Whether a population is just entering the transition to lower fertility or has made good progress toward replacement-level birthrates, programs intended to promote family planning need to examine context and identify ways to increase contraceptive use. Two articles and a special report in this issue of International Perspectives on Sexual and Reproductive Health make it clear that one size does not fit all.

The lead article, by Jason Davis and colleagues, reports that the indigenous people of the Ecuadorian Amazon—among the last cultures in the world to practice near-natural fertility—are moving toward lower birthrates. The total fertility rate among women from five indigenous groups in the area decreased from 7.9 to 7.0 births per woman between 2001 and 2012, and use of modern contraceptives increased from 2% to 19%. Despite these changes, total fertility remained high, contraceptive use remained low, and unmet need edged down slightly. Pointing out that women were less likely to be using a modern contraceptive method in 2012 if there was a health care worker in their community, the researchers note that these workers are usually older, respected community members with limited education and values favoring large families, and that half of those in the Ecuadorian Amazon are men. The researchers recommend that the selection process and training for health care workers be revised so that workers are more oriented toward advocacy for all aspects of women’s health, including family planning. They also note that including long-acting methods along with contraceptives would give users a way to avoid frequent travel over long distances to replenish supplies.

Women who live close to family planning services are more likely to use contraceptives, but the consistent availability of contraceptive supplies is also of critical importance, according to research that combined facility mapping and logistics data. The study, by Martha Priedeman Skiles and colleagues, found that the probability that rural women with the most access—as defined by distance, and by distance plus reliable access to supplies—used contraceptives was seven and eight percentage points higher, respectively, than it was among rural women with the least access. In addition, the probability of wanting to space or limit births among the urban women with the most access—according to the second definition—was 18 percentage points higher than it was among their counterparts with the least access.

Even in countries where contraceptive prevalence has risen over-all, creative strategies may be needed to increase use in poor and remote areas. A special report by Theresa H. Hoke and colleagues describes a cooperative effort between the Green Belt Movement, a Kenyan NGO dedicated to environmental conservation and community development, and a family planning project to increase demand for and access to contraceptive services in such areas. Environmental volunteers were trained to educate their communities about how limiting family size can lead to greater household prosperity and reduced depletion of resources like water and land for cultivation and grazing. The volunteers also referred interested couples to sources of family planning information and services. Feedback from key informants, and data collected from focus groups and from the volunteers themselves, the authors say, demonstrate the feasibility of using cross-sectional partnerships to promote family planning in underserved areas.

Also in This Issue

In Senegal, abortion is generally permitted only to save the woman’s life. Nevertheless, some 51,500 induced abortions were performed in 2012 and more than half resulted in complications, according to the country’s first-ever national study of abortion. Gilda Sedgh and colleagues found that 42% of women who experienced complications did not receive the care they needed. Poor women bore the greatest burden—they were far more likely than wealthier women to experience complications, but much less likely to receive medical treatment. The researchers recommend that women be able to receive postabortion care without risking arrest or interrogation, which can inhibit women from seeking needed care; that public health campaigns be implemented to educate women about family planning services; and that provision of contraceptive services be expanded to reduce the incidence of unintended pregnancy.

According to a literature review by Nicole Haberland, curriculum-based programs that address gender and power are more likely than those that do not to show reductions in rates of STIs and unintended pregnancy. Among the 22 evaluation studies from various countries that met the review’s inclusion criteria, 10 assessed interventions that addressed gender or power and 12 did not. Fully 80% of the interventions that addressed gender or power demonstrated significantly lower rates of STIs or unintended pregnancy, compared with 17% of those that did not. These results, the author asserts, provide strong evidence that gender and power should be considered a key component of sexuality and HIV education programs.

The Editors