It is sometimes hard to remember that not so very long ago, many--if not most--couples saw fertility as a matter outside their control. In many developing countries, social norms mandated lengthy periods of postpartum abstinence as a means of avoiding closely spaced pregnancies, but fertility was highly valued and few couples considered limiting the size of their families. Today, the majority of countries in the developing world have active family planning programs, and relatively few couples consider their family size as being "up to God."
In one way or another, the articles in this issue of International Family Planning Perspectives all deal with questions related to fertility control. Of women who want to space their births or stop having children, what proportion are not practicing contraception? What do women do when access to contraceptives is limited? What is the role of abortion: Do women use it as a backup when their contraceptive fails or as a substitute for contraception? Are women more likely to start using contraceptives after having an abortion? In this era of AIDS, are mass media campaigns an effective means of reaching large populations with messages encouraging the use of methods that prevent both pregnancy and sexually transmitted infections (STIs)?
• In the lead article, John A. Ross and William L. Winfrey confirm that despite greatly expanded access to contraceptive services, substantial numbers of women who say they want to space births or stop childbearing still do not practice family planning. Using data from national surveys conducted in the 1990s, the authors estimate that 17% of married women in developing countries have an unmet need for contraception [see article]. This proportion, which ranges from 11% in Central Asia to 24% in Sub-Saharan Africa, translates to 105.2 million women. The authors note that although the overall proportion of couples with unmet need has decreased, millions are still without protection against pregnancies they do not want.
Despite the high numbers of women with unmet need, fertility has begun to decline in most areas of the developing world, suggesting that women who want to stop childbearing find ways to do so. Agnès Guillaume and Annabel Desgrées du Loû look at fertility regulation in Abidjan, Côte d'Ivoire, where access to contraception is limited and abortion is illegal [see article]. Their survey of 2,400 women at urban health centers revealed that 40% had controlled their fertility through contraceptive use alone, 30% through contraception and abortion and 3% through abortion alone; 27% had done nothing to regulate their fertility. Of the women who had relied on both contraceptives and abortion, many had used abortion after experiencing a contraceptive failure. For a substantial proportion, however, abortion appeared to act as a trigger for contraceptive use, as they adopted a family planning method only after having terminated a pregnancy.
• Until early 1997, abortion was illegal in South Africa as well. In changing the law, the government sought to make safe pregnancy terminations accessible to all women by mandating that midwives, the primary caregivers in clinics, be trained to perform abortions. As Kim Dixon-Tetteh and Deborah L. Billings report, an evaluation conducted three years after legalization found that midwives provided high-quality care independent of physicians [see article]. Moreover, midwives consistently provided women with contraceptive counseling after their abortions, and nine in 10 clients received a method before leaving the clinic.
• In response to the HIV epidemic, condom social marketing programs have used mass media campaigns in an effort to reach as many people as possible. Sohail Agha and Ronan Van Rossem assess the effects of a campaign to promote use of the female condom, which was marketed as a family planning method to avoid the stigma associated with STIs [see article]. Their analysis examines both the impact of radio and newspaper messages and the effects of counseling by providers and of peer education. Peer education and provider counseling had stronger effects than mass media messages on female condom use, but reached only a fraction of the population exposed to the mass media campaign. As in previous studies, the mass media campaign indirectly influenced use of the female condom: Men and women exposed to campaign messages were significantly more likely than those who were not exposed to discuss the female condom with their partner, and these discussions in turn had a strong direct impact on use of the female condom.
Also in This Issue
Many developing countries cannot afford to provide free family planning services to all clients, yet identifying those who can afford to pay is difficult. Karen G. Fleischman Foreit proposes a simple test--whether women with young children obtain maternal or child health care from private-sector providers [see article]. Using data from three countries where most women obtain contraceptives from public sources, she demonstrates that if all pill users who paid for health care obtained contraceptive supplies from the private sector, government expenditures for family planning would decrease by 3-7%.
• Involving men in their female partner's reproductive health care can be beneficial, but little thought has been given to situations in which it may be detrimental. Karin Ringheim examines how gender power dynamics come into play when male partners are included in women's interactions with providers; she then discusses ways of equipping providers with the skills they need to ensure that inclusion of men does not compromise women's well-being [see article].