Why women who don't want to get pregnant don't use contraception

In the developing world about 120 million women have an unmet need for contraception. They want to postpone childbearing, yet they do not use contraception, often because of the unavailability of services and supplies. However, according to a recent article by John Bongaarts, the primary factors are lack of knowledge about a contraceptive method, concern about side effects, and the disapproval of the male partner in developing countries. Lack of knowledge means inability to describe the uses of a contraceptive, its side effects, and the locale of its availability. An approximate knowledge index was calculated for such women, which showed that knowledge level positively correlated with contraceptive prevalence. Countries where the index was below 50% had a contraceptive prevalence of 8% only. The determinant reasons why women were reluctant to use the pill, IUD, and sterilization had to do with health and the fear of side effects, such as nausea and increased bleeding. The contraceptive prevalence among these women was reduced by 71% for the pill, 86% for the IUD, and 52% for sterilization. In Sub-Saharan countries nearly 70% of women cited partner disapproval of contraception, although they had never discussed family planning with their partners. The central concept for reducing unmet need is access with quality, which means that services are voluntary, safe, and appropriate in delivery. Some of the recommendations to reduce the unmet need for contraception include: one-on-one same-sex discussions to increase contraceptive knowledge and acceptability; sensitive responses by programs to their client's health concerns; support by service providers to women negotiating with male partners in order to mitigate male disapproval; and sex education and family planning services to reduce unwanted and early sexual contact and pregnancy while girls develop identities apart from mothering roles.     

How Do Education and Family Planning Accelerate Fertility Decline?

Education and family planning can both be influenced by policy and are thought to accelerate fertility decline. However, questions remain about the nature of these effects. Does the effect of education operate through increasing educational attainment of women or educational enrollment of children? At which educational level is the effect strongest? Does the effect of family planning operate through increasing contraceptive prevalence or reducing unmet need? Is education or family planning more important? We assessed the quantitative impact of education and family planning in high-fertility settings using a regression framework inspired by Granger causality. We found that women's attainment of lower secondary education is key to accelerating fertility decline and found an accelerating effect of contraceptive prevalence for modern methods. We found the impact of contraceptive prevalence to be substantially larger than that of education. These accelerating effects hold in sub-Saharan Africa, but with smaller effect sizes there than elsewhere.     

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.     

Unmet need for couples: An analytical framework and evaluation with DHS data

While estimates of unmet need continue to be an important measure of the extent of demand for contraception and family planning programs success in developing countries, there are various reservations about the validity of these estimates. For instance, the traditional formulation of the measurement has relied solely on information from women while inferences from the findings are often drawn for couples. As more survey data have become available for both men and women in a number of countries, there is increasing evidence suggesting that husbands' preferences are indeed important determinants of the reproductive behavior of couples. This paper developsan analytical framework for measuring unmet need for couples. The approach: (1) takes a fresh look at the classification of pregnant and amenorrheic women, and (2) incorporates the contraceptive use and fertility preferences of husband and wife in estimating the level of unmet need in six sub-Saharan African countries. Our findings shows that taking these factors into account results in a 50 to 66 percent reduction in the level of unmet need in these countries. The importance of husbands' variables in determining the level of unmet need is clearly evident when examined among fecund couples in which the wife is neither pregnant nor amenorrheic. The implications of these findings for family planning programs and research are discussed.     

We must complete the population control system to control the population peak and achieve our population goal]

Since 1986, China has experienced another baby boom which is expected to last till 1997. If no effective measure is implemented to check population growth, the population target of around 1.2 billion will not be achieved. The author proposed four population regulation mechanisms that need to be strengthened. First, ideological education needs to be used to change people's perceptions about family size, so that couples would willingly accept small families. Second, financial incentives and penalties need to be used to direct people to regulate their fertility. The incentive and penalty technique directly affect the interests of the family and is likely to produce rapid results. Third, legislation can be used to regulate reproductive behavior, the laws and legislation which restrict social behavior should be utilized for population control purposes. Once legislation on fertility regulation is passed, those who violate the law can be penalized. Furthermore, legislation gives family planning (FP) workers legitimacy in implementing the program and can help avoid disputes in the process of FP program implementation. Fourth, provision of contraception and abortion services is an important mechanism to ensure the realization of the objectives of population growth control. Meanwhile, the effectiveness of contraceptive methods and the acceptance of abortion depends on the research and development of contraceptive technology and on abortion techniques. These fertility regulatory mechanisms have not be adequately established, and their functions have not been fully utilized. The current FP program is hampered by simplistic ideological education, abusive use of incentives and penalties, lack of legislation, and unmet needs in contraceptive development. To achieve the population targets, these mechanisms need to be strengthened.     

