PRB

More than 1.4 billion people around the world live in extreme poverty (defined as income of less than US$1.25 per day), and nearly 2 billion more live just above that level. The world’s poor not only lack household assets and income, but also suffer from malnutrition and poor health, hindering their economic opportunities and perpetuating the cycle of poverty.

The international community is committed to eliminating extreme poverty worldwide—the first of the eight Millennium Development Goals (MDGs) adopted by world leaders in 2000.¹ Reducing extreme poverty is seen as necessary not only for humanitarian reasons, but also because, as President Barack Obama stated at a recent United Nations conference on the MDGs, “In our global economy, progress in even the poorest countries can advance the prosperity and security of people far beyond their borders.”²

But decades of international assistance and programs costing billions of dollars have not eliminated poverty. It remains endemic in much of sub-Saharan Africa, where more than one-half of the population lives in extreme poverty. Even countries that have enjoyed considerable economic growth in South Asia and Latin America have large urban poor populations and pockets of abject poverty in many rural areas. In addition, the recent global economic crisis is expected to push another 64 million people into extreme poverty.³

Why have antipoverty programs failed? The reasons differ, but include such factors as corruption, civil conflicts, misguided policies, lack of follow-up, and insufficient aid. But there is growing agreement that many programs failed because they did not effectively engage the people they were trying to help. Without understanding the extent and causes of poverty within a community and without involving community actors, efforts were often wasted. Programs that involve the target populations from the outset offer greater hope of finding ways to lift people out of poverty and keep them from slipping back.

National governments and private organizations are seeking new approaches to fighting poverty that avoid the failings of previous programs. Some recent efforts that have focused on ways to fully engage the poor in poverty reduction have emphasized increasing access to family planning and reproductive health services.

Focus on Family Planning and Reproductive Health

In most countries, women from poor households are less likely to use family planning services than wealthier women, even when poor women want to delay or avoid pregnancy. About one-third of women in the poorest fifth of developing-country households worldwide have an unmet need for family planning—they did not want to get pregnant but were not using family planning methods. This is more than double the percentage of women in the richest fifth of households who have an unmet need. Improving access to high-quality family planning services among the poor is essential to eliminating this discrepancy and improving health equity.

Providing family planning services is also highly cost-effective, making it a logical starting point for poverty reduction. For a relatively modest investment, family planning can enhance maternal and child health, and even save women’s lives.⁴ It also serves as a gateway to the use of other health services. Nearly every woman will need maternal and reproductive health services, including family planning, at some point, and the experience will connect her with the broader health system, sometimes for the first time.⁵ She will be more likely to use health services in the future, and because women usually are the guardians of health for their families, they will be more likely to seek health care for their children. For example, the landmark Family Planning and Maternal Child Health (FPMCH) program in Matlab, Bangladesh, found that children who lived in villages with these integrated health services were more likely than those in other villages to have received all their basic vaccinations against childhood diseases.⁶

Expanding access to family planning can also lead to smaller families and slower population growth. Families, communities, and countries in the developing world are better able to meet the educational, health, and employment needs of young people when the population is growing at a moderate pace.

Link Between Poverty and High Fertility

Decades of surveys have documented the association between poverty and high fertility, and underscore the importance of expanding family planning services in poor communities. Women from poorer households have more children than women from wealthier households. In a study of 56 surveys from around the world, the poorest women had about twice as many children, on average, as the wealthiest women. While poor women often desire a larger family than wealthier women, they typically have more children than they wanted or intended to have. Poor women often begin childbearing at a young age and have more closely spaced pregnancies. High fertility, young childbearing, and short pregnancy intervals tend to be associated with poor child and maternal health, lower educational attainment, lack of economic opportunities, and restricted social mobility.⁷

The evaluation of the FPMCH program in Bangladesh found that, after 20 years, families living in villages with expanded family planning services had lower fertility and had prospered much more than families in villages with routine health services, where fertility remained higher. The smaller families had higher incomes and more savings.⁸ Youth in the lower-fertility villages had also completed more education, key for earning higher incomes as adults.

Preventing Risky or Unwanted Pregnancies

With low contraceptive use and high unmet need for family planning, the poor are at a much higher risk of unintended pregnancies and, consequently, for unsafe abortion. Nearly one-half of women with an unplanned pregnancy choose to terminate it—too often under unsafe conditions or performed by unskilled personnel.⁹ About 70,000 women die each year from complications of unsafe abortion, and many more experience long-term health consequences. Meeting unmet need for family planning saves lives by preventing unwanted pregnancies and promotes economic advancement by reducing family size.

