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    © 2011 Adrienne Allison World Vision, Courtesy of Photoshare

    Two women in Senegal discuss long-acting family planning methods. © 2011 Adrienne Allison World Vision, Courtesy of Photoshare


    West African countries have the highest fertility rates in the world, with an average of 5.5 births per woman; they also have the lowest levels of contraceptive use.

    As a longtime physician and family planning/reproductive health trainer at IntraHealth International, I see several reasons for this. When I started training male health providers in family planning services in West Africa in 1997, I was met with a lot of resistance. Many men thought that female clients wouldn’t want to talk to male health providers. But I told them, “It depends on how they see you. When you return to your facility, you need to tell people what you can do for them, advertise your new skills in family planning services, encourage women to come with their husbands so they can trust you as a couple, and build trust within community.”

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    The Leaking Bucket Phenomenon in Family Planning

    This blog post by Anrudh K. Jain, Distinguished Scholar of The Population Council originally appeared on September 9, 2014 in the Champions 4 Choice blog, a blog of the EnderHealth-led RESPOND Project. 

    Family planning (FP) programs in developing countries have been experiencing a phenomenon that I like to call “the leaking bucket.” Let’s say that you place a bucket under an open tap and watch the water level rise, until you discover a hole in the bottom of the bucket. Water is now leaking out of the bucket. Filling the bucket will be easier once the hole is plugged. In the same way, meeting women’s desire to reduce unwanted fertility will become easier once FP programs pay more attention to contraceptive discontinuation.

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    Findings from the first round of the Performance Monitoring and Accountability (PMA 2020) Ethiopia survey, an innovative mobile-phone-based survey, show impressive progress for Ethiopia’s national family planning programs.  Since the most recent Ethiopia Demographic and Health Survey (EDHS) in 2011, the modern contraceptive rate among married women has increased markedly from 27 to 33%; representing a 6% increase in just three years.  

    Gains in contraceptive use is highest in rural areas and among the poorest segments of the population.  PMA2014/Ethiopia also found marked increases in the use of more effective long-term methods such as implants, with an increase from 12% to 16% of the method mix.  

    Moreover, the survey’s findings reveal that the average number of children per woman in Ethiopia has steadily declined from 5.5 in 2000 to 4.4 in 2013.  Furthermore, the unmet need for family planning has sharply declined from 25% in 2011 to 19%, today with 9% of women wanting to delay their next birth and 10% wanting no more children.  The unmet need is highest for women in the poorest wealth quintile.

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    “Performance Monitoring and Accountability 2020” (PMA2020) -- a project that supports regular low-cost, rapid-turnaround, nationally-representative surveys using smartphones -- has released the findings from the first round of data collection in Ghana: our first launch country. This innovative approach to data collection allows policy makers, program managers, and public health researchers access to national estimates of various health indicators.

    The indicators generated from PMA2020 data provide consistency with the Demographic and Health Survey (DHS) measures.  The surveys also introduce new measures of family planning access, equity, quality and choice (e.g. whether contraceptive users obtained the method of their choice, decision-making on choice of current method, and availability of integrated health services). In addition, PMA2020 survey data captures indicators for adolescent reproductive health and family planning access and utilization for all women of reproductive age.

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    Methods provided by a clinic in Ethiopia

    Rights-based family planning includes a well-functioning health system with informed providers and appropriate methods in stock. This photo shows the methods provided by a clinic in Ethiopia.

    Earlier this week, governments from around the world committed to a “historic level of support for Sexual and Reproductive Rights” during the Commission on Population and Development. Rights are central to sustainable development and should be integrated into the post-2015 development framework. Rights around family planning are not just about coercion or forced sterilization, but the myriad other ways in which women and families might be denied appropriate information or methods due to age restrictions, poorly trained providers, or outdated and uninformed policies. A lot of what we do at K4Health is to help program managers and providers design and deliver quality family planning programs based on evidence. For example, the Bangladesh Knowledge Management Initiative helped address the information and training gaps from the national to community level.

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    At the International Conference on Family Planning in Addis Ababa, Ethiopia, this week, several Ministers of Health gathered to discuss the importance of investing in youth to save the lives of women and children. After visiting several community health centers yesterday, the ministers gathered at the High Level Ministerial Meeting (HLMM) at the African Union and shared priority activities to reach the demographic dividend. To learn more about the demographic dividend, the video below from Population Reference Bureau gives an easy-to-understand overview.

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    In Addis Ababa, Ethiopia, over the course of the next few days, thousands of family planning advocates will convene at the International Conference on Family Planning to share progress and chart the way forward for family planning. This is the third time I’ve had the privilege to be a part of this conference, which has continued to build on the visibility of the first conference that took place in 2009 in Uganda. The first conference created a platform for discussing global family planning and the second conference in 2011 was convened in Senegal to highlight family planning in Francophone Africa. This year, Ethiopia was chosen as the host country because of the progress the country has made in increasing the contraceptive prevalence. Their success is in part due to the work of Health Extension Workers (HEWs) who are on the frontlines of family planning service provision.  While the HEWs are indeed “amazing” as one visiting health minister stated, the success in Ethiopia would not be possible without the high-level commitments made by those in government including health ministers.

