(June 2008) Worldwide, more than 60 percent of women of childbearing age use some method of family planning, but the percentages range from less than 10 percent in some of the least developed countries, to more than 70 percent in other countries. Cultural, social, political, and historical factors may drive women to rely on one or two specific contraceptive methods, but research has underscored the importance of having a range of choices.

During a PRB Discuss Online, Lori Ashford, program director for policy communications at PRB, answered participants’ questions about family planning worldwide: trends in use, preferences for specific methods, and obstacles women face in gaining access to the most appropriate method for them.

June 5, 2008 1 PM EST

Transcript of Questions and Answers

John Glad: How can “family planning choices” be directed away from their current dysgenic thrust? And when will PRB finally stopping brushing off the topic of selection in the current human population? Aside from considerations of quality, there is also the clear selection for wanting children – now that sex is so easily divorced from procreation. What are we going to do when we have a world where everyone is as possessed with the desire to procreate just as much as they are now preoccupied with sex?
Lori Ashford: First, we should be clear that when we talk about family planning choices, this includes choosing to have children, as well as delaying or stopping childbearing. The ability of couples to decide freely the number and timing of their children has been recognized for several decades in international human rights agreements. If I understand your question correctly, I am not aware of evidence showing a selection process that favors (or predisposes) some people to have children rather than others. A number of factors, including economic, social, cultural, and political factors, as well as individual circumstances, can influence childbearing preferences. If I had to generalize about global trends, I would say there appears to be a convergence toward a desire for fewer but more educated children, particularly as people increasingly live in urban areas.

Geoff Dabelko: Lori, Do you see any potential for helping expand FP choices through integrated programs that incorporate community-requested services such as microcredit, health, water/san, conservation etc?
Lori Ashford: Absolutely – family planning can and should be introduced in integrated programs that meet a range of community needs, such as those you describe. It makes perfect sense from the perspective of community health for people to access a range of services near where they live. The barriers seem to be bureaucratic and technical: government ministries and departments may not coordinate with each other; donors may earmark funds only for specific purposes; and people with technical skills in certain development sectors (say, water and sanitation) may have little in-depth knowledge of other specialties (such as maternal and child health and family planning). You can’t just drop contraceptive supplies into an integrated program: Community-based service providers need to be trained to provide family planning information and some methods, and refer clients to other locations for methods that they don’t offer. Some of the best examples of integrated projects have been carried out by NGOs. PRB collaborated with local partners in the Philippines, Kenya, Ethiopia, Tanzania, and Madagascar to assess integrated programs and share lessons about best practices. Summaries of these assessments and individual projects are described in policy briefs posted on our website, www.prb.org, under the topic “Environment.”

Vijay Aryal: Among many modern methods of famly planning why are the hormonal methods like Depo provera, although they have many side effects, are popular in the developing countries?
Lori Ashford: Depo Provera is a hormonal injection that a woman receives once every three months. It is highly effective in preventing pregnancy and is safe, although some women (but not all) experience side effects like irregular bleeding and weight gain, particularly in the first few months of use. Injectable contraceptives (there are other brands and types as well) have become popular in many countries. Imagine – a woman only needs to think about contraception four times a year. And some women may prefer to use family planning discreetly – out of sight of their husbands and other household members. Also, a woman can become pregnant again if she wants to, soon after she stops using the method. Thus, the convenience and effectiveness of the method may outweigh concerns about side effects, which cannot be ignored but do tend to diminish over time. For more information about specific contraceptive methods, see Family Planning: A Global Handbook for Providers, available online at www.infoforhealth.org  

