Scaling up of family planning in low-income countries: lessons from Ethiopia

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Prof Daniel T Halperin (PhD)

Previous analyses have emphasised the crucial importance of family planning to achieve a range of health and other development objectives in developing countries. This Viewpoint focuses on the successful implementation of services in Ethiopia, Africa's second most populous country. Ethiopia's encouraging experience could challenge the widely held assumption that a decline in fertility must be preceded by sweeping economic and educational advancement, and offers other useful policy and programmatic lessons for other low-income countries, especially in sub-Saharan Africa.

In July, 2012, The Bill & Melinda Gates Foundation and the UK Department for International Development convened a historic London Summit On Family Planning to revitalise efforts to expand family planning services in developing countries. The urgency of realising this expansion has become more widely acknowledged as the adoption of family planning has shown to generate important public health outcomes, such as reductions in maternal and child mortality and abortions.1—5 Analysis also suggests that family planning is indispensable for achieving a range of other crucial development objectives, including several other Millennium Development Goals (MDGs) that address economic development, women's empowerment and education, and environmental protection.6—10 Nowhere are these services more needed than in sub-Saharan Africa, where in many countries contraceptive use continues to stagnate at about 10% and typically at least a quarter of women report wanting to prevent or delay pregnancy but do not use modern family planning methods.9—12

Yet, although there is widespread agreement that fertility decline is often associated with other aspects of socioeconomic development, scepticism remains in some quarters—for example, among some health economists— about whether the availability of family planning services can actually make a substantial difference towards reducing fertility rates in the lowest-income parts of the world, especially without the necessary contribution of distal factors such as education or increased wealth. Furthermore, although the London Summit underscored that there is clearly still a long way to go towards expanding service delivery in some key regions,8—12 we can learn much from successful experiences so far. Ethiopia offers an encouraging example, and one that seems to challenge the widely held assumption that a demographic transition towards reduced fertility must be preceded by broad socioeconomic advancement.

With a population of roughly 90 million, Ethiopia is Africa's second most populous nation after Nigeria, and remains one of the world's most impoverished and rural countries, although gross domestic product has more than doubled over the past decade. Public education is an increasing priority. Although the number of girls finishing primary school has risen sharply over the same period, still only about a third of women are literate.

Nevertheless, various other health indicators have steadily improved in recent years. According to nationally representative surveys, between 2005 and 2011, infant mortality decreased by 23%, falling from 77 to 59 deaths per 1000 births, and under-5 mortality declined by 28%, from 123 to 88 per 1000 births.13 Maternal mortality is still a substantial problem, but is being increasingly prioritised in policies and public campaigns, and has also begun to decline in recent years.13 Finally, adult HIV prevalence in Ethiopia remains at slighty more than 1%.13, 14

Family planning has probably played an important part in some of these broad health improvements. Between 2000 and 2005, reported use of modern contraceptive methods among married women of reproductive age rose from 6% to 14%, and jumped again to 27% in 2011,13 making Ethiopia one of the few countries where contraceptive prevalence has doubled twice in about a decade. During this period, the greatest surges in contraceptive use were in rural areas, even where severe poverty, female illiteracy, and early female age of marriage are largely entrenched.13 Between 2000 and 2011, the national fertility rate declined from 5•9 to 4•8. Meanwhile, fertility in the capital city, Addis Ababa, had already fallen to less than 2•0 by 2000 and by 2011 fell even further, to around 1•5, far less than the replacement level.13 This remarkable decline is due to a range of factors including delayed age of marriage—largely related to progress in women's educational, economic, and labour force participation in the city—and greatly expanded access to contraceptives.15—17 Access to abortion, which was already increasingly available even before it was legally liberalised in 2004,15, 17 also seems to have played a part.

Additionally, the expanding national availability of safe and affordable abortion services at public facilities and also offered by private non-governmental organisations (NGOs) such as the UK-based Marie Stopes International has undoubtedly reduced the number of unsafe procedures being done, which could also have begun to reduce maternal mortality.2—5,17 Between 2008 and 2011, the proportion of postoperative safe versus unsafe abortions performed, which were cared for at the country's largest maternal care facility, the Black Lion Hospital in Addis Ababa, rose from 43% (vs 57%) to 82% (vs 18%; unpublished).

Although the greatest declines in fertility so far have occurred in urban areas, where most of the socioeconomic gains have also occurred, the broad national surge in contraceptive use—including in many very low-income rural areas—would seem to call into question the assumption long held by some critics, most notably economists, that fertility can fall only in the context of sweeping educational and economic advancement.18—23 This view of demographic transition maintains that contraceptive uptake is fundamentally an outcome of improvements in women's educational and other socioeconomic measurements, and will inevitably take care of itself. Although various inconsistencies and limitations of the demographic transition model have been raised—and real-world examples such as Bangladesh seemingly contradict it1, 23, 24—many theorists continue to adhere to its underlying supposition that broad socioeconomic changes are a prerequisite for fertility reduction, and some have questioned whether making family planning services more widely available is therefore largely unnecessary or not particularly effective.21—23

