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Repositioning Family Planning A review of evidence of effective interventions_ English |
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Repositioning
Family Planning
a review of evidence on effective interventions
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Repositioning
Family Planning
a review of evidence
on effective interventions
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06 Foreward
08 Executive Summary
20 Chapter 1. Introduction
26 Chapter 2. Delaying age at marriage
40 Chapter 3. Delaying age at first pregnancy
52 Chapter 4. Promoting spacing between births
66 Chapter 5. Improving the quality of family planning services
86 Chapter 6. Conclusions and policy implications
table of contents
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FOREWORD
Experience has shown us that when
advocacy is backed by strong research
and evidence, it yields far better results
and contributes meaningfully to
policy development, efficient service
provisioning and effective implementation
of programs and interventions. Therefore,
strong research and documentation form
the foundation of PFI’s advocacy work.
As part of our strategy to “reposition
family planning within a women’s
empowerment and human rights
framework”, PFI has conducted a
systematic review of national and
international experiences in family
planning. This review, carried out under a
three year grant on “Advocacy for Change:
Repositioning Family Planning - Promoting
Birth Spacing” funded by the David
and Lucile Packard Foundation, looks at
programmes, innovations and policies on
delaying age at marriage, delaying age at
first pregnancy, spacing between births
and improving quality of family planning
services. It analyses and documents
promising programmes so that we can
learn from the processes and results
of other’s in the same field. The review
examines interventions from South Asia,
Africa and the UK and USA to identify
major strategies or combinations of
strategies that were found to be effective.
This document provides evidence
to support strengthening advocacy
for increasing public dialogue on the
importance of family planning and
scaling up successful family planning
initiatives. It identifies a range of
promising strategies that will help
reposition family planning as a means
of upholding the health and rights of
women, men and children. Morever, it
identifies strategies that are worthy of
further experimentation and upscaling,
and highlights the importance of
designing interventions that are creative
and rigorously evaluate the work that
has already been done.
This review would not have been
possible without the support of the
David and Lucile Packard Foundation.
In particular we would like to thank, Mr.
Lester Coutinho, Programme Officer and
Mr. V.S. Chandrashekar, Country Advisor,
Population and Reproductive Program at
the Foundation’s office in New Delhi.
We would also like to thank Dr.T.K.
Sundari Ravindran, Honorary Professor
at the Achutha Menon Centre for Health
Science Studies, Thiruvananthapuram
for her significant inputs in analysing the
review results and giving a final shape
to the document. Technical inputs from
the members of theTechnical Advisory
Group, Dr. Arvind Pandey (ICMR), Dr.
M.E. Khan (Population Council), Professor
Richard Cash (Public Health Foundation
of India), Dr. Alaknath Sharma and Dr.
Sumit Mazumdar (Institute for Human
Development), Professor Leela Visaria
(Gujarat Institute for Development
Research), Ms. Rekha Masilamani and
Dr. Rajani Ved were invaluable. Finally
we are grateful to Dr. Suneeta Mittal and
Dr. Vijayalakshmi Nanda for their critical
review of the draft report.
Poonam Muttreja
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Executive
Summary
Background
For decades, family planning has been
viewed chiefly as a means of controlling
the world’s population size. However,
with declining global population
growth rates1 the imperative to position
Family Planning as more than a means
of population control has become
increasingly evident. ‘Repositioning
family planning’ was a multilateral
initiative launched almost a decade
ago to increase political commitment
and funding for strengthening family
planning services in sub-Saharan Africa
[1]. The 2012 Summit on Family Planning
in London put the ‘repositioning’
approach firmly on the global map
by winning the support of national
governments, civil society and donors
from other regions of the world.
In the ‘Repositioning of Family Planning’
approach, the focus is on reaching all
women and men in developing countries
with quality family planning information
and services in order to meet their need
for fertility control. Voluntary adoption
of family planning would be a means
to reduce maternal and child deaths
[2]. Although not explicitly stated, the
emphasis on health and well-being
and on voluntary family planning is in
keeping with the notion of birth control
as a reproductive right.
In India, the National Population
Policy, 2000 (NPP 2000) affirmed the
government’s commitment to voluntary
and informed choice and consent of
citizens as users of Family Planning
and reproductive health program. One
of the objectives of NPP 2000 was to
delay age at marriage to at least 18
years and to address unmet need for
spacing and limiting births [3]. Ten years
later in May 2010, the Ministry of Health
and Family Welfare held a national
consultation on repositioning family
planning. This consultation announced
the government’s decision to reposition
family planning as a means to improve
maternal and child health. It is in this
context that the Population Foundation
of India’s (PFI) Strategic Plan over the
next five years (2011-2016), attempts
to reposition family planning within a
women’s empowerment and human
rights framework in India’s development
and maternal and child health (MCH)
policies and programs. This systematic
review is a part of PFI’s ‘repositioning
family planning’ initiative.
Why reposition family planning in
India?
There are several reasons why
‘Repositioning Family Planning’ is
especially important in the Indian
context.
To begin with, nine Indian states have
already achieved replacement level
fertility. However, low fertility has
not resulted in improved maternal
health, because of early marriage
and childbearing, and closely spaced
births. For example in Andhra Pradesh,
which had a below replacement level
of fertility of 1.79 children per woman
in 2005-06, 55% of young women age
20-24 years were married before they
were 18 years old, 18% of women age
15-19 had already begun childbearing
and 60% of women bore a subsequent
child within 36 months of a previous
birth [4]. In states with replacement
or below-replacement-level fertility,
repositioning family planning as a health
and development issue could contribute
to designing programs that addressed
1 The average annual growth rate of the global population has been declining, from 1.88%
during 1950s-1980s to 1.45% during 1980s to 2011 (World Population Prospects – The 2010
Revision. Department of Economic and Social Affairs, United Nations, NY, 2011. Vol I,
comprehensive tables).
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women’s other reproductive health
needs alongside fertility control.
Secondly, population momentum is
an important contributor to India’s
population growth. Even with declining
average annual growth rates, India is
adding about 18 million people annually
to its population, because the proportion
of people in the reproductive age
group is almost 50%. One way in which
population momentum can be checked
is by delaying age at first pregnancy
and by spacing subsequent births by 2-4
years. According to the UNFPA, raising
mothers’ age at first birth from 18 to 23
could reduce population momentum by
over 40 per cent [5]. The Indian Family
Planning program which has become
entrenched as a “sterilization only”
program needs to shake itself out of
its inertia and focus on these newer
priorities. The challenge is to not only
change tracks but also change its way of
doing things – i.e. upholding voluntary
acceptance and informed choice.
The third reason why repositioning
family planning is important is related
to the Indian Family Planning Program’s
long legacy of being driven by the
population control logic. Demographic
targets as well as targets for family
planning acceptance have been the
drivers of the program from its inception.
With the introduction of the ‘Target-
Free Approach’ in 1997 the program
seemed to have lost its fulcrum. There is
a need to infuse the program with a new
objective – that of improving health and
well-being and of upholding women’s
and men’s right to fertility control.
The present review: context,
objectives and methodology
The present review is a building block
in PFI’s initiative to reposition family
planning into MCH policies and national
development programs in Bihar and at
the national level. Four areas of focus
in terms of areas for intervention were
identified for the review keeping in view
the Indian context. These were i) delaying
age at marriage (as a means of delaying
age at first birth) ii) delaying age at
first pregnancy iii) promoting spacing
between births iv) improving quality of
family planning services
Context
Delaying early marriage
Early marriages are still prevalent
among a sizeable population of Indian
women. In 2005-06 more than half of
rural Indian women (53.4%) and more
than one-quarter (29.7%) of urban Indian
women age 21-29 were married by 18
years of age [4]. The highest proportion
was in Bihar (63.7%) closely followed by
Jharkhand (60.2%), Rajasthan (58.4%)
and Andhra Pradesh (56.2%) [4]. The
proportion of women married before age
18 declined between 1992-93 (54%) and
2005-06 (47%) and corresponded to an
increase of only 0.4 years in the mean
age at marriage in the same time period,
from 16.7 years in 1992-93 to 17.1 years
in 2005-06 [6].
Delaying age at first pregnancy
There is an urgent need to reorient
family planning programs so that young
married women and men are able to
achieve their reproductive intentions.
Early marriage followed by immediate
childbearing is a social norm in India.
In 2005-06 for the country as a whole,
adolescent birth rate was 90 per 1000, a
decline from 116 per 1000 in 1990-92 and
107 per 1000 in 1995-96. Rural areas had
close to three times the adolescent birth
rate (105 per 1000 women age 15-19) as
compared to urban areas (57 per 1000) in
2005-06 [4].
About 1 in 6 women age 15-19, or 16%
had begun childbearing in 2005-06.The
proportion of women who had begun
childbearing was 3% for women age 15
and increased sharply to 36% or more
than one in three for women age 19.
The proportion is highest in Jharkhand
(27.5%), West Bengal (25.3%) and Bihar
(25%), all located in Eastern India. In
contrast, in Goa, Himachal Pradesh
and Jammu and Kashmir less than
5% of women age 15-19 had begun
childbearing [4]. Data shows that not all
these pregnancies were intended. Unmet
need for spacing in 2005-06 among
women age 15-19 was 25.1%, and only
32.4% of the demand for contraception
was satisfied among this age group. Only
13% of married women in India age 15-19
were current users of any contraception
(2005-06), and only about half of them
(6.9%) used a modern method of
contraception [4].
Promoting birth spacing
Promoting birth spacing and the
use of effective spacing methods of
contraception is a major challenge
confronting the family planning
program. At the all India level, the
median interval since the preceding birth
in 2005-06 was 31.1 months [4], lower
than the recommended optimal birth
interval of 36 months [7]. More than 60%
of births occurred within three years of
the previous birth and only 28% have an
optimal birth interval of 36-59 months.
Also, the median birth interval is shorter
if the previous child did not survive (25.8
months) as compared to if the child was
living (31.8 months). The birth interval
falls short of 36 months in all but four
states of India – Kerala, Tripura, Goa and
Assam. Clearly there is a long way to go
towards spacing of births in India [4].
Non-use of traditional or modern
reversible methods of contraception
may underlie poorly spaced births in the
country. Of the three modern reversible
methods available free of cost in India’s
family planning program, the IUD is
the least widely used method (1.7% of
married women of reproductive age)
while the pill (3.1%) and the condom
(5.2%) do only marginally better. In fact,
use of IUDs has declined between the
National Family Health Survey-1 (NFHS-
1– 1992-93) and National Family Health
Survey-3 (NFHS-3– 2005-06) [4].
Improving the quality of family
planning services
The Indian Family Planning Program,
ambitious in scale and coverage, has
been successful in achieving steep
reductions in fertility across several
states. However, many of the early
achievements were at the cost of
providing quality services to the user.
In his introduction to one of the first
compilation of studies on quality
of care in India’s family planning
program, Koenig (1999) noted that the
program had been characterized by an
“overriding concern for numbers” – in
terms of acceptors of contraception
and specifically, sterilization. The
entire program was driven by targets
for family planning acceptance which
service providers had to meet under
threat of punitive action. This shaped
providers’ scant attention to quality of
care and preoccupation with meeting
their targets. The studies in the volume
stood testimony to poor quality of care
in terms of infrastructure and equipment,
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limited choice of methods, absence of
clinical protocols, shocking negligence of
infection control practices, and provider-
directed decision-making in relation to
whether and when a woman should be
using contraception [8].
The Reproductive and Child Health
Program that was launched in 1997
promised a paradigm shift towards
addressing broader reproductive
health needs of the family. Quality of
Care was an explicit focus, and targets
for contraceptive acceptance were to
be replaced by a “Community-Needs
Assessment” approach. Clients’ needs
were to be assessed and program goals
at the local level were to be set based on
this. Early assessments of the paradigm
shift were not encouraging. According
to one report by a non-governmental
organization, NGOs collaborating with
government were not allowed to adopt
Community-Needs Assessment and were
given targets to achieve [9].
There have been few recent studies on
quality of care in family planning services.
Data from the National Family Health
Survey-3 give some indications related
to specific dimensions of quality of care,
viz. informed choice. Less than a third
(32.2%) of current users of contraception
were informed about side effects or
problems of the method they were to
adopt, or were using. Even fewer (26%)
were informed about what to do if they
experienced side effects. In terms of being
offered a choice of a range of methods,
only 28% of users were informed by a
health or family planning worker about
other methods that could be used [4]. Yet
another paradigm shift may be needed to
alter the program ethos to respecting and
upholding clients’ rights in the provision
of family planning services.
Objectives
The review aims to answer the following
questions:
• A re interventions in developing country
settings related to
i. delaying age at first marriage
ii. delaying age at first pregnancy;
iii. promoting spacing between births and
iv. improving quality of care of FP
programs effective?
• What strategies or combination of
strategies have been effective?
Methodology
A systematic search was carried out in
major data bases to identify evaluated
interventions implemented in developing
countries pertaining to the four focus
areas, viz., interventions to delay age
at first marriage; to delay age at first
pregnancy; to promote spacing between
births; and to improve the quality of
family planning services. Identified
published as well as unpublished articles
in the English language were further
scrutinised for quality as well as strength
of evidence, and those that met a set
of clear inclusion and exclusion criteria
were included.
Publications pertaining to each focus
area were examined to identify the major
strategies used within each intervention
studied. Strategies or combinations
of strategies that were found to be
effective were listed out. Effectiveness
of interventions was gauged based
on whether interventions achieved
their intended objectives. In addition,
the strength of the evidence was also
taken into account, with experimental
studies ranking as the strongest, quasi-
experimental studies ranking next,
followed by ‘before-after’ studies.
Results
There was a serious dearth of studies
that evaluated interventions for all
four focus areas. A total of 62 studies
were included in the review. Most of
the studies were from Africa and South
Asia and a few from other developing
countries.
Given the small number of studies
overall and the limited strength of
evidence in many of these, it is difficult
to draw firm conclusions regarding
effectiveness. Similar interventions
would need to be implemented in
diverse settings using rigorous study
designs before we will be able to do this.
Nevertheless, the results we have do
point us in the direction of ‘promising’
strategies/combination of strategies.
Delaying age at marriage
The review included 23 studies that
evaluated 16 programs that aimed
at delaying age at marriage: seven
programs from Africa, two from
Bangladesh, one from Nepal and five
programs from India. These programs
adopted one or more of five strategies:
1) Financial incentives and/or support
to keep adolescent girls in school and
reduce drop-out rates.
2) L ife skills education and
empowerment programs for
adolescent girls and young women.
3) M icro-credit disbursement for
adolescent girls and young women.
4) Life skills education and mobilization
programs for young people (both
sexes).
5) C ommunity mobilization – Ranging
from targeted awareness raising
programs among parents and family
members of young people to broader
social mobilization of community
members at large.
Delaying age at marriage for girls was an
especially challenging goal to achieve.
Community norms on appropriate age of
marriage for girls was in some instances
well below 18 years, and even with
success in changing attitudes towards
early marriage, only very early marriages
(age 15 and below) could be prevented.
In most instances, however, even when
the community became aware of the
negative health consequences of early
marriage, they were unable to change
the practice. This was because there was
immense pressure from the community
on parents of young women to get them
married at the earliest opportunity. There
was fear of pregnancy in an unmarried
girl, which would bring shame on her
family. Also, in South Asian societies
in particular, an older girl would find it
more difficult to find a groom and may
have to pay a higher dowry. Another
reason for early marriages was girls’
poor access to high schools. When
high schools were located far away
from the community, parents tended to
discontinue their daughters’ schooling,
and this in turn led to opting for early
marriage for girls.
Interventions that combined multiple
strategies - life-skills education for
young women or for young people of
both sexes, together with intensive
engagement of the community – were
found to be effective in delaying age
at marriage. Life skills education was
broad-based, included ‘empowerment’
education alongside information on
sexuality and reproduction, and also
skill-development. Of equal or more
importance was to simultaneously
engage gate-keepers such as parents,
religious leaders and community
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elders with specific messages, while
at the same time carrying out media
campaigns to raise the visibility of the
issue within the community. Of these,
the PRACHAR project from India which
carries out life skills education for boys
and girls alongside intensive community
engagement has also been successfully
upscaled in the state of Bihar.
The ‘single’ strategy that helped
delay age at marriage in two rigorous
evaluations was providing financial
incentives/support to prevent adolescent
girls from dropping out from school.
Financial incentives together with
intensive community mobilization helped
prevent very early marriages (age 15or
below) in Ethiopia, but not marriages
between 16-18 years of age.
These findings have important
implications in the Indian context.
