Obama Reverses Bush Ban On Contraceptive Supplies to Leading Int’l Family Planning Organization

Jodi Jacobson

The United States Agency for International Development (USAID) today reversed a Bush Administration policy to block African governments from providing U.S.-funded contraceptive commodities to Marie Stopes International (MSI), one of the world’s leading family planning organisations.

The United States Agency for International Development (USAID) today reversed a Bush Administration policy to block African governments from providing U.S.-funded contraceptive commodities to Marie Stopes International (MSI), one of the world’s leading family planning organisations.  Restoring U.S. support will allow women to exercise their basic human rights while helping them avoid unintended pregnancies and unsafe abortions and reduce the spread of HIV and other sexually transmitted infections.

The ban imposed by Bush as part of a full-on attack on women’s access to contraception worldwide disrupted MSI operations in six of the affected countries – Ghana, Malawi, Sierra Leone, Tanzania, Uganda and Zimbabwe – including some where MSI delivers nearly a third of all family planning services nationally.

According to MSI chief executive Dana Hovig: 

“Today’s policy reversal is the latest example of the Obama Administration’s commitment to put people before politics [and] a sign of [it’s] determination to return science to the heart of US public health policy.”

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Hovig noted that lack of access to modern contraception contributes to the deaths each year of more than half a million women – or 1,500 per day – from pregnancy-related causes.  

Nearly one in four women in sub-Saharan Africa express a need for family planning services but do not have access.  Hovig states: 

“There has been clear evidence over many years that voluntary access to contraception is one of the best ways to reduce the number of maternal deaths in Africa, including those from unsafe abortions.  Research has shown that for every 100 IUDs made available to our programmes as a result of this decision, we will avert nearly 315 unwanted pregnancies, 45 unsafe abortions and two maternal deaths.”

The Bush Administration justified its September 2008 policy by falsely accusing MSI of being complicit in “coercive abortion and involuntary sterilizations” through its role as implementing partner to the United Nations Population Fund (UNFPA) in China.

Globally, MSI manages sexual and reproductive health programmes in 43
countries. In 2008 alone, MSI programmes protected the equivalent of 13
million couples from unwanted pregnancy, a 40% increase over 2006 and
the single largest two-year growth in the organisation’s 32 year
history. A majority of MSI’s family planning efforts are in rural,
underserved areas where women are particularly vulnerable and lives are
most at risk from unwanted pregnancy and unsafe abortion.

Commentary

Family Planning Initiatives Must Focus on People, Not Numbers

Anrudh K. Jain

Reaching quantitative goals should not take priority over quality of care, voluntary use of contraception, and informed choice. The needs, desires, and well-being of women are paramount.

In recent years, family planning experts have undertaken a number of major policy efforts to shine a spotlight on reproductive health worldwide. With this renewed focus on the power and promise of family planning, now is an opportune time to step back; examine past family planning and reproductive health initiatives; and ensure that lessons we’ve learned inform the work we do moving forward.

Above all, programs and policies should focus on improving the health and lives of people around the world, not numerical demographic targets. An overemphasis on reaching quantitative goals should not take priority over quality of care, voluntary use of contraception, and informed choice. The needs, desires, and well-being of women are paramount.

Looking Back

Prior to the UN’s 1994 International Conference on Population and Development (ICPD), family planning programs in developing countries often focused on the goal of reducing fertility and, in turn, slowing population growth. Indicators such as the percent of women using, or whose partners are using, contraception (the “contraceptive prevalence rate”), or the average number of children each woman would have by the end of her reproductive period (“total fertility rate”), were used by governments and funders to measure program success.

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The assumption was that addressing population growth was critical for a country’s economic development, with governments expecting that through trickle-down processes, the result would be improvements in the lives and well-being of its people. But because these indicators only measured specific numerical goals, and not the underlying intent of improving individuals’ well-being, many family planning programs implemented activities that were not fully client-centered, were coercive, and/or did not improve individual well-being or promote the rights of individuals to have the number of children they want, when they want them.

In response to global advocacy and concern about this approach, in 1994 the ICPD Programme of Action articulated that reproductive rights—including the right to decide the number, timing, and spacing of children—are an integral part of human rights and are essential to the realization of other fundamental rights. This confirmation pushed family planning programs to move toward improving individuals’ reproductive health and well-being, and allowing them to achieve their family planning goals.

Following ICPD, efforts were made by governments and NGOs to align the design and goals of family planning programs by incorporating values like quality of care, voluntary adoption of contraception, and informed choice. While there has been an important shift toward client-oriented care since 1994, and new indicators to measure clients’ health and informed choice have been proposed, implementation and measurement has been spotty.

Moving Forward

In 2012, the London Summit on Family Planning brought together the UK government, the Bill & Melinda Gates Foundation, UNFPA, USAID, national governments, donors, civil society, the private sector, and the research and development community to support the rights of women and girls to decide, freely and for themselves, whether and when to have children and how many they wish to have. At the summit, more than 20 governments made commitments to mobilize progress and donors pledged an additional $2.6 billion to enable 120 million more women and girls to use contraceptives by 2020. A global partnership, Family Planning 2020 (FP2020), was formed to achieve these goals.

In the March issue of Studies in Family Planning, a peer-reviewed journal published by the Population Council, we analyzed past family planning initiatives and renewed the call for new efforts like FP2020 to be built around one unifying goal: to meet the family planning needs and reproductive goals of their users—not simply to achieve macro level numerical targets like “120 by 20.”

FP2020’s goal was intended as a rallying call for the field, and to ensure that efforts are made at the large scale required to achieve public health benefit. Furthermore, FP2020 has nobly worked to identify core indicators that measure other kinds of progress than this numerical target. That said, this goal has also sparked some concern among those who remember family planning before ICPD, who fear that it may lead countries to unintentionally overemphasize the importance of reaching numerical thresholds, rather than concentrating on the well-being of their citizens.

