Hope – Population Matters-USA

What if every woman in the world had access to her choice of safe, effective contraception? So far, this is a dream, but two programs are helping this dream come true.

In the past, only members of the rich elite had access to family planning (at least among English-speakers). Francis Place in England (1823) and Margaret Sanger in the USA (1916) brought Family planning to disadvantaged people. Sanger is accused of having racist or classist motivation, but Place, a revolutionary thinker, was a commoner. He learned how the rich controlled their fertility and spread that knowledge through a series of pamphlets. Both of these pioneers realized that limiting a couple’s fertility would be likely to improve their well-being.

The London Summit on Family Planning in 2012 was organized to continue Place’s work, on an international scale. People gathered in London from 120 countries and included doctors, social scientists and financial donors who came up with an international program, Family Planning 2020 (FP2020). In those few years between 2012 and 2020 they hoped to provide 120 million women (and men) with contraceptive information and supplies.

One of UN2020’s initial concerns was that it not coerce people to use contraception, as happened in China and India. Social scientists drew up rules to try to avoid any semblance of coercion—all motivation had to be strictly voluntary. Thus, there would be no undue incentives nor any quotas. These steps would help ensure that all adaptors of contraception did so without pressure. In the organization’s own words, it “…is a global movement that supports the rights of women and girls to decide—freely and for themselves—whether, when, and how many children they want to have.” It is amazing that FP2020 functioned in some very patriarchal societies in Asia and Africa.

The governments of more than 30 of the world’s richer countries pledged money to support FP2020. Major funding included the US Agency for International Development, the Gates Foundation and the United Nations Population Fund. Although FP2020 worked in some of the least wealthy countries in the world, each of the 69 countries where they provided care also had to provide some funding.

The Covid 19 pandemic started just as FP2020 was ending. Despite the risk of spreading the virus, the program found ways to deliver high quality reproductive health care. The program was able to continue its outreach using strict precautions.

How successful was FP2020? The program fell short of its ambitions goal. The final tally is that it increased the number of modern contraception users by 46 million. Nevertheless, this is a pretty amazing feat! An impressive way of measuring the program’s success is that it doubled the number of users in 13 African countries. The use of modern contraception in these poor countries is estimated to have prevented millions of unsafe abortions and over a hundred thousand maternal deaths. What intervention could be more humane?

Because populations were growing rapidly where FP2020 worked, the need for family planning increased faster than FP2020 could reach potential users. It is estimated that the number of women of reproductive age grew by 15 million each year! That is the challenge for the program that succeeded FP2020, unsurprisingly labeled “FP2030”. The successor has more local direction and less management from donor countries, and has expanded to 82 countries. Funding is its biggest problem, unfortunately, especially since some funders have reneged on promised donations. FP2030 is directing its focus on adolescent pregnancy. If a woman is empowered by modern family planning when she is young, it is likely that she’ll be a lifelong user.

There is a success story here. The teen pregnancy rate is already dropping globally, thanks to programs such as FP2020 and FP2030.

Last month I wrote about the 5 countries I have enjoyed visiting in Africa, including citing their amazingly low per capita GDP. Although most of the population growth over the next decades is predicted to occur on that continent, I see some rays of hope.

There are two places in the world where studies have been done on ways to increase voluntary family planning, along with other important medical research. One is Matlab, Bangladesh and the other is Navrongo, northern Ghana. I had never heard of the Navrongo studies until shortly before visiting there!

Both Matlab and Navrongo have shown that community health workers can improve health significantly. In addition to family planning, the Ghanaian studies studied several successful interventions, including vitamin supplementation and mosquito nets treated with an insect repellant. Their family planning research showed that it is possible to increase contraceptive use and slow population growth even in an impoverished, poorly educated population. This is especially important research since Navrongo is close to the Sahel, and the people there are similar to Sahelians in their preference for large families.

In 1995, the beginning of the Navrongo studies, the average woman had about 5 children. Fifteen years later, in 2010, that number had dropped to a bit over 4, both in the Navrongo control group and in the country as a whole. One of the interventions decreased the fertility further, to 3.7; a significant reduction. Now, a decade later, the fertility rate for the whole country is 3.7 children per woman. That group was ten years ahead of the rest of the country! This group combined specially trained community health nurses (as opposed to stationing them at a clinic or hospital) and “zurugelu”.

“Zurugelu” means “togetherness for the common good”, and was male-centered in the past. For a better explanation, I asked one of the investigators who had worked in Navrongo what “zurugelu” meant. Here is Dr. James Phillips’ reply:

“The zurugelu approach is a social engagement strategy that involves merging the organizational system of primary health care provision with the traditional system of social organization and governance. When gender problems were evident, we attempted to turn patriarchy on end by working with women’s social groups in ways that were traditionally dominated by men. Social events, termed “durbars”, were traditionally male events that were led by traditional male social leaders. To build women’s autonomy and roles, we worked with leaders to eventually have women’s convened and women’s led durbars. We also had gender outreach activities for responding to the needs of women. As such, the “zurugelu” approach was a gender development strategy.”

(A “durbar” is a meeting of men with their chiefs.)

It is interesting that neither community health nurses nor zurugelu alone had much effect on fertility. Even though the nurses educated women about family planning and supplied the necessary materials, fertility did not decrease significantly in the regions where they were introduced but didn’t have zurugelu. Nor did zurugelu alone have much effect by itself. It took both working together for the fertility to come down.

The need for both nurses and zurugelu is a very important observation. The statement has been made frequently that worldwide over 200 million women want to limit their fertility but don’t have access to modern contraception. Since the nurses provided that access, we know that access alone isn’t enough—at least in this group of people. Apparently tradition and paternalism were significant barriers to using contraception. It took zurugelu to change attitudes before people made the most of what family planning was available.

What difference did zurugelu make? This traditionally male function opened the eyes of men to the needs of women. Furthermore, the Navrongo programs strengthen the roles of women.

Now, back to my visit in Ghana. It was dusk as we were driving from Navrongo back to Nalerigu. We passed a straw hut with smoke emerging from its roof.

“Is it on fire?” I asked.

“No”, my host replied. “She’s just cooking the evening meal.”

Although there is much beauty in northern Ghana, and everyone I met was friendly and warm, my impression is that life is difficult. Now that child mortality is a fourth of what it was 50 years ago, people will benefit from smaller families as well as more education.