International Family Planning Programs

Family planning programs occupy an unusual place in the public policy arena. They exist in virtually every nation in the world (see figure), yet they continue to spark controversy in some quarters. The Origins and Evolution of Family Planning Programs in Developing Countries, by Judith R. Seltzer, examines the main critiques of family planning programs and places these in historical context. The report also examines the research record to assess the validity of these criticisms and to document how programs have evolved in response to these criticisms. The intent in surveying this historical record is to enable readers to view current debates about family planning in a broader context and to evaluate the research evidence associated with claims made by proponents as well as critics of family planning programs.

The report addresses three main questions:

• What have been the main controversies and criticisms of family planning programs and were they valid?
• How have programs changed in response to criticisms and concerns?
• What are the lessons for policy that emerge from understanding these criticisms and the evolution of family planning programs in response?

Assessing the Main Criticisms of Family Planning Programs

To understand the main criticisms of family planning programs, it is helpful to review the three public policy objectives that have underpinned these programs:

1. the demographic rationale, which holds that reducing fertility rates and slowing population growth benefit developing nations
2. the health rationale, which focuses on mitigating the adverse health consequences of high fertility for mothers and childre
3. the human rights rationale, which rests on the premise that individuals and couples have a right to control reproductive decisions, including family size and the timing of births

The main criticisms of family planning programs have paralleled these three objectives, frequently questioning the goals of the programs or the efficacy of programs to accomplish them. In addition, family planning programs have faced criticisms on cultural and religious grounds. Each of these areas is discussed in more detail below.

Criticisms Associated With the Demographic Rationale

The demographic objectives of family planning programs are based on three assumptions: (1) Rapid population growth impedes economic development, and therefore lower rates of population growth and lower fertility will help improve living standards and human welfare; (2) couples in developing countries want fewer children and seek to regulate their fertility; and (3) making contraception widely available is an effective way to meet couples' desires for fertility regulation and to moderate high fertility. Each of these assumptions has been debated. More recently, as aggregate global fertility rates have continued to fall, some have challenged the continuing need for programs aimed at reducing fertility.

Economic Development

Criticism: Lowering high fertility and slowing population growth will not necessarily produce economic benefits. Concerns about the impact of rapid population growth assumed that such growth would hinder economic development in developing countries and threaten food supplies, natural resources, and the environment. This assumption was called into question by social scientists who disputed the link between high fertility rates and economic growth. The debate over the link between rapid population growth and economic development continued for decades because the research base was inadequate to resolve the areas of disagreement.

Valid? Until recently, there was no conclusive research evidence that high fertility impedes economic development at the macro or national level. However, research evidence from the last decade ¹ has demonstrated that substantial economic benefits can follow from reducing high fertility. Known as "the demographic bonus," these benefits result from falling birth rates: A shrinking share of the population consists of dependent children and a greater share consists of working-age adults, boosting productivity and allowing added savings or investment. This "bonus" is not inevitable, however--it depends on other policy variables, including economic opportunity, education, and commitment to public health.

The Need for Contraception

Criticism: People in developing countries want to have large families and are not interested in regulating their fertility. A common criticism of family planning programs voiced beginning in the 1960s centered on the demand for contraception. According to this criticism, most couples in developing countries would not be receptive to voluntary family planning because they preferred large families and thus had no desire to regulate their family size or the timing and spacing of births.

Valid? No. Since the 1960s, surveys of women and couples have consistently shown that a large proportion of them had favorable attitudes toward contraception and that many couples wanted no more children. The surveys also showed that among those not wanting more children, many were not practicing contraception and thus had an "unmet" need for contraception.

Program Effectiveness

Criticism: Family planning programs are not an effective way to reduce fertility or slow population growth. The efficacy of family planning programs to provide contraceptive services that would contribute to lower fertility, and ultimately to lower population growth, has been another key part of the debate over demographic objectives. Some social scientists and women's rights advocates questioned whether family planning programs were the appropriate policy intervention for reducing high fertility because they favored a broader approach to lowering fertility.

Valid? No. The research evidence gathered over many years has confirmed that voluntary family planning programs are an effective public policy in many developing countries for enabling couples to regulate their fertility. Research has also shown that family planning programs have helped increase the prevalence of contraception, which has contributed substantially to reducing fertility rates. Granted, the level of development in a given setting has also been important for reducing fertility. As development progresses, fertility rates tend to fall.

Population Explosion or Implosion?

Criticism: Because global fertility rates are falling and rates of population growth are diminishing, family planning programs are no longer needed. Some recent commentators on public policy have sounded an alarm about a coming population implosion--the so-called "birth dearth"--implying that population growth is no longer an important policy concern and therefore that family planning should no longer be a public policy priority.

