This issue of the journal seeks to accelerate interest in research on family planning services and uptake, and behavioral and population outcomes, by sharing findings from studies recently conducted on the continent and presented at the International Family Planning Conference held in Kampala, Uganda, between November 15 and 18, 2009. There are three main themes across the studies: 1) individual factors behind contraceptive demand, 2) programmatic factors influencing contraceptive practice, and 3) individual fertility and population change consequences linked to that use. The first set of studies examines the quality of contraceptive information and knowledge, gender roles, and timing of contraceptive adoption among various subpopulations in Africa, e.g., in-school adolescents, HIV-infected women of reproductive age, postpartum mothers, refugees and displaced populations, and men. The second set of studies assesses program factors influencing contraceptive norms and practices, such as models for integrating family planning and HIV care, coverage of family planning by the print media, and communications with adolescents. The third set of studies explores the relationship of family size and food security to child nutritional status, factors associated with contraceptive failure, and at the population level, fertility and climate change. Four of the papers are shared as research briefs, and one presents a road map to universal access to family planning, prepared during the 2009 conference.
“The Global Road Map to Universal Access to Family Planning” [Cates and Burris] links the 1994 Cairo conference to the 2007 addition of Millennium Development Goal 5b of universal access to reproductive health, and subsequently to the 2009 International Conference on Family Planning. Providing a succinct overview of lessons learned from the Kampala conference, Cates and Burris highlight three themes: 1) family planning and the Millennium Development Goals, 2) evidence-based policies, and 3) leadership and ownership of the field, particularly in sub-Saharan Africa.
The rest of this commentary summarizes the papers’ findings and concludes with reflections regarding future family planning research directions and research capacity building to serve African populations in need.
FACTORS INFLUENCING FAMILY PLANNING DEMAND
Adequate and correct knowledge about contraception
Effective contraceptive practice requires adequate and correct information about methods. Okanlawon, Reeves, and Agbaje observe extensive misperceptions and false beliefs about contraceptives and their safety among refugee youth in a Nigerian camp, which account, in part, for low use, unintended pregnancies, and school dropout for girls. Aryeetey and Kotoh analyze survey data from a Ghanaian district and find that while a large majority of female reproductive-age respondents believe that family planning methods are important and effective, a substantial proportion consider modern contraceptives to be unsafe. Male partners’ attitudes and service factors are among some of the other reported barriers to adoption.
Gender and male involvement
Contraceptive service delivery tends to be heavily gendered, oriented toward serving women at different points of encounter with the health system, such as family planning, antenatal, delivery, postpartum, and well-baby clinics. The single-gender focus exacts costs by distancing male sexual partners and spouses from family planning decisions and services. Onyango, Owoko, and Oguttu underscore the importance of this issue in their qualitative study in western Kenya regarding gender norms and traditional female-oriented approaches of reproductive health programs that discourage male involvement. Similarly, analysis of data from a local survey in Nigeria by Ijadunola et al. finds spousal communication about family planning and other family reproductive goals to be poor; socio-demographic correlates such as religion, educational attainment, and occupation are significantly associated with men’s opinions about and involvement in family planning.
As a measure of male involvement, Akinyemi et al. examine factors associated with current condom use and condom use at last sex in a large sample survey of sexually active men and women of reproductive age in five states of Nigeria. Younger and more educated respondents were more likely to be users, but overall use was low and inadequate among those who engaged in risky sexual behaviors.
Expanding the focus beyond individuals to couples, Gipson et al. share a qualitative study regarding the acceptability and feasibility of a home- and couple-based model of delivering HIV counseling and testing and family planning services in peri-urban Malawi. In-depth interviews with couples suggest that doorstep delivery and privacy are key attractive features of the model by which to transfer information and services.
The potential of postpartum contraception
Offering contraceptives to postpartum women can protect their health and that of their newborns by extending the interval to the next pregnancy. Borda et al. analyze Demographic and Health Survey data on postpartum married females in 17 developing countries to show that a large percentage resume sexual activity within six months and between one-quarter and one-third resume menstruation by one year. However, only a small number adopt contraception in the first year postpartum.
FACTORS INFLUENCING THE SUPPLY OF FAMILY PLANNING INFORMATION AND SERVICES
In Laar’s “Family Planning, Abortion, and HIV in Ghanaian Print Media,” the media is a grossly underutilized means of reaching people with key messages regarding health issues, especially reproductive health issues. Laar conducted a 15-month content analysis of the Daily Graphic, a national Ghanaian newspaper, and his findings show how infrequently reproductive health issues are covered by the print media.
One of the briefs, Oghenefego “Talk 2 Me Case Study,” describes how knowledge and the demand for knowledge can be tailored to programs that address the needs of subgroups within a population, in this case young people. Peer educators facilitated discussions in selected Nigerian secondary schools on sexuality, STI/HIV/AIDS, and other sexual and reproductive health issues. This innovation led to student stories being published in a monthly newsletter (Talk2Me) disseminated to both in-school and out-of-school young people. The success of the program and the desire for sustainability led to the birth of a club, Champion’s Forum.
