Family Planning – Population Matters-USA

**BRAZIL–**From: Policies for expanding family planning coverage: Lessons from five successful countries. Hellwig et al., 2024.

The Cairo Conference “Programme of Action” includes a statement that all people should have the right to decide freely and responsibly the number and spacing of their children. Unhappily, many people have been forced to follow the old adage “the rich get richer and the poor get children”.

Fortunately, this adage has been disproven in at least 5 countries where voluntary Family Planning (FP) has been made accessible to all, with little regard to income. Brazil, Ecuador, Egypt, Ethiopia and Rwanda were chosen for study because they represent different societies on different continents. 196 policies affecting the availability of FP services were identified in these countries from 1961 to the present, and the effect was described in a 2024 analysis. The progress in the availability of high-quality FP is amazing in all five of these countries!

The genocide in Rwanda was 30 years ago. Hunger was a factor that led to neighbors killing neighbors. People in many places in this largely agrarian society were not able to produce enough food to keep away hunger. Contributing factors included land degradation and rapid population growth; there was no violence in areas where people had at least 1500 calories of food per day. The average American eats almost twice that amount!

Back in the year 2000, few low-income people in Rwanda had access to modern FP. The country was largely Roman Catholic, which forbad modern FP and relied heavily on unreliable rhythm for birth spacing. Then, in 2005, the government started supporting a more effective method of natural FP, the Standard Days Method (SDM). The Church approved of SDM and it became popular. It is simple and is up to 95% effective—if used properly. Only 5 years after its introduction, the proportion of the poorest couples using effective contraception had risen to half!

The year 2005 also marked a presentation that changed attitudes in the Rwandan Parliament. The RAPID Model is a computer-based tool that stakeholders can use to demonstrate the effect of rapid population growth on different sectors, and the benefits of FP programs. The model demonstrated how FP can reduce mortality, improve health and increase the availability of women in the workforce. Rwanda has taken advantage of that benefit: almost 2/3 of members of parliament are women—the highest percentage of any country! RAPID also showed the economic benefits of FP—for every dollar spent on contraception, the government would save four. To quote a minister of health, “family planning is a tool of development.”

Since the five countries have different conditions and customs, each approached the need to slow population growth with different policies. For instance, the literacy rate is low in rural Egypt, so they used TV to get across FP messages. Ethiopia established primary health care for all—including contraception. Brazil focused on preventing adolescent pregnancies by improving sexuality education and facilitating access to FP for teens. In 2008 a change in Ecuador’s constitution named health care as a right, and ensured that women could make their own decisions about FP. Rwandan policies have already been discussed. It is remarkable that all 5 countries established policies that increased use of effective FP—and in 3 of the countries, there is equity between rich and poor in their use of FP.

Although each of these countries has its own policies and areas of focus, they all received help from the US government and from other rich countries. Nongovernmental agencies, such as the Gates Foundation, also provided expertise and resources. It is wonderful that all 5 of these countries did what they could to make family planning services available to all.

This graph shows the rate of covert contraception usage in Kenya

55 years ago a young patient and I were standing in the sun just outside the clinic doorway when a butterfly alighted on my left ear. “Yes, I would like to try an IUD” the patient said, amazed and apparently encouraged by the butterfly.

It was the summer between my 3^rd and 4^th years of medical school. My new wife and I were having a wonderful adventure at the Moravian Hospital in Puerto Cabezas, Nicaragua. The patient I had been persuading to try an IUD was also newly married and wanted something to keep from conceiving right away. She didn’t think her husband would approve of using birth control, however.

“If you had an IUD, he wouldn’t know about it unless you told him,” I had encouraged her. Apparently, the butterfly landing on my ear was the deciding factor, and I was able to insert a Lippes loop.

Hiding contraceptive use is a common strategy in many countries where patriarchy rules. Men in patriarchal societies usually desire large families, and don’t want their partners to make decisions about childbearing. Research has found that covert use of contraception is common in some African countries, especially for wives of polygamous marriages. As many as a third of women in some places conceal their use of birth control! Although I am certain that some women in the USA use contraception without their partner’s knowledge, I have not been able to find a study of its prevalence in this country.

Some birth control methods are easier to hide than others. A pack of pills would be easy to conceal, but it would be a dead giveaway if found. DepoProvera® shots are effective for 3 months and are easy to keep secret. A wife could go into town to shop, as usual, but also stop at the health clinic for her birth control shot. Indeed, some women have stated that is one of the reasons they chose thei method.

There is a new form of DepoProvera® that is packaged so that a woman can give it to herself at home. It is small enough that the pre-filled injection unit would be easy to conceal. Large studies in African countries have found women like this formulation, but unfortunately Sayana®Press is not available yet in the USA. There are other LARCs (Long-Acting Reversible Contraception): Nexplanon®, good for 3 years, and several IUDs, which last up to 10 years, are all easily concealed.

I do not recommend covert use of contraception. However, in some cases it is the only way that women can avoid unwanted pregnancies. Since the majority of family planning methods are female-controlled, the wife should—and can (by hiding her birth control)—have the last word about childbearing.

It only seems right that women should decide about family planning since birthing and most of the responsibilities for childcare rest on women’s shoulders. However, it is best if husbands and wives talk about whether to use contraception, and together choose the method that would be best. This is supported by a statement of friend, Dr. Stan Becker, who has studied reproductive health decisions among couples: “…reproductive health interventions that target couples are found to be more effective than those directed to only one sex.”

However, we don’t live in a perfect world—unfortunately, there are many couples where power and decision-making are not shared. Since family planning is recognized as potential driver of women’s autonomy and health, covert use of family planning can be seen as a symbol of agency for the women in these relationships.