Sarah Eustis-Guthrie on why she shut down her charity, & why more founders should follow her lead

Project Background and Decision to Shut Down

• Sarah Eustace Guthrie and co-founder Ben Williamson founded the non-profit Maternal Health Initiative (MHI) via the Charity Entrepreneurship incubation program to implement postpartum family planning in Ghana.
• The organization aimed to reduce short-spaced pregnancies by integrating contraceptive counseling into postnatal and immunization appointments, with a target cost-effectiveness of $70 per DALY averted and $50 to avert an unintended birth.
• After 18 months of operation, including two proof-of-concept tests and a pilot, MHI decided to shut down in January 2024 because the intervention failed to reduce pregnancy rates as anticipated.
• The decision was driven by the belief that continuing would actively make the world worse by diverting counterfactual funds from more effective projects, a burden that made operating a failing program psychologically and ethically untenable for the founders.

Key Findings on Intervention Failure

• Pilot Results: Surveys indicated no statistically significant increase in contraceptive uptake in immunization sessions; postnatal care showed a 20% uptake increase in a follow-up call but suffered from implementation failures in two of three hospitals.
• Pregnancy Rate Discrepancy: Subsequent research revealed that while contraceptive uptake increased, actual pregnancy rates did not decrease, contradicting the core assumption that increased uptake automatically translates to fewer pregnancies in this context.
• The Role of Postpartum Abstinence: The founders identified that cultural norms of postpartum abstinence (averaging 9 months in sub-Saharan Africa) meant many women counseling for contraception were not sexually active, rendering the intervention ineffective for the target population.
• The Role of Breastfeeding (LAM): The team discovered that non-exclusive breastfeeding often provided natural contraception with ~94% effectiveness, suggesting that women in the program were already protected from pregnancy without needing external methods, but were being urged to adopt contraceptives that offered little marginal benefit.
• IUD Risks: The team explicitly avoided inserting IUDs immediately post-birth due to concerns regarding informed consent, coercion, and the difficulty beneficiaries face in removing them later in low-resource settings.

Operational Mistakes and Lessons Learned

• Insufficient On-Ground Presence: The founders regretted not spending more time embedded in specific clinics, choosing instead to spread efforts across 18 facilities, which diluted their understanding of local realities.
• Over-Prioritization of Non-Core Tasks: Significant time was wasted on fundraising and administrative tasks (e.g., website design) rather than ruthlessly prioritizing the core question of whether the intervention worked.
• Inadequate Handling of "Yellow Flags": The organization struggled to systematically track and address early warning signs, such as bad gut feelings about baseline contraceptive access and skepticism about expert advice regarding abstinence.
• Expert Deference vs. Skepticism: The team made a mistake by overly deferring to experts who dismissed concerns about abstinence and breastfeeding, failing to recognize that their own observations contradicted the prevailing literature.
• Lack of Formal Re-evaluation Points: Unlike the recommended "reevaluation points" framework, MHI lacked a structured process for periodically pausing to assess if the underlying assumptions of the intervention still held true.

Systemic Critique of Philanthropy

• Donor-Beneficiary Misalignment: Guthrie highlighted a structural flaw where charities are incentivized to please donors (who hold power) rather than beneficiaries, as donors control funding while beneficiaries cannot easily punish ineffective programs.
• Trust-Based Philanthropy Limitations: While supportive of trust-based philanthropy (reducing reporting burdens), the speaker argues it conflates trusting non-profits with empowering beneficiaries, suggesting direct cash transfers (e.g., GiveDirectly) as a superior method for empowering individuals.
• The "Play Pump" Warning: The conversation cited the Play Pump failure (expensive, complex, ineffective water pumps) as an example of how fundraising momentum can override evidence, leading to net-negative outcomes for communities.
• Funding Rigidity: The founders found that major funders were unwilling to pivot funding away from postpartum family planning despite evidence of its limited efficacy, viewing the intervention as a fixed priority rather than a variable to be optimized.

Personal and Career Reflections

• Emotional Toll: The experience caused severe psychological stress, including sleeplessness and feelings of personal failure, though the community response to the shutdown was largely supportive of the decision's integrity.
• Career Pivot: Guthrie has since joined GiveWell's malaria team, utilizing the skills gained from MHI (problem-solving, handling uncertainty) in a new context.
• Advice for Aspiring Entrepreneurs: She recommends trusting oneself to ask "dumb" questions about proposed interventions, prioritizing co-founder trust over professional compatibility, and recognizing that "counting oneself out" of the effective altruism movement is a common but unnecessary mistake.
• Charity Entrepreneurship Program: Despite the failure of MHI, the speaker highly recommends the Charity Entrepreneurship incubation program for its ability to teach problem-solving skills and provide a supportive network, noting it was a high-value learning experience.