The PRACHAR model has already
been upscaled in one state. The
Kishori Shakti Yojana education and
empowerment program for adolescent
girls implemented through the Integrated
Child Development Scheme (ICDS) offers
a possible entry point for expanding
the PRACHAR approach in other priority
states. In addition to effecting suitable
changes in curriculum and project design
in life skills education for girls, parallel
life skills programs for adolescent
boys and young men would need to be
designed, evaluated and integrated. The
key to making these work is to combine
them with broad-based community
mobilization as well as targeted efforts
to change attitudes of parents and
other gate-keepers. This is crucial for
changing mindsets and making early
discontinuation of schooling and early
marriages socially unacceptable
As for financial incentives to prevent
girls from dropping out, India has several
conditional cash transfer schemes
operated by the central government
and various state governments aimed
at improving the status of the girl child.
Delaying age at marriage till completion
of 18 years of age is one of the
conditions for cash transfer in more than
10 of these schemes. The Dhanalakshmi
Scheme and Balika Samridhi Yojana
of the Government of India, Girl Child
Protection Schemes of Tamil Nadu and
Andhra Pradesh, Ladli Schemes of Delhi,
Apni Beti Apna Dhan Scheme in Haryana,
Ladli Lakshmi scheme of Madhya
Pradesh and Beti Hai Anmol Scheme of
Himachal Pradesh are some examples.
It would be important to evaluate the
effectiveness of these schemes in
preventing girls from dropping out
from school and in turn, delaying age at
marriage. The evaluations may provide
directions for suitably redesigning these
conditional cash transfer schemes to
better achieve the objective of delaying
age at marriage for girls.
Delaying early pregnancy
The systematic search yielded three
studies (on two programs) from India,
23 systematic reviews and evidence
syntheses from the United States of
America and the UK and seven studies
from Africa and Asia excluding India.
Except for the Indian studies, all were
interventions to prevent teenage
pregnancies outside marriage.
Effective intervention strategies to
prevent teenage pregnancies among
unmarried adolescents have been
summarized below keeping in mind the
changes already occurring in the sexual
and reproductive lives of young people
in India and also with a view to draw on
promising strategies that are relevant to
the Indian context.
Systematic reviews of intervention
studies from the US and the UK show that
sex-education programs by themselves
are ineffective in preventing teenage
pregnancy. Comprehensive youth
development programs which start
with interventions from early childhood
and address the social determinants
of teenage (unmarried) pregnancy
– educational opportunities, skill
development for livelihood, together with
sexuality and relationships education-
were found to be most effective.
Financial incentives/support to prevent
drop-outs and keep girls in school,
found to be effective in delaying age
at marriage in two studies from Africa,
were also effective in preventing teen
pregnancy out-of-wedlock.
Three Indian studies pertaining to two
programs evaluated interventions to
delay first birth in married young women,
and found these to be effective. In both
instances multiple strategies were used.
Three main strategies could be discerned:
i. Social environment building through
interventions with key gatekeepers as
well as with the larger community
ii. Providing sexual and reproductive
health education – jointly to young
married couples and also separately
for women and men
iii. Increasing access to contraceptive and
other reproductive health services.
Thus, both demand and supply side
factors were simultaneously addressed,
and a serious attempt was made to at
change social norms through community
mobilization.
One of the evaluated interventions is no
longer operational, but was the basis on
which the second effective intervention
was developed. This is the PRACHAR
project, being implemented in three
districts of Bihar. The scope for upscaling
this intervention and for adapting it to
the needs of other Indian states needs
to be examined. There is need for more
experimental interventions to address
the strong pressures that most young
Indian women face to prove their fertility
soon after marriage, and the barriers that
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adolescent and young couples face in
contacting the health care system prior
to parenthood [10-11].
Promoting spacing between births
Nine intervention studies were included
in the review. As with interventions
to delay early marriage, many of the
evaluated interventions to promote
spacing between births used two or more
of six specific strategies simultaneously.
These six strategies included:
i.T argeted messages for young married
women
ii.Targeted messages for young married men
iii. C ommunity mobilization – from
targeted meetings with gate keepers
to broader community awareness
building and attitude shaping
iv. E ngagement with health and allied
service providers within the public
and private sectors
v. Mainstreaming the optimal pregnancy/
birth spacing messages within the
government health system; and
vi. H igh level advocacy with policy
makers to integrate optimal
pregnancy/birth spacing as a policy
and program goal
Working intensively with women and
their husbands, alongside building
community support plus building health
worker capacity in providing suitable
services seems to be a promising
combination of strategies. Four Indian
programs - the Healthy Timing and
Spacing of Pregnancy (HTSP) project
and the Pragati project in Uttar Pradesh,
PRACHAR in Bihar and RHEYA in four
Indian states adopted this combination
of strategies and all of them were found
to be effective, three of four being quasi-
experimental studies. This is an approach
that tackled demand and supply-related
factors simultaneously.
Within the above combination of
strategies, approaches to working
with men need further exploration.
Interventions that did not intensively
target husbands but worked with men
in the community also seem to have
achieved good results.
Another combination of strategies worth
further experimentation and study is
clinic-based intensive counseling of
antenatal women and their husbands.
This approach appears to be able to
achieve effective results with a relatively
modest investment of resources.
In the Indian context, mainstreaming
the “healthy timing and spacing of
pregnancy” within policies and programs
would be an important first step. Spacing
of births, although mentioned as a
priority in policy documents, has not been
adequately emphasized within the Indian
family planning program. Much work
needs to be done in making providers
more conscious of prioritizing birth
spacing and in enhancing their knowledge
on modern as well as traditional methods
of spacing pregnancy. The HTSP program
in UP and the DISHA program in Bihar/
Jharkhand respectively have attempted to
mainstream the promotion of birth spacing
within the government health sector,
including provider training and community
mobilization. These models have the
potential for sustainable and affordable
upscale, and need to be explored further.
Making spacing methods acceptable to
potential users is yet another challenge
to be overcome. Currently, contraceptive
use is tilted overwhelmingly towards
sterilization. Research is needed to
identify barriers to acceptance of spacing
methods in different parts of India, and
to build context-specific communication
and behavior-change strategies based
on these. Clinic-based interventions with
pregnant women and their husbands
offer one major window-of-opportunity
to influence attitudes and behavior
related to spacing births.
The studies show that targeted
interventions with young married
women need to be complemented
with interventions with their husbands
or with groups of young married
men. While ASHAs and ANMs could
be trained to promote birth spacing
with women, it would be important to
identify a suitable male cadre to work
with young married men.
Improving quality of family planning
services
This review included 27 intervention
studies aimed at improving quality of
family planning services. Simultaneous
adoption of multiple strategies was a
feature also of these interventions. The
programs reviewed adopted one or more
of 10 strategies to improve access to and
quality of family planning services:
i. & ii. Community based service delivery
through female/male health workers
respectively
iii. & iv. Health facility-based targeted
counseling and education for women/
men
v. Expanding contraceptive choice
vi. Provider training for improving quality
of care
vii. Strengthening service provision
through improved organization,
equipment and supplies
viii. Integrating family planning with
post-abortion services
ix. Integrating family planning with
maternal health and delivery care, and
x. Community mobilization
Two combinations of strategies offer
most promise in terms of their ability to
improve contraceptive use as well as in
improving client satisfaction of services.
The first of these is the integration
of family planning services with post
abortion care and maternal health-
delivery care, provided this is not just a
mechanical addition of one additional
service. The effective interventions
examined also involved reorganizing
service delivery to suit client
convenience, provider training to make
service delivery more client-centered and
targeted family planning counseling for
women, and also their husbands.
Post-partum and post-abortion family
planning is well known in India.
However, much of the focus has been
on post-partum and post-abortion
sterilization. Also, imposing sterilization
or IUD insertion as a condition for
providing safe abortion services has
been reported in the 1990s by many
studies examining quality of care. The
policy recommendation from this review
would be to provide post-partum and
post-abortion family planning services
that are truly based on informed choice
following counseling; offer the full
range of contraceptives for the woman/
her partner to choose from, and come
together with improvement in overall
quality including humane treatment of
the client, as described above.
The other strategy that appears to offer
promise is the use of female and male
health workers for community-based
education and counseling and distribution
of contraceptives. We do not have a
male health worker cadre who provides
community-based family planning
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information and services – in fact, we do
not have any mechanism to systematically
reach men with family planning
information. Use of female community-
health workers to deliver services is again
a strategy well-known in the Indian family
planning program, and the ASHA is now
charged with this responsibility. The main
difference is that in many instances there
are in practice (whatever the official policy
may be) ‘targets’ for the community
health worker to fulfill.This transforms an
intervention that could improve quality
of family planning services by providing
information and services closer to the
woman’s home, into one with coercive
overtones. We need to reorient the role of
the female community health worker and
include male community health workers.
Their role would be to provide information,
facilitate discussion on the pros and cons
of different methods and help clients make
an informed choice of a method that is
acceptable to him/her.
Concluding remarks
This review has identified a range of
‘promising’ strategies that would help
reposition family planning as a means
of upholding the health and rights of
women, men and children. The results of
the review need to be interpreted keeping
in mind the very limited evidence on
which it is based. Many interventions
have not been documented, and those
documented are yet to be rigorously
evaluated. One of the key tasks ahead is
to systematically document and evaluate
existing interventions.
The review identifies strategies that
are worthy of further experimentation
and upscaling from among the pool
of interventions that have been
implemented thus far. However this
should preclude the possibility of
innovating what has not yet been tried.
There are other potential interventions
that are as yet to be tried or even
conceived: for example, programs that
uphold reproductive and sexual rights;
programs that provide a comprehensive
range of reproductive health services
of which family planning is an integral
part. It is as much a priority to design
and implement interventions that are
out-of-the box, as it is to have rigorous
evaluations of what already exists.
Safe abortion services have featured
among the strategies examined only as a
part of interventions that integrate family
planning with post-abortion care. Yet, any
attempt to reposition family planning
would need to include safe abortion
services as an important dimension of
upholding women’s health and rights.
We hope future reviews will examine
‘effective’ safe abortion services which
have woman’s safety and wellbeing as
outcome indicators.
Last but not least, all strategies
to ‘reposition family planning’
recommended above are by definition
guided by a human rights perspective. If
taken out of this context and perspective,
and superimposed with a ‘population
control’ imperative, we may achieve
fertility reduction, but without a
concomitant improvement in population
health and wellbeing.
References
1. Health Policy Project. Repositioning
Family Planning. Available from: http://
www.healthpolicyproject.com/index.
cfm?ID=topics-RepositionFP, accessed
2 February 2013.
2. Bill and Melinda Gates Foundation.
Family Planning: Strategy Overview.
Global Health program, April 2012.
3. United Nations Population Fund.
National Population Policy India 2000.
New Delhi, UNFPA, 2000.Chapter 1,
Introduction.
4. International Institute for Population
Sciences (IIPS) and Macro
International. National Family
Health Survey (NFHS-3), 2005–06:
India: Volume I. Mumbai: IIPS,
2007. Available from: <http://www.
measuredhs.com/pubs/pdf/FRIND3/
FRIND3-Vol1[Oct-17-2008].pdf>.
Accessed January 15, 2013.
5. United Nations Population Fund.
The New Generations, the Family
and Society. Population Issues
1999. Available from: <http://www.
unfpa.org/6billion/populationissues/
generation.htm>, Accessed January
15, 2013.
6. Gupta S, Mukherjee S, Singh S,
Pande R, Basu S. Knot Ready. Lessons
from India on delaying marriage for
girls [Internet].Delhi, International
Center for Research on Women; 2008.
Available from: <http://www.icrw.org/
files/publications/Knot-Ready-Lessons-
from-India-on-Delaying-Marriage-for-
Girls.pdf>. Accessed January 16, 2013.
7. W orld Health Organization. Report of
a WHO Technical Consultation on Birth
Spacing. Geneva, WHO, 2006.
8. Koenig MA and Khan ME. Improving
the quality of care in India’s family
planning program. New Delhi,
Population Council, 1999. Chapter 1.
9. Sudharshan H. Role of NGOs in
operationalising primary health
care services: Modalities for
replication of Karnataka’s experience.
Presentation given at the Training
Program on Health, Rights and
Women’s Empowerment, organized
by the MacArthur Foundation, 22-28
September, 2002, Bangalore.
10. Santhya KG and Jejeebhoy SJ. Young
people’s sexual and reproductive
health in India: Policies, programs
and realities. South and East Asia
Regional Working Paper, New Delhi,
Population Council, 2007, No. 19.
11. Santhya KG, Jejeebhoy SJ and
Ghosh S. Addressing the Sexual and
Reproductive Health Needs of Young
People: Perspectives and Experiences
of Stakeholders from the Health
and Non-health Sectors, New Delhi,
Population Council, 2007.
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Chapter 1
Introduction
Background
For decades, family planning has been
viewed chiefly as a means of controlling
the world’s population size. However,
with declining global population
growth rates the imperative to position
family planning as more than a means
of population control has become
increasingly evident. ‘Repositioning
Family Planning’ was a multilateral
initiative launched almost a decade
ago to increase political commitment
and funding for strengthening family
planning services in sub-Saharan Africa
[1]. The 2012 Summit on Family Planning
in London put the ‘repositioning’
approach firmly on the global map
by winning the support of national
governments, civil society and donors
from other regions of the world.
In the ‘Repositioning of Family Planning’
approach, the focus is on reaching all
women and men in developing countries
with quality family planning information
and services in order to meet their need
for fertility control. Voluntary adoption
of family planning would be a means
to reduce maternal and child deaths
[2]. Although not explicitly stated, the
emphasis on health and well-being
and on voluntary family planning is in
keeping with the notion of birth control
as a reproductive right.
In India, the National Population
Policy, 2000 (NPP 2000) affirmed the
government’s commitment to voluntary
and informed choice and consent of
citizens as users of the family planning
and reproductive health program. One
of the objectives of NPP 2000 was to
delay age at marriage to at least 18
years and to address unmet need for
spacing and limiting births [3]. Ten years
later in May 2010, the Ministry of Health
and Family Welfare held a national
consultation on repositioning family
planning. This consultation announced
the government’s decision to reposition
family planning as a means to improve
maternal and child health. It is in this
context that the Population Foundation
of India’s (PFI) Strategic Plan over the
next five years (2011-2016), attempts
to reposition family planning within a
women’s empowerment and human
rights framework in India’s development
and maternal and child health (MCH)
policies and programs. This systematic
review is a part of PFI’s ‘repositioning
family planning’ initiative.
Why reposition family planning
in India?
There are several reasons why
‘Repositioning Family Planning’ is
especially important in the Indian
context.
To begin with, nine Indian states have
already achieved replacement level
fertility. However, low fertility has
not resulted in improved maternal
health, because of early marriage
and childbearing, and closely spaced
births. For example in Andhra Pradesh,
which had a below replacement level
of fertility of 1.79 children per woman
in 2005-06, 55% of young women age
20-24 years were married before they
were 18 years old, 18% of women age
15-19 had already begun childbearing
and 60% of women bore a subsequent
child within 36 months of a previous
birth [4]. In states with replacement
or below-replacement-level fertility,
repositioning family planning as a health
and development issue could contribute
to designing programs that addressed
women’s other reproductive health
needs alongside fertility control.
Secondly, population momentum is
an important contributor to India’s
population growth. Even with declining
average annual growth rates, India is
adding about 18 million people annually
to its population, because the proportion
of people in the reproductive age
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group is almost 50%. One way in which
population momentum can be checked
is by delaying age at first pregnancy
and by spacing subsequent births by 2-4
years. According to the UNFPA, raising
mothers’ age at first birth from 18 to 23
could reduce population momentum by
over 40 per cent [5]. The Indian Family
Planning Program which has become
entrenched as a “sterilization only”
program needs to shake itself out of
its inertia and focus on these newer
priorities. The challenge is to not only
change tracks but also change its way of
doing things – i.e. upholding voluntary
acceptance and informed choice.
The third reason why repositioning
family planning is important is related
to the Indian Family Planning Program’s
long legacy of being driven by the
population control logic. Demographic
targets as well as targets for family
planning acceptance have been the
drivers of the program from its inception.
With the introduction of the ‘Target-
Free Approach’ in 1997 the program
seemed to have lost its fulcrum. There is
a need to infuse the program with a new
objective – that of improving health and
well-being and of upholding women’s
and men’s right to fertility control.
The present review: Objectives and
methodology
The present review is a building block
in PFI’s initiative to reposition family
planning into MCH policies and national
development programs in Bihar and at
the national level. The long-term goal
of the initiative is to reposition family
planning within a reproductive health
and human rights framework so that
every family is a planned family and
every child is a wanted, healthy child.