What Does True Success Look Like?

To measure true success, new indicators are needed. Take “met demand,” meaning the percent of women who are using a modern contraceptive out of the total who would like to avoid or delay having a child.

Currently, met demand is one of the core indicators of success for FP2020 and has also been proposed for inclusion in the post-2015 goals, which seek to ensure universal access to sexual and reproductive health services by 2030. It is a useful indicator, but it misses the full picture. It doesn’t capture whether women made the choice to embrace modern contraceptives voluntarily, or the quality of overall information offered to women about their practices and options.

Instead, we should be measuring indicators like client-provider interaction, content of information provided to clients, voluntary use of contraception, and informed choice. These indicators can only be measured at the service level and in the field. Though it adds some complexity to program evaluation, we believe family planning initiatives must develop confidential, respectful ways of observing consultations between providers and clients, or conducting exit interviews with clients, in order to measure the quality of care provided by a program. What exactly constitutes high quality of care will be made by experts in close consultation with users and advocates.

Additionally, in order to ease the challenges related to monitoring progress, we recommend that family planning indicators and targets be standardized across FP2020, as well as two other major policy initiatives: the UN’s proposed Sustainable Development Goals, which seek to define a range of global development targets for the next 15 years, and ICPD Beyond 2014, the UN review of the ICPD. This will reduce confusion and allow countries to implement—and evaluate—multiple initiatives simultaneously and successfully. In order to monitor progress at the global level, we need comparable data to be available regularly from many countries, which these programs can also provide.

It is an exciting time in the field of family planning. Amid the formulation of new policies and programs, we have an opportunity to shape the reproductive health agenda and influence the services that will be offered to people for many years to come.

Now is the time to develop a set of common indicators for family planning and reproductive health programs that go beyond outcome and output goals, and include process, information, and informed choice. This will ensure that our programs maintain focus on service delivery, meet the reproductive needs of users, and uphold the preferences and rights of the women they serve.

Commentary Abortion

To Better Serve Women, Link Family Planning to Abortion Care

Janie Benson

Logically, all women receiving abortion care should also receive contraceptive information, and a method if they wish one; likewise, family planning providers should be equipped to support women who have unintended pregnancies. However, integrating family planning and abortion care is often a challenge.

We know that women seeking comprehensive abortion care—whether treatment for complications of an unsafe abortion, or a safe, induced abortion—welcome information about and access to contraceptive methods as part of their care. Ensuring access to contraception is crucial to avoiding future unintended or unwanted pregnancies. Logically, all women receiving abortion care should also receive contraceptive information, and a method if they wish one; likewise, family planning providers should be equipped to support women who have unintended pregnancies.

However, integrating family planning and abortion care is often a challenge. Barriers include administrative and physical separation of abortion and family planning units in health facilities, unavailability of a range of contraceptive methods, lack of training among abortion providers in contraceptive delivery, and women’s lack of knowledge about contraceptive options. But when a concerted effort is made to ensure supplies and train health center staff, a majority of women who receive abortion care will leave with a contraceptive method—even in countries with low contraceptive use rates and restrictive abortion laws.

Ethiopia, where abortion is legal under a broad range of circumstances and where the 2013 International Conference on Family Planning was held, demonstrates the effectiveness of this equation—integrating both family planning and abortion services at the primary care level. In a 2008 study of 335 health facilities, 75 percent of women receiving abortion care in those facilities left with a family planning method in hand; and in primary care facilities, nearly 90 percent of women adopted a contraceptive method. The numbers would likely show greater contraceptive uptake now in 2013.

The results of a multi-country analysis that I presented last week with my Ipas colleagues Dalia Brahmi, Kathryn Andersen, and Achieng Ajode further bolster the crucial integration of abortion care and family planning. We reported on contraceptive method receipt among more than 500,000 women at the time of their abortion care. These services were offered in more than 3,000 health facilities across 14 countries in Asia, Africa, and Latin America.

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Uptake of contraception by abortion clients was strong, ranging from 55 to 79 percent across countries. Most women, regardless of location, choose oral contraceptives, injectables, and condoms. Acceptance of long-acting, reversible methods is relatively low in intervention sites in some countries. The type of facility also makes a difference; women seeking comprehensive abortion care in hospitals are less likely to receive a contraceptive method than those receiving care in primary-level centers.

Most of the interventions to improve abortion care were implemented in public sector hospitals, health centers, and clinics and included provider training in abortion services and contraceptive care, use of clinical guidelines consistent with the World Health Organization guidance for safe abortion, upgrades in abortion service record keeping, and increased availability of abortion and contraceptive commodities.

For example, the benefits of integrating family planning and abortion care are evident in Nigeria—a country in which abortion is legally restricted—where we examined several facilities. Nationally, just 8 percent of married women of reproductive age use modern contraception. Yet, in the intervention facilities included in the analysis, 68 percent of comprehensive abortion care clients left with a contraceptive method. And in Bangladesh, other Ipas research has yielded similar findings. In a study from earlier this year that examined the integration of family planning, menstrual regulation, and post-abortion care, post-abortion contraceptive uptake went from 3.2 percent at the beginning of an 18-month period to more than 45 percent at the end.

The lesson to those in the global health community is clear: Comprehensive interventions to improve abortion and post-abortion care can lead to women leaving health facilities with contraception to reduce repeat unintended pregnancy. The key to the success of interventions is training providers in contraceptive care, ensuring contraceptive commodities are available in the procedure room, and providing women with the needed information and a range of methods to choose from.

Women need compassionate care through all stages of their reproductive lives and must understand their options for such care. They must have supported access to family planning services, abortion care, and follow-up care without judgment.

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