Elements of Family Planning Success

Policies relating to contraceptive services (population, family planning and reproductive health policies) often receive weak or fluctuating levels of commitment from national policy elites in Southern countries, leading to slow policy evolution and undermining implementation. This is true of Kenya, despite the government's early progress in committing to population and reproductive health policies, and its success in implementing them during the 1980s. This key informant study on family planning policy in Kenya found that policy space contracted, and then began to expand, because of shifts in contextual factors, and because of the actions of different actors. Policy space contracted during the mid-1990s in the context of weakening prioritization of reproductive health in national and international policy agendas, undermining access to contraceptive services and contributing to the stalling of the country's fertility rates. However, during the mid-2000s, champions of family planning within the Kenyan Government bureaucracy played an important role in expanding the policy space through both public and hidden advocacy activities. The case study demonstrates that policy space analysis can provide useful insights into the dynamics of routine policy and programme evolution and the challenge of sustaining support for issues even after they have reached the policy agenda. (author's)

Matthew Connelly considers his book the first "global history of population control", which, at various times and places, encompasses eugenics, infanticide, pronatalist schemes, restrictive immigration policies, genocide, and family planning. His archival research exhaustively spans the late 1800s through to the mid-1980s, after which his research becomes a bit thin. He includes a numbing number of cameo appearances by the famous, the infamous, and the unknown. Although an occasional nugget of interest can be found in the first part of the book, most readers will find Connelly's attention to minutiae a powerful narcotic. (excerpt)

For nearly three decades, the total fertility rate in England and Wales has remained high relative to other European countries, and stable at about 1.7 births per woman. In this chapter, we examine trends in both period and cohort fertility throughout the twentieth century, and demonstrate some important differences across demographic and social groups in the timing and quantum of fertility. Breaking with a market-oriented and laissez-faire approach to work and family issues, the last 10 years have seen the introduction of new social and economic policies aimed at providing greater support to families with children. However, the effect of the changes is likely to be limited to families on the lower end of the income scale. Rather than facilitating work and parenthood, some policies create incentives for a traditional gendered division of labour. Fertility appears to have remained stable despite, rather than because of, government actions. (author's)

Benin became the first African country to introduce the SDM when the Ministry of Health (MOH) and IRH agreed in December 2000 to conduct a pilot introduction study in two urban centers, Cotonou and Parakou. The study determined that strong demand for the method existed; that the SDM could be offered effectively through existing service delivery channels; that there was a high degree of acceptability and continuation of use; and that the SDM could be used correctly and consistently. The government requested IRH?s help to expand delivery of the method nationwide, an effort that began in December 2004. As service sites multiplied, Benin participated in other international, multisite studies, including a long-term (up to two-year) follow up of users and a study to determine the impact of social marketing campaigns on SDM use, particularly comparing pharmacy and clinic-based services. There was no significant difference in correct use between clients who obtained the SDM through clinics and those who obtained it in pharmacies. The government has included the SDM in national reproductive health norms, policies, and training protocols and materials. The AWARENESS Project, in collaboration with local partners, trained more than 600 providers countrywide, recording more than 12,000 SDM acceptors between 2004 and 2007. The SDM is currently offered in more than 150 public, community, and commercial sites in all 12 departments of the country. An evaluation of the integration process after three years showed that the SDM is well integrated into the health system, and was offered in all visited clinics, where 57% of providers had been trained on the SDM. The Benin program serves as a demonstration site for neighboring francophone countries. (excerpt)

In 2003, the USAID Mission and the National Reproductive Health Program (PNSR) invited IRH to introduce the SDM in the Democratic Republic of Congo (DRC). The strategy focused on training providers and integrating the SDM into existing clinic, community, and pharmacy services in Kinshasa, Lubumbashi, and Bukavu, and the rural area of Katako Kombe. By 2004, 14 organizations were able to offer the SDM. CycleBeads are included in the national list of essential medicines and the five-year contraceptive security plan. The SDM is part of in-service family planning training curricula. The PNSR is developing national norms and protocols and intends to include the SDM. IRH also worked with the MOH to incorporate the SDM into national policies and logistics and reporting systems. However, the lack of overall government norms and functioning distribution and reporting systems is an obstacle requiring more comprehensive attention than the AWARENESS Project could offer. The program leveraged significant resources, as most partners paid for their own training programs and CycleBeads. The Congolese program participated in a study to determine the impact of the social marketing campaign, a general evaluation of SDM integration in the DRC. Major findings from the simulated client study showed that 89% of clinic providers gave spontaneous information on the SDM as opposed to only 38% of pharmacists; confidentiality was observed in over 70% of both clinics and pharmacies; 96% of providers in clinics told clients that CycleBeads represent a woman?s cycle while only 35% of pharmacists did so; and 7% of clinic providers attempted to convince clients to use other methods of family planning as opposed to 23% of pharmacists. The success of recent initiatives in DRC to introduce the TDM through services of an faith-based organization (FBO) suggest that this method may also be an appropriate addition to family planning services. (excerpt)

