By Alexandra Sifferlin
Ethiopia has over 77 million inhabitants, and is considered one of the poorer countries in Africa. But this year, it’s playing host to the annual International Family Planning Conference in its capital, Addis Ababa.
The conference showcases the fact that despite Ethiopia’s high poverty rate and political intrusions on free speech, it has one of the most progressive family planning policies in Africa. And that success is serving as a model, not only for other developing nations such as Rwanda and Malawi, but for developed ones as well.
Economically, family planning is critical for a country’s stability — by protecting women from unwanted pregnancies that can contribute to high maternal and child mortality rates, these programs also allow mothers to enter the work force, and empower them to contribute to their local economy. Family planning is a public health term for essentially means controlling the number of births a woman has, and spacing those births. The Bill and Melinda Gates Foundation estimate that 1 in 4 women’s lives could be saved if there were global access to contraception, for example. And family planning isn’t just focused on mothers. The Foundation found that about 3.2 million children die each year from preventable diseases, many of which could be avoided if families had access to proper medical care, such as immunizations and antibiotics.
Such efforts have translated into measurable changes already. In Ethiopia, public health facilities offer all available contraceptive methods for free, and that has contributed to a rise in contraceptive use among women. The percentage of women of reproductive age using family planning has jumped from 8% in 2000, to 15% in 2005, to 29% in 2011.
For men, the Ethiopian government sends male mentors directly to people’s homes, to educate those who are skeptical or against the idea of their wives planning their births. Family planning is also introduced to boys in primary school. Despite these attempts, however, male involvement in family planning is still considered a challenge for countries in the developing world.
What has worked to improve the way couples start their families and enhance childhood health? Here’s what Ethiopia, Rwanda and Malawi are doing right to strengthen family planning.
Recognizing that young people are sexually active: While it seems obvious, acknowledging that teens are having sex is a challenge for some administrations, especially conservative ones. A typical 18-year-old Ethiopian woman is already married and likely expecting her first child, and most women have around five. However, community health centers in that country now include youth services and private offices to not only educate teens, but provide them with the protection they need to practice safe sex or delay sexual activity.
Appreciating that most teens may not feel comfortable talking about sex with adults, some NGOs and organizations have taken more unconventional approaches to getting contraceptives to young people. Planned Parenthood Federation of America, for instance, partners with Mary Joy Aid Through Development to train Ethiopian teens to become peer health promoters. As promoters, they talk to other teens about sexual health issues and distribute contraceptives like pills and condoms.
“I’ve been surprised by young men asking what methods of contraceptives they should use,” says Josephat Nyamwaya, a program officer for the Planned Parenthood Federation of America’s Africa office, where he trains youth in many African communities like his roots in Nairobi. “I tell them at their age, condoms, but that they also need to support their girlfriends in their contraceptive decisions.”
Making family planning the law: In Ethiopia’s constitution, access to family planning is cited as a woman’s right. Similarly, Rwanda’s government has legislated strong policies for family planning, and saw uptake of contraceptives jump by 10-fold. In 2000, only 4% of married women of reproductive age were using modern contraceptive methods, but the rate spiked to 45% by 2010, thanks to the country’s National Family Planning Program, which revamped access to contraceptives by stocking up all public health clinics, trained more providers in family planning education, and encouraged more women to give birth in their health facilities rather than at home.
And to persuade couples to space children apart, or use contraceptives, the government of Malawi has focused on improving child health services. Ironically, the more dire their circumstances, the more children parents are likely to have, because they know that many won’t survive their first years. “You cannot tell people not to have [more] children if they don’t feel secure that they will survive,’ says Malawi Minister of Health, Catherine Gotani Hara.
Giving family planning prominence in the country’s constitution is an important step toward acknowledging the critical role that reproductive health plays in a country’s economic stability. “These countries that are having success have really come out front with the recognition that if they were to solve this problem, they would solve so many others in their country. When you don’t have that leadership, it’s really difficult to move forward,” says Beth Fredrick, director of advance family planning for the Bill & Melinda Gates Institute at Johns Hopkins School of Public Health.
