title: Providing free pregnancy test kits to community health workers increases distribution of contraceptives: results from an impact evaluation in Madagascar.
abstract: OBJECTIVE
  To improve access to contraceptives in remote and rural areas, sub-Saharan African countries are allowing community health workers (CHWs) to distribute hormonal contraceptives. Before offering hormonal contraceptives, CHWs must determine pregnancy status but often lack a reliable way to do so. No studies have evaluated the impact of providing CHWs with urine pregnancy test kits. We assessed the impact of giving CHWs free pregnancy test kits on the number of new clients purchasing hormonal contraceptives from CHWs.
  
  
  METHODS
  We implemented a randomized experiment in Eastern Madagascar among CHWs who sell injectable and oral hormonal contraceptives. A total of 622 CHWs were stratified by region and randomly assigned at the individual level. Treatment-group CHWs were given free pregnancy tests to distribute (n analyzed=272) and control-group CHWs did not receive the tests (n analyzed=263). We estimated an ordinary least-squares regression model, with the monthly number of new hormonal contraceptive clients per CHW as our primary outcome.
  
  
  RESULTS
  We find that providing CHWs with free pregnancy test kits increases the number of new hormonal contraceptive clients. Treatment-group CHWs provide hormonal contraceptives to 3.1 new clients per month, compared to 2.5 in the control group. This difference of 0.7 clients per month (95% confidence interval 0.13-1.18; p=.014) represents a 26% increase.
  
  
  CONCLUSIONS
  Giving CHWs free pregnancy tests is an effective way to increase distribution of hormonal contraceptives. As pregnancy tests become increasingly affordable for health-care systems in developing countries, community-based distribution programs should consider including the tests as a low-cost addition to CHWs' services.
  
  
  CONCLUSIONS
  No study has evaluated the impact of giving CHWs free urine pregnancy test kits for distribution to improve provision of hormonal contraceptives. Giving CHWs free pregnancy test kits significantly increases the number of clients to whom they sell hormonal contraceptives. Community-based distribution programs should consider including these tests among CHWs' services.
authors.affiliation: Abt Associates, 55 Wheeler Street, Cambridge, MA 02138, United States. Electronic address: Alison_Comfort@abtassoc.com.
authors.forename: Alison B
authors.initials: AB
authors.lastname: Comfort
authors.affiliation: Abt Associates, 4550 Montgomery Avenue, Bethesda, MD 20814, United States. Electronic address: slavea_chankova@abtassoc.com.
authors.forename: Slavea
authors.initials: S
authors.lastname: Chankova
authors.affiliation: Abt Associates, 55 Wheeler Street, Cambridge, MA 02138, United States. Electronic address: Randall_Juras@abtassoc.com.
authors.forename: Randall
authors.initials: R
authors.lastname: Juras
authors.affiliation: Abt Associates, 4550 Montgomery Avenue, Bethesda, MD 20814, United States. Electronic address: nhsi@dexisonline.com.
authors.forename: C Natasha
authors.initials: CN
authors.lastname: Hsi
authors.affiliation: Abt Associates, 4550 Montgomery Avenue, Bethesda, MD 20814, United States. Electronic address: Lauren_Peterson@abtassoc.com.
authors.forename: Lauren A
authors.initials: LA
authors.lastname: Peterson
authors.affiliation: Abt Associates, 55 Wheeler Street, Cambridge, MA 02138, United States. Electronic address: payal.hathi@gmail.com.
authors.forename: Payal
authors.initials: P
authors.lastname: Hathi
mesh_terms: D000328:Adult; D003153:Community Health Services; D003150:Community Health Workers / Q000706:statistics & numerical data*; D003271:Contraceptive Agents, Female / Q000008:administration & dosage / Q000600:supply & distribution*; D003278:Contraceptives, Oral, Hormonal / Q000600:supply & distribution; D003906:Developing Countries; D005260:Female; D006801:Humans; D007267:Injections; D008270:Madagascar; D008875:Middle Aged; D011258:Pregnancy Tests / Q000191:economics; D015397:Program Evaluation; D019035:Rural Health Services
chemical_list: D003271:Contraceptive Agents, Female; D003278:Contraceptives, Oral, Hormonal
keywords: Community health workers; Family planning; Hormonal contraceptives; Pregnancy tests; Sub-Saharan Africa