This goal is proposed to be achieved by
strengthening government programming
for family planning at the national
level and in Bihar through advocacy
informed by reviews and analyses of
programmatic innovations and policies
and using a convergence approach
demonstrated at the district level to
change social norms and improve
health outcomes. Strong research and
documentation will form the foundation
of PFI’s advocacy work and ensure
efficacy of the various initiatives.
To develop evidence based advocacy
strategies, the project aims to
systematically collate and review studies
based on national and international
experiences with a focus on the 4 key
areas of the Strategic Plan.
These include:
i. delaying age at marriage
ii. delaying age at first pregnancy
iii. promoting spacing between births; and
iv. improving quality of family planning
services.
This report presents the results of the
review and aims to strengthen the
evidence base to inform and guide policy
▶ Increase in proportion of women
and men who use contraception for
spacing births
▶ Increase in proportion of women
whose most recent birth was
optimally spaced
▶ Increase in client satisfaction with FP
services
▶ Increase in use of contraceptive
services and consequently in
contraceptive prevalence rates
• What strategies or combination of
strategies have been effective?
Methodology
To ensure the outcome of this Systematic
Review is relevant and of a high quality,
a Technical Advisory Group (TAG) was set
up consisting of members with a range
of experiences, in terms of both the topic
and methodology and application to
decision making.
advocacy and program implementation.
Objectives
The review aimed to answer the
following questions:
• A re interventions related to (i) delaying
age at first pregnancy; (ii) promoting
spacing between births and (iii)
improving quality of care of FP and
RH programs in developing country
settings effective in achieving one or
more of the following outcomes:
▶ Decrease in the proportion of women
age 20-24 years/20-29 years who were
married before they were 18 years of
age
▶ Increase in median age at marriage
▶ Increased use of reversible
contraceptive methods to delay first
pregnancy
▶ R educed proportion of first births
occurring before the mother is 18
years of age.
A systematic search was carried out in
all major databases and in websites of
bilateral and multilateral agencies and
non-governmental organizations working
on family planning, using search terms
related to each of the four focus areas.
Published and unpublished reports
and journal articles were identified
and scanned quickly for content. The
following inclusion criteria were used to
identify reports/articles to be reviewed:
• Articles in English.
• Geographical focus: India, South Asia,
Africa. Studies from other regions have
also been included where these were
the most dominant in the literature.
• Focus on 4 key areas of delaying
early marriage, delaying age at first
pregnancy, promoting optimal birth
spacing and improving quality of care
in family planning.
• Study design is experimental; quasi-
experimental; ‘before-after’; cross-
sectional end-line with a comparison
group. However, qualitative studies and
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Figure 1.1. Number of studies included in the review
S.No
Themes No of included articles
1
delaying age at marriage
23
2
delaying age at first pregnancy
3
3
promoting spacing between births
9
4
improving quality of care of family planning
and reproductive health (RH) programs;
27
Total
62
Figure 1.2. Study designs graded against strength of evidence
S.NoStudy DesignStrength
1
Experimental
A
2
Quasi-experimental
B
3
Before-After studies
C1
4
Cross-sectional end-line study with a matched
comparison group
C2
5
Cross-sectional end-line study with an unmatched
comparison group
C3
6
Cross-sectional qualitative endline study with no
comparison group
C4
7
Not a study but inference based on large-scale
survey data
D
A= strongest D=Weakest
descriptive studies that complemented
information provided by more rigorous
studies were also included in instances
of limited evidence.
studies rated as among the strongest.
Figure 1.2 above summarizes the criteria
that we have adopted, based on a scrutiny
of several systematic reviews.
• The studies satisfy the following quality
criteria: i) adequate description of their
aims, background and context; ii) clear
detail on recruitment, the sample and
data collection; iii) and appropriate data
analysis and interpretation (including
presentation of sufficient original data
and integration of data, interpretation
and conclusions). These were based on
quality assessment criteria developed
by Attree and Milton [1], Harden et al
[2], and McDermott and Graham [3]
When studies reported effectiveness of
interventions, the strength of the evidence
was rated from A (strongest) to D
(weakest) based on the study design, with
experimental and quasi-experimental
There have been challenges in identifying
and reviewing the documents and arriving
at credible conclusions. One was the very
limited number of intervention evaluation
studies that were available. While there
are a large number of interventions,
only brief project descriptions are
available in many instances. There are
very few interventions, which have
reported on their outcomes or impact.
Few interventions are designed within
a rigorous research framework so as
to measure and quantify their effects.
Further, various studies analyzed the
impacts and patterns at different time
periods which made it difficult to
synthesize and attribute the findings.
In addition to the heterogeneity of the
studies, the divergence in strength of
evidence made it difficult to arrive at a
synthesis.
The second challenge is that the
intervention studies have been carried
out at different time points in varied
settings, and have not all examined the
same indicators of effectiveness. When
a strategy is found to be effective but
by studies without an experimental
design, or when there are only one
or two studies that find a particular
strategy effective, it becomes difficult
to draw definitive conclusions about
the potential effectiveness of these
strategies for other settings.
The strategies and combination of
strategies found to be effective by this
review have to be understood within
these limitations. They are indicative of
strategies that hold promise, but need
to be piloted and experimented with
different settings and time-points, and
only then can firm conclusions be drawn.
References
1. Pamela A, Milton B. Critically
appraising qualitative research for
systematic reviews: defusing the
methodological cluster bombs.
Evidence & Policy: A Journal of
Research Debate and Practice
2006;2(1):109–26.
2. Harden A, Garcia J, Oliver S, Rees R,
Shepherd J, Brunton G, et al. Applying
systematic review methods to studies of
people’s views: An example from public
health. Journal of Epidemiology and
Community Health 2004;58:794–800.
3. Graham H and McDermott E.
Qualitative Research and the Evidence
Base of Policy: Insights from Studies of
Teenage Mothers in the UK. Journal of
Social Policy 2006; 35:21-37.
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Chapter 2
Delaying Age
at Marriage
Background
National and international communities
are increasingly recognizing early
marriage - marriage before the age
of 18 years – as a violation of girls’
human rights and as a hindrance to key
development outcomes with negative
social, health, and population growth
consequences.
Early marriage is associated with
lower educational attainment for girls,
limiting their employment opportunities
and economic security. These factors
contribute to limited access to social
and economic resources, low levels
of decision-making in the family and
increased vulnerability to violence [1-3].
Early marriage can pressure young
women to begin having children early.
Women who marry early also have on
average a longer period of exposure
to pregnancy and a greater probability
of higher number of lifetime births [4].
A multivariate analysis of 50 countries
confirmed that women with three or
more children were significantly more
likely to have been married before the
age of 18 years as compared to women
who had no children [5]. A recent Lancet
study documents the reproductive health
consequences of child marriage in India
[4]. Child marriage was significantly
associated with no contraceptive use
before first childbirth, high fertility (three
or more births), a repeat childbirth in
less than 24 months, multiple unwanted
pregnancies, pregnancy termination
and female sterilisation. This was true
even when other demographic and
socioeconomic characteristics remained
the same between women married as
children and women married as adults,
and even after controlling for duration of
marriage [4].
Studies also show that girls who
marry at an early age have negligible
sexual experience and information, no
autonomy, and little negotiating power
in sexual relations. Their partners often
are older and more sexually active,
putting young women at greater risk of
contracting reproductive and sexually
transmitted infections, including HIV
[3]. Young women who had married at
age 18 or older were more likely than
those who had married before age 18
to have been involved in planning their
marriage (odds ratio, 1.4), to reject wife
beating (1.2), to have used contraceptives
to delay their first pregnancy (1.4) and
to have had their first birth in a health
facility (1.4). They were less likely than
women who had married early to have
experienced physical violence (0.6) or
sexual violence (0.7) in their marriage
or to have had a miscarriage or stillbirth
(0.6) [3]. Findings underscore the need
to build support among youth and their
families for delaying marriage, to enforce
existing laws on the minimum age at
marriage and to encourage school,
health and other authorities to support
young women in negotiating with their
parents to delay marriage[6].
Early marriage in South Asia
Worldwide, more than 60 million women
age 20–24 were married before they
reached age 18[7]. Although the extent
of early marriage varies substantially
between countries, about half of the
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Figure 2.1. Causes and consequences of early marriage
Causal Factors
Associated Risks of Early Marriage
Socio Cultural
Religious & traditional practices, beliefs
Patriarchal society, norms
Community pressure
Fixed gender roles and gender discrimination
Lack of decision making power; low status of
women
Illiteracy, ignorance of the law and lack of
awareness
Decreasing Sex Ratio
Social disapproval/Stigma attached to SRH
Financial
Poverty and Illiteracy
Lack of employment ,
Marriage as a security
CM as a transaction for economic gain
Early marriage is ‘economical’
Socio-Cultural
Stigma and Abuse
Illiteracy& inadequate educational opportuni-
ties
Inability to avail employment opportunities
Low self esteem
Reinforcement of patriarchal social relations
and gender discrimination
Health risks
Lack of knowledge – how, when, where- on
SRH/services
Early childbearing
Unwanted pregnancy
Unsafe Abortions
Pregnancy related complications - pre-ec-
lampsia, obstructed labor, fistula
Premature or low birth weight babies,
Sexually Transmitted Diseases
Maternal/Infant Deaths
Legal and Political
Lack of political will and poor enforcement of
law on Child Marriage
Lack of information about the consequences
of early marriage
girls who are affected live in South Asia.
Despite a rise in median at marriage in
several South Asian countries over the
last half a century, child marriage among
girls continues to be a widespread
practice. According to the most recent
Demographic and Health Surveys, the
median age at marriage for girls in
South Asia was lowest in Bangladesh
(15 years) followed by India (16.8 years)
and Afghanistan (17.7 years); Maldives
(19 years), Pakistan (19.1 years) and
Nepal (21.6 years) did relatively better.
Sri Lanka had the highest median age at
marriage in 2006-07, of 23.3 years. In all
countries, the median age at marriage
was lower in the lower wealth quintiles
and increased with increasing
wealth [8-14].
India
The 2005-06 National Family Health
Survey (NFHS) data indicate that more
than half of rural Indian women (53.4%)
and more than one-quarter (29.7%)
of urban Indian women age 18-29
are married by 18 years of age. In all
central Indian states, all eastern Indian
states with the exception of Orissa, and
in Andhra Pradesh in Southern India
more than half of the women age 21-29
years were married before reaching the
legal minimum age at marriage. The
highest proportion was in Bihar (63.7%)
Figure 2.2. Age at first marriage by state: Percentage of women age 18-29 who were first
married by exact age 18 by residence and state, India, 2005-06
Urban
Rural
Total
India
29.7
53.4
45.6
North
Delhi
22.6
34.7
23.4
Haryana
32.9
45.2
41.4
Himachal Pradesh
13.7
14.4
14.4
Jammu and Kashmir
9.2
18.6
16.1
Punjab
19.4
22.9
21.6
Rajasthan
36.3
67.4
58.4
Uttaranchal
16.7
29.5
26.0
Central
Chhattisgarh
26.4
57.6
50.5
Madhya Pradesh
33.7
60.4
52.6
Uttar Pradesh
31.8
59.4
52.2
East
Bihar
37.8
68.6
63.7
Jharkhand
32.7
70.1
60.2
Orissa
27.8
39.5
37.5
West Bengal
31.3
62.3
53.3
North East
Arunachal Pradesh
38.7
43.0
41.7
Assam
25.7
40.9
38.2
Manipur
10.9
15.5
14.0
Meghalaya
13.3
28.2
24.1
Mizoram
15.6
24.4
19.4
Nagaland
19.4
23.7
22.4
Sikkim
17.1
31.9
28.7
Tripura
37.0
42.1
41.2
West
Goa
14.7
7.3
11.4
Gujarat
28.2
40.9
35.4
Maharashtra
29.2
51.8
40.2
South
Andhra Pradesh
43.4
62.9
56.2
Karnataka
29.7
48.8
41.0
Kerala
12.1
20.1
17.2
Tamil Nadu
20.7
29.5
25.2
Source: National Family Health Survey-3 [9]
closely followed by Jharkhand (60.2%),
Rajasthan (58.4%) and Andhra Pradesh
(56.2%). This indicates the persistence
of high levels of child marriage
although there have been significant
declines over the past decade (Figure
2.2 above) [9].
Data from the three National Family
Health Survey’s (NFHS) show that the
median age at marriage for women
has been increasing, from 16.4 years in
1992-93 to 16.7 years in 1997-98 and 17.2
years in 2005-06 [15-16, 9]. In all three
surveys, the median age at marriage
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for girls is much higher in urban as
compared to rural areas, and the urban-
rural differential, although converging,
continues to be substantial. The median
age at marriage for girls in urban areas
increased from 18.4 years in 1992-93 to
18.7 years in 1997-98 and 18.8 years in
2005-06. In rural areas, the median age at
marriage for girls was 15.7 years in 1992-
93, increased to 16.0 years in 1997-98 and
further to 16.4 years in 2005-06 [15-16, 9].
The association of early marriage with
economic and social disadvantages,
reported from studies, is seen also in
the NFHS data for India. Median age at
marriage for girls was much lower for
girls from the lowest wealth quintile and
girls without any schooling (15.5 years in
both instances). Girls from the scheduled
castes and scheduled tribes also had
a lower than average median age at
marriage, of 16.3 years and 16.5 years
respectively [9].
Evaluated interventions to delay
early marriages
A systematic search carried out in
accordance with the search strategy and
criteria for inclusion of studies described
earlier, 23 published evaluation studies
of interventions aimed at or contributing
to delaying marriage: 10 from Africa,
eight from South Asia (all except
one from Bangladesh) and five from
India [17-40]. These corresponded to
16 interventions. This included seven
interventions from Africa, two from
Bangladesh, one from Nepal and five
programs from India. Although some of
them were not experimental or quasi-
experimental studies, we included them
because of the very limited number of
studies available.
In 12 of the 16 interventions, delaying
marriages till 18 years for girls and 21
years for boys was a direct objective,
often among a number of other
objectives related to empowerment
of girls and young people and fertility
reduction. Two interventions in Egypt
were aimed mainly at increasing girls’
retention in schools, which in turn would
contribute to reducing early marriages.
The School-Based HIV intervention in
Kenya was focused on HIV prevention
and preventing early sexual activity.
Delayed marriage was an incidental
outcome of activities undertaken
towards these.
Target audiences
Eleven of the 16 interventions covered
only adolescent girls and young women,
four had interventions covering both
young women and men. Only four
interventions specifically mention
working with parents of young people,
while ten interventions were aimed at
key community gate-keepers and opinion
makers. One intervention was aimed at
policy makers for influencing legislative
change; and one worked with community
women’s groups to build adult women’s
awareness and support, with teachers as
key opinion-makers in the community;
and with medical officers to train
them to deliver adolescent-friendly
health services.
Eleven of the 16 interventions cover
multiple target audiences, while the
remaining five work only with adolescent
girls’ groups. Interventions appear to be
carried out by NGO workers from within
the community for the most part, but
a few interventions also include peer
leaders, teachers and community health
workers as change agents.
Strategies adopted
The 16 interventions reviewed adopted
one or more of five strategies addressing
or influencing the delay of age at
marriage.
1) Financial incentives and/or support
to keep adolescent girls in school and
reduce drop-out rates.
2) L ife skills education and
empowerment for adolescent girls and
young women.
3) Micro-credit disbursement for
adolescent girls and young women.
4) Life skills education and mobilization
programs for young people
(both sexes).
5) C ommunity mobilization – Ranging
from targeted awareness raising
programs among parents and family
members of young people to broader
social mobilization of community
members at large.
Multiple strategies were simultaneously
used in most instances (Figure 2.3). For
example, seven programs combine life
skills education of young people with
community mobilization in order to
create a supportive social environment
for delaying early marriages.
1) Financial incentives and/or support
to keep adolescent girls in school and
reduce drop-out rates
Four programs adopted this strategy: The
Zomba Conditional Cash Transfer Program
in Malawi, The Kenya School-Based HIV
Program, Berhane Hewan in Ethiopia, and
the Female-Secondary School Assistance
Program in Bangladesh.
In Malawi, high school girls were
paid 100 US dollars in ten monthly
installments of ten dollars each, of which
roughly 30% was paid directly to the
girl and the remaining to her parents or
guardians. The payment was conditional
on girls remaining in school and was
discontinued if they dropped out. In
addition, the secondary school fee was
paid directly to the school. Bangladesh’s
Female School Assistance Program
similarly paid a stipend to girls attending
grades 6-10 grades. This was conditional
on the following: a) The girls attended
school for a minimum of 75% of the
school year b) They obtained an average
of 45% marks or more in the final
examination c) They remained unmarried
till completing grade 10.
