Family Planning Topic Overview 250 million womeni around the world lack access to family planning services and contraception, which increases their risk of suffering from poor maternal health. Family planning helps to inform and educate women and their families on how to space births (which leads to healthier mothers and, in turn, healthier babies), control their family size (whether large or small), and to better care for themselves. It is a critical element in reducing maternal mortality because it increases a woman’s ability to avoid unintended or even dangerous pregnancies. This module examines the importance of family planning in developing countries through an interview with Lightness, a 16-year-old pregnant girl living in rural Tanzania. In Tanzania and throughout sub-Saharan Africa, there is limited access to family planning. Even where services are available, more subtle barriers further impede a woman’s ability to access them.
Background Information What is comprehensive family planning? Comprehensive family planning includes three primary components: 1) Counseling so that individuals and/or families are aware of the options and implications of each. This information ensures that individuals are equipped to make the best choice for their needs; 2) The contraceptive tool itself, which can include anything from a hormonal method such as “the pill,” to IUDs, female and male sterilization, diaphragms, and condoms; and 3) Follow-up visits so that there are opportunities to gauge whether or not the chosen method is working as expected and offer alternatives if not. All three components are critically important and must be integrated into any family planning program. What are the benefits of family planning? Family planning enables a woman and her family to make the best decision for their family size, timing, and sequencing. Ultimately, this control provides benefits in terms of greater economic and social freedom, but the impacts on health outcomes are equally important: Fewer unintended pregnancies: If family planning services were universally available, experts estimate that the number of unintended pregnancies would drop from 75 million to 22 million a year.ii
Fewer unsafe abortions: Unsafe abortions account for 13% of all maternal deaths. Each year, there are about 21 million unsafe abortions worldwide. Nearly all of these occur in developing countries, killing 46,000 women and leaving 8.5 million with injuries and complications.iii As a result of fewer unintended pregnancies, experts estimate the number of unsafe abortions would be reduced by 75%.iv Reduction in sexually transmitted infection and HIV/AIDS rates: In 2008, women made up 68% of all new HIV infections in sub-Saharan Africa. Poverty, gender-based violence, and physiology as well as lack of education, negotiating power, and social support have contributed to the feminization of HIV/AIDS. In addition to preventing pregnancy, some forms of family planning (such as condoms) can reduce the spread of diseases such as HIV/AIDS. However, benefits of family planning extend beyond the direct health benefits of preventing unintended pregnancies and sexually transmitted infections. Decreased maternal mortality means that fewer families must cope with the economic hardship of losing their matriarch. Use of contraceptives contributes to better educational prospects for children and delaying first pregnancies allows girls to finish schooling. Furthermore, reducing family size means parents can contribute more resources to each childâ€™s education, increasing the likelihood that girls will receive an education. Smaller family size reduces poverty, and more children completing school improves the financial outlook for the next generation. Slower population growth means less pressure on fragile natural environments. What are the barriers to comprehensive family planning? There are many barriers to providing women access to comprehensive family planning services. These barriers can be financial, logistical, or even cultural. Logistical: Women living in rural areas often have to travel long distances to reach healthcare facilities that provide family planning services. These clinics may be understaffed and understocked or may provide only limited services, such as condoms or contraceptive pills. Particularly for longer-acting contraceptives, such as injectables, intra-uterine devices or sterilization, trained providers may be available only at tertiary care facilities. Some types of modern contraceptive methods require multiple visits, which exacerbate these logistical problems. Financial: Although in many countries family planning services are subsidized, even small payments for services and commodities may make accessing these services impossible for women with financial burdens. Cultural: In many developing countries, women do not have enough power within their families to make decisions about their own fertility and therefore do not have the ability to visit facilities offering such services, even if distance and cost do not pose barriers. In some areas, existing societal norms create expectations for married women to have large families; men are
sometimes unwilling to limit their family size due to the perceived prestige of having a large family, especially of having sons. There is also a gender imbalance in sexual decision-making that can lead to unplanned pregnancy. Even married women are not always given a choice when to have sex or whether to use contraceptives or not. For poor young women, sex can be a means to financial security, and they may rather risk pregnancy than ask their partners to use condoms. Where is the highest need for family planning? Geographically, the greatest unmet need is in sub-Saharan Africa, where in 2008, 60% of all women (including non-married women and adolescents) who wanted to avoid pregnancy were not using family planning or were relying on traditional methods.v In Latin America in 2008, 25% of women who did not want to get pregnant were not using any form of family planning or were using a traditional methodvi and in South Central and Southeast Asia, only 33% of women who wanted to avoid pregnancy were using a modern contraceptive method.vii In these regions, women who are young, poor, uneducated and living in rural areas have the hardest time accessing family planning services due to the various barriers detailed above. In the developing world, about one in six teenagers over 14 is married.viii Girls between the ages of 15 and 19 are twice as likely to die in childbirth as women over the age of 20.ix They have even less power than adult women have to make decisions for themselves or negotiate within their families and are less likely to have money of their own. They may not be able to obtain information about how their reproductive system works or about any form of sex education— including how to prevent pregnancy or how to obtain care once they become pregnant. Family planning: clinical considerations Although some individuals with specific medical conditions may be limited in their choice of contraceptives, practically everyone can safely use almost any family planning method. Most methods are not complicated, thus can be made widely available and offered even where health care resources are limited. Evidence shows that individuals who receive the contraceptive method of their choosing are more likely to continue using that method. Good counseling helps both women and men seeking contraceptives to choose and successfully use the family planning methods that best suit them. Ready availability of a wide range of contraceptive options ensures that the right method is provided to the right client at the right time in their life. Some tips for successful counseling include: x ■ ■
Discussing the client’s situation, plans and what is important to him or her about a method; Helping the client to consider methods that might suit him or her;
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Supporting the client’s choice, giving instruction on use and discussing how to cope with potential side effects; Treating every client with respect and helping each client feel at ease; Encouraging the client to explain his or her needs, express any concerns and ask questions; Letting the client’s wishes and needs guide the discussion; Be alert to related needs such as protection from STIs; Ensuring the client’s understanding; Inviting the client to come back at any time.
