Family Planning Programs
FAMILY PLANNING PROGRAMS
Family planning programs are organized outreach activities, often under government auspices, that distribute information, services, and supplies for modern means of fertility regulation. While they vary greatly, the following are regarded as the principal ingredients of an acceptable program:
- A delivery system that includes, at a minimum, community clinics and referrals to secondary and tertiary health centers for complications, side-effects, sterilizations, and, where legal, abortion services. In many cases, the delivery system includes community-based household distribution systems.
- A range of contraceptive methods, including both temporary and permanent methods of contraception. Often this range includes "traditional" or "natural" methods.
- Good counseling services and fully-informed consent and choice in the decision to use a method, and which method to use.
- Accurate information about contraception and its side-effects, and appropriate referrals for alternative methods.
The birth control movement had its roots in Europe, principally Great Britain, and the United States in the nineteenth century, but it began to grow rapidly during the two decades before World War II. It was a movement closely allied with feminism and was led by Marie Stopes (1880–1958) in Britain and Margaret Sanger (1883–1966) in the United States. Its principal aim was to grant to individuals, but especially women, control over their own reproduction.
The global family planning movement in a sense began in 1952. In that year, a group of birth control activists, the heads of the family planning associations in eight western and Asian countries (the Federal Republic of Germany, Hong Kong, India, the Netherlands, Singapore, Sweden, the United Kingdom, and the United States) met in Bombay for the purpose of forming an international organization to spread birth control information and technology. The result was the International Planned Parenthood Federation.
Among the western countries, the family planning movement was at the outset strictly a private and philanthropic enterprise, and its leaders were not necessarily guided by identical motivations. Some, often called "neo-Malthusians" after the English economist and population theorist T. R. Malthus (1766–1834), were primarily driven by concerns about rapid population growth and its implications for social, economic, and political wellbeing. Eugenicists, active prior to World War II, were concerned with perceived dysgenic effects of fertility differentials that they traced to low contraceptive use among the lower classes. Still others, the "family planners," were motivated by a desire to bring modern contraception and its benefits to the largest possible number of people and to liberate them from the burden of unwanted pregnancies and childbearing. Some of the early leaders, like Sanger, had roots in each of these three camps.
Also in 1952, the Indian government identified uncontrolled fertility and the high rate of population growth as a national problem and promulgated the first national population policy. During the decade that followed, Taiwan, South Korea, Hong Kong, Pakistan, and Singapore initiated family planning activities. By the mid-1960s most of the countries of South and East Asia had established nationwide government programs.
Debate about "Supply" and "Demand"
Both the neo-Malthusians and the family planners believed that national family planning programs were urgently needed. For the planned parenthood movement, family planning programs were the goal. For demographers and population control advocates, family planning was a means to an end. But not all neo-Malthusians saw family planning programs as necessarily an effective means. Many scholars and intellectuals viewed family planning programs as perhaps a necessary but hardly a sufficient means to bring down high birth rates in poor countries. This skepticism about the ability of family planning programs to reduce fertility, particularly programs in which individuals and couples participate on a purely voluntary basis, resulted in a deep and sometimes bitter debate about what constituted appropriate population policy.
At the heart of the debate were these questions:
- Were people sufficiently motivated to limit their childbearing that voluntary family planning programs could bring about substantial fertility declines?
- If sufficient motivation existed, would organized programs be needed to spread birth control practice?
- Were additional measures ("beyond family planning") required to change childbearing behavior, either through inducement or coercion?
- Would people respond to direct appeals to bear fewer children?
- What priority should family planning programs command in comparison to other health programs and among government social expenditures in general?
One approach to seeking answers to these questions was through a series of surveys of knowledge, attitudes and practice (KAP) regarding fertility and birth control. These surveys were conducted in a number of countries from the late 1950s through the 1960s. They asked mostly women, but sometimes also husbands, how many children they wanted, whether they knew about and/or approved of family planning, whether they had ever used a family planning method, and so on. The surveys demonstrated a much higher than expected level of what was called "latent demand" for family planning: women knew about it, generally approved of it, and in many cases wanted fewer children than they actually had, or wanted to postpone or avoid the next birth, but were nonetheless not practicing a method. This information was used to try to persuade governments in developing countries to adopt population policies, with voluntary family planning programs as a central element.