A components method for measuring the impact of a family planning program on birth rates

One of the major goals of family planning programs worldwide has been to reduce the level of fertility in hopes of slowing the rate of natural increase and promoting social and economic development. Such programs have now been in existence for sufficient lengths of time to have had an impact on fertility levels. In general countries with organized family planning programs, marked declines in fertility levels have been observed. The extent to which such declines may be credited to organized programs has not been rigorously measured because an appropriate research methodology has been lacking. This paper describes one method of directly linking declines in fertility levels to the contraceptive protection experienced by a population. The contribution of organized family planning programs is estimated by decomposing the amount of total contraceptive protection into within-program and outside-program sources.     

The need for family planning

The purpose of this paper is to examine the evidence on the need for family planning. The available evidence on current levels of unmet need for contraceptives, fertility preferences, and the non-contraceptive benefits of family planning is reviewed. I argue that expansion of family planning programs is still needed. These programs provide couples with tools to reach their desired family size; can significantly impact maternal and child mortality by decreasing fertility and optimizing child spacing; and by decreasing fertility, slow population growth. It is therefore imperative to continue to expand the provision of family planning services.     

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.     

Economic development and fertility decline: lessons from Asia's newly industrialized countries

The general thesis that economic development and fertility decline are interrelated is substantiated in literature that discusses the successes of the newly industrialized countries of Hong Kong, Korea, Singapore, and Taiwan. When countries are developing rapidly, family planning accelerates the rate of fertility change, particularly among the poor uneducated rural population. Relying on economic and social development is not enough. National policy in Hong Kong, Singapore, Korea, and Taiwan recognized that population growth drains resources and the family planning programs operating since the 1960s contributed to a drop from 5 children/woman to 2 by 1988, and 70% of married couples used contraception. Coupled with this, age at marriage rose, contraception became more available, and educational and employment opportunities increased. Economically, the growth rate in the 1980's was 6-10% annually, with growth in the manufacturing and service sectors and export trade. Close economic ties evolved between governments and private sectors. Social development programs had been fully funded and gains evident in education, living standards, health care and nutrition, and life expectancy. The success of family planning is attributed to encouraging contraceptive awareness and use. Fertility reduction may occur with social and economic development, but no developing countries have reduced fertility without family planning. The relative importance of family planning may change over time, and reducing the cost through government sponsored family planning programs and encouraging the acceptability of contraceptive usage.     

The international family planning movement

Over the past 3 decades, the number of women using family planning has increased 6-fold to over 400 million married women of childbearing age. The evolution of behavior and attitudes toward using birth control among third world couples reflects the goals and hard work of an international network of individuals, governments and organizations. This article follows the progression of this movement, from early opposition in developed as well as developing countries, to the present day, when birth control is practiced by a slight majority of the world's women of childbearing age. Among world regions, contraceptive use ranges from about 17% in Africa to 75% in Asia. In some African countries, however, family planning is still a foreign concept, and fewer than 5% of women use any birth control. International organizations played a crucial role in spread of family planning by providing training for developing country professionals, funding actual family planning programs and helping to evaluate programs. But the success of a country's family planning program also was dependent upon a national commitment, and often on a strong socioeconomic setting. The private sector has had a limited role except in some countries, notably in Latin America, but its involvement is likely to expand in the future. Also, as financial support from the US and international organizations wanes, national governments will cover a larger share of the cost. The worldwide increase in the practice of family planning has led to fertility declines in many third world countries, slowing rapid population growth rates. For individuals, family planning has been a liberating influence, allowing them to participate more fully in the shift from traditional to modern society.     

