Reflections on a Remarkable Conference

In this article, Amy Tsui, PhD, reviews some of the most striking highlights from the International Conference on Family Planning 2013 in Addis Ababa, Ethiopia. Tsui is director of the Bill and Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.

In November 2009 I walked from the hotel compound with a young woman recruited to help support our first international conference on family planning held in Kampala, Uganda.  “How do I get involved in family planning?” she asked.  “I want to learn more about this field.  It is so positive.  Not like HIV.”  Uganda then had been weathering an HIV epidemic, which saw more than 120,000 new infections each year, more than half being women and children. They were the same groups who stood to benefit from family planning.  Indeed a third of married women in Uganda were assessed in 2011 as seeking to delay or stop childbearing but not contracepting—a staggering 1.11 million women.  Women reported that on average 1.5 of all their births were not wanted at the time.

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Women’s Growing Desire to Limit Births in Sub-Saharan Africa: Meeting the Challenge

The rising number of sub-Saharan African women desiring to limit births provides a key opportunity for family planning programs to meet their needs and accelerate fertility transition there, according to research presented November 15 at the International Conference on Family Planning.

In several sub-Saharan African countries, more women now would rather end childbearing than space out future births. Since intention to use contraceptives is an excellent predictor of reproductive behavior, particularly among women who want to limit future childbearing, understanding the characteristics of these women and how family planning programs can better meet their needs has the potential to improve the health and well-being of African families.

Lynn Van Lith, MPA, senior technical advisor at the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, worked with colleagues using demographic and health survey data from 18 sub-Saharan African countries to measure the associations between women’s age, reproductive intentions, contraceptive use and other characteristics, and their desire for limiting or spacing births.

The team found that nearly 14 percent (8 million women) want to limit childbearing, and another 25 percent want to space future births. Thirty-three is the average age at which the desire to limit births starts to outweigh the desire to space them, but in many countries, women as young as 23 wish to limit childbearing.

Limiting births has a greater impact on fertility rates than spacing births and is a major factor driving fertility transition. Family planning programs must prepare to meet the needs of these women who have been overlooked and underserved, Van Lith said, by addressing supply- and demand-side barriers-to-use.—Kim Martin

Decreasing Birthrate, Increasing Wealth

A team of investigators showed evidence of an all-important correlation between increased family wealth and fewer dependents in new research presented November 15 at the International Conference on Family Planning.

Saifuddin Ahmed, PhD, an associate professor in the Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, worked with colleagues to analyze data from the Demographic and Health Surveys, a USAID-led effort to gather information from a representative sample of households from 55 developing countries. They looked for a correlation between the economic health of families and their number of children.

Overwhelmingly, they found that the families with the fewest children tended to be wealthier than those who had more. These families are following the worldwide shift taking place across the last century, in which fewer births and deaths have led to a higher population of people between the ages of 15 and 65—working adults who can contribute to their country’s economy. Countries who have made this shift are experiencing the benefits of demographic dividend, the ability to employ more people with increased economic opportunities for the entire nation because fewer of the population are dependents.

One of the surest paths to realizing demographic dividend is accelerating ongoing fertility declines, Ahmed says—a challenge for countries such as those in sub-Saharan Africa where birthrates are some of the highest in the world and declines are nascent. However, countries lagging in demographic dividends are the ones least likely to invest in contraceptive access and choice, Ahmed explains. One reason may be a lack of empirical evidence showing a correlation between increased wealth and fewer dependents.

“In most of these countries, investing in contraceptive access and choice is extremely low,” he says. “These countries should expand their investment as soon as possible. They need to recognize and seize this golden window of opportunity.”—Christen Brownlee

At the Gateway: Action at Critical Moments Starts a Lifetime of Healthy Behavior

Doug Storey

Doug Storey

The social science literature has long recognized a connection between the use of “gateway” drugs and the later abuse of other more harmful substances. But is there such a thing as a positive gateway when individuals or families might be particularly receptive to health information and motivated to make positive behavior changes? Can particular actions taken at a critical “gateway moments” such as marriage, first pregnancy, or birth lead to a lifetime of protective health behaviors?