Identifying Barriers to Family Planning Use

Expanding family planning and reproductive health (FP/RH) services among the poor requires identifying the major barriers to their use and finding ways to overcome them. The USAID Health Policy Initiative—a project to create an environment that enables broader use of FP/RH services in selected developing countries—used several strategies to find and surmount these obstacles.¹⁰ HPI staff convened focus groups to learn about specific experiences, attitudes, and beliefs among the poor, and met with organizations that represented or included the poor, such as local governments, labor associations, and business groups. They also sought input from people who serve poor communities, such as family planning program staff.

Women living in poor communities tend to have less access to family planning services, but even those who do have access are often reluctant to use services. They may perceive religious opposition or disapproval on the part of their husbands or other family members, or have unfounded fears of contraceptive side-effects. For example, a Kenyan woman from a poor district explained that she did not use family planning because she had heard that contraceptives could produce continuous headaches and backaches—and that women who became pregnant while using contraceptives might deliver a baby with two heads.¹¹ While it is important to educate women about contraceptive methods and the potential for certain side effects to occur, family planning staff reported that women’s fears were best allayed by getting to know other women who had used family planning.

The actual or perceived opposition of husbands is an often-cited barrier to contraceptive use, but this can sometimes be overcome if spouses are taught to better communicate with each other about family planning issues, and by involving husbands in educational outreach about the benefits of family planning and birth spacing.

In some areas, language is a barrier because the clinic staff does not speak the local dialect. In other cases, women find the clinics unwelcoming and feel uncomfortable visiting them. In a poor indigenous community of Guatemala, women said they felt discriminated against by the nonindigenous medical staff.¹² In such cases, facilities may need restructuring to afford greater privacy or staff retained to treat all clients with dignity and respect.

In some cultures, women may not have the freedom to travel alone or without a male companion. In these communities, programs are more successful if staff can provide services to people in their homes. Inconvenient clinic hours or other logistical and financial constraints often hinder women’s access to family planning services. By asking the potential clients why they do not use family planning, and by discussing potential solutions with community leaders, program staff can craft appropriate strategies for reaching more people, particularly the poorest.

This global dissemination effort is the first of a series supported by PRB’s IDEA project, funded by USAID’s Bureau for Global Health.

Mary Mederios Kent is senior demographic writer at the Population Reference Bureau.

References

1. United Nations, “2015 Millennium Development Goals: Goal 1: Eradicate Extreme Poverty and Hunger,” accessed at www.un.org/millenniumgoals/pdf/MDG_FS_1_EN.pdf, on Sept. 28, 2010.
2. “Developing Countries Must Fend for Themselves,” The Statesman (India), Sept. 23, 2010.
3. USAID|Health Policy Initiative, Task Order 1, The EQUITY Framework: Influencing Policy and Financing Reforms to Increase Family Planning Access for the Poor in Kenya (Washington, DC: Futures Group, USAID|Health Policy Initiative, Task Order 1, 2010).
4. Rhonda Smith et al., Family Planning Saves Lives, 4th ed. (Washington, DC: Population Reference Bureau, 2009), accessed at www.prb.org/pdf09/familyplanningsaveslives.pdf, on Sept. 29, 2010; and Susheela Singh et al., Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health (New York: Guttmacher Institute and UNFPA, 2009).
5. Singh et al., Adding It Up.
6. James Gribble and Maj-Lis Voss, Family Planning and Economic Well-Being: New Evidence From Bangladesh (Washington, DC: Population Reference Bureau, 2009), accessed at www.prb.org/pdf09/fp-econ-bangladesh.pdf, on Sept. 29, 2010.
7. Imelda Zosa-Feranil, Cynthia P. Green, and Laurette Cucuzza, Engaging the Poor on Family Planning as a Poverty Reduction Strategy (Washington, DC: Futures Group, USAID|Health Policy Initiative, Task Order 1, 2009).
8. Gribble and Voss, Family Planning and Economic Well-Being.
9. Susheela Singh et al., Abortion Worldwide: A Decade of Uneven Progress (New York: Guttmacher Institute, 2009).
10. USAID|Health Policy Initiative, “Overview,” accessed at www.healthpolicyinitiative.com, on Oct. 13, 2010.
11. USAID|Health Policy Initiative, Task Order 1.
12. Sara Netzer and Liz Mallas, Increasing Access to Family Planning Among Indigenous Groups in Guatemala (Washington, DC: USAID|Health Policy Initiative, 2008).