Early Program Efforts and International Assistance
By the early 1960s the invention of both the birth control pill–the oral contraceptive–and the intrauterine contraceptive device (IUD) revolutionized family planning. Now, for the first time, easy-to-use, unobtrusive and easily distributed contraceptives could be made available at relatively low cost to entire populations.
The new technologies permitted large-scale family planning programs to be established or greatly expanded. With modern contraceptives, it became much easier to mount experimental service delivery systems and to test, in practice, how people would respond to the availability of family planning services. A number of field experiments were set up
around the world. One of the earliest and most successful was the Taichung experiment in Taiwan. A carefully designed experiment, with both treatment and control areas and excellent data collection and monitoring, the Taichung project demonstrated that there could be a strong and lasting effect from a voluntary family planning program.
International assistance for population programs began in the late 1950s and grew in the early and mid-1960s. In 1958 Sweden became the first western country to provide assistance for family planning with grant aid to Sri Lanka. Projects quickly followed in India, Pakistan, and other countries. Other western donors followed suit, providing grants to the International Planned Parenthood Federation and in a few cases directly to governments in developing countries. But the big breakthrough in public support for international family planning came in the late 1960s, first in 1966 and 1967 when the United States officially began to provide population assistance through the Agency for International Development (USAID), and a year later when the United Nations Fund for Population Activities (UNFPA–today called the United Nations Population Fund) was established and began to operate as a mechanism for channeling donor funds to developing countries.
Disappointing Results in South Asia
While the Taichung experiment and early program efforts in East Asia looked promising, the results of large-scale family planning program efforts in South Asia were quite discouraging. India and Pakistan both decided in the early 1960s to mount major national family planning programs based primarily on the IUD. While the programs were voluntary, women were strongly encouraged to accept IUD insertions, often in camp-like settings or on special days at clinics and dispensaries. In addition, the providers of the services, especially doctors trained to insert IUDs, received payments on a per-case basis.
Evaluations carried out a few years after these programs were initiated revealed widespread discontinuation of use, rampant rumors (often false) about side-effects, many cases of fraudulently reported insertions, and virtually no effect on birth rates. These results were disheartening to the two governments and to family planning advocates outside South Asia. Moreover, they seemed to confirm the skepticism of many demographers toward the family planning approach to fertility decline.
The failures of the IUD programs in India and Pakistan severely diminished support for the family planning approach and reinforced the view that a
broader "developmental" approach to population policy was required–an approach that, in programmatic terms, emphasized raising literacy levels, especially for girls; reducing infant and young child mortality; improving employment opportunities for women; establishing mechanisms to provide old-age social and economic security; and generally reducing the conditions of poverty and underdevelopment that give rise to a high demand for children.
Many economists, arguing that high fertility was a rational response to poverty and high child loss due to mortality, began to gain influence among development planners and policymakers. In South Asia there were calls for approaches beyond family planning, including cash incentives, "no-birth" bonus schemes, and even outright coercion on couples to limit their childbearing.
USAID's "Supply-Side" Approach
Notwithstanding such disappointing early results in South Asia, USAID, by then the largest donor of international population assistance, adopted an almost pure family planning approach as it rapidly expanded its population operations in the late 1960s and early 1970s. USAID's population program director, R. T. Ravenholt, believed firmly that there were millions of women throughout the world who, if given access to safe and effective methods of contraception, would use them. He often stated that true demand could only be measured in the context of actual availability of services. He was determined that USAID would do everything it could to ensure that such services would be available in as many countries as possible.
