PRB

(June 2009) Family planning saves the lives of millions of women and infants every year in developing countries. But it could save many more. Family planning could prevent up to one-third of all maternal deaths by allowing women to delay motherhood, space births, avoid unintended pregnancies and unsafely performed abortions, and stop childbearing when women have reached their desired family size.

During a PRB Discuss Online, James Gribble, vice president of International Programs at PRB, and Rhonda Smith, associate vice president of International Programs, answered participants’ questions about how family planning saves lives and improves health for women and children. Gribble and Smith are co-authors of the newest edition of Family Planning Saves Lives.

May 28, 2009 1 PM EST

Transcript of Questions and Answers

Issa Almasarweh: Hello James, Why in many countries (Jordan for instance) little attention is given to follow-up postpartum women for immediate FP counseling and use of contraception before early conception occurs?
James Gribble: Hi Issa. You have asked an interesting question. While many programs promote post-partum family planning, so often the attention shifts from the woman to the child during that time frame. Mothers may be likely to bring their children in for immunizations and well-child care, but less likely to return for post-partum care for themselves. To help avoid closely spaced pregnancies, programs should encourage women to return for postpartum care for their own health and to raise attention about family planning. However, they should also incorporate messages about family planning into antenatal care so that women have a clearer idea of what they will do to avoid a closely spaced, unplanned pregnancy. According to the website of the “Maximizing Access and Quality Initiative”, very few women (3%-8%) want another child within two years after giving birth; and 40 percent of women in the first year postpartum intend to use a FP method but are not doing so. What a missed opportunity! Tale a look at the data from Jordan to see what is happening—I wouldn’t be surprised if there are a lot of postpartum women who are not using family planning and who are not ready to get pregnant again.

Esther Nakkazi: I recently read about contraceptive security in Rwanda and my sense is that the country has achieved so much i wonder what has enabled them succeed? I would like to write a piece on male involvement in Family planning. Do you have any success stories in Africa?
James Gribble: Hi Esther. In recent years, Rwanda has made some incredible advances in family planning. According to DHS, use of modern family planning methods has increased from 4 percent in 2000 to 27 percent in 2008. A number of factors are attributed to this incredible growth:

• Government commitment to family planning was especially important to getting things going. The President and members of parliamentarians recognized the importance of addressing rapid population growth and supported policies that would foster family planning. Addressing population growth was also incorporated into Rwanda’s poverty reduction strategy, establishing ambitious goals for to address population.

• Coordination among donors and partners also helped in leading to a common set of objectives. The government began to support the purchase of contraceptive commodities and created a line item for contraceptives in the national budget. Services improved through in-service and pre-service training, which contributed to a larger number of family planning providers.

• Performance-based contracts were also put in place as a way to motivate better performance at health facilities. Under this type of program, facilities receive payment based on achieving key targets, such as percentage of women counseled on family planning; percentage of deliveries in health centers; percentage of children under age five sleeping under insecticide-treated bednets.

• In addition to these factors that affect the availability of family planning, efforts to increase the demand for modern methods have contributed to contraceptive uptake. Messages related to responsible parenthood, good health and family development, and the economic benefits of smaller families have been effective in generating demand for birth spacing among Rwandans.

Regarding successes in male involvement in family planning, there have been a number of successful programs that have addressed male involvement in different aspects of reproductive health:

• The Male Motivation Campaign, implemented in Guinea, with the objective of reducing unintended pregnancy;

• The Men in Maternity Care, implemented in South Africa, with the objective of involving men in antenatal care; and

• Stepping Stones and Sonke Gender Justice are programs in South Africa that involve men in HIV prevention.

Agunbiade Ojo: How do we address the problem of distorted knowledge on the benefits and risk associated with the use of contraceptives in sub-Saharan Africa?
Rhonda Smith: Dear Agunbiade Ojo, I’m so glad you brought up this important topic! Having lived and worked in several sub-Saharan Africa countries over the years, I am very concerned about seeing so many of the same perceived risks, myths, and misunderstandings about contraceptives persist over the decades. There are several issues here: (1) understanding the potential benefits and risks of using contraceptives versus pregnancy; (2) the problem of a distorted fear of side effects; and (3) negative rumors and myths associated with contraceptive use that are unfounded. Over the last decade, family planning in many sub-Saharan African countries has lost focus and resources amid shifts in development priorities. One casualty of reduced resources has been fewer (or less vigorous) information and education programs to inform the public and address misinformation about contraceptives. Revitalizing these programs, with a special emphasis on messages that directly counter rumors and accurately convey the potential benefits and risks of contraceptive use to the health of women and children could help. There is also evidence that women and their partners may be less knowledgeable and harbor more misinformation about long-term methods (IUD, implants) than short-term methods (condoms, oral and injectable contraceptives). Unlike short-term methods, there has not been as much marketing support for IUDs and implants to counterbalance negative myths. Information efforts need to include comprehensive provider counseling programs that aim to counter misinformation during client visits, and more innovative ways of communicating the facts about contraceptives in general. Engaging well known champions who can discuss their own experiences with selected contraceptives and serve as local models is one approach that has worked in the past. Another may be to develop a compelling presentation or street theater show devoted to this topic that can serve as a point of discussion from national to village level, providing accurate information on different contraceptive methods and correcting the myths and rumors. It would be interesting to hear how others are addressing this issue! Rhonda Smith

