The contribution of family planning programmes to these fertility transitions remains a matter of debate, but a recent assessment suggests that public action can not only accelerate the pace of decline but also hasten its onset by 10+15 years, making a huge difference to population size in the mid-term.

The International Conference on Population and Development (ICPD) at Cairo in 1994 marked a decisive shift in the justification for family planning investments away from demographic planning towards broader aims of reproductive health and reproductive rights. Among the top ten risk factors for disease burden in males and females of all ages in developing countries, unsafe sex ranked equal third. (See STIs.) Five of the leading causes of disease burden among women aged 15+44 are related to reproductive ill-health, including the consequences of unsafe abortion and complications of childbirth.

About one-fifth of all live-births in developing countries are unwanted and many more are mistimed. Unwanted births are at their highest level in societies where the level of contraceptive use lies in the range of 20+50%, when reproductive aspirations are often changing faster than birth control behaviour. In Kenya, for instance, the percentage of married women who reported that they wanted no more children rose from 16% to 49% in eleven years. When contraceptive use rises above 50%, the incidence of unwanted births falls, with substantial benefits in terms of obstetric morbidity and mortality. For similar reasons, the link between the level of contraceptive practice and the abortion rate is not straightforward, though poor quality family planning services no doubt contribute to high rates of abortion.

Following the ICPD, many countries are setting an operational goal of integrating family planning and reproductive health services, but this should not be pursued uncritically (see Lush). The contribution that family planning can make to reduction of reproductive ill-health, in particular STIs including HIV, is not immediately obvious. The most commonly used methods (sterilisation and oral contraceptives) offer no protection against infection (see Ambegaokar who also discusses method mix as an aspect of service quality in family planning programmes). Of course, better screening of family planning clients and better counselling are obvious steps that can be taken, but for the full potential of family planning and MCH services to be realised in controlling STIs, less invasive, less complex and less expensive diagnostic tests are urgently needed. The need to harmonise family planning and sexual health services is particularly acute in east and southern Africa where contraceptive practice is spreading rapidly and STI/HIV prevalence is most severe, but where use of the barrier methods that offer dual protections against unwelcome pregnancies and STI/HIV have not proved popular among clients or providers, partly because of their association with commercial or casual sex.

In the post-Cairo era it is important not to lose sight of the large body of research and experience concerning the effectiveness of family planning programmes. Thus we know, for instance, that affordability and physical accessibility are not usually crucial constraints, except in settings where the mobility of women is severely restricted. In those cases the provision of a doorstep service by female outreach workers is the key to success. The more pressing problems are the moral and social acceptability of modern contraception, fears about health risks and poor communication between partners. Accordingly, many of the more effective programmes have devoted considerable resources to information and educational activities and have sought to legitimise modern contraception by seeking the endorsement of influential segments of society, such as religious leaders and school teachers.

The success of many programmes has stemmed from their ability to break free of the medical model of provision (see Aggleton and Rivers). In the family planning field, subsidised sales of contraceptives through pharmacies account for a large share of overall family planning in many countries, particularly in Latin America. (Brugha and Zwi review private sector provision). Finally, many community-based distribution schemes, involving non-medical workers, have proved very successful. Such diversity needs to be maintained. No single type of service can meet the needs of all potential clients. For married women with young children, an integrated health and family planning service is typically the obvious and best option. For sexually active teenagers or for men, this mode of delivery is totally unsuitable: provision of suitable services for them is the priority for the future.

John Cleland,
Centre for Population Studies
London School of Hygiene and Tropical Medicine
99 Gower Street,
London WC1E 6AZ.

Tel: +44 (0) 171 388 3071,
Fax: +44 (0) 171 388 3076, j.cleland@lshtm.ac.uk

E: j.cleland@lshtm.ac.uk