    Health Extension Workers at the Maruchobot Health Post

    Health Extension Workers at the Maruchobot Health Post proudly discuss achievements in primary health services.

    Today, I accompanied a few visiting ministers of health and their staff from Nigeria, Uganda, and South Sudan on visits to a rural health post and health center. Located roughly 60km Northwest of Addis Ababa, both the Enchni Health Center and the Maruchobot Health Post realized recent gains in provision of family planning. Our first stop was the Maruchobot Health Post, which serves a population of 2,557 and 609 women of reproductive age. The post began providing family planning services five years ago and the two HEWs who work here are extremely proud of their accomplishments, which are also the result of active community engagement. Short-term methods dominate at this facility as well as at Enchni Health Center, the larger referral center and second stop on our visit. Sarah Opendi, Minister of State Health, Primary Health Care and Member of Parliament in Uganda said she learned how vital the community is in uptake of family planning in these two facilities. Dr. Margaretitto Leonardo, Minister of Health, Eastern Equatorial State, Republic of South Sudan, also commented on how data was prominently displayed at both the Health Post and the Health Center so all staff can see trends and progress. When discussing family planning, she said it could help a lot in Southern Sudan but there is a big need to address cultural taboos. That’s one of many issues that will be addressed during the conference this week. Dr. Leonardo said, “We have a lot to take home.” That’s what we aim to do here this week: share from the frontlines, continue to build visibility and political commitment for family planning, and take home lessons so we can continue to realize achievements like those Ethiopia has made. The visiting health ministers will convene again tomorrow to chart the way forward for family planning both collectively and in their respective countries. I look forward to hearing about their dialogue and commitments and I hope all were inspired by the HEWs we met today.

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    This year on July 11, World Population Day, organizations around the globe came together virtually to discuss the importance of family planning advocacy. Continuing a similar discussion that was hosted in November 2012 by the Measurement, Learning and Evaluation (MLE) Project for the Urban Reproductive Health Initiative, the Knowledge for Health (K4Health) Project used the hashtag #FPAdvocacy to highlight its new resource the Family Planning Advocacy Toolkit and the importance of family planning globally. 

    USAID Global Health Bureau engaging with K4Health and others in the #FPAdvocacy Tweetchat

    USAID Global Health Bureau engaging with K4Health and others in the #FPAdvocacy Tweetchat.

    More than 152 Twitter users joined the Tweetchat, which yielded 1,400 Tweets in a very short period of time. At the time of the chat, #FPAdvocacy was in the top three trending topics in the United States. Many prominent and influential people and organizations from the world of global health and development shared opinions, statistics, information and resources on family planning and family planning advocacy during the chat. These experts and advocates brought energy and passion to the intriguing conversation about how to move the family planning advocacy agenda forward. 

    The chat itself was a great mechanism for advocacy and an effective vehicle for promoting tools and resources for family planning advocacy. The forum allowed many people to have a voice in the conversation--not just large NGOs, but individuals worldwide who are passionate about family planning. In light of the first anniversary of the London Summit on Family Planning and the large commitment made by donor agencies, developing and developed countries to reduce the unmet need for family planning worldwide by 2020, the chat harnessed the growing energy and excitement about family planning in the global health community.

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    Last week, a great piece was posted to the Impatient Optimists blog about the USAID-funded Integrated Family Health Program (IFHP), which uses task-shifting and a unique service delivery model to improve access to a wider range of contraceptive methods among women in rural areas of Ethiopia. (Read more about IFHP here).

    A group of Ethiopian women practice implant insertion on a model

    A group of Ethiopian women practice implant insertion on a model.

    © 2009 Mengistu Asnake, Courtesy of Photoshare

    Having worked on the K4Health needs assessment and Network-Mapping study among family planning and reproductive health (FP/RH) stakeholders in Ethiopia, this topic was of particular interest to me. While Ethiopia has made huge strides in FP in the past couple of decades, only about 27% of women use a modern contraceptive method, and 25% of women still have an unmet need for family planning. Further, there is a stark contrast between urban and rural areas; use of modern methods is 56% in Addis Ababa, but is less than 10% in some of the most remote areas (Ethiopia DHS, 2011). Women—particularly those in rural areas—are clearly not receiving optimal care. And this is the case for millions of other women in hard-to-reach areas throughout the world.

    Since last year’s London Summit on Family Planning, the group Family Planning 2020 (FP2020) has set the goal of improving access to voluntary family planning information, contraceptives, and services to 120 million women in the poorest countries by 2020. While this is a daunting task, there are number of ways to start. Advocacy is extremely important, as is working with the Ministry of Health and local organizations to ensure that policies are supportive of a range of contraceptive methods. Operations research is crucial in order to be able to design evidence-based programs that respond to actual needs, preferences, and contraceptive use patterns among women—as well as their providers.

    In addition, those of us working in knowledge management (KM) will tell you that knowledge exchange has a crucial role to play in improving access to family planning in hard-to-reach areas.