In Kenya and Ethiopia there were no
cash incentives. Instead, the cost of
school uniform (Kenya), books and pens
and other supplies worth US$4 per year
(Ethiopia) were provided.
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2) Life skills education and
empowerment program for adolescent
girls and young women
Seven interventions included life
skills education and empowerment
programs for adolescent girls and
young women: Berhane Hewan in
Ethiopia, Ishraq and New Horizons
in Egypt, BRAC’s Adolescent
Development Program in Bangladesh,
Better Options, IHMP Pachod and
Vistaar programs in India. The content,
intensity and duration of these
programs appear to vary widely. For
example, some programs focused on
assertiveness and reproductive health
while others also imparted literacy
and numeracy and vocational training.
Many of the programs consisted of
organized classes one or more times
in a week with a well-developed
curriculum, while some such as Vistaar
in India had a more loose structure,
with government health workers
required to talk to adolescent girls on
specific health-related topics as part of
the once-a-month Village Health and
Nutrition Days in communities.
3) Micro-credit disbursement for
adolescent girls and young women
Various versions of the Adolescent
Development Program of the
Bangladesh Rural Advancement
Committee (BRAC) combined life skills
education programs for adolescent
girls and young women with the
provision of micro-credit. This included
for example the Employment and
Livelihood Program for Adolescents
(ELA) and the APON (Adolescent Peer-
led Education Program) /JVO (Junior
Village Organization). Adolescent girls
and young women formed groups of
their own and were given micro-credit
to start income-generation activities.
4) Life skills education and mobilization
programs for young people (both sexes)
Three programs: the Nepal Participatory
Youth Reproductive Health program, and
the DISHA and PRACHAR programs in
India have life skills education programs
for both sexes.
In Nepal, one of the interventions
consisted of training mixed groups of
peer educators on reproductive health,
who in turn were to educate their peers.
A complementary intervention provided
training in vocational skills to increase
economic opportunities. The DISHA
program for youth in India adopted a
very similar strategy of peer education
in sexual and reproductive health
and skill development for expanding
economic opportunities.
The PRACHAR program had a more
limited intervention consisting of
three five-hour sessions based on a
set curriculum and training manual.
Both boys and girls were trained, but
in separate groups. Trainers from both
sexes facilitated the groups.
5) Community mobilization
Eleven of 16 programs had community
mobilization as one of its intervention
strategies. These included the IAPEM
program in Yemen, Berhane Hewan
and USAID’-Pathfinder interventions
in Ethiopia; Ishraaq in Egypt, Tostan
in Senegal, Participatory Youth
Reproductive Health Program in Nepal,
and the Better Life Options, DISHA,
IHMP-Pachod, Vistaar and PRACHAR
program from India.
Within community-mobilization, two
specific sub-strategies were seen: one
consisted of targeted awareness raising
interventions among parents and family
members of young people and young
people themselves, while the other was
broader social mobilization of community
members at large in a campaign mode.
Targeted awareness raising interventions
often consisted of regular meetings
with target groups: parents and grand-
parents, young people, community
elders, and sometimes, religious leaders.
The Berhane Hewan program in Ethiopia
used a specific technique called the
“community conversation” technique
developed in Ethiopia. This consists of
participatory community dialogue for
problem solving. Community members
met once every two weeks and four
trained facilitators facilitated these
conversations. The Tostan program
in Senegal worked towards evolving
community consensus culminating in
a public declaration to prevent early
marriages within their communities.
Broader community mobilization was
more flexible, and aimed to raise
awareness through posters, mass
media campaigns and village events
including meetings with important
government officials.
Both these sub-strategies were adopted
in six of the 10 programs having
community mobilization as a strategy,
and two each adopted only one of these
sub-strategies.
Effectiveness of strategies
One or both of the following indicators
have been used by studies to measure
the effectiveness of programs:
statistically significant increase in the
mean age of marriage among girls
or decline in the proportion of girls
married before 18 years of age. Some
studies have also used indicators of
awareness of the correct legal age of
marriage or opinions on ideal age of
marriage for girls. Since many programs
have adopted multiple strategies
simultaneously, it is not always possible
to single out particular strategies as
causing the successful outcome.
Another complexity arises from the
varying quality of evidence depending
on the study design and sample. We
have taken into consideration both
the study results and the quality of the
evidence in drawing conclusions about
the effectiveness of a strategy or a
combination of strategies (Figure 2.3).
We first look at outcomes of the seven
programs that have employed one main
strategy. The Conditional Cash Transfer
Program in Malawi and the School-
based HIV program in Kenya have
employed the single strategy of financial
incentives or support to girls to stay in
school. Both these programs have been
effective to some extent in delaying
age at marriage for girls. The Malawi
program was successful in reducing
the proportion married below 18 years
among girls who were drop-outs at base-
line – 16.4% of base-line dropouts in the
intervention group were married at the
end of the intervention as compared to
27.4% base-line dropouts in the control
group. However, the intervention did not
achieve such an impact among girls who
were in school at baseline. In Kenya, girls
from intervention group were 12% less
likely to have been married at the end of
the program than girls from the control
group. Both these studies had adopted
an experimental design.
The New Horizons Project in Egypt
employed the single strategy of life-skills
education and empowerment for girls.
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Figure 2.3. Evaluated interventions: location, strategies employed, level of effective-
ness and strength of evidence
S.No Intervention Name
LocationStrategiesEffectiveness
1. ‘Integrated Action on
Yemen
5
No
Poverty and Early
Marriage’ (IAPEM)
Program
2. Berhane Hewan
Amhara,
1, 2, 5
Yes, in 10-14
Ethiopia
age group
3. USAID-Pathfinder
Mosebo,
5
Inconclusive
Interventions
Ethiopia
4. Ishraq Program
Rural upper
2, 5
In preference
Egypt
for early
marriage; also
dose response
5. New Horizons
Alexandria,
2
No
Beni Suef and
Qena, Egypt
6. Tostan
Kolda, Thies
5
No
and Fatick
regions, Senegal
7. Zomba Conditional
Zomba,
1
Yes
Cash Transfer Program Malawi
8. School-Based HIV
Western
1
Yes
Program
Kenya
9. Adolescent
BRAC,
2,3
Inconclusive
Development
Bangladesh
Program
10. Female Secondary
National,
1
Inconclusive
School Assistance
Bangladesh
Project
11. Participatory Youth
Nepal
4,5
Yes
Reproductive Health
Project
12. Better Life Options
Peri-urban
2,5
No
Program
slums, Delhi,
rural Madhya
Pradesh and
rural Gujarat, India
13. IHMP Pachod
Rural
2,5
Yes
Maharashtra,
India
14. DISHA program
Bihar and
4,5
Inconclusive
Jharkhand, India
15. Vistaar
Jharkhand, India 2,5
Yes
16. PRACHAR
Bihar, India
4,5
Yes
Quality of
evidence*
C4
B, C4,
C3
B
C4
C3, C4
A
A
B, B, B, B,
C1
D
B
C2
A
B
C1*
B
Strategies: 1= financial incentives/support to keep girls in school 2= Life skills education for adolescent girls and young women 3= Micro-
credit for adolescent girls and young women 4= Life skills education and mobilization of young people 5= Community mobilization
*Multiple responses correspond to the quality of evidence in different studies evaluating the same intervention
A= Experimental design B= Quasi-experimental design C1= Before-after study C2= Cross-sectional end-line study with a matched comparison
group C3= Cross-sectional end-line study with unmatched comparison group C4= qualitative end-line study with no comparison group.
The evaluation study found no difference
between girls in the intervention and
control groups in their preference for age
at marriage. The three programs which
used community mobilization as the only
intervention strategy were also not found
to be effective.
Taking into account both the study
results and the strength of evidence,
the combined strategies of financial
incentives for continuing in school,
life-skills education and empowerment
for girls and community mobilization
also proved effective in Berhane Hewan.
Findings from a qualitative end-line
study rated community conversations
as the most effective of the strategies
adopted, closely followed by the life-
skills education and empowerment
intervention through girls’ clubs.
Likewise, the Participatory Youth
Reproductive Health Project in Nepal
also found that a combined strategy of
life-skills education and mobilization of
young people together with community
mobilization was effective in significantly
reducing the proportion of girls married
before age 18 in the intervention as
compared to the control groups.
It must be noted that many of the
programs found delaying age at
marriage rather difficult to achieve. While
positive outcomes in terms of changes
in awareness and attitudes have been
recorded by many studies, translating
these into changes in behavior has not
been easy. Evaluations have identified
a number of social barriers. In some
settings such as in Yemen, poverty and
the absence of girls’ high schools nearby
encouraged early marriage. Girls left
school early also because there were
few female teachers, and the lack of
toilet facilities was another reason. In
other settings such as in Senegal and
Bangladesh, parents worried about
pregnancy out of wedlock and preferred
to see their daughters married early.
Older girls had often also to pay higher
dowry in Bangladesh, and this was a
factor that parents could not overlook
even if they knew of the disadvantages
of an early marriage.
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Given the very small number of
evaluation studies overall and the even
fewer evaluation studies that have
adopted an experimental or quasi-
experimental design, it is not possible
to draw firm conclusions from the
evidence available. However, it may be
observed that three strategies emerge as
relatively more successful in achieving
a delay in age at marriage as compared
to others: financial incentives or support
for keeping adolescent girls in school,
and combining life skills education for
girls alone or life skills education for girls
and boys with community mobilization.
Overall, multi-pronged approaches seem
to lend themselves to influencing the
various sources of social pressure for
early marriage of girls, as compared to
single strategies.
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Chapter 3
Delaying age at
first pregnancy
Background
Age at first birth is a direct determinant
of the pace of childbearing and has a
bearing on the total number of children a
woman may be expected to have. Early
childbearing impacts not only on fertility
but can have adverse consequences
on women’s life, their families, their
children’s health and wellbeing.
Studies in India and elsewhere document
that early and/or repeated childbearing
is a risk factor for poor maternal and
child health outcomes [1-7]. Maternal
death rates for young women aged 15-19
are twice as high as for older women
and research suggests that girls ages
10-14 are five times more likely to die of
maternal causes than women aged 20-24
[8]. Many adolescent mothers, especially
in poorer countries, are physically
immature, which increases their risk of
suffering from obstetric complications.
In addition, the mortality rates among
infants of mothers under age 20
averages about 50% higher than among
infants of mothers aged 20 to 29 [9]. Poor
newborn health resulting from births to
adolescents can have inter-generational
effects and long-term consequences for
diseases in adulthood [10].
Adolescent pregnancy is a worldwide
concern. About 11% of all births
worldwide (2008) were to girls aged
15-19 years. The adolescent fertility rate
worldwide was estimated to be 55.3
per thousand for 2000-2005, which
means that 5.5% of adolescents give
birth each year [10]. The United States
of America had in 2000-2009 among
the highest adolescent fertility rates
among industrialized countries: 41 births
per 1000 women age 15-19 years. New
Zealand was a distant second at 32
births per 1000 followed by UK (26 births
per 1000 women age 15-19). During
2000-2009 developing countries had
adolescent birth rates that were almost
twice as high (55 per 1000) as that in
industrialized (23 per 1000) countries
[10-11]. Early childbearing is particularly
common in Sub Saharan Africa, where
28% of women aged 20-24 had given
birth by age 18. In Niger, the percentage
reaches as high as 51%. Having a baby
by age 18 is common in other parts of
the world, such as in Bangladesh (46%)
and Nicaragua (28%) [11].
The context in which adolescents become
pregnant is very different in different
settings. Close to 100% of births to
adolescents take place within marriage
in Western Asia/Northern Africa, Central
Asia and South-Central and South
Eastern Asia. This is also the case in
India. In South America and Sub-Saharan
Africa, the proportion of adolescent
pregnancies and births within marriage
falls to between 70-80% [10]. Births to
unmarried adolescent mothers are more
likely to be unintended. Non-consensual
sex underlies a small but significant
proportion of adolescent pregnancies.
In more developed countries such as the
USA and UK, adolescent childbearing
occurs predominantly outside marriage
and disproportionately among the socially
and economically disadvantaged [10].
In India, the NFHS-3 (2005-06) data
shows that, for the country as a whole,
adolescent birth rate was 90 per 1000, a
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3.2 Page 22 |
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Figure 3.1. Teenage pregnancy and motherhood by states: Proportion of women age 15-19
Who have had
Who are pregnant
Who have begun
a live birth
with first child
childbearing
India
12.1
3.9
16.0
North
Delhi
3.8
1.2
5.0
Haryana
7.5
4.6
12.1
Himachal Pradesh
2.1
0.9
3.1
Jammu and Kashmir
3.4
0.8
4.2
Punjab
3.6
1.9
5.5
Rajasthan
12.6
3.4
16.0
Uttaranchal
3.6
2.6
6.2
Central
Chhattisgarh
11.2
3.4
14.6
Madhya Pradesh
10.6
3.0
13.6
Uttar Pradesh
11.2
3.1
14.3
East
Bihar
19.3
5.7
25.0
Jharkhand
20.8
6.8
27.5
Orissa
10.4
4.1
14.4
West Bengal
19.3
6.0
25.3
North East
Arunachal Pradesh
12.4
3.0
15.4
Assam
13.1
3.2
16.4
Manipur
5.2
2.1
7.3
Meghalaya
6.7
1.5
8.3
Mizoram
7.7
2.5
10.1
Nagaland
5.5
1.9
7.5
Sikkim
8.7
3.2
12.0
Tripura
14.0
4.5
18.5
West
Goa
2.6
1.1
3.6
Gujarat
8.9
3.7
12.7
Maharashtra
11.0
2.9
13.8
South
Andhra Pradesh
12.7
5.4
18.1
Karnataka
12.8
4.3
17.0
Kerala
2.9
2.9
5.8
Tamil Nadu
4.8
2.9
7.7
Source: NFHS-3 [12]
decline from 116 per 1000 in 1990-92 and
107 per 1000 in 1995-96. Rural areas had
close to three times the adolescent birth
rate (105 per 1000 women age 15-19) as
compared to urban areas (57 per 1000) in
2005-06 [12].
About 1 in 6 women age 15-19, or 16%
had begun childbearing in 2005-06.The
proportion of women who had begun
childbearing was 3% for women age 15
and increased sharply to 36% or more
than 1 in 3 for women age 19. Figure
3.1 presents data for Indian states on
proportion of women who had begun
childbearing in 2005-06.The proportion
is highest in Jharkhand (27.5%), West
Bengal (25.3%) and Bihar (25%), all
located in Eastern India. In contrast, in
Goa, Himachal Pradesh and Jammu and
Kashmir less than 5% of women age 15-
19 had begun childbearing [12].
A World Bank study indicates that
about 80% of population growth in
India between1990 and 2030 will be
from growth momentum [13]. This
implies that even if the country achieves
replacement-level fertility in 2010 (2.2
births per woman), the country’s total
population will still increase by half
a billion people by 2050. However,
delaying first births and increasing
spacing between first and second births
can minimize the effect of population
momentum.
This is possible if contraceptive use by
young couples is acceptable to families
and to society at large. Evidence from
qualitative studies in India highlight
several important social constructs
and compulsions that influence young
couple’s early reproductive life. Findings
show that many young couples want
to delay births but fail to translate their
desires into action due to a number of
social factors including social pressure
to bear the first child as early as
possible, and also due to programmatic
barriers such as failure to reach young
married couples with contraceptive
information and services before
childbearing begins. [14]
Unfortunately, the current family
planning programs do not meet the
needs of young married people,
According to NFHS-3, only 13% of
married women in India age 15-19 were
current users of any contraception (2005-
06), and only about half of them (6.9%)
used a modern method of contraception.
Unmet need for spacing among this age
group was 25.1%, and only 32.4% of the
demand for contraception was satisfied
among this age group (12).
The Framework in Figure 3.2 (page 46),
summarizes the key barriers to plan
pregnancies and resulting impacts on
health of the mother and child.
Evaluated interventions to prevent
early childbearing
The search yielded three studies from
India, 23 systematic reviews and
evidence syntheses from the United
States of America and the UK (21 from
USA and 2 from UK), and seven studies
from Africa and Asia excluding India.
Most of these reviews and studies are
of interventions to prevent teenage
pregnancies outside marriage and
of limited relevance to the Indian
context where the majority of teenage
pregnancies occur within marriage.
