in contraceptive use. Evidence that fertility has fallen in all experimental areas, however, suggests that some women who use family planning may deny doing so. When the two interventions operated jointly, their fertility effect equaled the sum of the influence of each arm operating separately and resulted in a 15 percent reduction in fertility between 1994 and 1999.
"This demonstrates that zurugelu and nurse outreach have an additive effect on fertility reduction," says Phillips. The success of this experiment has led the government of Ghana to begin implementing the combined approach nationwide.
Other results from the Navrongo experiment, including effects on child survival, are expected in the future.
Debpuur, Cornelius, James F. Phillips, Elizabeth F. Jackson, Alex Nazzar, Pierre Ngom, and Fred N. Binka. 2002. "The impact of the Navrongo project on contraceptive knowledge and use, reproductive preferences, and fertility," Studies in Family Planning 33(2): 141-164.
The Finnish International Development Agency, the Bill & Melinda Gates Foundation, the Andrew W. Mellon Foundation, the Rockefeller Foundation, and the United States Agency for International Development