Family Planning in Asia and the Pacific - International Council on ...

Introduction<strong>Family</strong> plann<strong>in</strong>g <strong>and</strong> fertility decl<strong>in</strong>e:research questions<strong>Family</strong> plann<strong>in</strong>g <strong>and</strong> contraceptionThe <strong>International</strong> Planned Parenthood Federation (IPPF)def<strong>in</strong>es family plann<strong>in</strong>g as:"The conscious effort of couples <strong>and</strong><strong>in</strong>dividuals to plan for <strong>and</strong> atta<strong>in</strong> <strong>the</strong>irdesired number of children <strong>and</strong> to regulate<strong>the</strong> spac<strong>in</strong>g <strong>and</strong> tim<strong>in</strong>g of <strong>the</strong>ir births.<strong>Family</strong> plann<strong>in</strong>g is achieved throughcontraception <strong>and</strong> through <strong>the</strong> treatmentof <strong>in</strong>voluntary <strong>in</strong>fertility 1 . "This simple <strong>and</strong> clear def<strong>in</strong>ition belies <strong>the</strong> long <strong>and</strong> torturedhistory through which family plann<strong>in</strong>g has become acceptedas normal behaviour across a wide spectrum of countries,both developed <strong>and</strong> develop<strong>in</strong>g, among all social classes <strong>and</strong>ethnic groups, <strong>and</strong> among members of all major religions.As of 2008, 63 per cent of married women <strong>in</strong> <strong>the</strong> worldwere us<strong>in</strong>g family plann<strong>in</strong>g <strong>and</strong> 90 per cent of <strong>the</strong>se wereus<strong>in</strong>g a modern method (Population Reference Bureau,2008). The worldwide use of contraception has doubledbetween 1980 <strong>and</strong> 2008 <strong>and</strong> is currently <strong>in</strong>creas<strong>in</strong>g atabout 1 per cent per year. To <strong>the</strong> pioneers who commenced<strong>the</strong> family plann<strong>in</strong>g movement <strong>in</strong> <strong>the</strong> late n<strong>in</strong>eteenth <strong>and</strong>early twentieth centuries <strong>the</strong>se numbers <strong>and</strong> trends wouldbe little short of amaz<strong>in</strong>g.However, <strong>the</strong> undoubted success of <strong>the</strong> family plann<strong>in</strong>gmovement must be qualified. The use of contraceptionvaries widely at <strong>the</strong> country level – from 86 per cent ofmarried women <strong>in</strong> Ch<strong>in</strong>a to under 2 per cent <strong>in</strong> Chad.In West Africa as a whole, only 9 per cent of women usea modern method of family plann<strong>in</strong>g; <strong>in</strong> Middle Africa,only 7 per cent. Outside Africa, low contraceptive use canbe found <strong>in</strong> Afghanistan (8.5%), East Timor (8.6%) <strong>and</strong>Azerbaijan (11.9%)(Population Reference Bureau, 2008).It is apparent that <strong>the</strong> global average contraceptive use rateis <strong>in</strong>flated by very high contraceptive prevalence <strong>in</strong> Ch<strong>in</strong>a.Among <strong>the</strong> less developed countries, contraceptive usedrops from 56 per cent of married women to 45 per centwhen Ch<strong>in</strong>a is excluded. Thus, less than half of all marriedwomen <strong>in</strong> less developed countries o<strong>the</strong>r than Ch<strong>in</strong>a areus<strong>in</strong>g contraception. Fur<strong>the</strong>rmore, of <strong>the</strong> 210 millionpregnancies that occur annually worldwide, only 47 per centresult <strong>in</strong> a planned birth; 22 per cent of pregnancies end <strong>in</strong>an <strong>in</strong>duced abortion <strong>and</strong> 17 per cent are ei<strong>the</strong>r unwantedor mistimed (Shah, 2002). In less developed countries, 100million married women would prefer to avoid a pregnancybut are not us<strong>in</strong>g any form of contraception to achievethat end (Ashford, 2003). Such women are said to have an“unmet need” for family plann<strong>in</strong>g.An unmet need for family plann<strong>in</strong>g not only places womenat risk of hav<strong>in</strong>g an unwanted birth, but also <strong>in</strong>creases <strong>the</strong>risk of maternal death or morbidity. Recourse to an illegalabortion <strong>in</strong>creases <strong>the</strong> risk of maternal death. Unwantedbirths pose risks for children’s health <strong>and</strong> well-be<strong>in</strong>g,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> possibility of neglect <strong>and</strong> <strong>in</strong>fant death.Stalled fertility transitionsIt has also become evident that many develop<strong>in</strong>g countries<strong>in</strong> various regions <strong>and</strong> subregions of <strong>the</strong> world haveexperienced “stalled” fertility transitions (Bongaarts, 2008).This phenomenon is also evident <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> region. Thereis a subgroup of <strong>Pacific</strong> isl<strong>and</strong> countries <strong>in</strong> which TFRshave rema<strong>in</strong>ed between 3.5 <strong>and</strong> 4.0 for more than a decadeafter <strong>in</strong>itially fall<strong>in</strong>g rapidly from about 7 or 8 <strong>in</strong> <strong>the</strong> 1960s<strong>and</strong> 1970s. A plausible explanation for this is that familyplann<strong>in</strong>g programmes were much stronger <strong>in</strong> <strong>the</strong> past than<strong>the</strong>y are today. It is a short step from that propositionto <strong>the</strong> view that, if family plann<strong>in</strong>g programmes were“streng<strong>the</strong>ned”, <strong>the</strong> fertility transition might be <strong>in</strong>ducedto cont<strong>in</strong>ue until replacement-level fertility was reached.Such arguments need to be treated with caution. First, tounderst<strong>and</strong> fertility levels <strong>and</strong> trends it is essential to take<strong>in</strong>to account all <strong>the</strong> factors that could contribute to fertilitychange (or its absence) <strong>in</strong> a specific country or group ofcountries, not only family plann<strong>in</strong>g programmes. Thereis a large literature that discusses <strong>the</strong> relative importance,for example, of socio-economic factors <strong>and</strong> mortalitydecl<strong>in</strong>e, as well as changes <strong>in</strong> norms <strong>and</strong> values <strong>and</strong> o<strong>the</strong>r“ideational” determ<strong>in</strong>ants of fertility. While <strong>the</strong> extent ofcontraception is obviously a key proximate determ<strong>in</strong>ant offertility levels, <strong>the</strong> socio-economic conditions that lead tocontraceptive use or non-use need to be considered <strong>in</strong> anycomplete explanation.The central facilitat<strong>in</strong>g role that family plann<strong>in</strong>gprogrammes play <strong>in</strong> contribut<strong>in</strong>g to fertility decl<strong>in</strong>e issupported by <strong>the</strong> generally close association betweencontraceptive prevalence rates <strong>and</strong> total fertility rates.In some countries it appears that <strong>the</strong> stalled fertilitytransition is related to a slow <strong>in</strong>crease, or even decl<strong>in</strong>e, <strong>in</strong>contraceptive prevalence. These circumstances have led tovarious efforts to “reposition” family plann<strong>in</strong>g on nationaldevelopment agendas. This implies that family plann<strong>in</strong>gshould be given higher priority with<strong>in</strong> reproductive healthprogrammes, <strong>in</strong>clud<strong>in</strong>g more fund<strong>in</strong>g.Many of <strong>the</strong>se concerns are applicable to <strong>the</strong> regionencompass<strong>in</strong>g <strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong>s. As already noted, <strong>in</strong>63