Nevertheless, we start this section with
a brief summary of findings on effective
intervention strategies from the most
recent systematic reviews of studies
from USA and UK. We also discuss
salient strategies from Africa and Asia,
before presenting findings from Indian
studies. This is done keeping in mind the
changes already occurring in the sexual
and reproductive lives of young people
in India and also with a view to draw on
promising strategies that are relevant to
the Indian context.
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Evaluated interventions to prevent
childbearing among unmarried
adolescents in the USA and UK
Teenage Pregnancy Prevention Programs
based in schools are the most common
interventions for teenage pregnancy
prevention in the USA and UK. Systematic
reviews and evidence syntheses provide
mixed evidence on the effectiveness
of these, probably because of the wide
variations in program components,
contents, frequency and intensity.
Interventions vary from single consultations
to multiple sessions ranging from 2 to 30
hours in total duration. In the US context,
they may be abstinence focused and
exclude any contraceptive information
or have a contraceptive focus; and they
may go beyond sex education to be multi-
component youth development programs.
A 2006 systematic review of 31 studies
reporting on 38 US-based randomized
control trials of sex education
interventions for teenage girls found no
consistent evidence that sex education
programs made an impact on the
probability that young people would
initiate sex, would risk pregnancies
or would become (or get someone)
pregnant. The size, direction and statistical
significance of impact estimates varied
greatly across the programs. However,
a number of individual studies found
positive impacts especially on increase
in contraceptive use. Of the intervention
strategies reviewed, multi-component
youth development programs were the
most promising [15]. Youth Development
Programs typically combine self-esteem
building, voluntary work, educational
support, vocational preparation, health
care, sports and arts activities as well as
Sex and Relationship Education (SRE).
Many of these observations are
corroborated in a 2012 synthesis of
evidence from the US on sex education
and other programs aimed at preventing
teen pregnancy, HIV and Sexually
Transmitted Infections [16]. Thirty-six
programs were reviewed which met
the criteria of having an experimental
or quasi-experimental study design.
Fourteen programs showed statistically
significant decline in adolescent birth
rates. Two of these were school-based sex-
education programs, a third was a school-
based service delivery program, eight
(including one which combined school
and community-based intervention) were
community-based interventions and three
were clinic-based interventions.
A review of reviews carried out by the UK
Health Development Agency concluded
that “Sex and Relationships Education”
(SRE) programs that were school-based
can have an impact, more so if they were
linked to contraceptive services.The
impact was in terms of young people’s
knowledge and attitudes, delay in
initiation of sexual activity and reduction
of pregnancy rates. The review found that
SRE programs on their own were unlikely
to bring about reduction in teenage
pregnancy rates unless they were part of
a multi-component intervention [17].
Another systematic review assessed
the effectiveness of strategies that
addressed specifically the social
disadvantages associated with early
parenthood [18]. Based on evidence from
six controlled trials and five qualitative
studies, the review concluded that early
childhood interventions and youth
development programs that tackled social
disadvantages in the early years of life
and provided social support, educational
support and skills training were effective
in reducing the risk of teenage pregnancy.
Overall, the verdict appears to be
in favor of multi-faceted youth
development programs, which
addressed social determinants of
teen pregnancy. Sex and relationship
education programs would be an
essential but not exclusive component
of such interventions.
Evaluated interventions to prevent
childbearing among unmarried
adolescent in developing country
settings.
We were able to identify seven published
studies including three syntheses
of evidence from experimental and/
or quasi-experimental studies on
effectiveness of interventions aimed
at promoting, among other changes in
behavior, increase in contraceptive use
and pregnancy prevention.
A comprehensive review by Family Health
International examined 83 studies of sex
education programs for young people
(9-24 years) aimed at one or more of the
following: changing beliefs, attitudes
and behaviors related to safer sex and
prevention of sexually transmitted
infections and pregnancy. Eighteen
of these studies were of interventions
carried out in 12 developing countries:
six in Africa, five in Central and South
America and one in Asia. Twelve of the
eighteen studies had data on increase in
condom use and only two had data on
increase in use of other contraceptives.
Conclusive positive evidence on increase
in condom use was found only in seven
studies while no conclusive evidence on
effectiveness was found with respect to
increase in use of other contraceptives.
The few studies that examined pregnancy
rates also did not produce any significant
positive results [19].
An earlier study by Family Health
International (2002) synthesizes a range of
interventions with youth to promote safe
sex, prevent high-risk sexual behavior
and pregnancy rates. All the evaluation
studies had adopted an experimental
or quasi-experimental study design.
Interventions included school-based
sexuality and HIV/AIDS programs, school-
based reproductive health education
programs, mass media campaigns,
community-based interventions, behavior-
change social marketing programs and
adolescent-friendly health services. Of
the interventions examined, a greater
proportion of community-based programs
and mass-media campaigns seem to
have a conclusive positive impact on
increase in use of condoms and/or other
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Figure 3.2. Key barriers to plan pregnancies and consequences for health in develop-
ing country settings
Time of Pregnancy
Early childbearing
due to early
marriage
Barriers to plan pregnancies
Adverse
Socio Cultural
• Social pressure to bear first
child as early as possible to
prove fertility
• Lack of knowledge on
contraceptives
• L ack of decision making
power
• F ertility as a sign of social
status
• F ear that use of
contraceptives will affect
future fertility
Programmatic
• L ack of awareness on
service delivery points
• Inadequate access to
quality Family planning
services
• N on- availability of
basket of choices for
contraceptives
• F amily Planning services
focused more on limiting
births after achieving
desired family size rather
than on delaying and
spacing their births
• L ack of target specific
communications to promote
contraception to all the
gatekeepers —young
woman, husband and
mother-in-law
• Insensitive attitude of
health providers and
provider bias against use
of contraceptives by young
women to delay first child
• L ack of Confidentiality
Health Outcomes
Increasing population
momentum
Maternal and Infant deaths
Pregnancy complication
Delays in the development
milestones of the child
Poor nutrition
contraceptives. Only one of eight school-
based reproductive health education
programs and three of seven school-
based HIV/AIDS and sexuality programs
showed significant positive results [20]
Sohail (2005) examined four sex-education
interventions in Africa that had been
evaluated using a quasi-experimental
study design. Pregnancy prevention
was not a direct objective of these
interventions, but would be an indirect
outcome of increase in contraceptive use
and especially of increased condom use,
which were direct program objectives.
The interventions were carried out in
Cameroon, South Africa, Botswana and
Guinea in the late 1990s, and adopted a
combination of several strategies: mass
media, sponsored events, peer education
and youth friendly services. Only the
intervention in Cameroon had significant
positive results in terms of increasing
contraceptive use among young women
as well as young men. This was also
the intervention that was of the longest
duration and had the largest coverage. [21]
The remaining four studies include
two randomized control trials from
Malawi and Kenya and two quasi-
experimental studies from Ethiopia and
China, respectively [22-25]. In Malawi,
the same Conditional-Cash Transfer
Program aimed at keeping adolescent
girls in school and encouraging drop-
outs to rejoin (which was effective in
preventing early marriage), also found
that baseline drop-outs were 5.1% less
likely to have become pregnant over the
past year, a reduction of more than 30%
and statistically significant at 5% level.
However, there was no change seen
among girls who were already in school
at baseline and remained in school
through the intervention [22]. In Western
Kenya, a program that provided school
uniforms as a means of reducing the cost
of schooling found (in addition to a delay
in age at marriage), that girls in schools
where free uniforms were provided
were 1.5 percentage points less likely to
have started childbearing at the end of
the intervention period, almost a 10%
decrease in teen childbearing [23].
The Berhane Hewan Program in Ethiopia
is an intervention adopting a multi-
pronged strategy that provided financial
support to keep girls in school, life-
skills education through girls’ clubs and
carried out community mobilization.
Girls from intervention villages were
more likely than control villages (odds
ratio 2.9) to have used contraceptives
[24]. Pregnancy rates were not available
from the study.
Bo Wang et al (2005) report on the
evaluation of a comprehensive sex
education program in Shanghai, China.
The intervention adopted multiple
strategies including the distribution
of educational materials, screening
of educational videos, lectures, peer
education, contraceptive and other
reproductive health services and
counseling. Both, high school students
and out-of-school youth were covered by
the program. Information was provided
on abstinence, healthy and non-coercive
sexual behaviors and contraceptive use.
The intervention resulted in increased
odds of contraceptive use (6.2) and
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condom use (13.3) in the intervention
group as against the comparison
group. The proportion of young people
who conceived or impregnated their
partner was significantly lower in the
intervention group (19%) than in the
comparison group (26%) [25].
The evidence from these studies is rather
disparate to lend itself to a synthesis. All
the same, a few observations may be
made. Programs that effectively prevent
girls from dropping out of high school
or help keep them in school through
financial incentives and support appear
to hold promise in terms of delaying not
only age at marriage (Chapter 2) but also
age at first childbearing. Sex education
programs as single interventions do
not seem to be as promising as those
which adopt multiple strategies including
mass media campaigns, community
mobilization, education and counseling
to adolescents and young people on
sexual and reproductive health and
service delivery.
Evaluated interventions to delay
childbearing among married young
people – India
Three studies from India were identified
through the search, presenting evidence
on interventions to delay first pregnancy
from quasi-experimental studies [26-28].
Two of these were about the PRACHAR
project in Bihar, while one was about
the RHEYA project on which PRACHAR
was based. RHEYA was implemented in
selected areas of Tamil Nadu, New Delhi,
Rajasthan and Madhya Pradesh.
The PRACHAR project was implemented
in the Nalanda, Nawada and Patna
districts of Bihar starting 2001, and is an
ongoing project. The first phase of the
project was from 2001-2006 after which
there was a change in implementation
strategy. Both the studies included
here are evaluations of the first phase.
Delaying birth of the first child until the
mother is 21 years old was one of the
specific objectives of the project [26-27].
The project used multiple strategies to
achieve its many objectives related to
fertility reduction. The first strategy was
community mobilization, called by the
project as “social environment building”.
Meetings were held with parents of
young married men, seen as the most
important sources of pressure for
childbearing immediately after marriage.
communication strategy used locally
appropriate media such as street theatre
and wall paintings.
Reproductive health training of unmarried
adolescents to prepare them to delay
the first child, described in the previous
chapter, must be seen as a key strategy
to delay first pregnancy in a setting of
arranged marriages. This is because
the first child cannot be delayed unless
interventions build intent to delay and
knowledge on how to delay in unmarried
adolescents before they marry.
The third strategy involved providing
education and information on
contraception and reproductive health to
young married couples. “infotainment”
parties were held for newlywed couples,
and educational meetings were held
separately for young married women
and men. Health care providers paying
home visits also targeted young married
women with no children or one child to
counsel them on contraceptive use.
The fourth strategy was increasing
access to services. Young couples were
encouraged to use government health
services for their reproductive health
needs. Local pharmacies were supported
in keeping stocks of contraceptive pills and
condoms, and local informal providers
were trained in reproductive health and
provision of contraceptive services.
The baseline survey was conducted
in 2002-03 in the project area and a
comparison area before the intervention
started, and the follow-up survey was
conducted in 2004, after 21-27 months
of intervention. There was a significant
increase (p< .01) in the intervention
area in the use of contraceptives among
women with no children. At the base-
line 3% of women with no births were
using contraceptives in the intervention
area, as compared to 2% in the
comparison area. After the intervention,
contraceptive use among women with
no children increased to 16% in the
intervention area while it increased to
3% in the control area [26].
The project also had reproductive health
education sessions for unmarried boys
and girls. A quasi-experimental study
evaluating the impact of this activity
of the PRACHAR project reported a
significant difference in age at first birth
between girls who had attended the
training (23.6 years) and girls who had not
attended the training (21.5 years) [27].
intervention and control groups in the
mean age at first birth – 21.3 years
versus 20.7 years. The mean interval
between marriage and first birth was
also significantly different – 27.1 months
in the intervention group as against 24.9
months in the control group [28].
In summary, the limited available
evidence points to the PRACHAR
model as being promising in terms
of effectiveness in delaying early
childbearing. In other words, a multi-
pronged strategy with interventions
for community mobilization, mass
media campaigns, efforts at changing
attitudes of key gatekeepers in young
couple’s lives, together with sexual and
reproductive health education, counseling
and service delivery for young people
- has a good probability of delaying
early childbearing. In order to be able to
make more conclusive inferences, such
interventions and rigorous evaluations
will need to be carried out in different
settings and contexts.
The report on the RHEYA project provides
comparatively sparse information.
The strategy adopted is exactly the
same as in PRACHAR. Only about 10%
(300) of the 3225 young couples who
had been part of the intervention were
interviewed in the end-line study. There
was a significant difference between
The PRACHAR model, although targeting
married adolescents for preventing early
childbirth, is not very different from the
relatively more promising interventions
with unmarried young people found in
other parts of the world, which also show
the effectiveness of addressing multiple
target groups simultaneously.
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Chapter 4
Promoting spacing
between births
Background
Birth spacing refers to the period
between a live birth or stillbirth and the
conception of the next pregnancy, while
‘birth interval’ is the period between
two live births. According to WHO, after
a live birth the recommended interval
before attempting the next pregnancy is
at least 24 months in order to reduce risk
of adverse maternal, perinatal and infant
outcomes. After a miscarriage or abortion,
the recommended minimum interval to
next pregnancy is at least 6 months in
order to reduce risks of adverse maternal
and perinatal outcomes [1]. Many surveys
provide data on birth intervals rather
than on birth spacing. The most recent
evidence suggests that the optimal
interval between two live births is 36-59
months [2-7].
By preventing closely spaced births,
family planning could save the lives
of more than 2 million infants and
children annually [7]. Poorly spaced
births increase the chances of pre-term
births, low-birth weight, and births that
are small for gestational age. Women
who conceive too soon after a birth,
miscarriage or abortion are more likely
to experience anaemia, premature
rupture of membranes, abortion or
miscarriage, and are also at a higher
risk of maternal death. Evidence from
research on whether a short birth interval
is associated with adverse nutritional
outcomes for the mother or the child
suggests that increasing birth intervals
has a positive effect on stunting and
underweight in children under five [8].
A close succession of pregnancies and
periods of lactation worsen the mother’s
nutritional status because there is not
adequate time for the mother to recover
from the physiological stresses of the
preceding pregnancy before she is
subjected to the stresses of the next. This
results in depletion of maternal nutrient
stores, with the subsequent increased
risk of adverse perinatal outcomes.
Adverse pregnancy outcomes can in turn
contribute to a poorly spaced pregnancy.
A study from Bangladesh found that
short intervals are much more likely to
begin with a non-live birth, miscarriage
or stillbirth perhaps because women
want to have a birth fairly quickly to
‘replace’ their recent unintentional fetal
or child loss [9].
Figure 4.1 summarizes the elevated
risks of adverse maternal, perinatal and
infant outcomes consequent to short
birth spacing.
Studies examining determinants of birth
spacing indicate that early marriage,
survival of the previous child, and
knowledge and use of contraception are
important factors [10]. It is also known
that many women fall short of their own
reproductive goals for birth spacing
and become pregnant earlier than
intended. The concept of “unmet need for
contraception” refers to the proportion
of women who do not want to become
pregnant but are not using contraception.
Unmet need for spacing methods, which
refers to non-use of contraception despite
intending to postpone the next birth,
varied from 17% in sub-Saharan Africa to
4% in the Middle East and North Africa
during 2000-2009. In South Asia, the
unmet need for spacing was 8% [11].
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Figure 4.1. Risks of Adverse Health Outcomes After Very Short Interval Pregnancy,
Compared to the Reference Group Interval Used in the Selected Study.
INCREASED RISKS WHEN PREGNANCY OCCURS 6 MONTHS AFTER A LIVE BIRTH
Adverse Outcome
Increased Risk
Induced Abortion
650%
Miscarriage
230%
Newborn Death (<9 mos.)
170%
Maternal Death
150%
Preterm Birth
70%
Stillborn
60%
Low Birth Weight
60%
INCREASED RISKS WHEN PREGNANCY OCCURS <6 MONTHS AFTER AN ABORTION OR MISCARRIAGE
Increased Risk with 1-2 Month Interval With 3-5 MonthInterval
Low Birth Weight
170%
140%
Maternal Anemia
160%
120%
Preterm Birth
80%
40%
Source: Conde-Agudelo et al 2000, 2005, 2006; DaVanzo et al 2004, Razzaque et al 2005 and Rutstein 2005 [2-7]
India
Less than a third of the births in India occur
after the optimal birth interval, according
to data from NFHS-3 (2005-06). At the
all India level, the median interval since
the preceding birth was 31.1 months.