Richard Cincotta: Tamar Sullivan’s paper finds that most contraceptive users in some North African countries are relying on the pill. Why this focus in N. Africa (is it largely distributed by the private sector)? And do public health analysts see problems in use patterns that are skewed toward the pill?
Lori Ashford: If you have a look at PRB’s Family Planning Worldwide 2008 Data Sheet, you can see that both the pill and intrauterine devices (IUDs) are widely used in Northern Africa, although the use of IUDs is clearly highest in Egypt. The reasons are likely historical – they have to do with how the family planning programs evolved. Also, the use of sterilization is low in this region because many Muslims believe it is against their religious faith to end their fertility permanently. (See”Islam and Family Planning” at www.prb.org.) Even without greater adoption of sterilization, however, Egypt, Algeria, and Morocco could move toward Tunisia’s level of contraceptive use, which is the highest in Africa and comparable to some European countries, as more temporary and long-acting methods are made available and used. In principle, there is nothing wrong with everyone choosing to use the same method (or two). But, if there are women who wish to avoid a pregnancy but are not using contraception (surveys show that this “unmet need” exists to some degree in most countries), then offering a broader range of choices could help meet this need and increase overall contraceptive use.

Dermot Grenham: As part of the range of family planning choices will you be advocating the use of natural family planning methods?
Lori Ashford: Natural family planning methods should certainly be included among couples’ choices of contraceptive methods. Some of the newer methods include the lactational amenorrhea method (LAM), which relies on exclusive breastfeeding for up to 6 months after childbirth. Other “fertility awareness” methods rely on beads, calendars or other means to monitor a woman’s most fertile time of the month; couples can either abstain from sex or use a condom on fertile days. Natural family planning requires commitment—usually on the part of both husband and wife—and has its advantages and disadvantages, as do all contraceptive methods. For example, a woman who chooses a fertility-awareness method can avoid the side effects of other modern methods, but she faces a somewhat higher chance of becoming pregnant than if she were to use hormonal contraceptives, an IUD, or sterilization. Couples need to weigh the pros and cons of these methods and decide what is best for them.

Mahesh Nath Singh: [How will a] wide range of family planning choices be effective for developing countries?
Lori Ashford: Research has long shown that where more contraceptive methods are available, contraceptive use is higher overall. A wide range of methods is beneficial for women and couples because it allows them to choose a method that best meets their preferences and individual circumstances. It is also beneficial for programs, because as more people use family planning, service costs typically fall on a per client basis. Also, health services can save resources by helping women avoid unintended pregnancies, because these pregnancies pose health risks for the mother and child.

Rahat Bari Tooheen: Ensuring a wide range of family planning choices would be the ideal situation for dealing with reproductive health issues. What constraints do you see for this scenario, and how can they be addressed?
Lori Ashford: The constraints to increasing the range of methods available are sometimes political or administrative – governments may impose restrictions or regulations on certain methods, or may not procure them along with other essential drugs and health supplies. Other constraints arise at the service level. For example, health providers might not take the time to explain various methods; may decide themselves what is “best” for the client, or may provide what is easiest and most efficient. And individual preferences also play an important role – some people are most comfortable using methods that their friends and relatives use, even when other methods are available. Overcoming these barriers requires promoting an environment that encourages informed choice – starting at the policy level and incorporating the concept into providers’ training and in communications and outreach about family planning.

RUGAZA Oussein: We at ARBEF in Rwanda have supported the government to introduce a variety of methods to meet the different needs of couples. We have found that many couples want a natural method, for a variety of reasons, and so we have been working to introduce the Standard Days Method into the mix. We would like to hear from you and others about on how this method might be incorporated into FP programs elsewhere to ensure wider choice?
Lori Ashford: In response to an earlier question, I talked about natural family planning, which includes the Standard Days Method – a fertility-awareness method. Resources related to this method and others can be found at the website for the Institute for Reproductive Health at Georgetown University at www.irh.org.