Michael Vlassoff: Yes, family planning saves lives, but so do many other health interventions. What has been lost from the debate is the other main benefit of family planning, namely how it helps speed up economic growth and reduce poverty. No other purely health intervention can claim this added “demographic bonus”. Promotion of family planning from the economic growth angle has sadly been left by the wayside, even though it could be used to persuade pro-natalist governments, such as Uganda’s, to rethink its lukewarm stance on family planning. Is anything being done in the donor community or elsewhere to re-energize the family planning movement from the demographic-economic perspective?
Rhonda Smith: Hi Michael, I completely agree that the links between family planning, economic growth, and poverty reduction have been largely lost from the debate. While the message that “family planning saves lives” is one that continues to play an important advocacy role in engendering support for family planning among selected audiences, it is not sufficient—particularly for high-level officials. Promoting family planning from the economic angle does seem to be gaining some ground recently. USAID is once again supporting the development of RAPID presentations in several countries in sub-Saharan Africa. These presentations explore the impact of high fertility and rapidly growing populations on the investment needs of different development sectors, including the costs of meeting future needs in education, health care, etc. USAID has also just supported the publication of a policy brief entitled “Family Planning and Economic Well-being: New Evidence from Bangladesh (available at www.prb.orghttps://www.prb.org/wp-content/uploads/2009/05/fp-econ-bangladesh.pdf) that shows how families in communities where an integrated family planning and maternal and child health program was implemented over several decades became wealthier (and healthier!) than families who lived in areas without the program. In addition, we have found that one of the policy advocacy challenges in demonstrating the family planning/economic link is trying to show the short-term benefits of investing in family planning. Policymakers are often most interested in short-term results. Through private funding, PRB is attempting to convey both the longer-term economic benefits (“demographic bonus”) as well as some short-term benefits, especially improving economic well being and building assets at the household level in one generation. The project features multimedia presentations using new software technology (video testimonials, country comparisons). One of our participating countries in this new advocacy project is Uganda! Rhonda Smith

Elhadi munsour: Every educated person knows that family planning saves lives. But in societies where males … are [dominant], together with low level of education, targeting women can hardly gain success, [instead] we need to work among males. the quesion is, is there any appropraite program of advocacy to applied to this category.
James Gribble: Good question, as constructive male engagement has been a very important issue in the reproductive health/gender work for several years. There was a recent meeting in Rio de Janeiro, Brazil on the topic and I think there will be materials forthcoming—keep an eye on the website of the Interagency Gender Working Group (www.igwg.org) for upcoming postings.That said, there have been a number of programs and studies that look at how to involve men more effectively in family planning and reproductive health issues. A recent assessment of several of these interventions identified “Together for a Happy Family”, implemented in Jordan, as one that is effective in engaging men in family planning and that works to transform gender norms. In addition to increased use of family planning, the intervention contributed to increased discussion between partners and shared decision-making about use of methods. Another effective program has been “Men in Maternity”, conducted in India between the Employees State Insurance Corporation and the FRONTIERS Project. This project led to greater couple communication about FP/RH decisions, increased use of post-partum family planning, increased knowledge of condom use for FP and dual protection, and higher levels of client and provider satisfaction. I encourage you to look on line for additional information and contacts for both of these programs. These and other similar programs may provide good examples of how to improve men’s involvement in FR and RH issues.