More than 60% occur within three years
of the previous birth. Only 28% have an
optimal birth interval of 36-59 months.
Also, the median birth interval is shorter
if the previous child did not survive (25.8
months) as compared to if the child was
living (31.8 months). Figure 4.2 gives data
on birth intervals for India and by state.
The birth interval falls short of 36 months
in all but four states of India – Kerala,
Tripura, Goa and Assam. Clearly there is a
long way to go towards achieving optimal
spacing of births in India [12].
Non-use of traditional or modern
reversible methods of contraception
may underlie poorly spaced births in the
country. Of the three modern reversible
methods available free of cost in India’s
family planning program, the IUD is the
least widely used method while the pill
and the condom do only marginally better
(Table 3). In fact, use of IUD has declined
between NFHS-1 and NFHS-3 [12].
Non-use of reversible methods of
contraception co-exist with unmet need
for spacing births. As observed in other
parts of the world, many Indian women
who would like to postpone the next
pregnancy are at the same time not
using a method of contraception. About
6.2% of women had an unmet need for
spacing births. However, unmet need
for spacing was much higher among
younger women: as high as 25% and
14.9% for women age 15-19 years and
20-24 years. Unmet need for family
planning overall and for spacing was also
higher among women from the lowest
economic groups (7.7%) as compared to
those from the highest (3.3%) [12].
One consequence of non-use of
contraception while not wanting to get
pregnant is the use of induced abortion
as a way of achieving the intended
spacing between two subsequent
births. In India not wanting another
child immediately or having become
pregnant after achieving desired family
size are among the most important
reasons why women seek induced
abortion. Women who have had an
induced abortion are at special risk of
Figure 4.2. Percent distribution of births during the five years preceding the survey by
interval since the preceding birth and median number of months since the preceding
birth, by state, India 2005-06
Months since preceding birth
7-17 18-23 24-35 36-47 48-59 60+
Total Median
no. of
months
since
preceding
birth
11.4 16.3 33.6 19.2
9.1
10.4
100
31.1
India
North
Delhi
13.3 12.9 28.1 16.8
13.1 15.7
100
33.4
Haryana
14.3 15.4 33.7 18.8
8.6 9.2
100
30.4
Himachal Pradesh 16.2 16.2 32.7 15.8
8.6 10.6
100
29.9
Jammu and Kashmir 11.2 15.5 29.3 19.4
10.6 13.9
100
32.0
Punjab
17.8 17.1 29.9 16.0
7.3 11.9
100
29.7
Rajasthan
11.7 17.1 36.1 20.5
8.3 6.3
100
30.2
Uttaranchal
12.5 15.2 31.5 19.1
9.6 11.9
100
32.4
Central
Chhattisgarh
8.9 14.4 34.3 18.2
12.6 11.7
100
33.0
Madhya Pradesh 12.2 18.4 36.6 18.6
7.5 6.8
100
29.2
Uttar Pradesh
13.0 17.2 34.2 18.3
8.6 8.7
100
29.8
East
Bihar
11.6 16.9 34.5 20.5
8.4 8.0
100
29.9
Jharkhand
7.8 16.2 36.5 19.9
10.9 8.6
100
31.5
Orissa
8.5 14.2 33.3 21.8
11.3 10.9
100
33.8
West Bengal
9.0 12.6 30.0 19.0
11.7 17.6
100
35.2
North East
Arunachal Pradesh 10.3 16.4 36.3 17.4
10.4 9.3
100
30.8
Assam
7.8 12.0 27.5 20.9
14.0 17.7
100
37.0
Manipur
6.5 13.4 31.7 18.8
15.5 14.0
100
35.4
Meghalaya
11.1 13.9 34.3 16.7
10.8 13.1
100
31.7
Mizoram
11.5 19.7 29.0 16.7
10.3 12.8
100
30.6
Nagaland
12.4 20.0 37.4 15.4
6.6 8.1
100
28.6
Sikkim
6.6 13.1 32.8 16.3
14.4 16.8
100
34.5
Tripura
7.2 13.4 24.7 18.9
13.7 22.2
100
39.0
West
Goa
8.4 12.3 26.1 19.8
11.1 22.2
100
37.4
Gujarat
12.1 16.8 37.0 17.3
6.7 10.1
100
29.2
Maharashtra
10.1 15.0 33.8 19.9
8.7 12.5
100
31.9
South
Andhra Pradesh
12.3 19.0 29.4 18.7
9.0 11.7
100
31.4
Karnataka
11.2 16.7 35.4 19.1
8.0 9.6
100
30.3
Kerala
5.9 12.9 20.6 21.3
12.7 26.5
100
41.2
Tamil Nadu
11.2 14.9 32.5 19.3
9.3 12.8
100
31.4
Source: NFHS-3 [12]
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Figure 4.3. Percentage distribution of currently married women by contraceptive
method currently used, according to residence
NFHS 1NFHS 2NFHS 3
Urban Rural Total Urban Rural Total Urban Rural
Total
Any method 51.1
37.1 40.7 58.2 44.7 48.2 64
53
56.3
Any modern
method
45.3
33.3 36.5 51.2 39.9 42.8 55.8
45.3
48.5
Female
sterilization 30.4
26.4 27.4 36
33.5 34.2 37.8
37.1
37.3
Male
sterilization 3.2
3.5
3.5 1.8
1.9 1.9 1.1
1
1.0
Pill
1.9
0.9
1.2 2.7
1.9 2.1 3.8
2.8
3.1
IUD
3.9
1.2
1.9 3.5
1.0 1.6 3.2
1.1
1.7
Injectables
0
0
0
-
-
-
0.1
0.1
0.1
Condom
5.8
1.2
2.4 7.2
1.6 3.1 9.8
3.2
5.2
Source: NFHS-3 [12]
repeat induced abortions [13]. Many
women do not receive immediate post
abortion family planning services, even
though they are at risk of pregnancy
within two to three weeks.
Inadequate information about various
methods appears to be one of the
factors contributing to unmet need for
spacing. While at least 98% of women
and men age 15-49 know one or more
methods of contraception, correct
knowledge on spacing methods was
limited. Among the three spacing
methods offered by the government
family planning program (pill, IUD,
and condom), 61% of women and
49% of men reported knowledge of all
three modern spacing methods. The
pill was most widely known among
women (85 %) and the condom was
most widely known among men
(93%).only 39% women knew that IUD
was placed in the women’s uterus
and less than 1% women knew that
some IUDs offer protection for 10
years (IUD 380A is being used in the
government facilities). This is reflected
in contraceptive-use patterns, with
female sterilization being the single
most widely used method [12].
Yet another factor contributing to
unmet need for spacing births may
be the limited control women in India
have over their lives [14-15]. In many
instances the husband controls fertility
and contraceptive use decisions.
Mothers-in-law also play a dominant
role in young woman’s contraceptive
use decisions [16]. In a study conducted
in Uttar Pradesh, 56% women of
reproductive age deferred health
care decisions to their mothers-in-
law and 15% to their husbands [17].
Furthermore, pressure from husbands
or in-laws can also lead to contraceptive
discontinuation [18-19].
Evaluated Interventions to promote
optimal birth spacing
Before reviewing the evidence from these
studies, it may be useful to first take a
look at two major intervention initiatives
to promote optimal birth spacing found in
the literature search: the “HealthyTiming
and Spacing of Pregnancy (HTSP)” and
the CATALYST project. These interventions
were carried out in a number of African
and Asian countries, although evaluation
studies using experimental or quasi-
experimental study designs could be
found only for two of these.
Figure 4.4. Causes and health consequences of inadequate birth
Causes
Socio Cultural factors
Poverty
Illiteracy levels
Inequitable access among
marginalized groups – adolescents,
rural poor
Low status of women
Gender discrimination
Desire for a Son
Lack of decision making power
Early marriage and childbearing
Social acceptability of contraceptive use
Program related factors
Lack of knowledge on contraception
Inadequate access to quality health
services
Weak infrastructure
Shortage of qualified providers
Lack of training
Natural disasters/ armed conflicts
Outcomes of inadequately
spaced children
Early child bearing
Closely spaced pregnancies/child
births
Induced abortions
Unsafe abortions
Unplanned pregnancies
Accelerated population growth
Miscarriage
Contraceptive discontinuation
Maternal/infant deaths
Inability to participate in economic
development
Healthy Timing and Spacing of
Pregnancy
HTSP programs aim to promote awareness
and knowledge about delaying first-time
pregnancy and spacing subsequent
pregnancies to minimize adverse maternal,
perinatal and infant health outcomes.Three
key HTSP messages are that the health
of mothers and children are significantly
improved when pregnancy occurs: “At
least 24 months after a previous live birth.
No earlier than 6 months subsequent to a
miscarriage or induced abortion and not
before a mother has reached the
age 1“ [20].
Key HTSP interventions have included:
▶ Advocacy at the policy level
▶ Education and counseling of women
and families
▶ Integration with family planning
services, and other programs as
opportunities present themselves:
e.g. with post-abortion care and with
Integrated Management of Childhood
Illness (IMCI) programs.
HTSP programs have been rolled out
in many developing countries as part
of the USAID-funded Extending Service
Delivery (ESD) project whose objective
is to increase the use of family planning
services especially in under-served
communities [20]. Our search identified
a quasi-experimental evaluation study of
an HTSP program in Nepal.
CATALYST
This was a health-project that promoted
family planning and reproductive
health services with the aim of lowering
maternal, infant and child mortality
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rates. One of its main strategies was
to advocate for birth spacing as a
high-priority and life-saving practice.
CATALYST carried out training for health-
care providers on behavior-change
communication and counseling on
“Optimal Birth Spacing Interventions”
(OBSI). It also carried out advocacy on
OBSI at the global and national levels.
The project was funded by USAID
and implemented by a consortium
of international NGOs between 2000
and 2005 in 15 countries.The OBSI
intervention carried out in Egypt
has been evaluated using a quasi-
experimental study design and is
included in this review [21].
Evaluated interventions to promote
optimal birth spacing in this review
The search yielded eight studies from
India and three studies from other
developing countries, which met the
inclusion criteria. Since some studies
were about the same program, the
number of programs reviewed are nine:
six from India, one each from Nepal,
Egypt and China.
In eight of the nine programs, promoting
optimal birth spacing was a direct
objective, often among a number of
other objectives related to promoting
use of family planning and reproductive
health services, and sometimes, delaying
early marriage. One intervention from
China was focused on preventing
unintended pregnancy through advanced
provision of emergency contraception
to women who had recently given birth,
and hence optimal birth spacing was
indirectly being facilitated.
Target audiences
The primary target groups were young
married women who were currently
pregnant or had recently delivered
a child and their husbands. In all but
two programs, there were multiple
secondary target groups including key
gate-keepers from the family such as
the mother-in-law and other elders;
community leaders and opinion-shapers
such as school teachers and religious
leaders, health service providers. In
addition to these various target groups,
the Tahseen (CATALYST) program in
Egypt and the HTSP Program in Nepal
explicitly mention targeting high-level
stake holders from the government.
The “Advanced Provision of Emergency
Contraception” project from China was
the only one covering a single target
group of post-natal women, while the
‘Men in Maternity’ (MiM) program
covered only pregnant women seeking
antenatal care and their husbands.
Strategies adopted
The nine programs reviewed adopted
one or more of six strategies addressing
or influencing birth spacing.
1) Targeted messages for young married
women.
2) E ducational and counseling interventions
aimed at young married men.
3) C ommunity mobilization – Ranging
from targeted awareness raising
programs among parents and family
members of young people to broader
social mobilization of community
members at large.
4) E ngagement with health and allied
service providers (government and/or
private sectors).
5) Mainstreaming optimal birth spacing
messages and services within the
government health sector.
6) High-level advocacy.
1) Targeted messages for young married
women
Eight programs (with the exception of
Tahseen, Egypt) delivered targeted
messages related to optimal birth-spacing
to pregnant or post-partum women and
to women whose youngest child was
less than two years old. In five programs
these messages were delivered through
house-visits by government community
health workers, while trained change
agents from within the community were
used in the PRACHAR program. The
DISHA program delivered its messages
through educational sessions for women,
while the MiM program and Advanced
Provision of Emergency Contraception,
both involved clinic-based counseling
and education.
The study of the PRAGATI program in Uttar
Pradesh gives details about the strategy
for targeted message delivery. Seven
visits were made during the pregnancy
and postpartum period, three during
pregnancy, three post partum including
one within two-days of child birth. Specific,
standardized messages were delivered
during each visit. Each subsequent visit
would follow-up to reinforce the messages
delivered previously and document the
use of services and adoption of desirable
practices [27].
2) Targeted messages for young married men
Five programs adopted this strategy, and
were a sub-group of the eight programs
which delivered targeted messages to
young married women. Husbands of
pregnant women and postpartum women
and women whose youngest child was
less than two years old were targeted
with messages. Messages were delivered
in community-based educational
sessions systematically in all but the MiM
program. In addition, the PRACHAR and
RHEYA programs also had home-based
counseling through male change agents
from the community, while the other
two programs made use of any available
opportunities to counsel men during
their house visits to meet their wives.
Messages to men were delivered in the
clinic setting in the MiM program.
3) Community mobilization
Community mobilization strategies ranged
from targeted awareness raising programs
among family members of young
people to broader social mobilization of
community members at large. Seven of
the reviewed programs (except the two
clinic-based) used this strategy. Targeted
awareness raising programs reached
out to mothers-in-law, parents of young
married couples, key family elders; and
also community leaders and opinion
shapers.TheTahseen program in Egypt
had religious leaders as an important
target group to influence.
A range of communication methods
and tools were used: group meetings,
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theatre, wall-paintings, pamphlets
and booklets, advertisement spots on
television and airtime on local radio.
In Egypt, literacy classes conducted by
the government’s education department
disseminated messages on optimal birth
spacing, and agricultural and irrigation
extension workers were trained to
disseminate the message to farmers.
4) Engagement with health and allied
service providers
Engagement with health and allied service
providers included consultative meetings
with the Department of Health and of other
concerned departments (e.g. Department
of Women and Child Welfare), and training
of health and allied service providers
from the public and private, formal and
informal health sectors.This was a strategy
adopted by six programs – five from India
and the HTSP program from Nepal. In the
HTSP programs in India and Nepal and in
the Pragati program, government service
providers and especially front-line workers
were trained as part of the strategy to
mainstream the optimal birth spacing
messages within the government health
system.The trained workers were then
charged with delivering targeted messages
on optimal birth spacing to young married
women and men. Such an approach
facilitates up-scaling of the strategy.
In three programs: PRACHAR, RHEYA
and DISHA, the focus was on training
health providers from the private sector,
which may include informal providers
and the traditional birth attendant,
and community workers of non-
governmental organizations. The Nepal
HTSP program trained both public and
private health providers.
5) Mainstreaming optimal birth spacing
messages and services within the
government health sector
The HTSP projects in India and Nepal
and the Pragati project in India worked
with the government health system and
personnel to implement birth spacing
interventions. This was done through
all potential programs and workers: for
example in India, both community health
workers and child care workers of the
Integrated Child Development Scheme
(ICDS) were trained and involved in the
implementation of interventions.
In the Tahseen program in Egypt, a
master stroke was getting OBSI included
in the National Clinical Standards of
Practice for RH/FP Clinical Service
Provision which guides clinical practice
standards not only in the public sector
but also in the private and NGO sectors.
Another success was the integration
of OBSI messages in the curricula of
pre-service as well as in-service health
professionals
6) High-level advocacy
The Nepal HTSP program and the
Tahseen program evaluations mention
high-level advocacy as an explicit
strategy. In Nepal, meetings were held
with the Central Reproductive Health
Committee members, and the National
Technical Working Group on Family
Planning to share information on the
intervention and its progress, including
the many challenges faced.
In Egypt, a concerted strategy to
evolve a consensus about the Optimal
Birth Spacing Interval (OBSI) included
engaging with key policy makers from
the Family Planning and Maternal and
Child Health Sectors.
Effectiveness of strategies
The following indicators have been
commonly used by studies as indicators
of effectiveness of programs: statistically
significant increase in contraceptive use
among postpartum women or women
with one child in the intervention as
compared to the control or comparison
group; and statistically significant
increase in the mean birth interval in the
Figure 4.5. Effectiveness of the programs in promoting optimal birth spacing,
strategies used and strength of the evidence
S.No Program NameStrategiesEffectiveness
1.
Tahseen (CATALYST
3,5,6
Effective in
project) , Egypt
changing awareness
2.
