Case study: fertility decline in Iran

Iran has experienced one of the most successful family planning programs in the developing world, with 64 percent decline in total fertility rate (TFR) between 1986 and 2000. This paper focuses on Iranians’ unique experience with implementation of a national family planning program. Recognition of sensitive moral and ethical aspects of population issues resulted in successful collaboration of technical experts and religious leaders. Involvement of local health workers, women health volunteers and rural midwives led to great community participation. Demographic and Health Survey (DHS) data in 2000 indicated a TFR of 2.0 births per women and 74 percent contraceptive use among married women. This case study will help policy makers and researchers in Moslem countries and other developing countries with high fertility rate to consider a successful family program as a realistic concept with positive impacts on nation’s health and human development.     

Barriers to contraceptive use among Pakistani couples

Despite the existence of a family planning program in Pakistan since 1965 and widespread knowledge among Pakistanis about contraception, there is a high level of unmet need for family planning. One recent survey found that while 53% of married women express the desire to avoid pregnancy, less than 20% use contraception. A recent Population Council study conducted in urban and rural areas of Punjab province investigated personal beliefs, family circumstances, social norms, and gender relations among 1310 married women and 554 of their husbands. The unmet need for contraception was highest among women over age 30 years, those with more living children, less educated women, and women living in rural areas. The study found that while most Pakistanis approve of family planning, obstacles to contraceptive use exist in most marriages. 97% of respondents who wanted another child wished for a boy. That preference for sons influences contraceptive use behavior. The fear of social disapproval of contraceptive use, perceived opposition from in-laws and husbands, and fear of health side effects and divine punishment were major reasons identified against contraceptive use. Female contraceptive users were more autonomous and likely to make domestic decisions without consulting their husbands, while husbands defer to social and cultural norms.     

Determinants of fertility and the unmet need for family planning in Indonesia

Indonesia's fertility has declined to an average of slightly more than 3 children/woman. The islands of Java and Bali have the lowest birth rates. Indonesia's family planning program has been a model of innovation, flexibility, and community involvement, and has been effective in reducing fertility, changing family preferences, and increasing contraceptive use. Fertility decline is also determined by factors other than contraceptive use, as provinces in Jakarta and East Java has low fertility and low contraceptive use. Recent research by Suyono and Palmore found that among cohorts of women in Jakarta lowest fertility rates were explained by greater nonexposure to pregnancy in an unmarried state or by a divorced or widowed status, and by infecundity. In East Java, fertility determinants were the same with the possible addition of lower coital frequency. The study estimated nonexposure due to marriage, infecundity, and contraceptive use. Policy considerations, however, are concerned with the exposed state of the percentage of time women are currently married, fecund, not using contraceptive, and sexually active. Suyono and Palmore also calculated the percentage of time spent in the exposed state by province. The estimates ranged from 12% in Yogyakarta to 25% in West Java and the Outer Islands. Exposed was further divided into groups with a manifest, latent, and no current need. Women with a manifest need for family planning are those who are aware of their contraceptive needs to stop or postpone childbearing and not using. Manifest need was highest in high fertility areas: 12% in Central Java, 13% in West Java, and 12% in the Outer Islands. Programs targeting these women should focus on wider availability of information and services. Women with latent needs are unaware of their need for family planning and are not using contraception. These women were also concentrated in high fertility areas. The percentage of years spent in the latent unmet need state was estimated at 23-24% in West Java and the Outer Islands. Program emphasis should be on education and motivation to show how family size can be controlled. Women with current need can be educated toward future acceptance.     

Microcredit,Family Planning Programs,and Contraceptive Behavior: Evidence From a Field Experiment in Ethiopia

The impact of community-based family planning programs and access to credit on contraceptive use, fertility, and family size preferences has not been established conclusively in the literature. We provide additional evidence on the possible effect of such programs by describing the results of a randomized field experiment whose main purpose was to increase the use of contraceptive methods in rural areas of Ethiopia. In the experiment, administrative areas were randomly allocated to one of three intervention groups or to a fourth control group. In the first intervention group, both credit and family planning services were provided and the credit officers also provided information on family planning. Only credit or family planning services, but not both, were provided in the other two intervention groups, while areas in the control group received neither type of service. Using pre- and post-intervention surveys, we find that neither type of program, combined or in isolation, led to an increase in contraceptive use that is significantly greater than that observed in the control group. We conjecture that the lack of impact has much to do with the mismatch between women’s preferred contraceptive method (injectibles) and the contraceptives provided by community-based agents (pills and condoms).     

