Family planning

Abel G.( MD, MPH, Ob Gyn Resident)

Outline
Introduction
Family planning in Ethiopia
 Introduction
Family Planning is having the number of children you want when
you want them
Objectives
1.Limit family size
2. Adequately space children
3. Reduce maternal and child morbidity and mortality
4. Help infertile couples to bear children
It is achieved through use of contraceptive methods and the
treatment of involuntary infertility
It is the center of maternal and child health improvement
Millennium Development Goal 5
Improve Maternal Health

Target 5A (set in 2000): Reduce the maternal mortality

ratio by three quarters between 1990 and 2015
Target 5B (added 2008):
Achieve, by 2015, universal access to reproductive health
 WHO Indicators MDG 5B
Contraceptive Prevalence Rate
Adolescent Birth Rate
Unmet Need for Family Planning
 History of contraceptive
Biblical times
Genesis 38:9 describes the story of Onan who uses coitus
interrupts as a method of contraception to avoid producing an heir
by his dead brother's wife.
Ancient Egypt
3000 BC : penis protectors used as protection against disease and
insects and also as a badge of rank and decoration.
1850 BC : crocodile dung mixed with honey and milk and place it
in the vulva. (Not as strange as it may sound as sugar ferments it turns
into lactic acid, a well-known spermicide.)
 1300BC : the Berlin Papyrus, one of the primary
sources of ancient Egyptian medical knowledge, tells us
of the first known oral contraceptive, a mixture of beer,
celery, and oil heated and drunk over four days
Oral contraceptives
1923 pure sample of oestrogen is obtained, an
important step in the development of oral contraception
1960 first oral contraception launched, Enovid-10,Pills.
There were almost seven times of today!
1969 progesterone only pills (multiple components)
1981 triphasic pills was developed
1982 biphasic pills
 Origins of FP Programs
For a long period of time motherhood was inevitable for most
women
Women have sought to control childbearing since ancient times
Herbs to prevent pregnancy and to induce abortion has been
used in ancient times
Women face high risk of death in trying to give life
Modern birth control movement started in 1912
Margaret Sanger, New York public health nurse opened the
1st FP clinic in 1916
 1920 the Birth Law which criminalized the
dissemination of birth control in France was
avoided
1921 Marie Stopes opened the UKs first family
planning clinic and marked the start of a new era
in which couples could reliably take control over
their fertility
1950s Margaret Sanger, founded the American
Birth Control League and was instrumental in
opening the way to access birth control
 Contraceptive use remained illegal in the US
until 1960s
Pills and IUD became available in 1960
US supreme court struck down laws barring
contraceptive use in 1965
Global Human Right Declaration in 1968
1976 Marie Stopes International was established
to provide accessible family planning services
globally.
Contraceptive use rose from 10 % then to 65%
now around the world
 Rationale for FP Programs
Demographic Rationale
Dominant rationale in the 1960s and 1970s
Reducing high fertility and slowing population growth
_Concerns over rapid population growth and high
fertility
_Surveys showed substantial unmet need for FP
Coale-Hoover theory (1950-1960)

Population development

Theory: high population growth cause poor

socioeconomic development
Policy : Government should intervene to
control reproduction
Revisionist theory (1970s)

Underdevelopment population

Theory : under development produce rapid

population growth
Policy : invest resources in developmental activities
 Revisionist Theory (1980s)

Population development

Theory :population is a neutral phenomena in the

process of development

Policy: other issues must take priority, like

Democracy, free markets
Health Rationale
Became prominent during the 1980s
The public health consequences of high fertility
became paramount
High rates of infant, child, and maternal
mortality
Abortion and its health consequences
FP could avert a third of maternal deaths
Human Rights Rationale
Became prominent in 1990s
The right to control reproductive decisions partly in
relation to demographic rationale
Found strongest articulation at the ICPD
Example
Chinas one-child policy
Romanias pronatalist policy
Indias mass sterilization camps
Indonesias IUD safaris
Ethio-Israeli women has been injected Depo
Advantages of FP
For women
Avoid unwanted and high risk pregnancies
Reduce morbidity and mortality
Children
Avoid morbidity and mortality
Better feeding, Care, Clothing, Schooling
Family
Improves family wellbeing
Better food, clothing, housing, living
Nations
Better Economic development
reduces the exploitation of natural resource
by reducing population growth
People's economic situation move faster in
countries where women have fewer children.
FP reduces youth dependency ratio
Conservation of Natural resources
World/Earth
Low demands on natural resources
Better opportunity for better life
The Lancet - Family Planning Series
Published July 2012
Broad discussion of effects of population and
family planning on well-being and the
environment
Published in advance of the London Summit on
Family Planning
Summit Goal: Mobilize global action supporting
the rights of 120 million additional women and
girls to access family planning without coercion
or discrimination
The Rebirth of Family Planning
Underlines critical importance of family
planning and calls for accountability.
1. Global population trends and policy options
2. Contraception and health impacts
3. Connection between population
demographics and climate change
4. Economic advantages of family planning
5. How human rights efforts can be leveraged
to satisfy unmet need for contraception
Paper 2- Contraception and health.