Mala: Is LARC (longacting reversible contraception) included in the choices for family planning? If alot of developed countries struggle to offer choices what hope do we have for women in under developed countries?
Lori Ashford: Long acting, reversible methods of contraception are important to include in the range of methods offered to women and couples. They can either be used to space pregnancies or to stop childbearing. The two main methods are intrauterine devices (IUDs), which can remain in place up to 10-12 years, depending on the type, and hormonal implants, which are inserted under the skin in the upper arm and are effective for up to 7 years. The advantages of both of these methods are that they are 99 percent effective in preventing pregnancy, and a woman can become pregnant again after the devices are removed. Hormonal implants are not widely used in developing countries because manufacturing costs have been high, making them unaffordable for many family planning programs and for individuals paying out of pocket. (Some new ones may come to the market soon, however.) IUDs, on the other hand, are inexpensive for family planning programs to purchase and provide; theoretically, they could be available everywhere in the developing world. However, awareness of the method is low in some countries (particularly in sub-Saharan Africa). Providers must be trained to insert IUDs properly and family planning users need more information about the method.

Issa Almasarweh: How can we ensure these choices when service providers implement their own polices because of their ideological reasons or economic interests.
Lori Ashford: You’ve raised a good point – that sometimes service providers create barriers to using certain contraceptive methods, because of their own beliefs or biases. As I mention elsewhere in this discussion, service provider training should include the concept of two-way communication between the provider and client; putting clients’ needs first; and adhering to the concept of informed choice.

J Kishore: There is enough evidence of socio-economic, cultural and behavoral reasons for not accepting contraceptives. None of the method is perfect contraceptive. So there is immense role of health professionals, social workers, and other activists to ensure availability of variety of contraceptives suited to their need which is lacking in India. There is no provision of counseling, quality of care, and handling side effects of contraceptives. This is urgently required.
Lori Ashford: I agree with you completely about access to a range of methods and the need for good quality care and counseling. In a country such as India where the family planning program began as early as the 1950s, service providers have been working in the communities for a long time as the national program has evolved. They need regular updates on the latest family planning methods and training in how to provide quality care, but this is likely only happening in a limited number of places where quality improvement efforts have been introduced. Training and supervision of health personnel is a huge undertaking in a country as large as India where much of the services are provided at the village level. It clearly requires both political will and resources (and perhaps, pressure from advocacy groups and consumers for better quality services).

Beth: I have heard anecdotal reports from several countries in Africa suggesting that desire for a coital dependent oral contraceptive method is high. Women see no point in using a contraceptive all the time when they have sex only sometimes; they want a pill that they can take only when they have sex. Indeed, I’m told that contrary to standard family planning recommendations, many women are using emergency contraceptive pills (and other types of pills) in this way. My questions are: (1) Do you have additional information about women’s desire for a method like this? (2) Given that such a method is likely to have only moderate effectiveness, should it nevertheless be developed and promoted if women want it?
Lori Ashford: I am not aware of a pill being developed that could be used only when a woman has sex, and I believe most health professionals would discourage using emergency contraceptive pills (in which oral contraceptives are taken in high doses) on a regular basis. I don’t know about the anecdotal evidence that you mention, but I do know that demographic and health surveys often show “infrequent sex” as a reason women give for not using family planning even when they prefer to avoid a pregnancy. Other options are available to these women, however. They could encourage their husbands to use a condom when they do have sex, or they could use hormonal injections (see discussion on Depo Provera under a separate question) or intrauterine devices (IUDs) so that they do not have remember to take a pill everyday. Both the injections and IUDs can be convenient for women who have infrequent sex, because a high degree of protection is provided without having to be prepared or have supplies on hand on any particular day.

Adrienne Allison: Why has the CPR in francophone Africa remained so low despite the fact that FP services have been promoted in Senegal, Mali, Burkina Faso etc, for more than 30 years?
Lori Ashford: There are a number of reasons for the slow adoption of family planning in Francophone (mainly Western) Africa: low female literacy, early marriage, desire for large families—combined with weak services. You might want to read an article by Jay Gribble on PRB’s website: see “Family Planning Use in West Africa” at www.prb.org. He cites an article by John Caldwell and Pat Caldwell that explains that “Early age at marriage, the social desirability of many children, and limited access to education are some of the factors that keep fertility from decreasing more rapidly.” The original paper citation is: John Caldwell and Pat Caldwell “Fertility Transition in sub-Saharan Africa” (paper presented at Conference on Fertility and the Current South African Issues of Poverty, HIV/AIDS and Youth, Pretoria, South Africa, Oct. 24, 2002). A second article, titled “Updating Reproductive Health Legislation in West Africa” (also at www.prb.org), discusses the anti-contraceptive laws passed in Francophone countries in the 1920s, and the move to overturn them following Cairo conference in 1994.