Integrating family planning and HIV services
Because unwanted pregnancies and sexually transmitted infections, including HIV, originate from unprotected sex, the integration of contraceptive and HIV services takes on special significance as a preventive program strategy. Makumbi et al., using community cohort data from the Rakai study, assess the association between uptake of HIV-related services and use of modern contraception among reproductive-age women. They find significantly higher use of condoms for family planning among voluntary counseling and testing (VCT) clients and HIV care attendees compared with those not receiving these services, pointing to the advantages of service linkages between family planning, HIV care, and preventing mother-to-child transmission (PMTCT) programs. Todd and colleagues use qualitative methods to explore perceptions toward and utilization of contraception among HIV-positive women of reproductive age in Kericho, Kenya. They find that even though women are favorably disposed to using contraceptives, their contraceptive decisions are often shaped by both their misconceptions about contraceptives and their HIV status. Kirunda et al. report in a brief that, following a quality improvement intervention, 15 facilities in Uganda show sustained improvement in the proportion of HIV-positive clients subsequently receiving counseling on FP methods from health care providers. These providers observe that FP-HIV service integration appears to increase the utilization of FP services and reduce stigma among their HIV-positive clients. A study by Leslie et al. of postnatal Rwandan clients receiving PMTCT care reveals that among those contracepting, most used the condom inconsistently and very few used long-acting or permanent methods, even though the majority of women report their last pregnancy to be mistimed or unwanted. The authors find a large discrepancy between the reported willingness of providers to discuss FP with their clients and clients’ reports that few such conversations ever take place. All four studies, conducted in three different sub-Saharan countries, report the potential benefits of linking HIV/PMTCT and family planning services.
Three studies examine outcomes beyond contraceptive practice. Otupiri, Mote, and Hindin identify socio-demographic factors related to the practice of induced abortion, behavior that reflects failed contraceptive provision and absence of use despite exposure to the risk of pregnancy. Analyzing data from a Ghanaian district survey of female respondents, the authors find that one-fifth of the respondents report ever having an abortion, with higher likelihood among those with more education, employed, married, or living in a peri-urban area.
The influence of family size, household food security status, and child care practices on child nutritional status is examined in a study conducted in Ile-Ife, Nigeria, by Ajao et al. Households with food insecurity and less educated mothers are more likely to have malnourished children under age 5. Family size was not significantly associated with nutritional status in this study.
At the population policy level, Mutunga and Hardee assess the inclusion of population and reproductive health interventions in National Adaptation Programmes of Action (NAPAs), established as part of the Marrakech Accords of the 2001 UN Framework Convention on Climate Change Conference. Recognizing that less developed countries (LDCs) are among the most vulnerable to, and have the least capacity to cope with, extreme weather events and the adverse effects of climate change, NAPAs were intended to provide assistance to LDCs in addressing the adverse effects. Mutunga and Hardee’s analysis of 44 NAPA countries, selected for their high vulnerability and low adaptive capacity, finds that less than half of them have proposed a single project in the health sector even though all prioritized this sector. One of the authors’ recommendations is that NAPAs should translate the recognition of population pressure as a factor related to the ability of countries to adapt to climate change into relevant project activities, including access to family planning and reproductive health services, girls’ education, women’s empowerment, and a focus on youth.
FAMILY PLANNING RESEARCH IMPLICATIONS
The cited findings represent a small percentage of all research carried out on family planning on the African continent and collectively suggest that contraceptive adoption is far from perfect and not well served by poor knowledge and interpersonal and mass communication efforts, uncoordinated sexual and reproductive health services mismatched with individual and couple needs, and inattention to vulnerable groups such as males, youth, and displaced persons. There is much margin for improvement in service delivery, individual learning, and the research enterprise.
In terms of research capacity, a review of the articles in this issue also reveals a need to support longitudinal data collection and measures and apply more rigorous analytic methods. Causal relationships are difficult to establish when the strongest tools of social, epidemiologic, and behavioral research cannot be brought to bear in studying the impact of a critical health intervention. The majority of the research papers here are based on cross-sectional study designs, which unfortunately provide limited information about causality. Such designs cannot establish temporally the sequence of cause and effect since measurement happens simultaneously. Sub- Saharan Africa–based research employing longitudinal data analysis methods or based on experimental or randomized controlled trial designs is needed to generate the quality of evidence that can underscore important causal linkages between factors of interest and adolescent, maternal, child, family, and population outcomes.
The qualitative studies presented here are helpful in revealing to a greater depth personal and community perspectives on sensitive reproductive health issues. Systematic analysis of the themes elicited through the qualitative methods of data collection can help frame the social construction of family planning and its many meanings. These can subsequently inform scale development, testing, and construction, providing measures unique to each country or subgroup setting if necessary. For example, how are side effects of modern contraceptive methods perceived and framed as a cause of infertility in the language and thoughts of youth, men, women, users, couples, or providers? Expanding beyond and capitalizing on the elicited narrative to enable improved measures are important next steps for qualitative research on family planning.
We also recommend meaningful and continent-wide efforts to build research capacity in research institutions, with a special focus on family planning and reproductive health and other population-level development outcomes. Such efforts can include institutional in-house research skill sharing; establishment of research groups within and across institutions in sub-Saharan Africa and linked to like groups outside the region; post-graduate training for faculty/staff interested in state-of-the-art analytic techniques; and a strengthened culture of rigorous scientific investigation, relying on peer-review mechanisms for evaluating technical merit as often as possible. Unfortunately, these research and training needs will be addressed only if policy and service gaps can be addressed concurrently. The quality of research evidence is unlikely to improve in the absence of a translation value placed on analytic findings by program and policy users. That translation itself requires that programs and services are appropriately capacitated and technically resourced to evaluate their effectiveness.
We believe the papers in this volume will raise the value placed on scientific effort to understand variations in family planning behavior. We also look forward to future studies that rigorously enhance the evidence base regarding the benefits of family planning. Embracing the benefits of family planning in sub-Saharan Africa often seems to rest on locally generated evidence, much as a new drug product requires clinical trial data in order to obtain federal approval for local consumption. We encourage initiatives to improve the ability of researchers, practitioners, and policymakers to secure the public’s health, especially its sexual and reproductive health, with the best possible research effort and results.
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