Case study

DFID Research: Choice for women. Family planning, health and rights in a world of 7 billion

Last month the United Nations Population Fund announced that global population has passed 7 billion. This landmark brings the issue of population growth and its impact into sharp focus

Hauwa'u, 25, mother from Rogogo community, Katsina.
Hauwa'u, 25, mother from Rogogo community, Katsina. Picture: Lindsay Mgbor/DFID

Last month the United Nations Population Fund announced that global population has passed 7 billion. This landmark brings the issue of population growth and its impact into sharp focus. Whilst population growth is often reported in an alarmist manner, it is implicated as a contributing factor across a wide range of development issues including resource scarcity, poverty, and increasing pressure on basic services such as healthcare. Population growth is a complicated issue where opinions are many and detail scarce. It is vital, therefore, that this landmark is used to explore areas where research can have greatest impact and help populations and governments overcome the challenges they face.

Population growth and the negative impacts associated with it are most acute in the world’s poorest countries. In fact, for every 100 people born, 97 are born in developing countries. This will add to the pressures that governments in these countries face to provide basic services like health and education for their people. In this context empowering individuals to be able to decide whether, when and how many children to have presents a critical challenge.

Lack of choice for women and girls is a major cause of poverty and contributes to a growing population by denying people the right to plan their families and avoid unwanted or unintended pregnancies. Giving women and girls choice through family planning is widely regarded as essential for increasing women’s health and reducing levels of maternal and infant mortality across the developing world.

Choice for women

Globally, 215 million women who want to delay or avoid a pregnancy are unable to gain access to family planning services. Each year there are 75 million unintended pregnancies with an estimated 44 million ending in induced abortions. The lack of choice women have over their own lives and bodies is a significant factor in rapid population growth. According to new WHO data, in 2008 an estimated 22 million unsafe abortions took place resulting in the deaths of 70,000 women and girls each year, although many go unreported.

If you add to this the fact that a woman dies in childbirth every 2 minutes (99% of them in the developing world), giving women the choice to decide will have considerable impact on both population growth and the global crisis in maternal heath.

DFID is investing in research that supports the UK Government’s Framework for Results on improving reproductive, maternal and newborn health (RMNH) in the developing world. The UK Government has strengthened its commitment to family planning as a strategy to reduce maternal mortality, with preventing unintended pregnancy and unsafe abortion as policy priorities. DFID is proud to lend its support to research projects that offer real and tangible benefits to women, and help facilitate opportunities that take them out of the poverty cycle.

DFID’s Reproductive, Maternal and Newborn Health (RMNH) evidence series provides a repository of findings and evidence concentrating on those areas where policy or practical decisions will have to be made. The series is primarily aimed at informing policy and the design and implementation of the UK Government’s framework for results. It concentrates on regions where DFID has a major presence (primarily Africa and South Asia) and on areas with direct links to policy and practical decision making.

Barriers to sexual health and reproductive rights

Access to family planning is not just a simple case of delivery on the ground. A recent systematic review compiled by a team from the University of Portsmouth highlights five core factors that often determine whether or not someone in a low income country has sufficient access to family planning services. These are:

  • geographic/physical accessibility (whether individuals have to travel to reach their nearest family planning facility)
  • economic accessibility (whether the price of travel to nearest facility or of contraceptives is affordable)
  • administrative accessibility (whether unnecessary rules inhibit use of services e.g. restrictive opening hours)
  • cognitive accessibility (whether individuals know about the services)
  • psychosocial accessibility (whether clients are constrained by factors such as perceived stigma in accessing services)

 

The review also suggests that the type, quality and mechanisms of service provided are important determinants of use. In addition, the range of contraceptives available to individuals may vary considerably due to provider bias, supply and the overall efficiency of the family planning services provided.

The socio-cultural terrain in which interventions are deployed is often overlooked. The challenges vary from country to country and establishing a thorough understanding of why unmet need exists and persists in country specific contexts is essential. Research has been successful in improving both our understanding of in-country contexts and the design of appropriate interventions in areas of access and education.