East Asian countries other than China, Vietnam, and North Korea (which in their family planning programs mixed the provision of services with application of strong administrative pressures to ensure that the services had clients) turned out to be the ideal testing ground for USAID's "supply-side" approach. Governments there, increasingly worried about rapid population growth and encouraged by the success of the Taichung experiment and Taiwan's subsequently successful family planning program, were now ready to move ahead with family planning programs (see Figure 1). A key figure in promoting this evolution of thinking and policy in the region was Spurgeon "Sam" Keeny of the Population Council.
Following the early efforts of planned parenthood pioneers and of organizations such as the Population Council, USAID moved quickly to establish major assistance programs in Korea, the Philippines, Indonesia and Thailand–and all of them thrived. The adoption of contraception grew rapidly in the early 1970s and fertility soon fell, in some cases more dramatically than ever before seen (see Figure 2). These were among the earliest major family planning success stories at a national level and they helped to restore confidence in the family planning approach.
Bucharest–the 1974 World Population Conference
The continuing uncertainty about the effectiveness of the family planning approach set the stage for the debate that ensued at the first intergovernmental World Population Conference, held in Bucharest under United Nations auspices in August 1974. Western delegations, led by the United States, hoped that the Bucharest Conference would adopt a global demographic goal, and that individual countries could be persuaded to set demographic targets for themselves–expressed either in terms of the rate of population growth or declines in birth rates. But this aspiration faced fierce opposition, both to demographic targets and to Western neo-Malthusianism. Many developing countries, supported by the Soviet bloc, China, and other non-aligned and socialist states, denied that rapid population growth was the serious problem alleged by the West and attacked efforts to push them toward adopting anti-natalist policies and programs as "neo-colonialist" or "imperialist." In addition, countries with large Roman Catholic populations and strong Vatican influence opposed efforts to spread modern birth control technologies–an opposition that has remained a constant at international conferences on population ever since.
This opposing coalition successfully blocked the United States and its Western allies in their efforts to press a strong demographic agenda. On the other hand, the vast majority of countries agreed on language that established access to family planning information and services as a basic right. In the words of the World Population Plan of Action adopted at Bucharest in 1974, it is "the basic human right of all couples and individuals to decide freely and responsibly the number and spacing of their children and… to have access to the necessary education, information and means to do so."
It is important to note that many of the countries of East and Southeast Asia that had already adopted anti-natalist population policies and strong family planning programs remained relatively quiet during the debate, refusing to join the more vocal opponents of the neo-Malthusian approach in Latin America, the Middle East, and Africa. India, the population policy and family planning pioneer, was among the most vocal countries in its opposition to Western-imposed population policies and family planning programs and was the strongest advocate of the alternative "developmental" approach. The head of the Indian delegation, Minister of Health Karan Singh, uttered perhaps the most famous quote at the Bucharest conference: "Development is the best contraceptive."
Progress after Bucharest
The debate about family planning reached a peak of intensity at Bucharest, largely owing to the absence of solid empirical evidence regarding the effect of family planning programs on fertility. Apart from scattered evidence from a few experimental projects and some highly suspect statistics generated by family planning programs themselves, there was little information from which persuasive conclusions could be drawn.
Fortunately, in the early 1970s USAID and UNFPA had agreed to launch the World Fertility Survey (WFS). The WFS was to collect information from women (and later their partners) in as many developing countries as possible on fertility aspirations, actual fertility experience, knowledge about and attitudes toward contraception, use of contraception, and many other variables, including socioeconomic background factors such as education, religion, income, and occupation. The purpose of the survey was to help developing countries, as well as donor nations and international organizations, to measure both what was happening to fertility and the reasons behind whatever changes were discovered.
The WFS was a great success. In its first five years, it conducted surveys in more than 40 countries,
including many of the largest. By the late 1970s analysis of these surveys and comparisons among them indicated that social and economic development variables, were, indeed, powerful determinants of fertility but that family planning programs in many countries were accelerating the rate of fertility change and, in some cases, apparently having an independent effect on it.