Family planning practice and women's fertility decision-making power

This paper investigates the effects of family planning practice on fertility decision-making power in South Korea. The log-linear analysis of the 1981 survey data by the Institute of Population and Health Services Research, Yonsei University, Seoul, Korea, shows that those urban and rural women who practice family planning or have experienced abortion exercise greater influence on a couple's fertility decision making than those who do not practice family planning or who have had no abortion experience. In addition, there is the interactive effect of abortion experience and contraceptive use on fertility decision making among urban women. This finding is significant because regardless of how birth control is available within a society, birth control use enhances women's decision making power where fertility is concerned.     

The dynamics of contraceptive adoption in Bohol,Philippines: 1976-1978

A researcher analyzed 1976 and 1978 data on 414 rural women who had never used a family planning method to prevent pregnancy and lived in the predominantly Catholic island province of Bohol in the Philippines to look at the influence certain aspects of the family planning program, begun in 1976, as predictors of changes in contraceptive behavior. 34.5% accepted contraception between 1976-1978. The researchers learned that couple traits (e.g., age, income, education, and religiosity) had only an indirect effect on change in contraceptive behavior. A desire to stop, limit, or space births (motivation) was a strong predictor of family planning method acceptance (p.001). Further couples who clinic providers contacted the most often or who had received more family planning services (services) were much more likely to use contraceptives (p.001). Indeed a significant relationship existed between motivation and services (p.001). Moreover couples who were truly motivated to use family planning methods did not let distance to family planning services prevent them from seeking these services (p.001). On the other hand, couples who confronted personal obstacles to family planning including social, psychological, and other subjective costs (cost index) tended not to accept family planning methods (p.001). A negative association existed between services and location of households vis a vis the intervention program (p.001) which indicated that the program did have an effect in the area of the province where it was located. In conclusion, the strongest predictors of change in contraceptive behavior included motivation, services, and cost index. Services and cost index indicated the great importance of interpersonal and/or client staff contact, especially since they were more important in influencing behavior change than distance and family planning site.     

The role of contraceptive supply and demand in Mexican fertility decline: evidence from a microdemographic study

This paper uses retrospective life history data to assess the impact of family planning services on contraceptive use in a rural Mexican township. Between 1960 and 1990 contraceptive use rose and fertility declined dramatically. Both contraceptive supply and demand factors were influential in these trends. The start of the government-sponsored family planning programme in the late 1970s was associated with a sharp rise in female sterilization and use of the IUD. However, once we controlled for the changing socio-economic and demographic characteristics of the sample, the presence of family planning services had no significant effect on the likelihood that women used modern reversible methods compared to traditional methods. Men and women expressed concerns about the safety of modern methods such as the pill and the IUD. Efforts to increase modern contraceptive use should place greater emphasis on communicating the safety of these methods and improving the quality of services.     

The Role of Contraceptive Supply and Demand in Mexican Fertility Decline: Evidence from a Microdemographic Study

This paper uses retrospective life history data to assess the impact of family planning services on contraceptive use in a rural Mexican township. Between 1960 and 1990 contraceptive use rose and fertility declined dramatically. Both contraceptive supply and demand factors were influential in these trends. The start of the government-sponsored family planning programme in the late 1970s was associated with a sharp rise in female sterilization and use of the IUD. However, once we controlled for the changing socio-economic and demographic characteristics of the sample, the presence of family planning services had no significant effect on the likelihood that women used modern reversible methods compared to traditional methods. Men and women expressed concerns about the safety of modern methods such as the pill and the IUD. Efforts to increase modern contraceptive use should place greater emphasis on communicating the safety of these methods and improving the quality of services.     