Future population growth: researchers in three countries quantify causes and propose policies

This article discusses Population Council analyses conducted by social scientists from India, Kenya, and the Philippines. These scientists agreed that population momentum would continue to increase population size, and that governments must strengthen and create a range of economic, health, and social programs and policies to slow population growth. Multiple approaches will be needed. John Bongaarts is credited with being the first to identify the key role of population momentum and to decompose growth into unwanted fertility, high desired fertility, and population momentum. Unwanted fertility is responsible for about 19% of projected population growth in India, 26% in Kenya, and 16% in the Philippines. High wanted fertility accounts for 20% of future growth in India, 6% in Kenya, and 19% in the Philippines. Population momentum can account for under 50% or over 90% of growth. Unwanted fertility can be addressed by fulfilling unmet need and increasing knowledge of methods, reducing the fear of side effects and disapproval, and eliminating poor service. Family planning programs need to be strengthened and integrated with maternal and child health services. Preferred and actual family sizes can be reduced by lowering infant mortality by means of increasing infant and child health services and girls' educational attainment. Population momentum can be addressed by delaying age at marriage and childbearing through improving social conditions. Investments in human development through education, training, and income generation can create the conditions for slowing population growth. Countries should decompose population growth into its components of unwanted and high wanted fertility and population momentum as a means of distributing resources most effectively.     

Using operations research to guide family planning program development and policy formulation in sub-Saharan Africa

The process by which a population policy and family planning program evolve in a given country is influenced by many factors that combine to make each country's experience unique. One of the most influential factors among these is the role played by external technical assistance, normally provided through donor-supported mechanisms. One donor-supported mechanism that seeks to guide the operational policy and program development process is technical assistance through operations research. Many questions are raised during the design of family planning programs that are often best answered with reference to empirical evidence collected through applied, or operations research (OR). This paper provides a review of the three main OR approaches currently being used in sub-Saharan Africa: diagnostic or needs assessment studies; experimental pilot studies; and intensive technical assistance for problem-solving and institutional development. The extent to which these OR approaches can play a role in family planning program development to improve and expand service delivery activities is discussed, and examples where these approaches have been used are given.     

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.     

China's first family planning publicity month

China conducted its 1st nationwide Family Planning Publicity Month in 1983, from New Year's Day to Spring Festival (February 13). The campaign emphasized the rural areas and focused on explaining why family planning is a state policy. The most noticeable achievements of this campaign were that every household became familiar with the fact that family planning is a basic state policy. The majority of the population take this policy seriously, realizing that strict control of population growth is both a good and imperative policy. More than 1,830,000 propaganda columns and photo exhibitions were displayed, 5,900,000 radio and television programs broadcast, 2,010,000 theatrical performances, movie and slide showings presented, and 97,000,000 copies of materials published for public dissemination. The activities were varied and interesting, vivid and lively, and purposeful and persuasive. 1 of the most effective methods of publicizing population control has been the presentation of comparative statistics. This aspect of the campaign was a specific and lively form of education in population theory and practice. The presentation of statistics that show the relationship among population, land use, grain produce, and income enabled the population to reason out why population growth needs to match economic and social development. Another important accomplishment of the publicity month was that a large number of couples of reproductive age became convinced of the need to use contraception. According to the incomplete statistics, 8,860,000 people had surgical operations for birth control. The universal promotion of ligations by either partner of a reproductive couple who already had given birth to a 2nd child was an important development of family planning technique promoted simultaneously with the promotion of IUDs. The increase in the number of people doing family planning work was another achievement of the publicity month. More than 15,240,000 publicity personnel and 760,000 medical personnel were trained. The enthusiasm of the Party and the people contributed to the success of the publicity month. The success of the publicity month is inseparable from the achievements and experience gained through China's longterm pursuit of family planning.     