Acceptability affects both whether people will choose to use any of the available methods and whether they continue with their chosen method. Little or no information, opposition to use, and concerns about side effects are major influences driving up unmet need. Cultural and religious barriers are a force for preventing access to family planning as are domestic laws and policies. This further isolates low income women and increases the likelihood of unwanted pregnancies and serious health problems.

Communicating reproductive rights

Realising Rights: improving sexual and reproductive health for poor and vulnerable populations was a DFID supported research consortium led by the Institute of Development Studies (IDS) at the University of Sussex. The project which ended in 2010, addressed the fact that, in many countries, issues of sexual health and reproductive rights remain invisible, taboo, poorly understood and poorly communicated. Communication and education remain significant challenges. Engagement with policy makers and the media throughout the developing world remains paramount.

Using mass media channels is vital for breaking down barriers to choice and educating people on the benefits of family planning. A persistent problem is that reproductive health, women’s rights, gender issues and maternal wellbeing are not communicated to the public effectively. Whilst progress is being made, many issues are bypassed or are not reported in an accurate manner. The problem is most acute in sub-Saharan Africa where media coverage of reproductive health issues is poor due to low capacity and a lack of coverage by media professionals.

A Realising Rights working paper has recommended that a sustained mix of strategies be used to motivate, strengthen capacity, and build relationships between journalists and researchers that increase the effectiveness, quality and quantity of media coverage on sexual and reproductive health issues. Alongside generating new information on the state of reproductive health across the developing world, the project pioneered engagement with journalists and policymakers and promoted public debates on sexual health issues that are often stigmatised and sensitive.

For example, Realising Rights lobbied the Kenyan Government on the issue of domestic violence and marital rape in the hope of improving women’s rights to legal redress and raising awareness of the profoundly negative physical and mental health impacts of rape.

Maternal mortality: Seeking innovative solutions to save lives

DFID has a long history of supporting research into maternal and newborn health within its overall strategy on family planning. Research contributes through knowledge generation, building evidence of cost-effectiveness and a less obvious ‘challenge function’ which is critical for moving policy forward.

Past research successes include the DFID funded Initiative for Maternal Mortality Programme Assessment (IMMPACT), led by Aberdeen University, which generated evidence on the effectiveness of mother/infant services in developing countries. The project has so far yielded highly influential findings including new knowledge on the magnitude, causes and consequences of maternal mortality. Phase II of IMMPACT’s research efforts are in place and further funding efforts are expected to support activities through to 2012.

‘Towards 4 and 5’ was a DFID funded research project led by the Institute of Child Health that ended in 2010. It focused on ways to improve mother and infant care at both the facility and community levels. The project completed 3 large scale randomised controlled trials in poor populations of Nepal, India and Bangladesh. The study revealed the potential for a 45% reduction in newborn mortality where the trials were conducted. Despite some inconsistencies within the results and persistent problems in Bangladesh, it is hoped that these findings will bring about changes to national policy in the region.

In Sierra Leone - a country in the bottom rankings of the Human Development Index with unacceptably high maternal and child mortality rates - DFID research is trialling the use of ‘mHealth’ mobile phone technologies as part of Phase 1 of the DFID ‘New and Emerging Technologies Research Competition’. Those who require health services make and receive phone calls or text/voice messages related to treatment or organising transport to clinics. A growing body of literature suggests mHealth is a promising development for improving health services for poor people and those living in marginalised areas.

Conclusion

Rapid population growth has the potential to exacerbate some of the most serious challenges humankind has ever faced. Its negative impacts are most evident in the developing world where resources are few and basic services under ever increasing pressure. Issues around population growth are complex, multiple and overlapping and include resource scarcity, unemployment, poverty and migration, and reinforces the need for universal access to family planning and choice for women and girls.

Worldwide, the desire for smaller families is increasing. However, poor access to services and a lack of information and education continue to hamper service expansion and provision to those with the greatest need. Research shows that family planning is a powerful tool for breaking cycles of poverty, ill health and preventable disease that ruin lives and keep people and societies poor.

Better access to family planning will help slow population growth, empower women and accelerate development progress. Progress is being made but there is still a lot of work to do, particularly in those countries with weak healthcare systems or poor track-records on women’s rights and gender issues.

Published 17 November 2011