Health worker pilot project

In a survey conducted by the Kavar Village Health Worker Project in Iran, among married women, aged 15-44, residing in 16 villages served by project trained, auxillary rural health workers, 28% used oral contraceptives, while only 13% of the women who resided in 16 control villages served by untrained rural midwives used oral contraceptives. Among women in the 25-35 age bracket, the % of oral contraceptive users in the project villages was twice as great as in the control villages. Surprisingly, despite the strong Muslim tradition extant in these villages, no significant differences in usage were found between those villages served by male auxillary health workers and those served by female workers. The auxillary health workers had been trained to provide a wide variety of preventive and curative medical services, in addition to providing family planning and contraceptive distribution. At the time of the survey, these workers had been serving the 16 villages for 21 months. In the 16 control villages the nonresident midwives had received no training but had been provided with oral contraceptives for distribution.     

New survey finds fertility decline in India

A brief indication was provided of demography, fertility, and contraceptive usage and knowledge based on the recent 1992/93 Indian National Family Health Survey. The sample included 88,562 households and 89,777 ever married women aged 13-49 years in 24 states and the National Capital Territory of Delhi. About 38% of household members were aged under 15 years. The sex ratio was 944 females to 100 males. 54% aged over 5 years were currently married; 10% were widowed, divorced, or separated. 43% were literate and 9% had secondary or higher education: 67% for females in cities and 34% in rural areas. Female literacy was 82% in Kerala but under 30% in Rajasthan, Bihar, Uttar Pradesh, and Madhya Pradesh. During 1990-92, the crude birth rate was 28.9 per 1000 population. Total fertility was 3.4 for women aged 15-49 years: 3.7 in rural and 2.7 in urban areas. 31% of parents had been sterilized. 26% desired no more children. Only 6% of women with four or more children desired another child. 99% of urban and 95% of rural respondents had knowledge of at least one modern or traditional method. Female and male sterilization were the most well-known modern methods. 47% of women had ever used contraception: 42% with a modern method and 12% with a traditional method. 41% were current users of family planning: 36% with a modern and 4% with a traditional method (45% in urban and 33% in rural areas with a modern method). The highest contraceptive use was in Kerala, Himachal Pradesh, Maharashtra, and Punjab states and Delhi (over 50%). The two most populous states, Uttar Pradesh and Bihar, had the lowest rates, which were under 25%; other low usage was in Assam and several small northeastern states. 75% of all female modern contraceptive use was female sterilization. 12% in urban and 3% in rural areas used a modern spacing method. Use increased with increased educational level. Rural sources of supply emphasized public facilities: sterilization and IUDs.     

Do incentives matter? – Evaluation of a family planning program in India

Indian Family Planning programs in the past haveintroduced a number of approaches such as providingmonetary benefits, and motivational programs toimprove contraceptive use among rural illiteratewomen. Under the Ammanpettai family welfare program,the Melatur PHC administered three program typesinvolving a combination of monetary and motivationalapproaches to improve contraceptive use in threetreatment areas. The program was introduced duringJanuary 1989 and was simultaneously discontinued aftera period of two years. The present evaluation wasconducted in 1994. Data from a random sample of 933non-sterilized women at the time of social surveyusing a questionnaire approach is used in this study. The implementation of incentive programs in asocio-economically homogenous population has resultedin an increase in the likelihood of current ofcontraceptive use. The results of this study suggestthat motivational programs are more likely to improvelong term use of temporary family planning methodsthan cash incentive programs. One implication of ourfinding is that motivational programs should provide peer based family planning education and training incommunity work to contact persons who make door todoor visits to promote family planning programs.     

Estimating unmet need for contraception by district within Ghana: an application of small-area estimation techniques

The importance of meeting the unmet need for contraception is nowhere more urgent than in the countries of sub-Saharan Africa, where the fertility decline is stalling and total unmet need exceeds 30 per cent among married women. In Ghana, where fertility levels vary considerably, demographic information at sub-national level is essential for building effective family planning programmes. We used small-area estimation techniques, linking data from the 2003 Ghana Demographic and Health Survey to the 2000 Ghana Population and Housing Census, to derive district-level estimates of contraceptive use and unmet need for contraception. The results show considerable variation between districts in contraceptive use and unmet need. The prevalence of contraceptive use varies from 4.1 to 41.7 per cent, while that of the use of modern methods varies from 4.0 to 34.8 per cent. The findings identify districts where family planning programmes need to be strengthened.     