Falling fertility in Indonesia: success in national family planning

This publication summarizes the findings of the National Indonesia Contraceptive Prevalence Survey (NICPS), which revealed a rapid decline in Indonesia's fertility rate. This article also describes how the successful Indonesia family planning program is designed and maintained. Since 1975, fertility rates have dropped from 5.5 to 3.3 children per woman. Those practicing contraception during the same period has risen from 400,000 couples to 17 million. Contraceptive education is high (e.g. 95% of all married Indonesian woman are familiar with a modern contraceptive method). The Indonesia family planning program cooperates with other government activities designed to improve people's health and welfare. It emphasizes access to contraceptive methods and promoting the idea small family. The program was structured to us extensive community involvement, and cultural beliefs were incorporated into program policy; Islamic leaders were consulted before program implementation. The program is flexible so that the differing needs of each region can be effectively met by the family planning program. The future main goal will be to contain a potential population boom when the 40% of the present population which is under 15 years of age becomes reproductively mature.     

现行中国计划生育政策对中国人口安全的影响

本文从人口安全的定义出发,简单的分析了我国在发展中所面临的主要人口安全问题,并发现这些问题大部分都与我国的计划生育政策有着密切的关系。简要地阐述了我国现行计划生育政策的发展产生过程和主要内容。结合我国现行的“晚婚、晚育、少生、优生”的计划生育政策和我国主要的人口安全问题,从人口结构和人口素质两个方面,重点分析了我国计划生育政策对人口安全的影响。最后得出结论,要抓住现在的机遇期,调整现行的人口政策,最终实现中国人口与社会、经济、资源以及环境的协调可持续发展。     

New perspectives on population: lessons from Cairo

The lessons from the 1994 World Population Conference in Cairo, Egypt, are summarized in this publication. The topics of discussion include the evolution of population policies, the changing policy environment, demographic trends, and solutions in the form of gender equity, provision of reproductive health services, and sustainable social and economic development. The program of action supported by 180 governments and targeted for 2015 articulated the goals of universal access to a full range of safe and reliable family planning methods and reproductive health services, a specified level of reduction in infant and child mortality, a specified level of reduction in maternal mortality, an increase in life expectancy to 70-75 years or more, and universal access to and completion of primary education. Other features include goals for improving women's status and equity in gender relations, expansion of educational and job opportunities for women and girls, and involvement of men in childrearing responsibilities and family planning. Steps should be taken to eliminate poverty and reduce or eliminate unsustainable patterns of production and consumption. Population policy must be integrated within social and economic development policies. About $22 billion will be needed for provision of family planning and reproductive health services by the year 2015. Costs will increase over the 10-year period due to the increased population to be served. Per person user costs for family planning alone are higher in countries without infrastructure and technical skills. Actual costs vary with the cost of contraceptive supplies, patterns of use, and efficiency of delivery systems. Although the plan offers 16 chapters worth of advice and recommends 243 specific actions, countries will have to be selective due to cost limitations. The 20/20 Initiative is proposed for sharing social service costs between international donors (20%) and host countries (20%). A separate UN projection of need is for 33% of support from international donors for family planning and related programs. The constraints to the implementation of the action plan are identified as the rate of demographic change, the extent of public support for population limitation and provision of family planning services, and potential conflicts of interests and funding between cooperating agencies. The World Bank has developed guidelines for policy development according to a country's identification as an emergent, transitional, or advanced country.     

A Population Policy Rationale for the Twenty‐First Century

I propose that the primary goal of twenty‐first‐century population policies should be to strengthen the human resource base for national and global sustainable development. I discuss the shortcomings of the three dominant twentieth‐century population policy rationales: acceptance of replacement‐level fertility as a demographic goal; realizing a “demographic dividend” from the changing age structure; and filling the “unmet need” for family planning. I demonstrate that in all three cases the explicit incorporation of education into the model changes the picture and makes female education a key population policy priority. Population policies under this new rationale could be viewed as public human resource management. I argue that 20 years after the Cairo ICPD the international community needs a new rationale for population policies in the context of sustainable development and that a focus on human capital development, in particular education and health, is the most promising approach.