In the last 60 years, Slovakia has experienced comparatively high and most recently very low fertility, long periods of stable fertility alternating with periods of changes, periods of substantial as well as lesser state interventions. Fertility was above replacement in 1990 and declined to the lowest-low levels during the period of transformation. Postponement of life course transitions -leaving the parental home, marrying and becoming a parent -became widespread among younger cohorts after 1990. High unemployment of young adults, increasing economy-driven migration and problems to gain a stable job contribute to this phenomenon. Reproductive behavior is changing, yet Slovak society remains culturally conservative. The dominant form of partnership is marriage, although extra-marital childbearing is rising. Cohabitation is spreading mainly as a prelude to marriage but is not widely approved. Population measures have a long tradition, although 15 years after regime change their nature is very different than that of the state socialist era. Considerable attention was and is being paid to population problems, however, the government has not designed and implemented a comprehensive system of family and population policies. (author's)

Policies relating to contraceptive services (population, family planning and reproductive health policies) often receive weak or fluctuating levels of commitment from national policy elites in Southern countries, leading to slow policy evolution and undermining implementation. This is true of Kenya, despite the government's early progress in committing to population and reproductive health policies, and its success in implementing them during the 1980s. This key informant study on family planning policy in Kenya found that policy space contracted, and then began to expand, because of shifts in contextual factors, and because of the actions of different actors. Policy space contracted during the mid-1990s in the context of weakening prioritization of reproductive health in national and international policy agendas, undermining access to contraceptive services and contributing to the stalling of the country's fertility rates. However, during the mid-2000s, champions of family planning within the Kenyan Government bureaucracy played an important role in expanding the policy space through both public and hidden advocacy activities. The case study demonstrates that policy space analysis can provide useful insights into the dynamics of routine policy and programme evolution and the challenge of sustaining support for issues even after they have reached the policy agenda.

The use of contraception varies widely around the world, both in terms of total use and the types of methods used. In many countries, women and couples rely largely on one or two contraceptive methods, because of government policies, the way that national family planning programs have evolved, and cultural or social preferences (see box below). Understanding why people prefer some contraceptive methods over others can be useful for strengthening family planning programs. Having a broad range of methods available is a key element of the quality of family planning services and raises the overall level of contraceptive use. Family planning programs ideally should offer choices of methods for all stages of people's reproductive lives, so that they can have the number of children they want, when they want them. (excerpt)

This article deals with fertility concern in Russian and Finnish population policies. The article points out that some commonly known discourses are persistently used as arguments in fertility-related population policies. In Finland, these include, for instance, discourses on "ageing nation" and "economic competitiveness". Russian policymakers use a "crisis discourse" that consists of three sub-discourses: "demographic crisis", "reproductive health in crisis" and "family crisis". The Russian government implements pronatalist population policies, whereas Finnish authorities hesitate to use the term "population policy" because of its emphasis on reproductive rights on the one hand, and the negative associations of population policy on the other. Russia has both population and family programs, as well as a new law with a specifically pronatalist emphasis. Conversely, Finland uses family policy as a tool of population policy. (author's)

The use of contraception varies widely around the world, both in terms of total use and the types of methods used. In many countries, women and couples rely largely on one or two contraceptive methods, because of government policies, the way that national family planning programs have evolved, and cultural or social preferences (see box below). Understanding why people prefer some contraceptive methods over others can be useful for strengthening family planning programs. Having a broad range of methods available is a key element of the quality of family planning services and raises the overall level of contraceptive use. Family planning programs ideally should offer choices of methods for all stages of people's reproductive lives, so that they can have the number of children they want, when they want them.