Basic policies of the Philippine Population Program

This history of the Philippine Population Commission, which was created in 1969, is summarized. In 1970 President F.E. Marcos defined the government's task in this area as: 1) educating the people on the urgent need for population control; 2) disseminating knowledge on birth control techniques; and 3) providing facilities, especially in rural areas. Funding began in 1971. The 4 basic policies are noncoercion, integration, multiagency participation, and the partnership of the public and private sectors. The noncoercion policy means that all birth control techniques are offered and couples are free to use or reject whatever they wish. This has probably slowed the spread of family planning, but has also minimized opposition. Family planning has never been the domain of 1 agency but has been implemented through many agencies working together. Now it is being implemented through total community development plans, of which family planning is merely 1 component. This approach puts irrigation workers, agricultural development workers, and many others on the family planning team. private agencies have also had an important role to play in the development of the total program. For the past 5 years these have been mainly voluntary sociocivic and health associations whose interests are very close to or naturally related to family planning. Now the entry of business into the Population Program through the commercial contraceptive marketing program has enlarged the role of the private sector in the diffusion of family planning products and services. It is possible that the partnership between the public and private sectors may soon be based on segmentation of the target population with government agencies going deep into rural areas while private organizations concentrate on urban and adjacent rural areas.     

How economic development and family planning programs combined to reduce indonesian fertility

This paper examines the contributions of family planning programs, economic development, and women’s status to Indonesian fertility decline from 1982 to 1987. Methodologically we unify seemingly conflicting demographic and economic frameworks into a single “structural” proximate-cause model as well as controlling statistically for the targeted (nonrandom) placement of family planning program inputs. The results are consistent with both frameworks: 75% of the fertility decline resulted from increased contraceptive use, but was induced primarily through economic development and improved education and economic opportunities for females. Even so, the dramatic impact of the changes in demand-side factors (education and economic development) on contraceptive use was possible only because there already existed a highly responsive contraceptive supply delivery system.     

吉林省“计划生育服务车”基层服务研究

吉林省榆树市自2003年开展"计划生育服务车"基层服务以来,市计生局发挥服务车机动、便捷的特点,采取"直接进屯,服务到人,逐村推进,一年一回"的服务方式,有效地提高了避孕节育措施的落实率,稳定了农村育龄人群的生殖健康水平。在各方面综合因素作用下,服务车的发展运行健康、有序、规范,拓宽了人口计划生育事业的发展空间,提升了新时期人口计划生育工作的水平和品质,提高了农村计划生育人群和家庭的生育、生活和生命质量。表现了人口计生部门转变工作思路、改进工作方法,推进基层基础工作,乃至推进计划生育的整体工作力度。     

Contraceptive determinants in three leading countries

The purpose of this paper is to examine the relative importance of access to family planning and the motivation to restrict fertility in determining contraceptive use in three countries that have led the fertility transitions in their regions: Colombia, Tunisia, and Zimbabwe. A structural equations model is estimated where endogenous fertility intentions are allowed to affect contraceptive method use. Simulation methods are then used to quantify the size of the impact of intentions and access on method choice for the three countries. The results demonstrate that even after controlling for fertility intentions, family planning program variables still have important effects in all three countries.     

Family planning in choiseul province,Solomon Islands

The results presented are from a rural prevalence survey on family planning in Choiseul Province, Solomon Islands. Married women aged 15–49 years with at least one living child and married men whose wife met the same criteria, provided data on knowledge, attitudes and practices of contraceptive use. Fifty one per cent of the female sample were using some form of contraception, 26 per cent reversible and 25 per cent non-reversible methods. Sixty-five per cent of men claimed that they or their spouse were using a method of family planning. Tubal ligation was the most common currently used method (25 per cent in the female survey). Desired family size was four for both males and females. Knowledge and approval of family planning was high, with 83 per cent of females and 81 per cent of males knowing of at least one method. Problems in accessing information and services for family planning include cultural and logistical constraints. Religious affiliation was the major variable affecting knowledge, use and approval of contraceptive methods. Nearly a quarter of the sample lived further than two hours travel time from the nearest health clinic supplying contraceptive methods. These clinics often have only an intermittent availability of supplies. A strong interest in family planning was demonstrated by both respondents and service providers.     

