Elements of Successful Family Planning
Interview with Robert Blum
Interview conducted February 14, 2008 by Rose Reis and Heather Sanders
Rose Reis: Where are young people concentrated in the world?
RB: Well, most young people live in developing countries. 86% of all young people live in sub-Saharan Africa, in Asia and Latin America.
RR: Given all their other client needs and limited resources, why should family planning and reproductive health programs in developing countries invest in adolescent health services?
RB: To me that’s an easy question of why is investing in family planning and reproductive health so critical? First of all, we know that the outcomes for young people improve with every year that they delay pregnancy. Secondly, we know that the age of marriage is increasing in countries around the world. Thirdly, we know that education is becoming an increasing priority and pregnancy and education, in fact, don’t cohabitate very well. So what happens is if you become pregnant, you’re out of school. So family planning is in fact investing in human resources. It’s investing in young people to give them the space and time not only to develop and to mature, but to achieve education and to achieve the goals that will build a nation.
RR: Do you believe that there should be separate programs for adolescents or should they be integrated into existing family planning programs?
RB: I think that providers need to understand the needs of young people as being different from those of adults. That being said, it’s by and far very difficult in most settings to run separate family planning programs. So I don’t think that, per se, for them to work for youth that they need to be separate or isolated. They can be integrated.
RR: What is the best way to reach out to young people to generate demand for family planning services?
RB: I think in many places I would do a few things. One is I would work with the adults in the community. I would bring adults in and particularly those who shape opinions, I would build relationships with faith leaders, I would build relationships with academic, the teachers, as well as with parents, because they really remain important. Two, I would be very strategic to give very clear messages that family planning is not just about girls, it’s about boys as well. And that you create environments that are welcoming for males as well as females. And in part what that means is to think about staffing and the staffing patterns of the services as well—that it’s not just an all female staff.
RR: So what would it look like then in terms of a composition? Would there be a separate portions of the program for the adolescent boys?
RB: So I think the way it could look like is first of all, to me effective services aren’t just saying, “You come to me”. It’s also saying, “I will come to you”. So it could well be running groups in a school for boys as well as girls. It could well be giving presentations or running groups in a mosque or a church. It could well be doing activities in a community forum that involves and educates young people and then says we have services available. So that they understand that male and female are welcome to use these services. But I think it requires being proactive, it requires going outside the clinic facility, if you really want to engage young people where they’re at.
RR: They won’t come into the clinic?
RB: I think if your expectation is that you’re going to open a clinic and just sit there and wait for youth to come, they’re not going to. Let me tell you one story, because to me it reflects some of the barriers of getting into a clinic.
For many years, I ran a clinic in Minneapolis in the United States. We ran it among other times on a Saturday morning. It was downtown. It was on the second floor. There was a shop on the first floor. No sign anywhere, anywhere, that said it was family planning, because we didn’t want this to be stigmatized for kids. One Saturday morning a young woman came in for contraception and had some insipid opening line like “How’s it going?”
And she said, “You wouldn’t understand”.
I said, “Try me. You might be right, but try me.”
She said, “Well this morning you know I got up and I was sitting with my parents and my girlfriend, who’s out in the waiting room, she slept over last night. So my dad asked where we were going. And we said we we’re going downtown and we’re going to go shopping and he sort of looked at me like he knew. I think he knew that I was coming here. But he didn’t say anything. And then I went down to the bus stop and there were these people over separate from where I was and they were sort of looking at me and laughing. They knew—they knew, they knew that I was coming here for birth control. But I got on the bus anyways. So, the bus came but I didn’t get off right in front of the clinic.”
Now remember there wasn’t a sign anywhere that said this was a clinic. It was right downtown and there was a shop there.
She said, “I got off two stops further down.”
“Why?”
“‘Cause I didn’t want anyone to know where I was going.”
Well I don’t know if I laughed right at that moment or not, but I grew up in New York City. I grew up in a city, at that time had about 8 ½ million people. And many more times than once, I wouldn’t get off at the stop where I really wanted too; I got off at one or two stops further down because I was sure that all of New York City was watching me.
And she said, “Well I walked back and then I came up here. By the time I got up here, everyone knew.”
Well yeah, probably by the time she walked into a family planning clinic, everyone knew why she was in the family planning clinic. What didn’t dawn on her is that no one really cared. This was not a big deal for them.
I tell that story because for young people, whether in the United States or anywhere else in the world, there is this sense that “I’m transparent. That you, an adult, can look through me, and you know what I’m thinking. You can see inside of me. And so I feel extremely vulnerable. So am I just going to walk into your family planning clinic because you put up a big sign? Nuh-uh. No. Because it says too much to me about myself. Particularly if it’s taboo to be having sex and not be married. If I walk in that clinic I am announcing to myself as well as to the world that I’m sexually active. If I don’t come in, I don’t have to deal with it.”
