Overcoming barriers: what has been done, and what is being done?

What has been done?

During the 1960-1994 ‘Reproductive revolution’, the average worldwide fertility rate fell from 6 children to 3, marking a 50 percent decline. Also during this time, contraceptive prevalence rose from the initial levels of 10% to the current 60% level. The decline in fertility recorded has been largely attributed to public policies that have increased access to contraception, in fact one analysis has estimated that at least 50% of the decline is due to the rise in family planning programs.

So, how did this happen?

Access to contraceptives was provided around the world through family planning programs. Success in these programs began in Asia, and soon spread around the developing world, reaching Africa, South America and South Asia. This post will touch on two programs implemented in Indonesia and Ghana, respectively, that were successful and used as a basis for other such programs internationally.

Indonesia

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International organisations first turned their attention to Indonesia in 1956, where the U.S. Agency for International Development funded the training of several Indonesian doctors in family planning in New York. The goal was that these doctors would return to Indonesia to work in clinics that provided contraceptive services. However, the President at that time refused to allocate government funding for that program.

This soon changed when the country experienced a change in government. The government that came to power became interested in the provision of contraceptives and family planning. In 1966, the Indonesian branch of the Planned Parenthood Association, along with government, established The Jakarta Pilot Project, the first government-funded family planning program. To combat the moral and religious reticence that surrounds contraception, their first act was to compile and publish a pamphlet on the ‘Views of Religions on Family Planning’. This document included the general acceptance of the principles of contraception by the religions of: Islam, Protestantism, Catholicism, and Balinese Hinduism. This pamphlet resulted in a turn in public opinion around the morality of birth control, from strongly negative to strongly positive and was strongly accredited for the success of the project.

After the success of the Jakarta project, in 1967 and 1968, the regime initiated a national family planning program. The Indonesian Planned Parenthood Association transferred its already existing clinics to the National Family Planning Coordinating Board (NFPCB) and the number of field workers increased to 6000.
This family program was one of the most effective melding of government and society in Southeast Asia. Its success was in part due to the participation and support of social institutions that are traditionally not involved in family planning (opposed to it in many other countries). Such organisations included; religious groups, manufacturing establishments, cultural troupes, and youth groups.

Contraceptive use has become an accepted practice among almost all political, religious, and social groups in Indonesia. In fact during the 1997 Asian financial crisis, the program was not affected at all, something that is usually the first to be cut.

Ghana

Another example of how access to contraceptive services can be successfully provided can be seen in Ghana.

In 1967, the Ghana branch of the Planned Parenthood Association began to lobby the Ghanaian government for a national family planning policy. This proved effective where later on in that year, the Ghana was the first African country to sign the World Leaders’ Declaration on Population.

Two years later in 1969, the government published its policy paper ‘Population Planning for National Progress’. This document received widespread international acclaim and approval for its comprehensiveness.

Part of the policy included that the government would undertake programs that not only provided services to space or limit their reproduction, but to also provide information and advice.  

It provided contraceptives for distribution to three groups: government hospitals and health centres; private family planning clinics; and outlets of the Ghana National Trading Corporation, a retail network.

This program proved successful by decreasing the average birthrate from 7.0 births per woman in 1970 to 4.4 by 1998. Its success was suggested to be because of 4 things:

  1. they acknowledged that contraception was more than a health service, and should not be run by the Ministry of Health
  2. even though the program aimed to provide information as well as services, the government was perceived as providing a service rather than placing moral pressure on the population.
  3. they did not depict contraception as a national duty.
  4. they withdrew media advertising, which prevented resistance from the community that argued that providing contraceptive services encourages sexuality and promiscuity.

Indonesia and Ghana are only two examples of success stories from around the world. Other successes have been seen in Latin America and in south Asia.

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What are we doing now?

Currently, there are many programs and initiatives that work towards providing access to contraceptive services worldwide. Generally, these aim to achieve international target of universal access to reproductive and sexual health care services by 2030. They include; aiding developing countries with the implementation of programs that provide contraceptive services, increasing awareness of contraception and associated issues and involving more than just the women in family planning decisions.