J Kishore: Education and income of family and mothers are directly linked with the low birth rates. These factors are considered good alternative methods of family planning. In majority of urban areas due to privatization and lack of proper implementation of legislations large number of mothers are delivering by cesarian sections which is associated with high mortality and morbidity. Conceptually even health profssionals are not understanding what family planning is? It is important to teach how to avoid unwanted pregnancy. If it is wanted then how to appreciate and care for it.
Rhonda Smith: Dear J. Kishore, Yes, education and higher levels of family income are linked to lower birth rates. Although education and income typically drive down fertility levels, they don’t take the place of family planning methods or the need for strong family planning services today. I agree with you that some health providers may not fully understand the benefits of family planning or the importance of including family planning as an esssential component of women’s broader health care needs. It is also of great concern that so many women have an “unmet need” for family planning. These are women who say they want to space their births or avoid having any more children, but are not using any family planning methods. Studies show that as many as 200 million women in developing countries have an unmet need for family planning, and one of the consequences of this “unmet need” is large numbers of unplanned pregnancies. Reaching women and their partners who have a stated need is the first step in reducing unplanned pregnancies. While ensuring access to family planning services is one dimension of this challenge (services close to home, variety of methods, congenial setting, low cost, few barriers to eligibility), women and their partners also need information and they need to be encouraged to discuss family planning. Strengthening community education and behavior change programs is crucial. Within the health system, taking advantage of every opportunity to integrate family planning into other heath services (maternal and child health, HIV/AIDS services) is another essential step, with the integration focus on no missed good opportunities! In reference to your comment about the increasing numbers of unnecessary Cesarean section in urban settings—this is alarming for several reasons including the shift of resources to non-essential interventions in resource-poor settings and the additional health risks to mothers and newborns following a cesarean section. We have the same problem across the country right now in the United States. Although clearly beneficial and life-saving in selected circumstances, the absolute indications for cesarean section apply to only a small proportion of births. Reasons for the increase appear to rest more with professional styles and practices rather than the health needs of mothers or babies. If you are interested in more on this topic, see: http://www.childbirthconnection.org/pdfs/evidence-based-maternity-care.pdf; and Community factors affecting rising caesarean section rates in developing countries: An analysis of six countries, Social Science and Medicine, Vol. 67, Issue 8 October 2008, pages 1236-1246. Rhonda

Sri Moertiningisih Adioetomo: Through RH Costing model I estimated that if CPR increased to 70% in 2015 compaerd to 57% in 2005, there would be 4.7 millions births averted. Meaning that 4.7 millions pregnancies would be averted. Therefore, maternal mortality would be avoided. The question is: Is it possible to estimate reduction of Maternal Mortality ratio from this method?
James Gribble: Hi—The Reproductive Health (RH) costing model is designed to help countries estimate how much it would cost to scale-up a basic package of reproductive health services – ranging from family planning, antenatal and delivery care to emergency obstetric care and STI treatment – from current to universal coverage levels. I have to say that I am not familiar with it. However, I am familiar with the SPECTRUM Suite of models, which includes modules on demographic projections, effect of family planning, HIV, and safe motherhood. The safe motherhood model includes input on costs of different types of services, and builds on the demographic and family planning modules. SPECTRUM can be used to estimate reductions in maternal mortality ratios based on interventions selected and budget amounts. Scott Moreland and colleagues at Futures Group used SPECTRUM in their analysis of how reducing unmet need for family planning can contribute to achieving the MDGS, including the reduction in maternal mortality ratios. Sorry I can’t answer your question about the RH costing model, but I hope pointing you in the direction of SPECTRUM will provide you with a useful tool as well as a way of comparing results obtained from the RH costing model. Jay

Huma: [Can you discuss] how the fertility rate will effect Europe and USA in 50 years from now?
Rhonda Smith: Dear Huma, Although we have no way of knowing for sure what the effect will be in 50 years, we can speculate on the following: Between now and then, the fertility rate will determine the degree of population aging in Europe and the US. Over the next few decades, Europe’s and the U.S.’s population structure will change substantially. The baby boom generation (1940s to mid-1960s) will gradually move into retirement, swelling the ranks of the over 60s. Aging is most advanced in Europe where the number of people 60 or over surpassed the number of children a few years ago. By 2050, Europe could have twice as many older persons as children. The U.S. still has a larger number of children under 15 than elderly today, so the population will not age as quickly. In Europe, the fertility rate will greatly influence the degree to which populations decline in size in many countries. The majority of European countries are well below replacement level fertility (2.1), which signals a continuing decline in population size, as compared to the U.S, which is at replacement level. The exceptions are France and some of the northern European countries (Denmark, Iceland, Norway, Sweden) where the current total fertility rates are around 2.0 and similar to the current fertility rate of the U.S. The fertility rate will also influence the degree of shortages in the labor force, leading many European countries to consider increased immigration. Rhonda