So, what we need to do as providers is break down the barrier and a beautiful clinic doesn’t do it. A beautiful clinic, a clean clinic, providers who understand young people make a difference. There is a significant step. But we need to be proactive to meet kids where they are.
RR: You described some of the ways that adults can interact with kids to get them into these services. Do their peers help as well? What can their peers to generate demand?
RB: I think peers can be extremely helpful and can actually be extremely off-putting. But, when you look at the literature on peer education and the effect of peer education it’s not particularly encouraging. And the reason I think why it’s not particularly encouraging is that a lot of adults set up peer education programs because it’s cheap. Because kid labor doesn’t cost anything. We can recruit a group of young people and we’ll give them a curriculum and we’ll have them go out and do it. Low and behold those programs at the end of the day have no impact.
Some of them do. And what those that do, where they seem to work is that there is intense adult involvement with the peer educators. So the peer educators get a lot of adult support, adult guidance, they bring back situations that come up, they can be briefed, they get guidance and then they go back out. So it’s not cheap. To do it well it’s not cheap. It still requires adults to be heavily invested in the peer educators. That’s one thing
Two is that there is some evidence that when you look at peer education, those that are the greatest beneficiaries of peer education is the educators, not those that are recipients of education but those that are delivering the education. So, knowing that, you say, “Boy, maybe one of the things that we can do is recruit young people who are themselves most at risk for becoming pregnant and train them as peer educators.” Well you say, “Why on earth would we want to have those that who are most at risk as peer educators?” Well maybe because the process itself, of becoming peer educators, is protective. And there’s some evidence to say, “Hmm, you know what? It may very well be protective.” So that’s another thing.
The third thing, when I ran clinical services used young people, is that we would have young people in the clinic and they would be available to be with clients, and particularly new clients who came in. And they’d say, “You know, this is your first time here and you might feel a little awkward or a little scared. And what I can do is not only explain this situation for you, but if you want I can go into the exam room with you, I can sit there with you. And I can help make sure that you understand what’s going on and you understand what the physician (or nurse, or whoever else is the provider of care) is saying.” And, what we found is that peer interpreter, if you would, also was then, at the end of the encounter when the woman left, was to say to the provider “You know, let me give you a little bit of feedback of what I saw.” So this person was an educator, not just for the client but for the provider as well. And it was very powerful.
RR: Can you describe where you’ve seen this implemented?
RB: Where I’ve seen this?
RR: Which projects?
RB: What I’m describing is a project in Minnesota when I ran community-based family planning services.
RR: So you were a provider?
RB: For thirty years
RR: Wow. In terms of peer support, reporting back to a supervisor or getting training from a supervisor, that kind of collaboration, where do you see that in developing countries been successfully implemented?
RB: That’s a difficult question for me to answer because my work in developing countries has really not been around clinical service delivery and family planning. So, I’m just not exposed to very much of that.
RR: Well, you already addressed my next question which was should programs work with parents?
RB: Programs should have working-with-parents very high on their agenda for so many reasons. But the simplest is because parents are critical of the lives of young people and if you can bring parents on (as well as other adults) to understand the value of family planning you have a hugely increased likelihood of success and effect for a kid.
RR: How do you do that?
RB: Well, I think first of all, it is how do we as providers define our role? And I think many of us who really are impassioned about working with young people define our role as being a Kid Advocate. I defined my role very differently. I defined my role and I encouraged for 30 years all those people who I trained, to say your role, the best advocacy that you can do, is to be a bridge. Your role is to bridge between a kid and a parent, between a young person and whatever other adults or situations that they’re faced with. And because young people often don’t have others who can help them bridge. So in my experience, for example, it was the rare young person who was pregnant who didn’t want to speak with her mother particularly about the fact that she was pregnant. She didn’t want to be alone. There were exceptions of kids who were in abusive families and alcoholic families. But the majority of kids wanted to speak with their parents. I see part of a role of a provider to say “Let me help you do that. You don’t have to do it alone. I can help you. So, if you want I can invite your mother in. We’ll set up a time to come and sit down and meet.” To say what we’re about is making those connections.
Another strategy is to help parents understand early on, before their kids begin to have sex, that look you might not want your daughter or son to be sexually active at the age 14, 15, whatever, pick an age, before marriage. I understand that and I respect that. But wouldn’t you agree with me that you would rather that if she or he does, that they don’t wind up pregnant, that they don’t wind up with HIV, that they don’t wind up with STDs? So if you have any reason to believe that your son or daughter may be in a relationship, maybe you want to encourage them before they have sex to be thinking about this, because I think we could all agree that that would be the worst of outcomes if they wind up with HIV, or pregnant. So let’s think about this: how we want now to deal with it. So those to me are some of the kinds of things.