L. Ritz: How are cultural values and respecting life addressed with clients in varied countries?
Lori Ashford: It is hard to answer this question for all countries of the world, with the diversity of cultures and beliefs that exists among and within countries. Legal systems (and interpretation of laws) also vary a great deal from one country to another with regard to how they protect individual rights. There is an international consensus, however, developed at the landmark 1994 International Conference on Population and Development, that meeting individual and family needs should be at the center of family planning programs. Delegations from about 180 countries met and hammered out this consensus agreement, which places women’s rights, empowerment, and health needs at the forefront of population and development efforts. The agreement also made clear that “in no case should abortion be promoted as a method of family planning.”

Oswell Rusinga: The link between fertility and sexuality in Sub Saharan Africa is now complicated in the era of HIV/AIDS. Given the situation that hormonal contraceptives are dominant, how ensuring a wide range of family planning choices integrated in reducing the transmission of HIV.
Lori Ashford: The use of condoms has increased since the HIV/AIDS epidemic became widespread, but it is still fairly low. Couples need counseling on how to prevent pregnancy as well as protect themselves from sexually transmitted infections, including HIV/AIDS. Women need to be aware that hormonal methods (e.g., pills and injections) do not provide protection against HIV. Couples may need to use what is called “dual protection,” for example, the pill plus a condom for HIV protection. Counseling on the use of these methods can and should be given anywhere that family planning, HIV, or other health services are provided.

Renan: We see today the entire world concerned about global warming and food security. But almost no politician or organization put family planning among the solutions for those problems? Don’t you think it is time face this taboo?
Lori Ashford: I think you are right that family planning has been largely absent in international discussions about global warming and food security. There are likely several reasons for this: First, the connections between population size and climate change (and food security) are complex. Consumption and resource management are important intervening factors. Second, many people working on climate change or food security issues may not be comfortable talking about family planning, which they may view as a sensitive issue. Since the 1994 conference in Cairo (mentioned earlier), the notion of “population control” is viewed as unacceptable because it can lead to coercive practices to limit chidbearing. But there is no question that family planning is an important element of development efforts: it is directly linked to health and mortality, to women’s empowerment, to family well being and children’s education, and has a role to play in conservation efforts. Many women want to avoid a pregnancy but need the information and means to do so. You might want to also see my earlier answer regarding integrated programs that address population and conservation issues at the community level.

paige passano: If initiating a new intervention in a country where the population has minimal access to modern methods of FP due to infrastructure breakdown and lack of health workforce, I want to know more about best practices for determining the array of methods to be offered. Please explain (or give examples on line) of various methodologies of needs analyses that are available to determine appropriate options (assuming all options cannot be offered due to budgetary restrictions?)
Lori Ashford: Family planning has been successfully introduced in many countries that have very weak health infrastructures. Bangladesh pioneered the well-known doorstep delivery of contraceptives, where volunteers in the community visited women’s home to inform them about family planning and provide contraceptive supplies and referrals. Many other countries in Africa and elsewhere adopted this model of community-based distribution– quite successfully, I might add. Other ways to provide family planning in these settings include social marketing, where subsidized family planning products are made available through existing commercial outlets, like drug shops and other local vendors. Additionally, some countries have used mobile services (vans, or camps, as they are called in some places) to make periodic visits to remote, rural areas that would not otherwise have access to family planning services. Ideally, family planning should be included as part of a package of essential health services provided through a universal, primary health care system. But until these services are strengthened and become truly universal, the innovative methods described above have proven successful in reaching some of the poorest and most remote communities.