Valid? Not for developing countries. The birth-dearth discussion has focused selectively on Western Europe and a few other highly developed nations, such as Japan, where fertility rates are below replacement level (defined as 2.1 births per couple). While fertility rates have declined in many nations in the past half-century, global population growth is projected to continue well into the 22nd century. There remain sizable variations among regions and countries in levels of population growth and fertility. For most of the world's nations, especially in the Middle East, Africa, and South Asia, the major demographic challenge over the next several decades will continue to be reducing mortality and fertility through a combination of economic growth and social-sector programs, including those in education, health, and family planning.

Criticisms Associated with the Health Rationale

The health objectives of family planning programs have prompted four main concerns. The first criticism, voiced by health advocates and women's rights advocates, has focused on contraceptive technology and contraceptive safety. The second issue is whether there were indeed health benefits associated with regulating fertility. The third, and most controversial, aspect is the relationship between abortion and contraceptive use. The fourth, also raised by health advocates and women's rights advocates, concerns the quality of care in family planning programs and the importance of considering family planning in the broader context of reproductive health, including safe pregnancy, women's nutrition, breast-feeding, and HIV/AIDS prevention.

Narrow Technological Focus

Criticism: Family planning programs are sometimes too narrowly focused on contraceptive technology. Critics of the role of contraceptive technology have questioned whether programs would be the technological fix that proponents assumed. Many health advocates thought more emphasis should attach to the social and cultural influences on women's lives, which affect their ability to take advantage of contraception. They held that the safety and efficacy of various contraceptive methods were also very much shaped by the health infrastructure, which is weak in many settings.

Valid? Many of these concerns were valid. As a result, family planning programs have in many instances given both greater attention to contraceptive safety issues and greater emphasis to the broader context of women's lives. As a result, women's perspectives have had greater impact on contraceptive development and research.

Health Benefits

Concern: Family planning and fertility regulation may not provide the important health benefits for women and children that they are presumed to offer.

Valid? No. The health benefits of family planning have been well documented. Research has confirmed that safe and effective contraception helps to reduce maternal mortality by reducing the number of births and high-risk pregnancies, including unintended pregnancies. Family planning can also improve child health and survival by reducing the number of births associated with higher risks (births less than two years apart; births to very young and older women; and higher-order births, i.e., birth of the fifth or subsequent child). The documented health benefits of family planning have become an important consideration in the adoption of national population policies, especially in African countries. As the promotion and use of condoms has become an important component in the campaign against the spread of HIV and AIDS in the developing world, the health benefits of family planning have become even clearer.

Abortion and Contraceptive Use

Criticism: Family planning programs promote abortion or increase its likelihood. In recent years, the question of whether family planning programs advocate or promote abortion has figured prominently in the U.S. policy debate over public funding for family planning programs overseas.

Valid? The preponderance of evidence suggests not--that, in fact, the opposite is true. A sizable body of research conducted in many areas, including Bangladesh and the former Soviet Union, has shown that the presence of quality family planning services can reduce abortion by reducing the incidence of unintended pregnancies. It is also increasingly recognized that some women will choose to end unintended pregnancies through abortion regardless of whether it is legal in their country. Given this reality, family planning programs that provide postabortion care, which includes contraceptive counseling, are increasingly supported as a way to reduce repeat abortions. This fact also means that it is especially important to provide family planning to reduce unintended pregnancies in areas where abortion is illegal, because of the high risks of maternal mortality and health problems associated with unsafe abortions.

Quality of Care

Criticism: Family planning programs pay insufficient attention to client needs and quality of care and tend to ignore other aspects of women's reproductive health care. For more than a decade, there has been increased interest in the quality of care provided by family planning programs. Health care advocates, women's rights advocates, and others pointed to evidence--such as levels of discontinuation of contraceptive use and the unmet need for contraception--that implies that clients' needs and quality of care were receiving insufficient attention. And they have pointed to women's other health needs that also merit attention.

Valid? Yes, in some settings family planning programs focused heavily on contraceptive supply without enough emphasis on the quality of services delivered or women's other health needs. Concern over this issue helped motivate research aimed at improving the quality of family planning services and thinking about the best ways to integrate family planning services with other aspects of reproductive health, without unduly compromising the former. At the International Conference on Population and Development (ICPD), held in Cairo in 1994, representatives of 180 countries agreed to the goal of universal access to reproductive health information and services by 2015. The ICPD Program of Action endorsed the broader context of reproductive health instead of the narrow approach to family planning. Family planning was considered one of the basic reproductive health services (the others included prevention of sexually transmitted diseases; adolescent reproductive health; and maternal health care, e.g., safe pregnancy, safe abortion where legal, and women's nutrition). USAID has joined the general move toward more client-centered approaches to family planning and also the shift to the broader context of reproductive health for its family planning assistance. Studies that assess the effects of improved quality have shown initial, promising results. Efforts to measure and improve the quality of care and to integrate family planning with other reproductive health services present ongoing challenges for health services in countries around the world and for the international donor and research communities.