I think there’s another issue that many communities confront but perhaps not terribly well. And that is in many communities, in many environments, sexual abuse is not uncommon and sadly, I think it’s not even viewed as sexual abuse. There are communities where transition to womanhood at 16 means that someone will come and knock at your door and they will have sex with you on your 16th birthday. There are not uncommon situations where teachers take advantage of kids and other adults take advantage of kids. And I think that one of the things that communities, villages, townships, need to think through is how do we want to respond to those kind of situations? It’s one thing to say to our son or daughter “Don’t have sex until you’re married, you’re 20, you’re 50, fill in the blank.” But it’s a whole other thing to start saying in many other settings, 20, 30, 40 percent of young people tell us that they’ve been sexually abused. How do we want to respond to that? Do we want to turn an eye and say “This isn’t really an issue for us”? Do we want to say “Well, if you give us a goat, you’ve paid us back for the assault on our daughter?” or do you want to say “This is attempted murder”? In an environment where HIV is high, isn’t that really what we’re talking about? What are the standards? And so I think there are many ways of engaging parents and other adults in this conversation.
RR: You mentioned violence. Is that something, along with sex education or self-esteem, that programs should be incorporating into their programming along with reproductive health services?
RB: When we think about violence and sexual violence, there are few levels. One is yes, young people need to understand that if they have sex with someone, they are making a proactive decision. It is not just saying no here, but yes here. And that anything where I am not proactive in that decision in fact is victimization. So, that’s one thing. And to understand that if it is no, how so I protect myself? What are the things that I can do to minimize my risk of being sexually abused?
But having said that, that puts all the responsibility on the young person and the truth of the matter is a lot of these situations are environmentally, socially, condoned. And that’s the other level that really needs to be addressed. Is to what extent do we, as a society as a community, want to condone this type of behavior? Or do we want to say no, this is not how we choose to have our young people treated, and if we do what are the consequences of that for the perpetrator.
RR: Did you program address violence in the services?
RB: It is something that we always asked about and it was also something that we were always sensitive to. When I say we were sensitive to it, what we saw in clinical practice, and what we trained providers to be really conscious of, is that if a young person responds in an unusual way to a physical exam, that A. You stop, you stop what you’re doing and, B. You should have your antennae out and say “Is this response because of previous assault?” And that going through an exam may trigger that sense of assault as well.
But you’re better off stopping, pulling back and saying “Why don’t you get dressed and let’s talk about this? Because it doesn’t have to all be done today; we can set it up to come back tomorrow, next week.” A very important part is building that relationship because what you want is to have a young person who is engaged and comfortable and if a clinical encounter is a repeat assault, she’ll never be back, or he’ll never be back.
RR: That’s really interesting. What about self-esteem and sex-ed. Is that something that family planning programs should be providing? Pamphlets?
RB: So let me comment on self-esteem. It’s a wonderful thing and you can’t teach it. It doesn’t happen that way. You didn’t build your self-esteem because someone gave you a lecture about self-esteem, and I didn’t either. You build your self esteem by having experiences by having experiences and someone said, “You were terrific at that. That was really great and you were fabulous on the football field today. You did brilliantly in the play. You did fabulously on that exams. Congratulations.” It comes from parents that say [clapping] “Bravo. That was wonderful. We loved what you did.” That’s how you get self-esteem.
So if you say how do you build self-esteem in kids? Give them opportunities to do things that they’re able to do, watch them achieve and applaud loudly. That builds self-esteem.
There’s a very conservative program in the United States that is an abstinence-only program. And abstinence only programs are not very effective programs. The woman who runs this program is also a child development expert. She’s very smart and she’s also very rich. And what she does as a central part of her program is that she has a choir that these kids that are in this program participate in. And she finds the best band leader she can find. They’re not singing abstinence songs, they’re making music. And they meet two to three times a week and make music. And at the end of the year, she books out the Kennedy Center in Washington, this big amphitheater, and she invites their parents and grandparents and aunts and uncles, and then invites all the dignitaries in Washington and everyone else to hear the choir. Now on the side, she’s doing some sex education. But what she knows is that you want to engage kids, you want to engage families? Have them see their kids excel in something and stand back. Think about the self-esteem a kid would have standing at Kennedy Center on stage singing. You don’t learn that in a lecture. That’s excelling. I mean, that’s a grandiose example but it is something we can do in every town and village, we can think about ways of creating environments where kids can be confident and excel and be told: you were great. That builds self-esteem.
RR: What are some key challenges and barriers to providing adolescent health in family planning or other reproductive services in developing countries, and how can programs overcome these barriers?
RB: The barriers of providing family planning and reproductive health services in developing countries. There must be a ga-zillion barriers. One is that family planning isn’t on the radar screen in developing countries because it’s been trumped by HIV. So, HIV has sucked not only all of the air out of the conversation, but also all the money. So there are very few resources. That’s one.