One of these initiatives is Family Planning 2020, a partnership formed during the 2012 London summit on Family Planning, consisting of over 40 countries. It aims to have 120 million more women in the 69 of the world’s poorest countries be able to have contraceptive access by 2030 3. The organisation works with multiple stakeholders such as governments, civil society, multilateral organisations, the private sector and the research and development community to achieve this.

 

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Like most initiatives, Family Planning 2020 provide
s country level support for the implementation and support of programs that expand access and use of contraceptive services. It helps to spread knowledge and evidence about these methods as well as helps advocate for a rights-based approach to contraception for women and girls. In addition, it also monitors and tracks the progress towards these aims by collecting data.

 

Since the 1980s, male cooperation has been regarded as a key strategy in expanding the access and use of contraceptive services. As a result, some programs have focused on promoting male involvement in contraceptive use and family programs. For example, in Ethiopia several media campaigns have been undertaken to involve males in contraceptive and family planning decisions as well as providing more male oriented methods of contraception.

In addition, male interventions have also been used to increase contraceptive acceptance by their female partners. For example, a strategy was recently used in rural Vietnam, aimed to increase acceptance of IUD by Vietnamese women by targeting men in a health education campaign to increase male participation in reproductive decisions.  

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World Contraception Day (WCD) is an campaign that occurs worldwide every year on the 26th of September. It aims to raise awareness of contraception and the different types of methods that are available, as well as highlight the great number of women who do not have access to it.

 

This initiative is aimed especially at younger women, providing information about the different contraceptive methods available, so that they can make informed reproductive choices.

The WCD initiative is very prevalent on social media, allowing them to utilise the most effective channels to communicate their message to younger women. It also allows women from all over the world to share their story, raising awareness of the problems women still face regarding contraception in the developed world.

If we are already doing these things, why do we need more?

Though these programs and initiatives are helping to address the lack of access to contraceptive services, more still needs to be done if the goal of universal access to reproductive and sexual health care services including contraception by 2030 is to be reached.

Two targets, set by different organisations, regarding contraceptive access, have already failed to have been met.  

The first, was the original Millennium Development Goal to improve maternal health. In addition, the Programme of Action on Population and Development, developed in 1994, recommended that all countries seek to provide universal access to a family-planning methods by the year 2015, also fell short. In fact, only nine countries, including Vietnam, Cambodia and Honduras, reduced unmet need by at least 50 per cent (a minimal benchmarks) from 1994 levels.

Currently, one in ten women in developing countries have an unmet need for contraception. This number is projected to change little between the present and 2030. In fact, the percentage of women who have access to contraception is projected to decrease in Eastern Africa, from 24% to 18% between now and 2030.

Despite renewed calls and increased donations, contraceptive access has fallen on the list of developmental priorities. Complacency will result in a failure to reach universal access by 2030, and the health and social outcomes for women worldwide will suffer as a result.


References:

  1. Bongaarts J, Mauldin W, Phillips J. The Demographic Impact of Family Planning Programs. Stud Fam Plan. 1990;21(6):299–310.
  2. Robinson WC, Ross JA, editors. The Global Family Planning Revolution: Three Decades of Population Policies and Programs. Washington DC: The World Bank; 2007
  3. Family Planning 2020 (UK). About FP2020 [Internet]. London, UK: Family planning 2020; 2017 [cited 2017 Feb 20]. Available from: http://www.familyplanning2020.org/about
  4. Sterberg P, Hubley J. Evaluating men’s involvement as a strategy in sexual and reproductive health promotion. Health Promot Int. 2004;19(3):389-96.
  5. Greene ME, Mehta M, Pulerwitz J, Wulf D, Bankole A, Singh S. Involving Men in Reproductive Health: Contributions to Development. Geneva: Millennium Project; 2016.
  6. World Contraception Day. About [Internet ]. WHO [cited 2017 Feb 20]. Available from: https://www.your-life.com/en/for-doctors-parents-etc/about-wcd/
  7. Trends in Contraceptive Use Worldwide 2015 [Internet]. New York: United Nations; 2011 [cited 2017 Feb 20].
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