Cleland J, Conde-Agudelo C, Peterson H, Ross J, Tsui A.

Contraception and health. Lancet 2012;380:149-56.
Contraception and Maternal Mortality

Saifuddin Ahmed, Qingfeng Li, Li Liu, Amy O Tsui

Maternal deaths averted by contraceptive use: an analysis of 172 countries
The Lancet, Volume 380, Issue 9837, 1420 July 2012, Pages 111-125
Reducing Maternal Deaths by Satisfying Unmet Need for
Contraception
Contraception is a Life-Saving Public Health Intervention

Prevents 272,000 maternal deaths per year

Averts 44% of maternal mortality annually
Satisfying unmet need
Would avert an additional 104,000 maternal deaths
per year
Would result in additional 29% reduction in
maternal deaths
Without contraceptive use, global maternal death
rate almost 2-fold higher

Saifuddin Ahmed, Qingfeng Li, Li Liu, Amy O Tsui

Maternal deaths averted by contraceptive use: an analysis of 172 countries
The Lancet, Volume 380, Issue 9837, 1420 July 2012, Pages 111-125
Paper 2- Contraception and health.

Cleland J, Conde-Agudelo C, Peterson H, Ross J, Tsui A.

Contraception and health. Lancet 2012;380:149-56.
Paper 5 : Use of human rights to meet the unmet need for family
planning.
Design plans to provide universal access not only for
married women but for unmarried women and adolescents
and those marginalized by income, occupation, or other
Remove legal and regulatory barriers
Make commodities available according to the WHO Model
List including emergency contraception
Train adequate health workers and provide health facilities
Subsidize services
Establish transparent mechanisms for establishing quality of
services and assess progress towards equitable access

Cottingham J, Germain A, Hunt P. Use of human rights to meet the unmet

need for family planning. Lancet 2012;380:172-80.
Making family planning a national development priority.

Co-authors
Pierre Damien Habumuremyi, Office of the Prime Minister,
Government of Rwanda, Kigali, Rwanda.
Meles Zenawi, Office of the Prime Minister of the Federal
Democratic Republic of Ethiopia, Government of Ethiopia,
Addis Ababa, Ethiopia.

Family planning empowers women to

take charge of their lives whilst also
enhancing their contributions to family
wellbeing and overall national
development.
What will it take to eliminate preventable maternal deaths?
Co-authors
Kate Gilmore, UN Population Fund, New York, NY
Tedros Adhanom Gebreyesus, Ministry of Health, Addis Ababa,
Ethiopia

Using a health-system-strengthening
approach for scale-up, family planning
should be made available in every
community and in every facility
Barriers to Contraceptive Access

Lack of knowledgeable, skilled health workforce

Lack of health system infrastructure
Supply chain logistics
Lack of managerial capacity
Lack of political will
Religious and cultural practices
Gender inequality
Rape, forced marriage & forced fertility
Continuing challenges of family planning
Continued research and development are needed
More method options improve the accessibility
The need for FP services will continue to grow:
The number of women of childbearing age in the
developing world will rise from 1 billion in 1990 to 1.5
billion by 2010
Overlooked needs by some segments of society
require special efforts:
young people
marginalized group
urban and rural poor
 Access barriers remain
Improving physical, financial and legal access to
contraception can reduce unintended pregnancy
Barriers to wider use of fertility regulation
Potential users perception, concerns, and fears
regarding harmful effects on health
Poor quality family planning services
Male dominance and opposition to some
contraceptive methods
Traditional and cultural taboos
Measurements in FP
Common measures of contraceptive practice
Contraceptive prevalence rate
Couple Year of Protection (CYP)
Contraceptive continuation rate
Contraceptive failure and reason
Contraceptive method mix
Unmet and met need of Family planing
Demand for Family planning
Demand for family planning refers to the desire or
motivation of women or couples to control future fertility
Demand for family planning can by for
limiting
spacing
 Met and Unmet Needs of FP
1. Contraceptive prevalence is a measure of met
demand for fertility control.
2. Unmet need for contraception is measured as the
proportion of women in a sexual union desiring to
space or limit childbearing and not using contraception
3. Total potential demand for fertility control is
measured by contraceptive use + unmet need
 Unmet Need for Contraception

Women are defined as having an unmet need if they are:

