With fertility declining in many developing countries, it is tempting to think that family planning has become part of societal norms and that couples will continue to practice contraception even if no special efforts are made to offer them information and services. Yet many women who say they want to space their births or want to end childbearing still do not use a family planning method to control their fertility. Levels of unmet need around the world suggest that there is much more that family planning providers can do to provide couples with information and make services more accessible and acceptable. The articles in this issue of International Family Planning Perspectives examine some of these issues.
Although Mexico's community-based distribution programs raised contraceptive prevalence from 30% in 1976 to 60% in 2005, the country's integration of family planning into general health services called for new means of identifying the women who were most likely to need and want family planning advice and services. One such program innovation—a policy change that incorporated family planning counseling into the clinical guidelines for prenatal care—grew out of the recognition that appropriate birth spacing can improve maternal and infant health. In the lead article, Sarah Barber examines the effects of this policy on contraceptive uptake during the postpartum period [see article]. Of more than 2,200 postpartum women interviewed in 2003 and 2004, 47% were using a modern contraceptive. Women who had received family planning counseling during prenatal care had significantly higher odds of using a method than were those who had not. They were more likely to be relying on the IUD (odds ratio, 5.2), condoms (2.3) or sterilization (1.4) than to be using no method.
Arwen Bunce and colleagues shift the emphasis to men by looking at factors affecting vasectomy acceptability in Tanzania [see article]. Despite rapidly increasing contraceptive use, prevalence remains low (20% in 2004) and long-term and permanent methods—especially vasectomy—are seldom used. Data collected during focus groups with vasectomy clients, their wives, potential vasectomy clients and women who had had a tubal ligation, as well as in-depth interviews with vasectomy clients, indicated that vasectomy clients had often had the procedure either because they were concerned about their wives' health or because they felt they had had all the children they could support and educate. Both men and women noted that providers need to educate men directly about vasectomy, as men would not be receptive if the suggestion to have the procedure came from their wives.
For a global view of family planning programs, we turn to the most recent assessment of national program effort, by John Ross and colleagues [see article]. Using scores assigned by in-country informants on 30 program features in four categories ( policy, service, evaluation and accessibility), the authors found that family planning effort increased between 1999 and 2004, both globally and within regions. (When the data were weighted by population size, total scores decreased slightly overall, but increased in four out of six regions.) According to responses to new questions on justifications for programs, the strongest emphasis was on improving maternal and child health and preventing unwanted births, while the least stress was placed on unmarried youth and women receiving postabortion care.
For many years, researchers have debated the roles played by family planning programs and levels of desired fertility in fertility decline. Unnati Rani Saha and Radheshyam Bairagi use DHS data and information from the Matlab Demographic Surveillance System to investigate the relationship between desired fertility and actual fertility, and why a steady increase in contraceptive prevalence in Bangladesh between 1993 and 2000 was not accompanied by a decrease in fertility [see article]. Noting that fertility was elevated among women with no sons and those who had lost a child, they calculate that a preference for male children and high levels of child mortality explain almost two-thirds of the difference between desired and actual fertility. They also conclude that a reduction in breast-feeding and an increase in the use of less effective methods during the 1990s may be responsible for the lack of fertility decline during a period of increasing contraceptive use.