Six ways to increase uptake of family planning
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When France’s President Emmanuel Macron warned at the G20 heads of state meeting last summer that high fertility was a “civilisational” challenge acting as a brake on development in Africa, he was heavily criticised on social media.
Yet his message reflected the longstanding concerns of many observers over local growth, environmental damage and future global stability. It is particularly relevant for francophone western and central Africa, where the number of children per mother is as high as seven in countries like Niger.
Although rising populations can stimulate innovation and ideas, too many people risks undermining progress in other areas highlighted in the FT’s 50 Ideas to Change the World project, from economic growth and climate change remediation to political stability and health reform.
“There will be major pressures on urbanisation, and huge pressure to move to greener pastures,” says John May, a demographer specialising in Africa who is based at Georgetown University. “But there is not the enthusiasm you might expect for family planning. I’m not optimistic.”
As Nigeria’s former president, Olusegun Obasanjo, said recently at a discussion in London, some leaders across Africa argue for a pronatalist policy of maintaining and encouraging high birth rates: they claim the need to populate low-density parts of their countries for strategic reasons including security.
Rising family size in part reflects improved nutrition and health systems which have cut infant mortality, while in some parts of Africa it has yet to be followed by the classic “demographic transition” seen in other parts of the world where birth rates have fallen.
The result is rising pressure on land and ecosystems, helping trigger conflict and diluting the impact of economic growth. As Africa’s population expands sharply, there is also discussion about greater regional and inter-continental migration, itself sparking fresh tensions in other countries.
50 ideas to change the world
We asked readers, researchers and FT journalists to submit ideas with the potential to change the world. A panel of judges selected the 50 ideas worth looking at in more detail. The first tranche of 10 ideas are about meeting the challenges of a growing world population. The next 10 ideas, looking at solutions for growing energy and resource needs, will be published on January 8, 2018.
While there is no doubt that “birth control” has sometimes been coercive, as in the case of China’s one child policy or India’s forced birth control programmes in the late 20th century, modern discussion on family planning has focused on the rights of women to choose when, whether and how many children to have.
Early marriage of women reduces their chance to complete schooling, undermining the potential for development. Early and frequent childbirth carries health risks for young mothers and babies alike.
There were an estimated 134m women with “unmet demand” who wanted but were unable to obtain modern methods of contraception last year. “On the current trajectory we will not reach our targets,” says John Skibiak, director of the Reproductive Health Supplies Coalition, an international partnership of public, private and non-governmental organisations seeking to safeguard access to reproductive health.
He warns that the prospect of reduced funding of programmes from donors including the US, which has already cut its support for the UN Population Fund (UNFPA), could cause backsliding after several years of progress. “It’s a real worry.”
Nonetheless, there are a number of innovations which offer the prospect of more effective and widespread family planning for women who seek it:
1. Reproductive technologies
There have long been efforts to develop new approaches to family planning, including male contraceptives. While women’s rights and wishes frequently still remain neglected, long-acting, slow-release injectable contraceptives offer greater potential to give them control. Recent products such as Sayana Press are both discreet and reduce the risk of supplies of more traditional, shorter lasting commodities running out.
2. Supply chains
New ways are being explored to pool the procurement of supplies across regions and countries, with donors providing guaranteed volumes to incentivise manufacturers to invest and produce at low cost. Tracking and partnering between public supplies and private distributors and retailers offers potential to reduce waste and cases where stocks run out. “When you increase supply, demand itself grows,” says Mr Skibiak. This approach is being tested out in a programme in Senegal.
3. Mobile phone outreach
Telephones have the potential to transform family planning. They can help monitor contraceptive supplies and improve distribution. Their wide availability, portability and privacy also mean they can provide advice targeting remote communities, and frequently excluded groups. A study in Rwanda, for instance, suggested young people need more information but often feel family planning services are for married couples and not designed for them. The programme experimented with sending young people information about sexual health via text messages.
4. Working with religious leaders
Some communities within leading faiths — notably within Christianity and Islam — are perceived to be resistant to family planning — as with Catholic objections to abortion. Yet many religious leaders are proving increasingly open to the argument that sexual and reproductive health for women is essential for community welfare. Fighting early marriage and encouraging spacing of children is becoming more accepted. The influence of clerics is pivotal in winning wider support for programmes. The UNFPA and other organisations, for example, are working with leaders in places such as Sokoto, Nigeria and in Chad to change attitudes.
5. Piggybacking with other services
Growing attention is being paid to the value of integrating contraceptive provision into other networks and services, allowing them to reach a larger group. Young mothers, for instance, may prove reluctant to visit a family planning office because of social pressures or simply inconvenience and cost. However, they are motivated to bring in their infants to clinics for vaccinations and more willing to seek contraception at that time. A project run by Care International in Benin, for example, found that when mothers were offered birth control at the same time as vaccinations for children, the uptake of both services increased.
From microcredit in the Ivory Coast to phone credit vouchers in South Africa, “nudges” from policymakers and modest rewards can have a powerful influence on individual behaviour — whether through greater information on prevention of pregnancy and sexually transmitted diseases or the provision of contraception services. Marie Stopes, the UK-based reproductive health charity, ran a project in Madagascar distributing vouchers for family planning services via mobile phone. Projects like these have shown that even small cash payments to young women and their families — some unconditional, others linked to indicators such as a failure to become pregnant — can significantly reduce teen pregnancy, school drop out for early marriage, and infection.
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