Judging the nudge: applying behavioural economics to promote PAFP in Nepal

We know that many women receiving a safe abortion or post-abortion care service are not looking to become pregnant again soon. However, not every woman is receiving the necessary post-abortion contraceptive counselling to make an informed choice on future options. In Nepal, we identified this unmet need and implemented an intervention to address it.

In 2014, it was identified that the current method mix in Nepal was suboptimal, with 71% of post-abortion clients choosing to take-up either no contraception or a short-term method. Findings from Sunaulo Parivar Nepal, an implementing partner of Marie Stopes International, confirmed this too.

Sunaulo Parivar Nepal provide around 40,000 safe abortions every year. Half of the women served shared that they would like to delay their next pregnancy by at least two years. However, despite the clinics offering reliable long-acting reversible contraceptive methods (LARCs) at an affordable price, uptake of LARCs following an abortion remained low overall, with one in four women choosing to take one.

To understand how we could better serve the women who do not intend to get pregnant again soon, by increasing access to LARCs, we collaborated with Ideas42 to undertake a behavioural economics intervention. The aim was to ensure clinics offered tailored contraceptive counselling and a good method mix to all women visiting their clinics.

Following in-depth interviews with providers, we established that although providers are well-trained and well-motivated, they faced two key provider-level barriers:

• As no performance data was shared between clinics, they found it difficult to benchmark their service delivery against others
• In larger clinics, role sharing and diffusion of responsibility made it easier to assume that another colleague had provided the client with post-abortion family planning counselling.

The outcome was a lack of accountability and consistency in post-abortion contraceptive counselling. This meant women were not receiving the counselling they need to make an informed choice on onward contraception, leading to an imbalance in method mix.

To address this shortfall, we began sharing analytics between the clinics. We sent monthly posters to each clinic comparing contraceptive uptake in their clinic with other similar clinics in the network. This set the aim of providing client-centred contraceptive counselling to all safe abortion clients, to provide women with an informed choice over their onward contraceptive options.

The intervention presented a low-tech and cost-effective solution that was successful in extending access to women. Uptake of LARCs grew from 22.6% to 29.6% as providers shared that the posters helped them to shift their focus to providing consistent post-abortion contraceptive counselling to all clients and a good method mix, including both short-term methods and LARCs.

Find out how in our two-page programming brief:

Judging the nudge: applying behavioral economics to promote PAFP in Nepal.