Bhola Koirala: how family planning matter can saves females lives? can i get its importance in improving maternal health?
Rhonda Smith: Dear Bhola Koirala, Thank you for your question. It is not always easy to see the direct link between family planning and women’s health. While most women welcome pregnancy and childbirth, the risks of illness and death associated with these events are very high in some parts of the world. In developing countries we know that a woman’s lifetime risk of dying due to pregnancy and childbirth is 1 in 75, or almost 100 times higher than in developed countries where the lifetime risk in only 1 in every 7,300 pregnancies and childbirths. Lack of access to good prenatal care and delivery services plays a big role in the health outcomes of pregnancy and childbirth. But we have also learned that family planning could prevent as many as one in every three maternal deaths by helping women to avoid high-risk pregnancies that are:

– too early (girls under the age of 18 face a higher than normal risk of death or disability from pregnancy)

– too many (women who have had many babies are more likely to have problems with their later pregnancies, and face increased risk of complications and death).

– too late (women over age 35 have a higher than normal risk of death or disability);

– too frequent (women who have babies too close together have a higher risk of illness and death. Woman should wait at least two years after giving birth before trying to become pregnant again. This birth interval protects the health of the mother). Research also shows that may women who are not using family planning and have unplanned or unintended pregnancies, turn to abortion. Since abortion in not legal or is still highly restricted in many countries, women turn in desperation to persons lacking the necessary skills to safely conduct an abortion, or who work in an environment lacking the minimal medical standards, or both. Tragically, many of these unsafely performed abortions lead to disability and death. If more sexually active women who want to avoid unplanned pregnancies and high-risk births were using family planning, many more lives could be saved. Rhonda

harriet mitteldorf: Why not embark on an aggressive program to popularize advantages of 1-2-child families for parents and children as well as available resources. And I agree with Issa.
James Gribble: Hi, One of the ideals that emerged from ICPD was that women and men should be able to choose the timing and spacing of their children, and have access to family planning methods that help them achieve those goals. This idea puts women and men into the role of decision maker about reproductive decisions. Information about the health benefits of family planning can also help inform their decisions, as can evidence that shows the importance of family planning as an important part of poverty reduction strategies. Globally, women and men are increasingly recognizing the costs of children and the economic benefits of having fewer children. Most family planning and reproductive health programs focus on having fewer children and avoid setting targets, such as 1-2 children. In a country with very high fertility, it’s likely to be difficult to persuade people to have 1-2 children; however, they may see the benefits of having fewer children. Ultimately, it is the choice of the woman and man to decide, but information about the health and economic benefits of family planning can be useful for helping people with the decision. Jay

Subhas Yadawad: Family Planning cetainly saves many more lives. What is the scope of “Family Planning”? What are the components included in Family Planning? What is the difference between Family Planning and Family Welfare?
Rhonda Smith: Dear Subhas Yadawad, Family planning means planning when and how many children to have and how to prevent unintended pregnancies. It covers areas as varied as when and why to get pregnant, the number of children that are wanted, what to do when an unintended pregnancy occurs, and the types of family planning methods to use to delay, space, or avoid a pregnancy (modern contraceptives as well as traditional methods). Essential components of family planning programs include counseling clients on all available methods of family planning, the provision of contraceptives, follow-up and referral systems for all clients, maintaining adequate records for each client, supervision of all providers to ensure that client needs are met, and maintaining an effective logistics and supply system for contraceptives. Family welfare generally defines a broader set of issues and needs. Family welfare programs can include the provision of basic human requirements such as food, clothing, and shelter as well as the provision of health care services or other critical social sector services such as as care of the elderly, education, sanitation, etc. Family planning services could be supported under a broader family welfare program. I hope this provides some clarity! Rhonda

Dr. Anima Sharma: Hi, I live in a developing country in asia and have worked in Health Sector as a social scientist. My qualitative data narrates that FP plays a vital role in eliminating the risk of excessive and unwanted pregnencies especially to the people of the vulnerable sections and economically weaker sections where quality pre-natal and post natal care is in accessible to the people due to sociocultural reasons. Hence, do not you think that FP Campaign alone may not bring the desire result but we should also stress upon the quality and accessibility of the pre-, post- natal care along with it? It should be an integrated programme in which Medical people and Social Scince people should work hand in hand. What do you think about it? My question is to the both of you.
James Gribble: Hi—and thanks for an interesting question. While we often focus our attention on family planning, we usually put it in the context of a broader reproductive health framework. Your point about integrated programs makes a lot of sense because it allows all of the woman’s reproductive health needs to be handled through the same program. I recently heard an interesting fact: if a woman who wants to have four children, she will spend 16 years of her reproductive life avoiding pregnancy; which suggests that there is a long time—and many opportunities—to have her become a client at a family planning program. With an integrated program, there are more opportunities to reach women with antenatal care, delivery services, and postpartum care. Another important aspect of an integrated program is that it can provide more comprehensive information; for example, including information about family planning during antenatal care is an important time to reach women who experience an unplanned pregnancy—especially in places where use of postpartum care is low. And you are right again about quality being important—if services are poor quality, what incentive is there for clients to return? I also appreciate your perspective about multidisciplinary teams working together in designing health programs. A combination of medical, social science, communications, and administrative staff all have complementary roles in creating and operating health programs. Jay