Two is that we have too often a very linear very simplistic about what makes a difference in impacting sexual and reproductive health. Specifically, we say, “If we can put condoms in your hands,” [poof symbol with hands] “You got it.” Well, a condom in the hand doesn’t do much in terms of contraception. So then the question is why would I be motivated to use the condom, even if I have it? So simply marketing contraception makes a difference but it’s sort of like necessary but not sufficient. So then what we have to do, we have to understand where kids are coming from, we have to understand how they think about the world, we have to understand how they engage the world, we have to understand what their priorities are and we have to think about how do we then deliver our services within their context, within their development, within their understanding and not believe that “simply” (and I put simply in quotes because I understand that in many places it’s very far from simple) but making contraception available is often not sufficient to achieve utilization. So I think that kind of understanding isn’t there.
And I also think that all too often there is the arrogance of the service provider to say, “We have our training, we have our education, and we’re really committed, and we open our doors and we expect you to come.” But it generally doesn’t work that way. So I think that it requires affectively working with young people a bit more humility to say, “We’ll meet you on your turf,” and not just say we expect you to come to ours.
RR: What are some myths why the health providers aren’t giving reproductive health services to adolescents?
RB: Some of the myths. One is that they won’t speak to me if I ask them questions. Two is that they’re not interested anyway. Three is that they’re not having sex and if they are having sex they shouldn’t be and why is this my problem anyway? My experience repeatedly has been that young people really seek out and want adults. They’re afraid. They feel vulnerable. Seeing healthcare providers is a very threatening experience because you’re both psychologically and physically naked. And it is not a situation that most of us wildly and enthusiastically say “Woo-pi-doo, let’s put ourselves in that position.” So there’s a natural reluctance and as providers we often misinterpret that natural reluctance as hostility or indifference. When I encountered kids who were very off-putting, very aggressive, very belligerent I would stop and I would say “Time out a second. What’s going on here? Am I wrong? But I was under the impression that you came here because you wanted to be here; that no one dragged you here; that you came because you wanted to be here. And you seem very angry and upset now. Is it something that I’ve said; is it something that I’ve done; is there something else going on? Because for us to keep going makes no sense. So let’s back up.”
A mentor of mine once said, “when progress fails think of process.” And by that he meant when you have a clinical plan of what you want to do and it’s not working, stop—take a step back and say what’s going on and why isn’t it working?
RR: Some programs emphasize “abstinence only” as the only completely reliable method to avoid pregnancy. This is not a viable strategy for married adolescents. So could you talk about where they fit into the picture and how programs can ensure that they’re not excluded?
RB: Ok now, say the question in English. What are you asking?
RR: Where do married adolescents fit into family planning services? Can you basically talk about developing country context?
RB: I think that one issue that providers need to wrestle with and come to terms and the clinic and institution that is providing the services, need to think through is: Do married women of any age have the right on their own to make these decisions? And most people would argue yes, that this is a woman’s prerogative to make that decision. So then the message, whether you’re married or not, is that you are in control of your body. You are in control of your reproductive future. And what we can do is provide you the tools to be in control of your body. If you choose not to use them, that’s your choice. But make it a choice. Make it a deliberate. Much like we were talking about earlier for unmarried adolescents: If you are going to have sex, make it your choice to have sex and not something that happened to you. Make it your choice to become pregnant and not something that just happened to you. Now while my values may be to have a family size of X and yours is a family size of Y, that’s fine. Make it your choice. And that to me is the message for married adolescents.
And we also know that in many countries of the world, there is a sizable age difference between the husband and the adolescent wife. And her risks for example of HIV/AIDS and for STDs are substantially higher. So it’s one thing to try to get a husband to use condoms, which in many settings is probably not going to fly very well. And then we need to think of building in other kinds of barrier contraception that might help young adolescent married woman not only avoid pregnancy when she wants to avoid pregnancy, but reduce her risk of STDs and HIV.
RR: How do you get married adolescents to come to clinics?
RB: Beats me. Never done it. So I can talk from neither the literature nor experience.
RR: Often times, I think that they’re encouraged not to seek any family planning services, until at least they have a baby.
RB: I think this is where elders in the community, in truth. Not having ever done it, I would look to the elders in the community, the older women. To say “can we build, in a village in a community, a group of senior women who are respected and who might then become the ones to reach married adolescents? Or as part of their prenuptial conversations? And in many societies that occurs. There are these discussions between older women and younger women to reach them. At times, older women are very instrumental around the time of menstruation and that’s another opportunity. I think I would probably try to connect with them as a strategy.
RR: Interesting answer. Would you like to make any other comments about anything we’ve touched upon?
RB: No, I’ve talked about more things than I don’t know anything about. Anything more will get me in trouble.
