Andrew Mitchell, UK Secretary of State for International Development (far right), and Melinda Gates attend the London Summit on Family Planning, July 11, 2012 (Gates Foundation/Flickr).
In late 2012, the United Nations Population Fund’s (UNFPA) State of the World Population report sparked controversy in a number of circles by re-affirming that family planning and access to contraceptives are not only human rights, but also policy tools to improve women’s reproductive and economic health. While critics claim that increasing family planning places reproductive rights over religious liberties, others argue the potential impact of such policies at the ground level is too powerful to ignore. To gain a better appreciation for its challenges and benefits, Vanessa Humphries spoke to family planning experts working to increase its implementation and uptake across Africa.
According to the World Health Organization, family planning allows for individuals to control the spacing and timing of births, and to attain their desired number of children. In the short-term this can create the potential for lower maternal and infant mortality rates through fewer unintended pregnancies, and also reduce HIV/AIDS transmission, unsafe abortion practices, and enhance education and employment opportunities for women. According to the Gates Foundation, over the long-term family planning policies lead to reduced pressure on natural resources, improved national economic growth and enhanced status for women.
Because of its far-reaching potential, providing the means to reduce unwanted pregnancy is cited as one of the most cost-effective health policy interventions that currently exists. As Dr. John Nduba, Director of Reproductive and Child Health at the African Medical & Research Foundation (AMREF) states, “family planning could almost be viewed as a vaccine for the improvement of maternal health.”
In many African countries, however, the implementation of family planning policies is challenged by social and cultural barriers that surround the acceptance of contraceptive methods. Dr. Akinyele Dairo, Sexual and Reproductive Health Senior Program Advisor at UNFPA says that this is due to misconceptions about family planning in some cultural traditions. “You can have a full supply of contraceptives,” he explains, “but without awareness and acceptance, they will expire before people come to use them.” In response, Dairo and UNPFA are working to improve how the benefits of family planning services are communicated to policy makers and populations. This includes the involvement of high-level stakeholders such as parliamentarians and religious leaders, but also mass media awareness campaigns on radio and television.
Ute Stallmeister, spokesperson for the German Foundation for World Population (DSW), also emphasizes the importance of involving traditional and religious leaders. Without including these individuals, Stallmeister says, target groups such as the young and unmarried will not feel comfortable, or be able to access family planning services. Nduba re-iterates the challenge facing young single women; across sub-Saharan Africa, 40 percent of unmarried 15 to 19 year old females do not have access to family planning (compared to 22 percent among those married in the same age group), and annually, about half of their 7.9 million pregnancies are unintended.
Another critical issue facing family planning – even after policies have been accepted in a nation or community – is that supply systems are weak and contraceptive supplies go out of stock due to poor procurement and distribution procedures. Jane Hutchings, Global Program Leader on Reproductive Health at PATH explains that contraceptive injections, a method in high demand where family planning programs exist in Africa, are often unavailable. “If a woman goes and expects to find an injection, but it is not available, she could be advised to use the pill or condoms, but this may not suite her life, and then she may walk away with nothing, which could end up in an unplanned pregnancy.” To further explore the health impacts of contraceptive availability, PATH is involved in with the Reproductive Health Supplies Coalition, which aims to help to address challenges of supply chain weaknesses in the future.
In order for African countries to maintain their current growth trajectory, Dr. Akinyele Dairo explains, the continent needs to change its population structure
A related challenge to contraceptive availability is stocking products in clinics that can facilitate access to a variety of birth control methods. Depending on the contraceptive chosen – longer term methods such as an intrauterine device can last for years, whereas oral or injectable contraception necessitate clinical visits every few months – there are different challenges to accessibility. As Hutchings notes, “with shorter term contraception, it’s four times a year where a woman has to get to a place where those methods are provided, which can be very difficult depending on when the clinic is open and where it is located.” Hutchings explains that another concern is that health care has been compartmentalized in many African countries, meaning women have to go to different clinics for maternal health, family planning and their children’s check-ups.
To lessen the accessibility problem, Hutchings suggests integrating health services from a consumer perspective. When supplies are restricted to health centres, she says, it makes access even more of a challenge. To this end, PATH is working on projects that train community health workers to supply certain contraceptives, which allow stockpiles to exist at a smaller community level.
Another important determinant of successful family planning services is the level of education attained by girls and women. Nduba points to the link between education and acceptance of contraception, citing the KDHS 2008-9, which suggests that 60 percent of married women with at least secondary education use a modern contraceptive method, compared to 40 percent of women with incomplete primary education and 14 percent who never attended school. To address this, Nduba stresses that investment in education of girls to the secondary level would compliment concurrent family planning policies.
Despite the practical issues facing family planning on the ground, however, one of the higher-order challenges has been getting the issue on the policy agenda of African countries with competing health priorities. According to Dairo, the most effective approach with policy makers is to emphasize the economic benefits of family planning. In order for African countries to maintain their current growth trajectory, he explains, the continent needs to change its population structure. Currently it is very youthful (particularly in age groups under 15), causing high levels of dependency on those who are of working age and leading to decreased potential for stable economic growth.
Additionally, there is also the lost economic productivity that comes from unplanned pregnancy and unsafe abortions practices; these not only strain the health system and contribute to maternal mortality, but deny women continual employment and education opportunities. “When we package all of these things to a policy maker,” explains Dairo, “family planning becomes more attractive.”
The most effective action with regard to policy makers, according to Hutchings, is to have a government-spoken commitment to family planning at the highest levels of government. With a well articulated and repeated commitment to family planning from the top, she argues, targeted policies focused on the most pressing needs will cascade.
Malawi, Rwanda and Ethiopia, for example, have greatly improved their family planning uptake in the past 10 years. Dairo explains that the similarity between these countries is a high level of political commitment, where the government invests in family planning and communicates its importance to their people.
Despite the challenges, experts acknowledge there have been some major successes increasing awareness around the importance of family planning services in Africa. Nduba cites the third International Women’s Conference held in Nairobi (1985) and the International Conference on Population and Development (1994) as improving consciousness surrounding the right of women in Africa to regulate their own fertility. “These events created the platforms on which major programmes promoting family planning in basic health service on the continent were built,” he says.
Dairo points to the successes of the African Union to date, citing the Continental Sexual and Reproductive Health Policy (January 2006) as a strong step forward in explaining the benefits of family planning to policy makers. Additionally, the Africa Union pushed for the Campaign for Accelerated Reduction of Maternal Mortality in Africa in 2009, which has now been adopted by 37 countries.
Furthermore, in July 2012 the Bill and Melinda Gates Foundation, United Kingdom government and UNFPA launched the Family Planning Summit in London. The event’s aim was to mobilize global policy, financing, commodity and service delivery commitments for family planning services in developing countries, and ended up mobilizing financial commitments totaling $2.6 billion (USD).
Despite its detractors, the UNFPA report and increased momentum for family planning policies will make it more difficult for African policy makers to waffle on issues of contraceptive funding, programming and budgeting. There are, as discussed above, a number of challenges ahead before family planning can reach its policy potential, and is enforced as a human right. Dairo puts it best: “We will know when family planning is confirmed as a human right, when every woman and man know that they are able to use family planning services when they need them, so if anyone prevents them from using them, including the government, community, or individuals, it is a violation of their human right.”
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