Bringing family planning services to the people: In both Ethiopia and Malawi, health extension workers are the key to reaching community members and getting them to clinics, as well as providing them with access to family planning programs. In Ethiopia, every community is allocated a hospital, a smaller health center, and a health post—which is staffed by two health extension workers. To supplement their efforts, the governments of these countries, using funds from the U.S. Agency for International Development (USAID), developed the Women’s Development Army. Members of the army, which include local community mothers who are trained by extension workers, go door to door, educating women about family planning, and hosting small gatherings of five community members to discuss reproductive health and answer questions in an informal setting.
‘I had my first [of five children] when I was just 15 and didn’t know about family planning,’ says Yenenesh Deresa, a member of the Women’s Development Army of Burayu, Ethiopia. “Now we sit around coffee and I talk to women about family planning. They’re empowered to make their own decisions and have safer pregnancies.”
Realizing the value of educating girls: If countries like Ethiopia, Rwanda and Malawi can lower their fertility rate, there’s a possibility that they could experience a bump in the economy, known as reaching the demographic dividend. That’s when younger generations join the workforce, and the greater proportion of this cohort that can find employment and live independently, the fewer dependents a country has. The first step toward achieving this condition is to lower fertility rates, but the younger generation needs to be educated to succeed in the workforce and there needs to be jobs available as well. While educating both genders is critical for such success, making sure that girls receive their degrees is especially important, since about a quarter of girls in low-resource countries drop out of school once they get pregnant.
“Empowerment [of women without education] is complicated. If girls need to be educated and attend schools, they need to be protected from unplanned pregnancies,” says First Lady of Ethiopia, Roman Tesfaye. “If we do not address these issues for women, it will be too challenging to become a middle income country.”
The push to protect women through health measures that will keep her in schools is slowly playing out even in rural communities. “You can see that things are changing now for women. I am a woman, and I am a leader here,” says Zewdtu Areda, head of health zone near Muka Turi, Ethiopia where she oversees health services offered for the area.
Offering all forms of birth control: Even in the U.S., research shows that when all methods of contraception are offered at low cost, women tend to pick long-acting reversible contraceptives (like implants and IUDs) over condoms and pills. Ethiopia, Rwanda and Malawi all provide contraceptives at no cost in public health clinics, and in line with prior research, women tend to choose the longer-acting, more discreet methods. However, clinics continue to offer the less popular methods in order to give women a full spectrum of choices, so women can decide for themselves which methods are best for them.
Changing cultural acceptance of family planning: Health clinic workers often hear the same requests from women — they want birth control, but don’t want their husbands to know they are using a contraceptive. Even with progressive policies, in countries like Ethiopia cultural stigmas against limiting reproduction remain. Health workers often meet young women in public, outside of the clinic, to give women birth control so her husband won’t know she visited a family planning program.
Changing cultural norms remains a challenge, but officials in Rwanda rely on community health workers to talk to men about why they should support family planning and about how planning their children can mean having healthier children and potentially fewer children to support. They even encourage male family planning methods such as vasectomies. When men come in with their wives to discuss family planning measures, health workers cite the surgery as an option, and encourage it alongside circumcision to prevent diseases like HIV although it’s still not a popular choice.
In Malawi, public health officials are enlisting the help of respected elders. A campaign headed by community chiefs that promotes family planning for couples, for example, includes the voice and perspective of men. “In the villages, we try to include as many men as possible. Men are very affected. In rural settings in Malawi, the breadwinner is usually the man. So if they cannot control their family, they’re the ones in trouble,” says Gotani Hara.
Public health officials are hopeful that the success of these initiatives in the developing world could spill over to industrialized nations as well — including the U.S. — that still struggle to reduce rates of sexually transmitted diseases, unplanned pregnancies and infant mortality. If there is one lesson to learn from these programs, it’s that the most successful strategies don’t come from doctors or government officials, but from peers — mothers, friends or respected elders – who, it turns out, have the strongest voice when it comes to talking about sex and families.