(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.