To investigate, Douglas Storey, PhD, director for Communication Science and Research, Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, worked with colleagues to examine the evidence from three datasets: the Egypt Minya Village Health surveys between 2004-2008, the Nigeria Urban Reproductive Health Initiative baseline survey (2011) and the Nigeria Demographic and Health Survey (2008). The team analyzed the association between six gateway behaviors and various other antenatal, neonatal, postpartum, intrapartum and early childhood behaviors to determine which gateway moments had the greatest influence on subsequent health behaviors.

In a presentation November 15 at the International Conference on Family Planning, Storey reported that behaviors associated with the greatest number of other subsequent health behaviors were those that occur earliest in the family health lifecycle: interpersonal communication with one’s spouse about health; and receiving four or more proactive antenatal care visits that help women and couples anticipate the future health challenges they face.

The findings suggest that by promoting these two gateway behaviors at the critical gateway moment of pregnancy, programs can catalyze subsequent positive family health behaviors, thereby making more efficient use of health program resources. A new operations research study in Nigeria is currently testing this gateway approach under field conditions.—Kim Martin

Stacking the Deck for Contraceptives

ginny bowenGhanaian women’s dislike of contraceptives, especially hormonal ones, has been well documented and could be an important factor behind the decline in contraceptive use in this sub-Saharan country. Understanding the reasons for this aversion could help family planning advocates tailor their messages, says Lt. Virginia Bowen of the United States Public Health Service, an Epidemic Intelligence Service Officer with the CDC who in 2013 earned a PhD and in 2008 an MHS from the Johns Hopkins Bloomberg School of Public Health. Bowen presented research November 14 at the International Conference on Family Planning.

To learn why Ghanaians often shun contraceptives and whether demographics play a role, Bowen and colleagues asked 259 women getting care at an antenatal/postnatal clinic in Accra, the capital, to listen to one of two tales about fictitious women for whom having a baby would be a stigma:  a young, unmarried high school student; and an older, married woman who already had four children. The participants then played a card game that involved gradually paring down reasons the particular fictitious woman might avoid contraception, leaving only their top three choices.

The volunteer respondents tended to choose very different reasons why the two female characters would avoid contraceptive use. For the young, unmarried woman, the top reason—a fear of later infertility—was chosen three times as often as the next popular choice, which was fear of contraceptive failure. For the older, married woman, three choices tied for first place: a partner’s opposition to contraceptive use, a dislike for “unnatural methods” and a fear of infertility.

The scope of concern over infertility surprised Bowen and her colleagues. “If this fear was so salient with our group,” Bowen says, “why aren’t we putting educational messages on billboards or seeing it dispelled everywhere we turn in the family planning sector?”—Christen Brownlee



Making Contraceptive Access More Equitable

Public health donors are increasingly interested in supporting demand-side financing programs in which individuals receive vouchers or cash for participating in family planning, for instance, or taking advantage of safe delivery services.

Although embraced for their potential to increase access by the poor to healthcare services, a question remains:  Are incentive programs reaching their targets? The answer is yes, according to new research that focused on a family-planning voucher program in Kenya. Results of that study were presented November 13 at the International Conference on Family Planning by Karampreet Sachathep, PhD Candidate in Population, Reproductive and Family Health, Johns Hopkins Bloomberg School of Public Health.

The program, which ran from 2006-2012, offered low-income Kenyan women in some communities the opportunity to purchase a heavily subsidized voucher for long-acting or permanent contraception methods (LAPM). Using data from household surveys collected by the Population Council, Sachathep and colleagues created concentration curves—a technique most often used in economics research—to provide a visual representation comparing LAPM utilization between the rich and poor in areas where vouchers weren’t offered and where they were.

They found that in areas where the program wasn’t in place, LAPM use was slightly skewed toward the rich. But in areas where vouchers were distributed, LAPM use was higher among poor women.

“Donors want to know whether they are reaching the poorest of the poor with these programs,” Sachathep says. “Here, you can see that these targeting mechanisms really are successful.”—Christen Brownlee