sbyadawad@sify.com: sbyadawad@sify.com Popularity of vasectomy is very low. There are many reasons and misconception for that. What efforts are made to popularize it?
Lori Ashford: You are right that use of vasectomy is very low around the world, with only a few exceptions, such as China, South Korea, the U.K. and the Netherlands. There are many misconceptions about vasectomy, the most common of which is that it could affect men’s virility. Clearly, more education about the method and training of service providers in no-scalpel vasectomy is needed on a larger scale. Communication strategies need to raise awareness of the method; dispel myths and misperceptions, and create a more positive perception of vasectomy. Involving men in family planning and reproductive health is an important step, and many programs have been working on this front over the last decade with varying degrees of success. Some efforts in Latin America to introduce vasectomy have been successful relative to what has happened elsewhere. You might want to read about these efforts on the website of the Population Council: www.popcouncil.org.

Paula Tavrow: How soon will new contraceptive technologies become widely available, such as an improved female condom? And will a male pill be available in the forseeable future? What else looks promising?
Lori Ashford: It takes a very long time (many years, even decades in some cases) to develop a new contraceptive product, bring it to the market, and make it available on a large scale. But more research is going on than most people probably realize. Two reports (Population Reports, by the INFO Project) that you might want to refer to are: Implants: The Next Generation (2007) http://www.infoforhealth.org/pr/k7/k7.pdf. New Contraceptive Choices (from 2005): http://www.infoforhealth.org/pr/m19/m19.pdf. Male methods have been in development for some time, and will likely result in an injection or implant, rather than a pill. The Population Council is one of the leading organizations in the development of male contraception. You can learn more about it at their website: www.popcouncil.org.

Diouratie Sanogo: In Mali, we have been working with the governrment and several other organizations to increase use of modern methods of family planning, emphasizing healthy timing and spacing of preganancies. Among the many methods offered is the Standard Days Method, which has opened up communication about family planning and sexuality in communities since many different groups are capable and feel comfortable talking about the method, including women’s and men’s groups and Imams (Muslim leaders). Can you comment on the importance of getting communities involved in awareness raising on family planning methods and techniques that have worked for doing so?
Lori Ashford: Gaining the acceptance of community leaders for family planning has been key to many successful programs throughout the developing world. One of the most striking cases is Iran, where family planning was incorporated in the national health program (and contraceptive use increased rapidly) after the program gained agreement from highest level clergy in the country that there was no prohibition in Islam against family planning. Bringing religious leaders together, informing them, and building consensus can be a long but essential process. In Mali, in recent years, the Policy Project and Health Policy Initiative have worked with religious leaders to raise awareness about family planning to gain their support – and not to be an impediment to the adoption of family planning. You might want to refer to the project website: www.healthpolicyinitiative.com or contact the USAID mission in Bamako for more information. Also, PRB is developing an advocacy toolkit for community leaders and others, in collaboration with the World Health Organization and other African organizations. If you send me your address, I’ll be glad to send you a copy of the materials once they are complete.

S. Lancaster: Are you aware of any new methods being designed (or in the pipeline) that keep women’s global and local contraceptive attribute preferences in mind (privacy issues, tolerance or intolerance for side-effects such as increased or decreased bleeding, integrating STD protection such as incorporating antimicrobials, etc.)? How can we keep the research moving forward on that front? I ask because it seems that if we can map attribute preferences (per local custom or other things that impact choices) it would help guide resource distribution and knowledge disemination. Do you know what the best resource for watching that research might be? Thanks!
Lori Ashford: Thank you for your question and please see my response to Paula Tavrow.

For Further Reading:

Lori Ashford, Ensuring a Wide Range of Family Planning Choices (Washington, DC: Population Reference Bureau, 2008), available at www.prb.orghttps://www.prb.org/wp-content/uploads/2008/06/familyplanningbrief.pdf (PDF: 25KB).

Donna Clifton, Toshiko Kaneda, and Lori Ashford, Family Planning Worldwide 2008 Data Sheet (Washington, DC: Population Reference Bureau, 2008), available at www.prb.org/pdf08/fpds08.pdf (PDF: 740KB).