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Judith Bruce is Senior Associate, and Anrudh Jain is Director of Programmes, Programmes Division, the Population Council, New York.
A long overdue revolution in family planning is under way.
Since modern methods of family planning began to be made available in the 1950s and 1960s, the mandate of those who provide the services has often been ambiguous.
On the one hand, most family planning workers are motivated by a wish to help individuals choose safe and acceptable means to space or limit pregnancies. On the other hand, fears about rapid population growth are a powerful lever for dislodging the funds for family planning programmes, and this has led some managers to feel that their real priority is to reduce fertility.
Many programmes have been caught between these two conflicting mandates. Often the demographic imperative, and the funds that accompany it, have proved the weightier. Where this has happened, family planning programmes have often come to emphasize quantity over quality, coverage over service, and population worries over individual needs.
The same influence can be seen in the criteria commonly used for measuring the effectiveness of such programmes - `acceptance rates', `couple-years of protection', or even `proportion of women using long-term methods of family planning'.
Unwanted fertility
At the heart of these conflicting pressures is the lack of a clear distinction between wanted and unwanted fertility, and a corresponding confusion about what family planning can and cannot do.
Social and economic change can cause people to want to space births or to have fewer children. Family planning programmes can permit the safe exercise of such choices.
In free societies, family planning programmes prevent only unwanted fertility - which may be as low as 5% in some developing countries and as high as 25% in others. But to do so effectively and sensitively, they must have the clear and single mandate of assisting individuals and couples to avoid the pregnancies which they themselves define as unwanted.
The main job of family planning programmes is therefore not to promote smaller families per se but to meet existing demand with services that are respectful and competent.
When this is accepted as the unambiguous mandate, then the emphasis inevitably shifts to the quality of services being offered and their responsiveness to individuals' requirements.
As the quality of service becomes the paramount consideration, the criteria for evaluating programmes also change. Intermediate goals become important - the ability to offer a choice of methods, the provision of adequate information to guide that choice, the technical competence to provide the various methods safely, the respect shown for dignity and privacy , and the long-term care of each individual.
This new emphasis on individual care would improve most family planning programmes. It would revolutionize others.
Because of past emphasis on quantity, there have been relatively few evaluations of quality. But from the studies that are available, disturbing findings have emerged. In one survey in Tanzania, for example, fewer than one third of women attending a family planning clinic were even asked about their reproductive intentions. In another study in Nairobi, fewer than half of family planning providers washed their hands before performing a pelvic examination. In an observation study in Bangladesh, only 9 out of 19 workers washed their hands before inserting an IUD.
In general, individuals are receiving insufficient information to make a well-founded choice. In some programmes, consultations are far from private. In many cases, reproductive health issues are not on the agenda.
In the worst of these programmes, the number of users is less a measure of the quality of service than of the desperation of those who use them.
Many programmes are now attempting to reverse this neglect.
Paradoxically, all of the evidence suggests that improving the quality of family planning services would also be the best way of meeting unmet demand, of uncovering any latent demand, and of ensuring that those who come to family planning clinics continue to plan their families, according to their needs, over their child-bearing years. Indeed the evidence from most countries suggests that family planning programmes that truly help individuals to achieve their own reproductive goals also have a greater imp act on reducing fertility than programmes that are motivated and measured by demographic targets.
The recent round of Demographic and Health Surveys, for example, shows very high levels of early dropout in some programmes - an indication that the problem is not lack of `coverage' but lack of satisfaction with the method or quality of service being offered.
Client-centred
In particular, long-term contraceptive use is usually significantly higher if family planning services offer a choice - not just in the first instance, but over time - rather than promoting any one particular method. A study in Indonesia, for example, revealed that 85% of women who had not received the contraceptive of their choice had dropped out of the programme within one year; of those who were using the method of their choice, only 25% had dropped out.
In other words, it is clear that a range of methods, competently provided, will attract more users and permit the switching between methods that is the foundation of satisfied and sustained use of contraceptives.
Similarly, unwarned-of and unattended side-effects are a major cause of dissatisfaction with family planning services, and of the discontinuation of contraception. This too can only be remedied by better-quality and more client-centred family planning services.
For all of these reasons, it must now be considered irresponsible to manage and measure family planning programmes by the use of targets or quotas for specific methods. For such criteria threaten the very ethos of client-oriented, high-quality family planning services.
Instead, the success and efficiency of family planning services should be evaluated by how well they enable people to meet their own reproductive goals in a healthy way. This is certainly more difficult to measure than the number of acceptors, but it is by no means impossible. It requires, first of all, an understanding of the individual's reproductive intentions. We have proposed a method of evaluation - the HARI index (standing for `Helping Achieve Reproductive Intentions') - which would follow a sample of clients over time to find out what proportion met their reproductive goals in a safe and healthy way.
Finally, family planning programmes must begin to play a part in supporting voluntary and equal sexual partnerships. A few brave programmes are now seeking to help their clients, usually women, to involve their partners, if they wish, in taking responsibility for reproductive health, family planning and, eventually, close involvement with wanted children. Such services are concerning themselves with the woman's unequal status in so many of the decisions that affect her sexual and reproductive health, and t hey are beginning to grapple with the harsh social realities of women's lives, including male dominance in sexuality and in making decisions over fertility.
In other words, the better family planning programmes are working to deserve their names - by providing a genuine service not just to individuals and couples, but to families.