Human Rights Concerns

Criticism: Family planning programs can be coercive and ignore basic principles of voluntarism and individual welfare and rights. Human rights advocates have contended that the emphasis on demographic goals and targets set by some government programs in developing countries may interfere with women's rights to autonomy in decisions about childbearing and contraception and can have a coercive effect on reproductive decisions.

Valid? Yes; to some extent in some areas, these criticisms have been validated by research. Goal- or target- oriented programs in several nations, notably China, India, and Indonesia, have exhibited varying degrees of coercion or social pressure. China in particular has been the focus of humanitarian concerns. These concerns have resulted in a number of policy and program changes and have heightened the sensitivity of international donor organizations to these issues. For example, the United Nations Population Fund (known as UNFPA), one of the largest donor organizations, has prompted the Chinese government to allow experimentation that sets up alternative models of service delivery to address quality-of-care issues and choice of methods. By late 1999, some 660 counties and urban districts had begun pilot projects emphasizing quality of care.

In 1998, the U.S. Congress passed legislation to reinforce human rights principles associated with U.S.-supported family planning programs in developing countries. Known as the Tiahrt Amendment, the legislation renewed emphasis on USAID's long-standing commitment to the principles of voluntarism and informed choice in family planning and opposition to coercive sterilization and abortion.

Cultural and Religious Criticisms

Cultural Intrusiveness

Criticism: Family planning programs represent a cultural intrusion into the affairs of developing countries. Charges of cultural intrusion by the West have occasionally been directed at family planning programs from several perspectives, including Islamic fundamentalists and South American leftists. Family planning programs were sometimes viewed as attempts by foreign powers to contain the growth of developing nations' populations. These concerns often presumed that the desire to regulate fertility was a Western preoccupation not shared by a majority of women in developing countries.

Valid? Cultural sensitivity issues have arisen in some countries in connection with program implementation and service delivery. Many programs have adapted services to fit cultural contexts, such as providing door-to-door delivery in more traditional Islamic countries where women are discouraged from appearing in public. Community participation in program development has been key in addressing cultural concerns. Furthermore, surveys of women in developing countries have shown both widespread desire to regulate fertility and an acceptance of family planning.

Religion

Criticism: Family planning violates the teachings of some religious traditions. Concerns about respecting religious teachings in particular regions and localities have been a long-standing consideration for some family planning programs. Perhaps the strongest opposition comes from the Catholic Church, which prohibited artificial contraception in 1930. The Church opposes interfering with the process of conception and also views contraception as immoral because it may promote marital infidelity and lead to the debasing of women. However, the teachings and beliefs of most religious traditions are diverse and complex, making it difficult to generalize about religious responses.

Valid? Research is a severely limited tool in assessing religious or ethical appropriateness. Studies have shown, however, that religious concerns over family planning programs vary widely in developing countries, and that such programs are not incompatible with the beliefs of many. Thus it is not surprising that the majority of couples in predominantly Catholic and Islamic countries use contraception. One important observation from research is that involving religious leaders in policy development has improved acceptance and understanding of family planning programs.

Lessons for Policy

Several lessons for guiding policy emerge from reviewing the criticisms and controversies surrounding international family planning programs.

• Since their origins in the 1960s, family planning programs in the developing world have not been static. They have evolved in response to valid criticisms, changing views of their needs and objectives, lessons from program assessment, and increasing knowledge about effectiveness in varying political and cultural contexts.
• Programs must continue to adapt as the global challenges evolve. Approximately one billion adolescents--the largest cohort in history--will soon be entering their years of sexual activity and childbearing. They will be among the growing numbers of individuals and couples seeking services. Satisfying their needs will add considerably to the challenges of service delivery in the future.
• Adapting the health care rationale to current global conditions will require new organizational and financing arrangements. New combinations of reproductive health services, particularly those that address HIV/AIDS and sexually transmitted diseases, will require reconfiguring services as well as new expertise, training, and financial resources.
• Governments and donor organizations should continue to support the participation of women's groups and health advocates, whose criticisms have contributed to improvements in policy and program design.
• Research continues to be vital in understanding how and where programs have been most effective, and in identifying future needs and how they might be addressed.

Notes

• [1] A report from Population Matters describes this research evidence in greater depth (The Demographic Dividend: A New Perspective on the Economic Consequences of Population Change by David E. Bloom, David Canning, and Jaypee Sevilla, RAND MR-1274-WFHF/DLPF/RF/UNPF, 2002).

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Topics

• Family Planning
• Gynecology