HTSP implemented through
1,3,4,5,6
Effective
Extending Service Delivery
Project , Nepal
3.
Advanced provision of emergency 1
Not effective
contraception to prevent
unintended pregnancy, China
4.
HTSP Project, UP, India
1,2,3,4,5
Effective
5.
Pragati , UP, India
1.2,3,4,5
Effective
6.
PRACHAR, Bihar, India
1,2,3,4
Effective
7.
DISHA, Bihar and Jharkhand, India 1,3,4
Effective
8.
RHEYA, Delhi, Madhya Pradesh
and Tamil Nadu, India
1,2,3,4
Effective
9.
Men in Maternity (MiM),
Delhi, India
1,2
Effective
Quality of evidence
C1
B
A
B
C1
B
B
B
B
Sources: [22-31]
Strategies: 1= Targeted messages for young married women 2=Educational and counseling interventions aimed at young married men 3=
Community mobilization 4= Engagement with health and allied service providers (government and/or private sectors) 5=Mainstreaming
optimal birth spacing messages and services within the government health sector 6=High-level advocacy
Quality of evidence: A= Experimental design B= Quasi-experimental design C1= “Before-After” study
intervention as compared to the control or
comparison group. The China study uses
pregnancy rate at one year postpartum
in the intervention versus the control
group as the indicator to assess. Studies
have also used indicators of change in
proportion of target population with
correct knowledge and/or appropriate
attitudes towards birth spacing.
Only one of the nine evaluations
adopted an experimental study design,
six adopted a quasi-experimental study
design with a pre-post evaluation, and
two were before-after studies. All studies
but one were found to be effective in
achieving their stated objectives.
In the Tahseen project which used
community mobilization and high level
advocacy, those who attended plays
produced by the project increased their
knowledge of the OBSI interval from
27% to 60%; religious leaders, from 19%
to 98%. Men attending literacy classes
registered an increase in knowledge
about OBSI as well as about its benefits
to the mother and the foetus. All were
statistically significant increases at the
1% level, but the study was a before-
after study with no comparison group,
to be able to attribute the changes to this
particular intervention.
The Nepal HTSP project found that
84% of women in the intervention area
were using a method of contraception
7-15 months postpartum as compared
to 63% of a comparable group of
women in the control area. Ninety
percent of the women used Lactational
Amenorrhea Method as the first method
and subsequently all of them shifted to
a modern contraceptive method. This
program did not target men but seems to
have achieved its objectives.
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Four Indian programs: the HTSP project,
Pragati, PRACHAR and RHEYA- have
adopted a similar combination of
strategies – education and counseling of
women and their husbands, community
mobilization and engagement with/
training of health care providers. All of
them have been found to be effective,
and three of these have strong evidence.
The HTSP Project in India successfully
increased both knowledge about
spacing methods and use of postpartum
contraception in the intervention
group. Fifty seven percent of women
in the intervention group were using a
contraceptive method at nine months
postpartum, as compared to 30% in the
comparison group. Also, only 24% of
women in the intervention group were
not using a contraceptive method at
nine months postpartum as compared to
45% non-users in the comparison group.
In the intervention group, condoms
were the most common method (41%)
followed by traditional methods (20%)
and the IUD (2%).
The Pragati program registered
significant increases in contraceptive
use among postpartum women in all
three intervention areas at the end of
the intervention: from 17% to 27% in
Moradabad, from 9% to 33.9% in Lalitpur
and from 12% to 27% in Ballia. This was a
unique intervention in terms of tailoring
messages to suit specific time points
during pregnancy and postpartum,
but the absence of a comparison
group makes it difficult to assert that
these increases were the direct result
of the intervention and not any other
underlying or intervening factors.
The PRACHAR program found a
significant increase in contraceptive use
in the intervention area among women
with one child – from 6% at baseline
to 25% at endline. This increase was
also significantly higher than in the
comparison area. The RHEYA program
which adopted a similar methodology
reported that the mean interval between
first and second births at endline
was 35.2 months in the intervention
area as compared to 33.9 months in
the comparison area, a statistically
significant difference.
The DISHA project did not have
interventions specifically targeting
husbands, but worked with women,
community and health care providers.
It also had an educational intervention
targeting young unmarried women
and men with reproductive health and
life skills education. The intervention
with unmarried young people appears
to influence behavior after marriage.
Youth exposed to DISHA’s education
program were 60% more likely to report
contraceptive use after marriage as
compared to those not exposed to
this intervention.
Mainstreaming birth spacing promotion
activities within the government health
sector, adopted by HTSP projects and
Pragati, has the potential for sustainable
and affordable upscale, and needs to be
explored further.
The Men in Maternity Program
intervened with pregnant women and
their husbands in a clinic setting, with
education, counseling and service
provision. This strategy is also seen to
be effective. Contraceptive use at 6-9
months postpartum was significantly
higher in the intervention as compared
to comparison groups. Among non-
users, intention to use contraception was
significantly higher among women in the
intervention group as compared to the
comparison group. No such relationship
was found for men.
In China, advanced provision of
emergency contraception to postpartum
women, while increasing use of
emergency contraception, did not reduce
the risk of unintended pregnancy and
induced abortion. There was no difference
in pregnancy rates at the end of 1 year
among women in the intervention as
compared to the control group.
Two tentative conclusions emerge
from examining this evidence. One, is
that working intensively with women
and their husbands alongside building
community support and health worker
capability in birth spacing is a potentially
promising combination of strategies
for an effective birth spacing promotion
program. Within this, the significance
of working with men has to be explored
further. Some interventions which cover
men as part of community mobilization
without having specifically targeted
interventions for husbands also seem
to achieve effective outcomes, and the
reasons for this need to be examined.
The second tentative conclusion is that
clinic-based interventions such as the
Men in Maternity program seem to hold
promise, and have the advantage of
being focused, less resource-intensive
and lends itself to rigorous monitoring
and evaluation.
More intervention studies are needed
that experiment with these approaches
which will allow for a better synthesis of
evidence of effectiveness.
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268.
16. Singh K, Bloom S, Ong Tsui A.
Husbands’ reproductive health
knowledge, attitudes, and behaviour
in Uttar Pradesh, India. Studies in
Family Planning 1988;29:388–99.
17. Stephenson T, Tsui AS. Contextual
influences on reproductive health
services in Uttar Pradesh, India. Studies
in Family Planning 2002; 33: 309-320.
18. Foundation for Research in Health
Systems (FRHS). Community
involvement in reproductive health:
findings from research in Karnataka,
India [Internet]. Washington, DC,
Population Council, 2004. [accessed
January 6 2013]. Available from:
http://www.popcouncil.org/pdfs/
frontiers/FR_FinalReports/India_RH_
Small%20Grant.pdf
19. Gandotra M. Contraceptive
choice, shift and use continuation:
a prospective study in Gujarat.
The Journal of Family Welfare.
1990;36(3):54–69.
20. BASICS III. Healthy Timing and
Spacing of Pregnancy (HTSP) : End
of Project Report. [Internet]. USAID/
BASICS, 2005. [accessed January 6
2013]. Available from: http://www.
basics.org/reports/FinalReport/HTSP-
Final-Report_BASICS.pdf
21. CATALYST Consortium. End-of-Project
Report [Internet]. USAID/CATALYST
Consortium, 2005. [accessed Jan 16
2013]. Available from: pdf.usaid.gov/
pdf_docs/PDACG357.pdf
22. Berhane E, Dupont V. The TAHSEEN
model for reaching the urban poor in
Egypt. A promising practice [Internet].
USAID/Extending Service Delivery
Project; 2007 May. Report No.: 3
[accessed January 5 2013]. Available
from: http://www.esdproj.org/site/
DocServer/TAHSEEN_Urban_Poor_
Model__7_12_07_Final.pdf?docID=601
23. Pathfinder International. Nepal:
reaching the urban poor with family
planning/HTSP messages [Internet].
Pathfinder International/Extending
Service Delivery Project; Report No.:
3601 [accessed January 6 2013].
Available from: http://www.esdproj.
org/site/DocServer/ESD_Legacy_
Nepal.pdf?docID=3601
24. Hua X, Cheng L, Hua X, Glasier A.
Advanced provision of emergency
contraception to postnatal women
in China makes no difference
in abortion rates: a randomized
controlled trial. Contraception 2005;
72:111-116
25. Khan ME, Sebastian MP, Sharma U
et al. Promoting Healthy Timing and
Spacing of Births in India through a
Community-based Approach. New
Delhi , Frontiers Program, 2010.
26. S ebastian MP, Khan ME, Kumari K
and Idnani R. Increasing Postpartum
Contraception in Rural India:
Evaluation of a Community-Based
Behavior Change Communication
Intervention. International
Perspectives on Sexual and
Reproductive Health, 2012, 38(2)68–77.
27. W orld Vision United States and India
The Right Messages – To the Right
People – At the Right Time. New Delhi,
World Vision, 2008
28. D aniel EE, Masilamani R, Rahman
M. The effect of community-based
reproductive health communication
interventions on contraceptive use
among young married couples in Bihar,
India. International Family Planning
Perspectives 2008; 34(4):189–97.
29. Mathur S, Malhotra A, DasGupta
S, Mukherjee S, Kanesathasan A.
Should interventions address the
full complexity of transitions to
adulthood? Lessons from a program
experience in India. 2009 [Internet].
[accessed Dec 25 2012]. Available
from: http://iussp2009.princeton.edu/
papers/93085
30. W ilder J, Masilamani R, Mathews A.
Reproductive health of young adults
in India: The road to public health.
Pathfinder International/India; 2006
Sep.
31. V arkey, L C, Mishra A, Das A et al.
Involving men in maternity care in
India [Internet]. Washington, DC:
Population Council, 2004; [accessed
Jan 6, 2013]. Available from: http://
www.popcouncil.org/frontiers/
frontiersfinalrpts.html
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Chapter 5
Improving quality
of family planning
services
Introduction
Although users of family planning
have perhaps always held it central to
contraceptive use, “quality of care” in
family planning programs became an
issue of study and discussion only since
the late 1980s, as a result of a growing
realization that poor quality of care may
be impeding the progress of family
planning programs.
One of the earliest frameworks that set
the standards and norms for evaluating
quality of care in family planning is the
Bruce-Jain framework [1-2].
The framework concerns itself with
quality at the service-delivery level, and
outlines six elements to capture the
multidimensional nature of quality of care:
i. Choice of methods - number of
contraceptive methods offered on
a reliable basis; methods offered
to serve needs of major subgroups
(age, gender, breast-feeding women);
satisfactory choices for couples wishing
to space/limit births; no unnecessary
restrictions upon methods.
ii. Information given to clients -
information provided to clients
during service interactions which
allows clients to choose and use
contraception with competence and
satisfaction. This includes information
about method contraindications,
method advantages and
disadvantages, how to use selected
method, potential side effects,
and continuing care from service
providers.
iii.T echnical competence - providers’
clinical techniques; observance of
protocols; and asepsis in clinical
conditions.
iv. Interpersonal relations - the degree of
empathy; trust/rapport, confidentiality/
privacy; and sensitivity by provider to
the client’s needs
v. Mechanisms to encourage continuity
and follow up - encouraging continuity
of use through well-informed users/
formal program mechanisms.
Mechanisms could include both mass
media and client-based follow-up
mechanisms (return appointments,
home visits to clients).
vi. An appropriate constellation of
services - the extent to which family
planning services are situated to be
convenient and acceptable to clients.
This includes their accessibility
(distance, timing, cost) and the degree
of integration with other services
(vertical, integrated with maternal and
child health services, comprehensive
reproductive health services).[1-2]
Quality of care and contraceptive use
Several studies indicate that perceptions
of quality will guide decisions related to
adopting a contraceptive method. For
example, a longitudinal study of women
in Bangladesh demonstrated that those
who perceived that they had received
good quality of care from field-workers
were significantly more likely to adopt a
contraceptive method than were those
who did not. Some 3,632 women who
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had been visited by a female field-worker
and who were not using contraceptives
at the baseline were followed up
twice over a period of 30 months. The
respondents were asked about their
perceptions of the quality of care they
had received from the field-worker.
Multivariate analysis demonstrated
that women who reported higher levels
of care as measured by interpersonal
rapport were 27% more likely than those
who did not to adopt a contraceptive
method within the next 30 months [3].
The relationship between perceived
quality of care and adoption of
contraception was found to hold in a
completely different setting in Tanzania.
Community perceptions of the quality
of the available family planning services
were measured by interviewing a
number of key informants in each
community [4]. Each informant was
asked two questions: how would most
women (or men) describe the quality of
a specific family planning facility and
how would they rate on a scale ranging
from one to five the overall impression
women (or men) have of that facility. The
informants also reported on accessibility
of the facility, distance, and travel time.
This information was linked to data on
individuals’ practice of family planning
and family background collected for
the Tanzania Demographic and Health
Survey (DHS). The level of contraceptive
use among women was higher where
quality was perceived to be better and
lower where quality was perceived to
be poor. Of the factors measured at the
community level, only quality had a
significant effect on contraceptive use.
Quality of care is also an important
determinant of whether a person who
initially adopts a contraceptive method
continues to use it. A study carried
out in the Philippines examined the
relationship between continuation
of contraceptive use and the clients’
perception of the quality of family
planning services that they had
received. Quality of care was evaluated
using 24 indicators representing five
dimensions: assessment of client needs,
the information conveyed, the choices
offered, whether the client was treated
well by the provider and whether she
was linked to follow-up services. A
composite variable combining the five
aspects of care represented total quality.
The study found that continued use of
contraceptives 16 months after adoption
was significantly associated with quality
of care. The probability of continued
use was 55%, 62% and 67% for women
whose reported quality of care score
was low, medium and high respectively
[5]. An Egypt study analyzing 2003
Interim Demographic and Health Survey
Data found that use of the IUD among
women who used public-sector health
facilities was significantly related to
quality of services, after controlling
for confounding variables. Quality
of care was defined in terms of four
dimensions: counseling, examination
room, supply of contraceptive methods
and management [6].
Other studies have reported the
association of contraceptive continuance
with specific aspects of quality of care.
For example a study of more than a
thousand women in Indonesia found that
after adjusting for confounding variables,
women who received a method of their
choice were significantly more likely to
continue use as compared to those who
did not receive a method of their choice.
The discontinuation rate was as high as
72% among women who did not receive
a method of their choice as compared
to only 9% among those who were able
to receive a method they had wanted
[7]. Inadequate information given by the
provider about potential side effects of
methods is another important dimension
seen to affect continuation rates for
contraceptives. A study on contraceptive
discontinuation in Niger and the
Gambia reported that in Niger, 37% of
women who reported having received
inadequate counseling discontinued
contraceptive use as compared to only
19% of those who said they had received
adequate counseling. The corresponding
figures for the Gambia were 51% and
14% respectively [8].
Quality of services in the Indian
Family Planning Program
The Indian Family Planning Program,
ambitious in scale and coverage, has
been successful in achieving significant
increases in contraceptive prevalence
rates and in effecting steep reductions in
fertility across several states. However,
many of the early achievements were at
the cost of providing quality services
to the user.
In his introduction to one of the first
compilation of studies on quality
of care in India’s family planning
program, Koenig (1999) noted that the
program had been characterized by an
“overriding concern for numbers” – in
terms of acceptors of contraception
and specifically, sterilization. The
entire program was driven by targets
for family planning acceptance which
service providers had to meet under
threat of punitive action. This shaped
providers’ scant attention to quality of
care and preoccupation with meeting
targets. The studies in the volume stood
testimony to poor quality of care in
terms of infrastructure and equipment,
limited choice of methods, absence of
clinical protocols, shocking negligence of
infection control practices, and provider-
directed decision-making in relation to
whether and when a woman should be
using contraception [9].
The Reproductive and Child Health
Program that was launched in 1997
promised a paradigm shift towards
addressing broader reproductive
health needs of the family. Quality of
Care was an explicit focus, and targets
for contraceptive acceptance were to
be replaced by a “Community-Needs
Assessment” approach. Clients’ needs
were to be assessed and program goals
at the local level were to be set based on
this. Early assessments of the paradigm
shift were not encouraging. According
to one report by a non-governmental
organization, NGOs collaborating with
government were not allowed to adopt
Community-Needs Assessment and were
given targets to achieve [10].
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There have been few recent studies
on quality of care in family planning
services. Data from the National Family
Health Survey-3 give some indications
related to specific dimensions of quality
of care, viz. informed choice. Less
than a third (32.2%) of current users of
contraception were informed about side
effects or problems of the method they
were to adopt, or were using. Even fewer
(26%) were informed about what to do
if they experienced side effects. In terms
of being offered a choice of a range
of methods, only 28% of users were
informed by a health or family planning
worker about other methods that could
be used [11].