Thinking about several problems of the research of our family planning strategy]

On the basis of 1982 census data, it is estimated that from 1987-1997 13 million women will enter the age of marriage and child-bearing each year. The tasks of keeping the population size around 1.2 billion by the year 2000 is arduous. Great efforts have to be made to continue encouraging one child/couple, and to pursue the current plans and policies and maintain strict control over fertility. Keeping population growth in pace with economic growth, environment, ecological balance, availability of per capita resources, education programs, employment capability, health services, maternal and child care, social welfare and social security should be a component of the long term development strategy of the country. Family planning is a comprehensive program which involves long cycles and complicated factors, viewpoints of expediency in guiding policy and program formulation for short term benefits are inappropriate. The emphasis of family planning program strategy should be placed on the rural areas where the majority of population reside. Specifically, the major aspects of strategic thrusts should be the linkage between policy implementation and reception, between family planning publicity and changes of ideation on fertility; the integrated urban and rural program management relating to migration and differentiation of policy towards minority population and areas in different economic development stages. In order to achieve the above strategies, several measures are proposed. (1) strengthening family planning program and organization structure; (2) providing information on population and contraception; (3) establishing family planning program network for infiltration effects; (4) using government financing, taxation, loan, social welfare and penalty to regulate fertility motivations; (5) improving the system of target allocation and data reporting to facilitate program implementation; (6) strengthening population projection and policy research; (7) and strengthening training of family planning personnel to improve program efficiency.     

Family growth and family planning: Responses to a family-planning action program in a rural district of Thailand

A resurvey of a rural district in Thailand, of about 70,000 population, was conducted after a family-planning program had been in operation for eight months in order to ascertain indications of effectiveness of the program. Both the "before" and "after" surveys employed a 25 percent simple random, though non-overlapping, sample of married women 20-44 years of age whose husbands were living. The only difference in design and execution was the inclusion in the resurvey of questions about the action program. Barring one or two exceptions, the characteristics of the two population samples were so similar that differences in knowledge, attitudes, and practices could be regarded as effects of the program.The action program not only made itself widely known in the district, it also evoked a highly favorable appraisal, to such an extent that nine of every ten women thought the program should be extended over the entire kingdom. Motivation to engage in family planning increased perceptibly. A substantial proportion (23 percent) of the women who formerly disapproved of the practice changed their attitudes to approval, mainly because they had become convinced of the harmlessness and the utility of fertility control. Less than 3 percent of the former approvers had become negative.The proportion of women who claimed some kind of knowledge about contraceptive methods more than doubled during the eight months of the program's operation. More impressive, however, was the change in actual use of methods, which rose from 1 to 21 percent of the eligible women (women who were not pregnant, subfecund, or sterilized). Another 16 percent, in the resurvey, planned to begin use of contraceptives in the near future, in most instances after a current pregnancy. The frequency of acceptance of family planning practice exceeded the expected frequency among women who were approaching or had attained the "ideal" number of children (4.0 children). High-parity women 40 or more years of age seldom accepted clinical assistance.     

Fertility in botswana: The recent decline and future prospects

Recent estimates of fertility in Botswana suggest a rapid decline of more than two births per woman between 1981 and 1988. This paper proposes that the baseline fertility was overestimated but that nonetheless fertility declined by about one birth per woman during the 1980s. The decline in fertility was linked to a deterioration in social and economic conditions caused by a major drought in the early 1980s and to the increased availability of family planning services in the same period. Fertility apparently began to rebound in the late 1980s in response to improved conditions, which came about as a result of a successful drought relief program. Future declines in fertility depend on the continued success of the family planning program, particularly in rural areas.