Abstract
BACKGROUND: Family planning remains a cornerstone of reproductive health strategies to reduce maternal and child mortality by preventing unintended and high-risk pregnancies. Despite the implementation of the FP2020 initiative, empirical evidence on its population-level impact in the Democratic Republic of the Congo (DRC) remains scarce. This study examined the association between modern contraceptive use as a proxy for exposure to the FP2020 era expansion of family planning services and high-risk pregnancies and under-five mortality during the FP2020 in the DRC era. METHODS: A quasi-experimental Difference-in-Differences (DiD) design was applied using Demographic and Health Survey (DHS) data from 2013 (pre-intervention) and 2023 (post-intervention). Women aged 15-49 years with at least one live birth were included for maternal outcomes, while all live-born children within five years preceding each survey were analyzed for child outcomes. Weighted analyses employed Linear Probability Models (LPMs), adjusting by potential confounder variables. RESULTS: The prevalence of high-risk pregnancies among modern contraceptive users declined from 58.6% in 2013 to 54.5% in 2023, while under-five mortality decreased from 10.4% to 5.9% over the same period. DiD estimates revealed a significant reduction in high-risk pregnancies among users in urban areas (β = -0.067) (95% CI: -0.133 to -0.003), and a substantial decline in under-five mortality in rural areas (β = -0.031) (95% CI: -0.059 to -0.002). Results remained robust across model specifications, and a parallel trends test confirmed model validity (p > 0.5). CONCLUSIONS: Findings demonstrate that the FP2020 initiative and increased modern contraceptive use contributed to measurable reductions in maternal and child health risks in the DRC. Expanding access to family planning within universal health coverage (UHC) frameworks could further reduce health inequalities and accelerate progress toward the Sustainable Development Goals (SDGs).