Fecund
married or living in union
not using any contraception
do not want any more children, or
want to postpone for at least two years
Unmet need also includes:
Pregnant or amenorrheic women
With unwanted or mistimed pregnancies/births, and
Not using contraception at time of last conception
Expanded definition of unmet need
May include women who
Are using an ineffective method
Using a method incorrectly
Using unsuitable or unsafe method
 What are the reasons for unmet need?
1. Lack of access
To preferred method
To preferred provider
Physical distance may not be of major importance, but other
costs are, such as monetary, psychological, physical and
time
2. Poor quality of services:
Choice of methods
Provider competence
Information given to clients
Provider-client relationships
Related health care services
Follow-up care
 3. Family community opposition (power
relationships in the household)
Pronatalist
Concerns about unfaithfulness
Fear of side effects
Objections to male provider
Religious objections
4. Health concerns:
Actual side effects
Fear of side effects
5. Lack of information and misinformation
about
Available methods
Mode of action/how to use
Side effects
Source/cost of methods
6. Little perceived risk of pregnancy
Meeting unmet need, how?
1.Improve access to good quality services
Offer choice of methods
Eliminate medical barriers
Expand service delivery points
Home delivery
Social marketing
Provide confidentiality
2 . Involve men/husbands as well as women
3. Improve communication about: legitimacy of family
planning
Source of family planning information and suppliers
Misinformation and rumors regarding effects/side effects
Risks of contraception
Risks of pregnancy
4. Link family planning to other services
Prenatal care
Post-partum care/breastfeeding
Immunization
Post abortion care
Child health services
STI/HIV
Family planning in Ethiopia
 Background
The rapid population growth in Ethiopia is a serious
challenge to the development efforts of the nation.
Ethiopia has one of the highest rates of population
growth in the world and is the second most
populous country is Sub-Saharan Africa.
If the current rate of growth remains unchanged,
Ethiopia's population of 79 million will double in
less than 25 years and reach 350 million by the year
2050.
 Females and males constitute 49.5% and 50.5%
of the total population.
Ethiopias population is young with an average
age of 17 years.
The population density is 67.9/km2
Life expectancy at birth for females and males is
55.4 years and 53.4 years
 Women aged 15 49 years constitute 23.4% of
the total population.
Under five children account to 12.2% of the
population, and 42.6% of the total population is
under 15 years of age.
Adolescents aged 10 19 years, young people
aged 15 24 years and youth 10 24 years of age
make up 26.0%, 20.6% and 34.7% of the total
population, respectively (Census Report
2007).
 The potential health service coverage is 90%. Health
service utilization is 0.3%
The health service delivery follows a three tier
system.
The primary health care unit with one health center
and five satellite health posts serve 25,000 people.
The district hospital with four referring health
centers serves 100,000 people.
Zonal hospitals and regional referral hospitals
provide health care for 1 million and 5 million
people, respectively.
Historical Background and progress of FP programs
in Ethiopia
Modern FP services in Ethiopia is pioneered by The
Family Guidance Association of Ethiopia, established
in 1966.
1970 FGAE became associate member of IPPF
1975 FGAE became full member of IPPF
Though established in 1966, FGAE was not actively
involved in FP service until 1975
Even after 1975 its services were limited in Addis
only
.
 1980 FP service started in government health
facilities
National population policy adopted in 1993
NHP and HSDP launched and included FP
programs and set targets
 With the adoption of The Population Policy in 1993,
local and international institutions partnered with
the government in expanding FP programs and
services.
The National Office of Population was then
established to implement and oversee the strategies
and actions related to The Population Policy.
 In 1996, The Ministry of Health released
Guidelines for FP services in Ethiopia to guide
stakeholders as well as expand and ensure quality
FP services.
In this guideline, the ministry designed new
outlets for FP services in addition to the pre-
existing facility based and outreach FP services.
Moreover, integration and linkage of FP services
with other RH services has been emphasized in
other policy and strategic documents to enhance
FP utilization.
FP is widely provided under four main reasons:
Socioeconomic or demographic concern;

Health considerations;

Human right arguments; and

Justice and equity reasons.