The Departments of Reproductive Health and Research (RHR) and Making Pregnancy Safer (MPS) at the World Health Organization (WHO) have developed a series of guidelines and tools to promote evidence-based practices in sexual and reproductive health within programs. The guidance developed by WHO/RHR and WHO/MPS includes: norms, standards and protocols designed to inform the development and revision of national policies and standards; programmatic guides to inform the development of sexual and reproductive health programs; tools and clinical guides designed to be used by health-care providers in clinical setting, according to evidence-based norms. The guidance covers a range of themes, including maternal and neonatal health, family planning, prevention and control of reproductive tract infections and sexually transmitted infections (RTIs/STIs) and the prevention of unsafe abortion. The various documents are based on scientific evidence and have been developed by WHO/RHR and WHO/MPS as generic global materials that are not specific to any one national context. (excerpt)

This report presents the results of a survey of FY 2006 public expenditures for family planning client services, family planning education and outreach activities, sterilization services and abortion services. We look at expenditures nationally, for each state and for each funding source. We also compare FY 2006 data for family planning client services with those from a series of prior surveys between FY 1980 and FY 2001. As in past reports, we also look at data on abortion utilization; because of restrictive reporting requirements and other policies around abortion, it is the only of the services for which reasonable estimates of utilization are universally available. The data in this article represent the most complete summary of public funding available. Given the methodological concerns mentioned below, however, the data (along with data from prior surveys) should be considered an approximation, rather than a precise accounting. (excerpt)

In India, DELIVER worked in three states, namely Uttar Pradesh (UP), Uttaranchal, and Jharkhand, in northern India. However, many of the technical assistance activities during this report period were focused on UP and then on Uttaranchal. When DELIVER started working in UP, the largest state in India with 160 million people, contraceptive prevalence rate was barely 19 percent, and the entire public sector contraceptive logistics system was in disarray. Therefore, many of the interventions involved setting up systems, system streamlining, training, and system strengthening in working with local partners, such as the State Innovation in Family Planning Services Agency (SIFPSA) and the Indian Institute of Management, Lucknow. Since the Government of India (GOI) provides contraceptives to states through federal programs, the issue in UP was not having the funds or contraceptives, but of ordering an appropriate quantity of contraceptives, receiving them in timely manner through the federal government, and ensuring their delivery when needed. By 2005, the contraceptive prevalence rate in UP had risen to 29 percent. In working with the Ministry of Health and Family Welfare (MOHFW), DELIVER's interventions and strategies focused on developing awareness of and commitment to contraceptive security and institutionalizing and optimizing a logistics system. Contraceptive security work included assistance in developing a work plan and procurement policies, and streamlining and strengthening the public sector logistics system through training and development of the Supply Procedure Manual: An Instructional Manual for the Logistics People, the Storekeepers Manual, and a supervisory checklist. Setting up a logistics management information system (LMIS) and a logistics management cell (LMC) were part of the technical assistance strategy to build capacity. A primary thrust of technical assistance in India was using available local resources; however, continued support is needed in capacity building, system functioning, and monitoring and supervision as the program grows. (author's)

In April 2007, Mexico City's legislative assembly voted to liberalize abortion law to permit the interruption of pregnancy in the first trimester. The city is a federal district-similar to Washington, DC-and has a state-like autonomy. The law is in place only in Mexico City; Mexico's states still have restrictive abortion laws. The Council's research and collaboration with local nongovernmental organizations, universities, professional associations, and the Mexican government helped bring about this groundbreaking legislation. "The Population Council's research findings on abortion in Latin America have been used by government officials and women's rights advocacy groups to shape evidence-based policies, including the recent change in abortion law in Mexico City," says Sandra G. Garcia, the Council's director of reproductive health for Latin America and the Caribbean. In 2007, Garcia was honored as a recipient of the Guttmacher Institute's Darroch Award for Excellence in Sexual and Reproductive Health Research. She was cited for "research documenting abortion-related knowledge, attitudes, and practices in Mexico" that "played an important role in the...recent decision to legalize first-trimester abortion." (excerpt)

The impact of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA, or welfare reform) on the economic circumstances of women and children has received substantial research attention, but provisions of the act that attempt to influence women's reproductive behaviors have been much less studied. Provisions of PRWORA encouraged states to intensify efforts to restrict access to abortion and to decrease rates of nonmarital births, particularly among teenagers. Using state-level data, this study analyzes the effects of state policies enacted in the wake of welfare reform, controlling for prior rates of abortion and unwed births. The authors find that economic-based incentives have only minor, and inconsistent, influence on statewide rates of abortion and nonmarital births in 2000. Results are consistent with feminist scholarship proposing that noneconomic considerations are more central in women's decision making about reproduction than economic factors. (author's)