Yet despite the absence of a fundamental transformation in many socioeconomic indices (especially in rural areas, where 80% of the population continues to reside), by 2011 the average number of desired children (from women asked how many children they would ideally like to have?) in Ethiopia had declined from about five in 2001 to fewer than four only a decade later.13 Studies show that the main reasons for this shift relate to the increasingly high cost of raising children, the scarcity of arable land—since increasingly there is less land available to meaningfully subdivide between sons—and women's perceptions that their educational and economic prospects would be encumbered by needing to care for a larger family.15—17,25,26
Recent data from national surveys and other sources show that use of long-acting contraceptive methods, particularly implants, is growing steadily.13, 15, 17, 26 However, many family planning users are continuing to rely on short-term methods—mainly the injectable contraceptive medroxyprogesterone—partly because of misconceptions about side-effects from longer-term methods such as implants and intrauterine devices, which include widely held beliefs that these devices can weaken women's bodies and impair their ability to perform manual labour.9, 11, 12, 23, 25 In any event, in Ethiopia there is widespread agreement that both governmental (local and national) and various NGOs and other private entities are strongly committed to expanding access to voluntary family planning services.15—17,25,26

When a large and diverse number of key informants, such as local NGO officials and donor representatives, from across the country were asked to identify the major factors behind Ethiopia's family planning success,26 the most commonly mentioned points included strong commitment from and leadership by the government, beginning with the (recently deceased) Prime Minister Meles Zenawi. As long-time former Health Minister Tedros Adhanom Ghebreyesus, a consistently strong family planning champion has emphasised “When you plan, be ambitious. Do it at scale”.26 Other points included the extensive outreach of services in the rural areas through an ambitious Health Extension Workers (HEWs) Programme, started in 2004; improvements in infrastructure, especially health centres and health posts; and in health system quality, particularly regarding logistics and supervision (including donor-funded NGOs supporting the government when necessary—eg, providing supplies during periods of stock-outs); inclusion of local health partners in the national programme; and “a sense of pride, purpose, and optimism that Ethiopia is on its way to meeting the MDGs”.26—28 Other observers have noted the escalating on-the-ground demand for contraception, stemming from a series of demographic, economic, and social pressures, and also generally as part of women's empowerment and of efforts to combat maternal mortality and morbidity.14, 17, 26

Fairly similar reasons for programmatic success have been identified in several other African nations that have achieved substantial family planning gains in recent years—countries which are also among the world's poorest and most rural (appendix), including Rwanda (where contraceptive use has recently risen to 45%),26, 28 Malawi (where long-term methods and female sterilisation in particular have made substantial inroads),26, 29 and Madagascar.30 However, a unique feature in Ethiopia has been the creation of a new cadre of government health workers, the HEWs, to staff rural health posts and the intensive reliance on these health providers to offer family planning services within the community. These rural public workers, who now number more than 35 000, are usually female, and receive a year of general health training and a modest monthly salary.31 They mainly offer basic services such as immunisations, health education, and short-term family planning methods (condoms and oral and injectable contraceptives).

However, in 2009, Ethiopia became the first African country to train lower level health providers (the HEWs) to insert contraceptive implants—a single-rod etonogestrel implant.26 In some instances, HEWs have also done medical (misoprostol-induced) abortion32 (although only more skilled health-care professionals such as nurses or physicians can remove implants or do clinical abortion procedures and sterilisations). An innovative pilot study in Tigray Province showed that lay community volunteers can even be successfully trained to safely provide injectable contraceptives to their neighbours,33 which could potentially free up HEWs to offer more long-term methods such as implants.
A 2010 UNICEF-designed survey34 of about 400 HEWs and 10 000 of their clients showed that 93% of health posts provided family planning services in the previous year. The average number of new family planning clients in the year preceding the survey was 153 clients per health post, with an average of 157 revisiting family planning clients.

Health posts in the Amhara region seemed to do better, with an average of 245 new and 253 revisiting family planning clients per post in the preceding year, consistent with the somewhat higher contraceptive prevalence rate in the province. The three main services recalled by clients as having been offered by HEWs were family planning (63%), immunisation (41%), and health education (38%), suggesting that the Ministry of Health's prioritisation of key health interventions has been successful. This was additionally supported by the four leading reasons stated by clients for visiting HEWs: family planning (36%), health advice or counselling (21%), immunisation (18%), and treatment of malaria (16%). Although most clients rated all the HEW services as being either “very satisfactory” or “satisfactory”, family planning received the highest score (a total of 77%).

One obvious conclusion from such findings would be to more widely disseminate some of the features that have been used to improve family planning service delivery in Ethiopia, specifically the importance of strong government commitment (including advocacy from champions both within and beyond the health sector), strategic investments, effective public—private partnerships, and well coordinated donor support. Although many challenges remain—in 2011 a quarter of women still had unmet need for contraceptives in Ethiopia13, 17 and use continues to be low in some of the more remote areas—the generally encouraging experience in Ethiopia and in some other very low-income countries should provide inspiration and useful policy and programmatic lessons for elsewhere in sub-Saharan Africa. In particular, the importance of task shifting of basic health services such as family planning to lower-level cadres35 like the rural HEWs is a useful model that could be emulated (and rigorously assessed through operations research). Such lessons would be especially pertinent for regions with huge and rapidly growing populations, including Nigeria and most of west Africa, the Republic of the Congo, and nearly the entire Sahel region,9, 11, 12, 36 which continue to have distressingly low rates of contraceptive use along with high unmet need and weak provision and promotion of family planning and other basic reproductive health services. Indicative of Ethiopia's willingness to have a leadership role.

The International Conference on Family Planning, cohosted by the Bill & Melinda Gates Institute for Population and Reproductive Health, will be held this week in Addis Ababa, Ethiopia, with the objective of assertively promoting the goals of the 2020 Initiative launched at the 2012 London Summit. (

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