Up-to-date medical eligibility criteria for various contraceptive methods are available on the Centers for Disease Control and World Health Organization websites.
The video module includes: ■ ■ ■ ■ ■
Interview and footage of Lightness Stefano, pregnant girl, Tanzania Interview and footage of Ebaraka Stefano, Lightness’s mother, Tanzania Interview with Joy Phumaphi, Vice President, World Bank Human Development Network Interview with Eliezer G. Mkamba, the Assistant Medical Officer who performed Lightness’s cesarean section, Tanzania Interview with Anika Rahman, President of Americans for United Nations Population Fund, United States
Discussion Guide Opening Questions ■ ■ ■
What is your initial reaction to the video? If you could talk to anyone in the video, who would it be? What would you say? What is your impression of Lightness? Of her mother?
Family Planning Questions ■ ■ ■ ■
How could access to family planning have changed Lightness’s story? What are Lightness’s primary barriers to accessing family planning? Adolescents such as Lightness make up one group that need access to family planning. What are other groups? How are their needs different? What are some of the benefits of limiting family size? Are there any drawbacks? If so, what are they?
Social Questions ■ ■ ■
What are the implications of Lightness’s pregnancy for her mother and family? What are the implications of Lightness’s pregnancy for her future? Lightness says she hopes she has a boy. Why do you think she says that?
There is no mention of the baby’s father in the video. What does this tell you about Lightness’s relationship with the baby’s father? Do you think he will be involved in raising their child? What are some of the other social issues that may prevent women from using family planning methods?
Activities 1) Millennium Development Goals & Family Planning In 2000, the United Nations developed eight measurable goals to address poverty in the world; all 192 UN member states, including the United States, committed to reaching these by 2015. Goal 5 is to improve maternal health. Break the class into groups. Ask each group to find connections between at least three of the other Millennium Development Goals and family planning. Have the groups brainstorm possible actions that would address the Millennium Development Goals and help more women gain access to family planning. ■ ■ ■ ■ ■
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Goal 1: Eradicate extreme poverty and hunger Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 4: Reduce child mortality Goal 5: Improve maternal health o Target 5a: Reduce by three quarters the maternal mortality ratio o Target 5b: Achieve, by 2015, universal access to reproductive health Goal 6: Combat HIV/AIDS, malaria and other diseases Goal 7: Ensure environmental sustainability Goal 8: Develop a global partnership for development
2) Birth Control Options Have the class list all forms of birth control that they can think of. Write out the positives and negatives of each method. ■ ■ i
What are some of the barriers to each method (especially for women in developing countries)? What are some of the social/family issues that may affect choice of method?
Guttmacher Institute. Facts on Investing in Family Planning and Maternal and Newborn Health. November 2010. http://www.guttmacher.org/pubs/FB-AIU-summary.pdf Last Accessed 1/14/2011 ii Guttmacher Institute. Facts on Investing in Family Planning and Maternal and Newborn Health. November 2010. http://www.guttmacher.org/pubs/FB-AIU-summary.pdf Last Accessed 1/14/2011 iii Shah I, Ahman E. Unsafe abortion in 2008:global and regional level and trends. Reproductive Health Matters. November 2010 (18:36) p.90-101
Guttmacher Institute. Facts on Investing in Family Planning and Maternal and Newborn Health. November 2010. http://www.guttmacher.org/pubs/FB-AIU-summary.pdf Last Accessed 1/14/2011 v Ibid. vi Guttmacher Institute. Latin America and Caribbean Fact Sheet. Facts on Investing in Family Planning and Maternal and New Born Health. Updated November 2010. http://www.guttmacher.org/pubs/FB-AIU-Asia.pdf Last Accessed 1/14/2011 vii Guttmacher Institute. South Central and South East Asia Fact Sheet. Facts on Investing in Family Planning and Maternal and New Born Health. Updated November 2010. http://www.guttmacher.org/pubs/FB-AIU-Asia.pdf viii UNFPA. Fact Sheet: Yong People and Times of Change. August 2009. http://www.unfpa.org/public/cache/offonce/factsheets/young_people#fn09 ix Ibid. x World Health Organization Department of Reproductive Health and Research and Johns Hopkins Bloomberg School of Public Health/Center for Communications Programs (CCP), INFO Project. Family Planning: A global handbook for providers. Baltimore and Geneva: CCP and WHO, 2007.