Another scientific enterprise that helped to resolve the debate was a family planning experiment in the Matlab area of Bangladesh. There, the International Centre for Diarrhoeal Disease Research maintained a detailed demographic and health surveillance system that permitted measurement of the effects of a variety of health interventions. Taking family planning as one of these, scientists succeeded in demonstrating that even in a highly impoverished, resource-constrained setting, the provision of a reasonably high quality family planning program could bring about significant and lasting effects on fertility. The Matlab Project seemed to disprove the assertion that fertility could not decline except in the context of broadly and substantially improved living standards.
The decade between the Bucharest Conference and its successor, the International Conference on Population (ICP) in Mexico City, held in 1984, was a period of consolidation and expansion of family planning programs. Nearly all countries, whatever their position had been at Bucharest, either developed or permitted the development of family planning service delivery programs during this decade. This was true whether countries had explicit anti-natalist population policies or not. Indeed, many countries in Latin America, for example, encouraged the expansion of voluntary family planning programs on the grounds that they were shown to improve both maternal and child health. The Mexico City conference, which was intended as a review of the World Population Plan of Action adopted at Bucharest, strongly reaffirmed the idea that family planning should be a basic right that governments should ensure for their people.
In the mid and late 1980s family planning programs flourished. Impressive gains in contraceptive use were recorded in nearly all parts of the world, and there were corresponding declines in fertility (Figure 3). By the end of the decade, contraceptive
use globally was estimated to be over 50 percent among women of reproductive age, and the total fertility rate had fallen from its mid-1960s peak of around six children per woman to less than four (Figure 4). A significant majority of women in the developing world were getting contraceptive supplies and services from publicly-supported family planning programs.
But there had been clouds building on the family planning horizon for a number of years. Critics of the family planning movement began to call for reforms over concerns that some countries, including such large countries as India, China, Bangladesh, and Indonesia, were employing coercive or semicoercive measures to induce people to limit their fertility. Feminist groups in several countries began calling quite vocally and insistently for a broader, more inclusive approach to women's health needs. They called this new approach "reproductive health."
Some in the reproductive health movement blamed the demographic goals of many family planning programs for creating a narrow perspective that often ignored women's health. They insisted that programs should no longer provide just contraceptives and family planning information, but should also attend to other women's health problems such as unsafe abortion, sexually transmitted diseases and reproductive tract infections (including HIV/AIDS), and emergency obstetrical care. Furthermore, they argued, the family planning approach ignored such other important aspects of population policy as girls' education, women's employment, the empowerment of women in matters of inheritance and political participation, and reducing infant and child mortality. These feminists called for comprehensive population policies that replaced demographic targets with holistic concern about women's well being, most especially their health.
By the early 1990s these calls for reform and for the reproductive health approach had penetrated the thinking of many international organizations and donor agencies. Governments in the developing world were somewhat slower to respond, but the issue exploded onto the world political stage at the International Conference on Population and Development (ICPD) at Cairo in 1994, the third decennial intergovernmental population conference.
It is probably fair to say that the family planning approach to population policy ended at Cairo, to be replaced, in the ICPD Programme of Action, by what was now being called the reproductive and sexual health and rights approach. To be sure, family planning remained a significant, even a central, part of reproductive health, but the 180 or so governments that gathered at Cairo clearly rejected demographic and family planning targets in favor of the more comprehensive approach. While Bucharest and Mexico City had certainly mentioned these other measures, it was not until Cairo that the international women's movement had acquired sufficient strength to place the empowerment of women at the forefront of population policy.
In the years since Cairo, most governments around the world have modified their population and health policies to conform with the Cairo Programme of Action. Governments vary widely, though, in the extent to which they have really made the transition from family planning to a more comprehensive approach. For many governments the rhetoric of Cairo has not been translated into real program reforms.
See also: Birth Control, History of; Contraception, Modern Methods of; Contraceptive Prevalence; Induced Abortion: Prevalence; Population Policy; Reproductive Rights; Sanger, Margaret; Unwanted Fertility
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Steven W. Sinding