Information on abortion levels and trends can inform research and policies affecting maternal and reproductive health, but the incidence of legal abortion has not been assessed in nearly a decade. Statistics on legal abortions in 2003 were compiled for 60 countries in which the procedure is broadly legal, and trends were assessed where possible. Data sources included published and unpublished reports from official national reporting systems, questionnaires sent to government agencies and nationally representative population surveys. The completeness of country estimates was assessed by officials involved in data collection and by in-country and regional experts. In recent years, more countries experienced a decline in legal abortion rates than an increase, among those for which statistics are complete and trend data are available. The most dramatic declines were in Eastern Europe and Central Asia, where rates remained among the highest in the world. The highest estimated levels were in Armenia, Azerbaijan and Georgia, where surveys indicate that women will have close to three abortions each, on average, in their lifetimes. The U.S. abortion rate dropped by 8% between 1996 and 2003, but remained higher than rates in many Northern and Western European countries. Rates increased in the Netherlands and New Zealand. The official abortion rate declined by 21% over seven years in China, which accounted for a third of the world's legal abortions in 1996. Trends in the abortion rate differed across age-groups in some countries. The abortion rate varies widely across the countries in which legal abortion is generally available and has declined in many countries since the mid-1990s. (author's)

This guide is designed to help family planning champions-including civil society and NGOs, international and donor organizations, and interested government officials-and other stakeholders promote the inclusion of family planning issues and programs into Poverty Reduction Strategy Papers (PRSPs). Countries prepare PRSPs to qualify for loans and debt relief from the World Bank and International Monetary Fund (IMF). As a condition of receiving assistance, the PRSPs must outline the macroeconomic and social policies countries will adopt to alleviate poverty and, ultimately, accelerate progress toward meeting the Millennium Development Goals (MDGs). From the perspective of family planning advocates, the PRSPs can demonstrate the government's commitment to devise, fund, and implement family planning initiatives. From the perspective of governments and PRSP planners, satisfying unmet need for family planning is an innovative approach for reducing poverty that can help countries more easily achieve a range of socioeconomic goals. (excerpt)

Before the government instituted birth control policies, did Chinese families deliberately control birth and fertility? Some scholars believe that natural fertility was indeed a fact in Chinese population history; others argue that the Chinese controlled their fertility by such positive checks as late fertility onset, early stopping of reproduction, and long intervals between births. This article joins the debate by providing ethnographic data collected in Xiaoshan, Zhejiang, in 2002. The ethnographic case studies show that deliberate fertility limitation did exist in both rural and urban communities in Xiaoshan. In addition, the article challenges the assumption that Chinese fertility was shaped by collective control rather than individual interests. On the contrary, it demonstrates that the agency of individuals, particularly of women, was often the driving force in family reproduction. (author's)

This volume argues that the advent in many developing countries of population policies designed to reduce their population growth rates and make methods of family planning widely available constitutes one of the most extraordinary social and political change phenomena of the 20th century. To say that these changes were revolutionary is not hyperbole, and a case could be made that the events of the 1960s and 1970s rival other dramatic shifts in public policy in previous centuries, such as the public provision of safe water and sewage disposal. Within this overall context, few scholars or observers would have given much credence to the notion that Colombia, among the most conservative and religious countries in Latin America, would be the first nation on that continent to adopt an explicit population policy advocating a reduction in the population growth rate and the widespread availability of family planning methods, especially to the poor. Fortunately, the context, process, and sequence of events have been documented in a series of articles and books. This chapter, drawing heavily on the aforementioned works and supplemented by the authors' observations, attempts to summarize the extraordinary events that occurred in the 1960s and 1970s and draw lessons that could be applicable to similar issues currently and in the future. (excerpt)

Concerns since the mid-1980s have included issues of the growth of the labor force, the vibrancy of the work-force, and the country's ability to sustain economic growth in the face of persistent below-replacement-level fertility and population aging. A larger population is now considered desirable to provide the critical mass for future economic growth. Planners consider the constraint of geographic size to be less critical than in the past, because they believe that the country can comfortably accommodate a much larger population of more than 5 million people, compared with the 3 million thought desirable earlier. Cheung, however, cautions against too rapid population growth to reach the larger population size, citing the momentum generated by pro-natalist population policies and the difficulty of reversing them . Population planning has become a much more complex balancing act between the economy's needs for more and better qualified workers and such social and political considerations as the size of the dependent population and ethnic balance. (excerpt)