)
 Factors contributing to limited FP services in
Ethiopia
Lack of political support and commitment
Until the 1980s family planning was considered some
thing hostile to the interest of the country by policy
makers
Restrictive laws
Civil and penal code articles discouraging the
manufacturing, distribution, importation, advertising and
publicity of contraceptives
Cultural and socio economic factors
Women's status
Value of children
Beliefs and religious faith
 Achievements of the FP Program
Promulgation of the national population policy in
1993
Family planning service was legalized
The quality of service provided has improved
Continuing skill training of providers
Wider range of contraceptive methods available
Better equipped health facilities
Increased number of service such as outreach
Policy Environment
The Ethiopian Government is a signatory to several
International Conventions/Charters and declarations
including :
the 1987 Safe Motherhood Conference in Nairobi;
the 1990 World Summit for Children;
the 1994 International Conference on Population and
Development (ICPD)
the 1995 Fourth World Conference for Women.
the Convention on Elimination of all forms of
Discrimination against Women (CEDAW)
the Millennium Declaration.
 The constitution of Ethiopia in article 35 clearly
states Women shall have equal right
with men, laws costumes and practices
that oppress or cause bodily or mental
harm to women are prohibited To
prevent harm arising from pregnancy and
child birth and in order to safe guard the
health, women have the right of access to
family planning information education
and capacity.
 The National Health Policy: states its main objective
as to give a comprehensive and integrated primary
health care in a decentralized and equitable fashion.
The policy states that mother and child health deserves
due consideration.
The national policy on women
Mitigating impact of inequitable customary laws
Increase access of women to economic and productive
resources
Better legal back up to women etc.
 The National Population Policy: The overall
objective of the population policy is to harmonize
the rate of population growth with economic
development and thereby improve the welfare of
the people.
Among the targets set two are related to family
planning
Reducing the current total fertility rate to
approximately 4.0 by the year 2015
increase the prevalence of contraceptive use
to 44.0% by the year 2015
 20-year Health Sector Development Plan
(HSDP) strategies of RH:
Delegate to the lowest service delivery level
possible, the provision of all FP methods, especially
long-term and permanent methods
Increase access and utilization of quality FP
services
Create acceptance and demand for FP, with
special emphasis on populations rendered vulnerable
by geographic dispersion, gender, and wealth.
 The five year growth and transformation
plan of FDRE not only aims to attain a fast
economic growth of 14.9% per annum but also
ensure the expansion of quality health service and
education to attain the millennium development
goal and also ensure the benefit of the youth and
women through capacity building and good
governance
Where are we currently?
 Knowledge of contraceptives
Knowledge of at least one method of contraception is
nearly universal among both women and men
Men and women are almost equally likely to have heard of
a modern method (98 and 97 percent, respectively).
Both women and men are more familiar with modern
methods of contraceptive than with traditional methods.
A higher proportion of men than women have heard of a
traditional contraceptive method (64 and 50 percent,
LAM is the least known modern method ( 3 %)
 Contraceptive prevalence rate
The contraceptive prevalence rate for all Ethiopian women
age 15-49 is 20 percent.
The contraceptive prevalence rate is 29 percent for
currently married women, and 57 percent for sexually
active unmarried women.(5% in 1990 , 29% in 2011)
Modern methods of contraception are more commonly
used by the interviewed women.
The most common modern method used by each group of
women is injectables, currently used by 14% of all women,
21% of currently married women, and 32% of unmarried
sexually active women.
Un meet need of family planning
25% of currently married women have an unmet need for
family planning16 % for spacing and 9 % for limiting.
(34% vs 25%)
Unmet need is almost twice as high among rural women as
among urban women (28% versus 15 %).
Almost one in every three Ethiopian women (29 %) has a
met need for family planning16 % for spacing and 12 %
for limiting.
The total demand for family planning among currently
married women is 54 %, A little more than half (53 %) of
this demand is satisfied.
Of the total demand for family planning, the demand for
spacing is one and a half times as great as the demand for
limiting (33 and 21 %, respectively).
Fertility level
The total fertility rate is 4.8 children per women.
Fertility declined only slightly between 2000 and
2005, from 5.5 children per woman to 5.4, and
then decreased further to 4.8 children in 2011.
Rural women are having about twice as many
children as urban women
Childbearing begins early in Ethiopia. More than
one-third (34 percent) of women age 20-49 gave
birth by age 18
National guideline of family planning
Family Planning services shall be delivered
through the following service delivery modalities:
Community based services
Facility based Family Planning services
Social marketing
Outreach services
 Range of services
Counseling
Provision of contraceptives
Screening for gynecological malignancies
Education on screening and treatment of sexually
transmitted diseases
Prevention of and treatment of infertility
The contraceptive mix in Ethiopia will consist of the following
commodities and methods:
Natural Family Planning Methods,
Abstinence
Fertility awareness based methods: Standard Days Method
(SDM), Rhythm(Calendar) Method, two-days method,
Cervical mucus (Billings ovulation) method, Sympto-thermal
method
Lactation amenorrhea method (LAM),
Withdrawal method
Modern Family Planning Methods
Male and Female Condoms/Diaphragms and other barrier
methods
Vaginal Contraceptive Foam Tablet and jellies
Emergency Contraceptives
Progestin-Only Pills
Combined Oral Contraceptives
Injectables contraceptives
Implants
Intra-Uterine Contraceptive Devices
Bilateral tubal ligation
Vasectomy