(introduction...)
National family planning programs have been associated with
notable increases in contraceptive use and consequent declines in fertility.
Family planning programs predominantly emphasize voluntary acceptance of
contraception, usually include an important informational and educational
component, and focus especially on the needs of married women but often also
reach others The "cafeteria" approach, meaning the provision of many types of
contraceptives so that each person can choose the most appropriate, is often
favored but often also honored in the breach. Oral contraceptives and condoms
are the base of many programs' inventories, but some earlier programs relied and
continue to rely heavily on methods, such as the intrauterine device (IUD), that
are less prominent in programs that started later. Over time, such newer methods
as injectables and implants have found their own niches. Overall, however, the
main trend has been toward permanent methods: sterilization has become simpler
and more demanded and now accounts for half of all contraceptive use.
How contraceptives are delivered to potential users varies.
Building on efforts by private doctors and voluntary organizations, early
programs (and most in their earlier phases) depended on clinics, which can offer
a wide range of methods and ensure appropriate medical facilities. The limited
number of clinics quickly poses a problem in a developing country; over time,
various ways to bring contraceptives to people in their villages, homes, and
work places have been devised. Many programs have diversified, adding such
approaches as community-based distribution, mobile teams, home visiting,
subsidized commercial sales, or employee programs. The clinical component in
many programs receives relatively less emphasis, and program personnel have
become more varied as nurses, midwives, pharmacists, and lay distributors have
taken on larger roles.
Focusing primarily on contraceptive use, programs target the
primary behavior change that causes fertility to decline in the transition from
high, traditional, relatively stable fertility to low, modern levels at which
couples are only replacing themselves. Fertility is also affected by other
important behaviors (called "proximate determinants" by demographers). Of these,
marriage delay in the course of modernization contributes to lower fertility,
although to a lesser extent; breastfeeding tends to decline, raising fertility
somewhat, because the menses return more quickly; and abortion has an important
though highly variable effect. Individual programs may include interventions to
affect marriage, breastfeeding, and abortion, but such interventions have tended
to be limited. Nevertheless, programs have affected these other proximate
determinants at least indirectly. In the long run, readily available
contraception reduces resort to abortion. Trend data over 30 years for Hungary,
for example, show abortion declining with increased contraceptive use, as do
data from other settings, such as South Korea. Recent reports from Russia and
Kazakhstan show declines in abortion in the 1990s as contraceptive services
expanded.1 However, in the early program, abortion may become more
common if services cannot fill the demand to limit fertility.
1But even at high levels of contraceptive
prevalence, abortion does not entirely disappear, partly because of
contraceptive failures. The legality or illegality of abortion has little
influence on such trends (Cohen, 1997).
Experimental, country-specific, and cross-national evidence
indicates that, by increasing contraceptive use, programs do contribute
substantially to reducing fertility. This effect, however, is not universal. It
depends on a program adopting a strategy responsive to whatever specific demand
for contraception exists in the sociocultural setting, as well as on the staff
mastering the basics of service
delivery.