Agatha Onovo: Knowing that family planning can save lives, why don’t teenage girls and women in Sub Saharan Africa (Nigeria in particular) access family planning services and what can be done to get them to accept and access family planning services?
Rhonda Smith: Hi Agatha, This is a good question! Early childbearing poses serious health risks. Maternal death rates for young women ages 15 to 19 are twice as high as for older women. Children born to adolescent mothers also face higher risks of illness and death than those born to mothers in their 20s. Research shows that lack of information, fear of side effects, and other barriers—geographic, social, and economic—prevent young people from obtaining and using family planning methods. Other studies in sub-Saharan Africa (including Nigeria) reveal that nurses’ attempts to stigmatize teenage sexuality, their scolding and harsh treatment of adolescent girls, and their unwillingness to acknowledge adolescents as contraceptive users, also undermine the effective use of contraception by girls. Youth need better information on reproductive physiology and sexual health, and detailed information on contraception. They also need youth-friendly services and providers who are open and willing to serve youth with respect as clients. For teenage girls and BOYS(!), experts in the field believe we need to be much more proactive in reaching out to young people, taking the messages and information to where they are—schools, community groups, clubs, churches. One example in Nigeria is the “Kyautatawa Iyali” or Family Welfare Project in northern Nigeria state. Since 2001, CEDPA (a U.S.-based NGO) has supported a program to improve reproductive health. Working hand-in-hand with faith-based organizations and community groups, the program engages families and entire communities to recognize the benefits of family planning for improved health and the need to meet the reproductive health needs of young people. A hallmark of the program is the delivery of door-to-door information and services to families and youth. If you are interested in finding out more about this effort go to: http://www.cedpa.org/content/news/detail/1993 ~Rhonda

Pushpanjali Swain: I work on population and health issues in India. Family Planning definitely save more lives provided advocacy regarding family planning is done suitably. However, poverty is a major issue which needs to be addressed. People living with poverty need more children for more hands for work and in the process of bearing children, they lose some. Due to poverty and malnutrition woman too die due to child birth. In this situation, how family planning would help to save more lives?
James Gribble: Hi—Historically, countries that have gone through the demographic transition have started with reductions in infant and child mortality, which contributes to population growth during that window when fertility remains high. Basic child survival interventions have been around and are generally accessible, and we have seen that infant and child mortality has decreased. Poverty in urban areas is likely to lead to smaller fertility because parents see the costs of raising children—food, clothes, education, etc. Your point may be focused more on rural poverty, where children may provide labor for the family’s livelihood. But even in most rural areas, families also experience costs associated with raising children. As family lands get subdivided through the years, what might have supported a larger family is likely only to support a smaller family. Larger families may not be as feasible as they once were. As you point out, family planning contributes to saving lives through reducing high-risk pregnancies—it saves the lives of mothers and children. I have seen evidence about the toll that maternal mortality takes on child mortality—that if a mother dies, her infant and children are much more likely to die. In the more usual case of the mother surviving child birth, family planning contributes to saving lives of children through promoting birth spacing, reducing the number of birth to young women, older women, and women who have had many children. One final comment—recent research from the rural area of Matlab, Bangladesh indicates that long-term investment in family planning and maternal-child health also contributes to economic well-being of families and communities. So not only is family planning a “best buy” health intervention, but it is also an effective part of poverty reduction strategies. Jay

Meskerem Bekele, Ethiopia: In our country there is a question which many of mothers asked me when I have tried to talk about family planning. Our ancestors married when they are 12 or 13 years old. they had 10 or more than children but they were healthy. What makes the difference today? Others asked ” if I am well economically who can tells me to limited my the number of my children? Is family planning concerned economically only?Can we think one family responsible for his family only? Please tell me the methods which you use to teach about family planning
James Gribble: Hi—The memories of th