Evaluated interventions to improve
quality of care in family planning
services
Many innovative approaches for
improving quality of family planning
services implemented in a variety of
service-delivery settings. A 2003 review
of a cross-section of such innovations
concluded that there were few rigorous
experimental studies on the effectiveness
of interventions in improving quality and
in turn, achieving the ultimate objective
of improving contraceptive acceptance
and continuation [12].
The effectiveness of integrating family
planning services with other health
and development services formed the
subject of a review carried out in 2010.
Nine programs were identified where
family planning was integrated with
health services such as immunisation
programs, HIV/AIDS programs and
development interventions such as
water and sanitation and micro-credit
programs. The review concluded that
evidence supporting the integration
of family planning with other health
services remained weak [40].
A more recent (2011) systematic review
sought to synthesize evidence on
what works in family planning [41].
This review included 63 studies; 42 of
which were about interventions mainly
aimed at generating demand for family
planning services, and 21 studies that
examined interventions that were to
improve supply of services. The 21
studies on supply-side interventions
included one study on a voucher
program to increase adolescents’ use of
services, nine studies on interventions
that made family planning services
more accessible, including community-
based distribution programs; and 11
studies on improved quality of care, e.g.
expanding method choice, improving
client-provider interactions and other
approaches including integrated delivery
of care. The overall conclusions were
that interventions that increased access
to services had a strong positive effect
on family planning outcome; and that
quality improvement has a moderately
positive impact on family planning
knowledge, attitudes and behavior.
The present review
We have included in the present review
supply-side interventions aimed at
increasing quality of care in family
planning services3. A systematic search
carried out in accordance with the
inclusion criteria for study design and
quality yielded 27 published evaluation
studies of interventions. Six of the studies
were from India [13-18], six from South
Asia [19-24], 12 from Africa [25-36] and
three from other developing countries [37-
39]. Details of the sample size, sites and
findings are presented in Annex 4.
3 We have not included interventions integrating family planning with HIV/AIDS services,
the majority of which are located in the African setting. For lessons from integrating family
planning with HIV/AIDS, see “Integration of MNCH and nutrition, FP and HIV: Final report”.
Washington D.C, Global Health technical Assistance Project, 2011.
Target audiences
Of the 27 studies, 16 were about FP
interventions addressing the general
population of women and men: 11
were interventions with married
women of reproductive age, three were
interventions with women and men while
one intervention each addressed men
alone and eligible couples. The remaining
11 studies examined interventions that
were aimed at women seeking post-
abortion care (8 studies) or pregnancy
and delivery-related care (3 studies).
Strategies adopted
The 27 programs reviewed adopted
one or more of 10 strategies to improve
access to and quality of family planning
services (Figure 5.1).
1) C ommunity based service delivery
through female health workers
2) Community based service delivery
through male health workers
3) H ealth facility-based targeted
counseling and education for women
4) Health facility-based targeted
counseling and education for men
5) Expanding contraceptive choice
6) Provider training for improving quality
of care
7) S trengthening service provision
through improved organization,
equipment and supplies
8) Integrating family planning with post-
abortion services
9) Integrating family planning with
maternal health and delivery care
10) Community mobilization
Four of the above strategies may be
grouped under the quality element
“appropriate constellation of services”.
These are strategies one and two,
which include a broad range of
community-based service provision and
contraceptive distribution interventions,
and strategies eight and nine that
integrate family planning with other
reproductive health services. Five
strategies: strategies three through seven
- are attempts to improve quality of
services within health facilities including
training and building provider capacity
for client-centered services. Strategy
ten engages the community as a
complement to improvements in service
delivery, as a means of encouraging
continuance of and sustaining motivation
for using contraception.
While it is customary to classify many
of the above strategies as ‘supply-side’
strategies, we believe that it may not be
easy to categorize strategies strictly into
supply and demand side. This is because
improved quality of care impacts on
contraceptive use mainly through
encouraging clients to use services, and
impacting on demand for contraception.
1) Community based service delivery
through female health workers
Ten programs (eleven studies) included
community-based service delivery
through female health workers. In
seven of these programs, this was
the main intervention strategy [13-15,
19-20, 22,24]. In two programs this
was complemented by community
mobilization [26-27], in one by a male
health worker program [35] and in one
instance, it was one of the components
of a comprehensive quality of care
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Figure 5.1. Intervention strategies adopted by and effectiveness of programs to improve
access to and quality of care
S.NoStudy
Country of StrategiesEffectivenessStrength of
location
evidence
1. CEDPA 1991
India, Urban slums,
1
Yes
C1
Gujarat
2. Kak et al 1994
India, Samastipur
1
Yes
C1
N.Bihar
3. Parveen et al 1994 -do-
1
Yes
C4
4. Varkey et al 2004
Delhi, 6 ESI clinics
3,4,9
Yes
B
5. MLE 2012
India, UP: Agra,
3, 5,6, 7,8,9,10 Yes
C1
Aligarh, Allahabad,
Gorakhpur
6. CEDPA, 2003
India, Jharkhand,
1,5,6,7,10
Yes
C1
Ranchi dt.
7. Mullany et al 2010 Eastern Burma
1
Yes
C1
8. Douthwaite and
Pakistan
1
Yes
C2
Ward 2005
9. Bolam et al, 1998
Nepal, urban
3,9
Yes
A
Kathmandu
10. Shrestha 2002
C. Nepal, kakani
1
Yes
C1
Village
11. Talukdar et al 2009 Bangladesh,
3,6,7
Yes, client
C1
urban slums Dhaka
satisfaction
12. Kincaid DL 2000
Bangladesh,
1
Yes
B
3 thanas
13. Sanogo et al 2003 Senegal, Thies,
3,5,6,7
Mixed; client B
Kaolack, Saint
satisfaction
Louis, Tambacounda
increased,
and Fatick regions.
not CPR
14. Debpuur et al 2002 Ghana, Navrongo.
Model 1:10 No for models B
Model 2: 1 1&2. Yes for
Model 3: 10, 1 model 3
15. Lutalo et al 2010
Uganda, Rakai
1,10
Yes
A
16. Shattuck et al 2011 Malawi- Mangochi
2
Yes
A
province;
17. Mwangi et al 2008 Kenya; Embu district, 3,9 Inconclusive C1
eastern Province,
18. Solo et al. 1999
Kenya; 6 public
3,6,7,8
Yes
C1
hospitals in
Mombasa, Kisumu,
Nakuru, Meru,
Eldoret and Nyeri.
3 models tested
19. Abdel –Tawab
Southern Egypt,
3,4, 6,7,8
Inconclusive A
et al 1999
6 public hospitals
in Menia
governorate
S.NoStudy
20. Youssef et al 2007
21. Johnson et al 2002
22. JIRAMA, 1993
23. Katz et al 1998
24. Frontiers 2000
25. Costello et al 2001
26. Diaz et al 1999
27. Langer et al 1999
Country of StrategiesEffectivenessStrength of
location
evidence
Egypt, 6 public
3,6,7,8
Yes
C1
hospitals in Fayoum
and BeniSuef
governorates.
(2 GH and 4 Dt.H).
2 models tested
Zimbabwe; Harare
3,6,7,8
Yes
B
GH intervention;
MpiloCentrel H
Bulawayo control.
Madagascar, Central
7,10
Yes
B
Province; Comparing
three models
Rural Mali,
1,2
Yes
B
Kolondieba
Burkina Faso; 2 large
3,6,7,8
Yes
C1
hospitals in
Ouagadougou and
Bobo-Dioulasso;
Philippines, Davao
6,7
Yes, client
B
del Norte,
perception of
Compostela Valley
improved
provinces
quality
Bolivia, three
3,6,7,8
Yes
C1
hospitals in La Paz,
Santa Cruz de la
Sierra and Sucre resp.
Mexico, Oaxaca
3,5,6,7,8
Yes
C1
Public Hospital
Strategies: 1: Community based service delivery through female health workers; 2: Community based service delivery through male health
workers 3: Health facility-based targeted counseling and education for women 4: Health facility-based targeted counseling and education for
men 5: Expanding contraceptive choice 6: Provider training for improving quality of care 7: Strengthening service provision through improved
organization, equipment and supplies 8: Integrating family planning with post-abortion services 9: Integrating family planning with maternal
health and delivery care 10: Community mobilization
A= Experimental design B= Quasi-experimental design C1= Before-after study C2= Cross-sectional end-line study with a matched
comparison group C3= Cross-sectional end-line study with unmatched comparison group C4= qualitative end-line study with no comparison
group satisfied contraceptive users interacted with non-users and talked about family planning [24]. In both instances, these activities were
in addition to providing contraceptive services.
improvement program involving
community as well as health facility-
based interventions [18].
There were two different types of
female health workers – in one, local
women from the community were
trained as outreach workers after a brief
training, and in the second, women with
paramedical training were recruited, as
in the case of the Lady Health Workers of
Pakistan, employed by the Department
of Health of the government [20]. Female
health workers’ job typically included
counseling for family planning, recruiting
new users and providing supplies
and resupplies of condoms or oral
contraceptive pills. They referred women
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choosing clinical contraceptives to health
facilities and often accompanied them.
Follow-up of family planning adopters
is another important component of their
responsibilities. The range of services
offered varied based on the level of
training, and Lady Health Workers
in Pakistan provided in addition to
the above, maternal and child health
services, and treated minor illnesses [20].
There were some innovative variations
to this approach. In a program in
Nepal, government female community
health workers (FCHVs) were given
“empowerment” training in family
planning, which enhanced their ability to
analyze and find solutions to problems
that women in the community encounter
in using family planning services, and
enabled them to conduct participatory
group discussions with women in the
community [22]. In Bangladesh, a “social
network” approach was adopted. Women
Family Welfare Assistants (FWAs) were
trained in communications skills. They
then organized peer group discussions
at least once a month within the
community. In these “jiggashas”,
2) Community based service delivery
through male health workers
Male community health workers provided
community-based contraceptive services
in only two of 27 programs. In Malawi,
an experimental study evaluated the
effectiveness of male ‘motivators’ in
increasing contraceptive use among
current non-users. Married men who were
30 years or older and using a modern
method of contraception were chosen
based on their enthusiasm for modern
contraceptive use.The male health workers
shared with young male non-users their
own experiences of contraceptive use,
encouraged them to participate actively in
family planning decisions, demonstrated
the correct use of condoms and supplied
condoms when requested [28]. In Mali,
male community health workers educated
and distributed supplies of non-clinical
methods of family planning to men, while
their female counterparts did the same
with women [35].
3) Health facility-based targeted
contraceptive counseling and education
for women
Targeted contraceptive counseling and
education for women was a component
of 13 programs. In eleven programs
targeted counseling for women was
one aspect of comprehensive service
- integration and/or improvement
programs [16-17, 21,23,29-33,36, 37-39].
For example, all programs for integrating
family planning with post abortion
care included this as a strategy. In two
instances, there was also counseling for
women’ s husbands and counseling for
the couple [16,31].
Of these, one program [21] had targeted
counseling and education for women
as the only strategy. In Kathmandu in
Nepal an experimental intervention was
implemented with three experimental
arms and one control arm. In all three
experimental arms, post-partum mothers
were provided with targeted messages
related to post-partum and post-natal care
and family planning. The models differed
in the timing and frequency of messages.
One group each received health and
family planning education immediately
postpartum and after three months
respectively, while the third group
received health education at both times.
4) Health facility-based targeted
contraceptive counseling and education
for men
The “Men in Maternity’ project in Delhi,
India included targeted family planning
counseling and education for men.
Husbands of women seeking antenatal
care in Employees State Insurance
Corporation (ESIC) dispensaries were
counseled on family planning, given
information on correct use of condom,
and given take-home brochures with
salient messages [16].
In Egypt, counseling of husbands was a
component of an intervention to improve
post-abortion care and integrate family
planning services with post-abortion care
in six public hospitals [31]. Counseling
of women and their husbands was
done separately so that women can ask
questions or express concerns freely.
Husbands were recruited for counseling
only after receiving consent from their
wives. A strict ethical protocol was
developed and adhered to, to ensure that
no information pertaining to the woman’s
medical condition that could pose a risk
to the woman is unintentionally divulged
to the husband (e.g. the woman may
have sought to terminate a pregnancy
without her husband’s knowledge).
The content of counseling revolved
around four main messages: patient’s
need for rest and adequate nutrition;
warning signs in the post-abortion period
that warranted medical attention; the
possibility that fertility would return
within two weeks; and the need for
adopting family planning to prevent ill-
timed or unwanted pregnancy [31].
5) Expanding contraceptive choice
Expanding contraceptive choice by
increasing the number of methods
available to clients is one of the key
elements of quality of family planning
services. Only four programs of the
27 reviewed here explicitly mention
expanding contraceptive choice as a
component of interventions to enhance
quality of care. Two of these are the
Urban Family Planning Initiative in
Uttar Pradesh and an integrated family
planning and health intervention in
Jharkhand [17-18]. Expanded method
choice in these programs included
two traditional methods: lactational
amenorrhea method and the “standard-
days” method – on which accurate
information was given to potential
users – postpartum women who had
not completed their desired family size.
The third was a health facility-based
intervention in Senegal to improve
contraceptive uptake among women,
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Multi Dimensions of QoC
Choice of Methods
Information given to clients
Technical Competence
Interpersonal relations
Continuation and follow up
Appropriate constellation of
services
Figure 5.2
Strategies
Community-based delivery
of family planning services
through female and/or male
health workers
Health-facility-based
targeted contraceptive
counseling and education of
women and/or men
Expanding contraceptive
choice
Provider training
Improvement in
infrastructure, supplies
Organization of clinic timings
and services in tune with
client needs
Integration of FP services
with post abortion care, and
maternal health-delivery care
Community mobilization
Outcomes
Increased adoption
and continuation of
contraception
Increased client
satisfaction, increase in
clients reporting improved
quality of care
in which NORPLANT, the contraceptive
implant, was added to the basket of
contraceptives provided [25]. In one
instance expanding contraceptive choice
was part of an integrated post abortion
care and family planning program in
Oaxaca, Mexico [39].
6) Provider training for improving
quality of care
Improving quality of care in any family
planning program is likely to involve
training and capacity-building initiatives
for varying levels of health care
providers on a variety of topics and skills.
For example, deploying community-
based service providers would involve
training a new cadre of workers and
building capacities of those who are
responsible for their supervision.
However, in 12 of 27 programs reviewed,
provider training is a specific strategy for
improving quality of care. In programs
where family planning services were
integrated with post-abortion care,
providers were trained in contraceptive
technology as well as in improving post-
abortion care [17, 30-33, 36,38-39]. Where
contraceptive choices were expanded,
provider-training focused on the delivery
of the new contraceptive technology
and on counseling. For example in the
integrated RCH/infectious diseases
outreach program in Jharkhand, India,
providers were trained on delivering
injectable contraception and also
in counseling for correct use of the
lactational amenorrhea method and
standard-days-method [18]. In Senegal,
providers were trained in implanting and
removing NORPLANT [25].
Improving inter-personal communication
was another dimension of training in
all the programs, but was a key focus
in some, such as the “Client-centered
approach to FP” project in Davao
city, Philippines [37]. In the Davao
Project, providers were trained in
communications skills for listening to
clients and responding with “relevant,
accurate and complete information”
[p.306]. In addition, perspective building
workshops were held on gender and
sexual and reproductive rights. The
training included physicians, nurses
and midwives and consisted of several
refresher courses. In programs which
included managerial and organizational
changes, training focused on
management, including management of
information for better planning [37].
7) Strengthening service provision
through improved organization,
equipment and supplies
As with training of providers, improving
the availability of equipment and
services are a necessary prerequisite
for improving quality of family planning
services in any program. The 11
programs that specifically mention the
above strategy include the 8 in which
family planning services were integrated
with post-abortion services [17, 30-
33, 36, 38-39]. In all these programs,
one of the models of service delivery
tested for feasibility was the provision
of family planning services within the
gynecology or obstetric ward settings.
In many instances this meant finding
additional space or reorganizing
existing space to include a counseling
room/space and a treatment space. It
also involved reorganizing timings of
services, reallocation of staff timing to
provide additional services and in some
instances, co-ordination with family
planning service providers from another
department of the same health facility.
Two programs – one in Jharkhand, India
[18] and another in the urban slums of
Dhaka, Bangladesh [23] also invested in
reorganizing services to suit client needs.
Strengthening of Management
Information Systems (MIS) is specifically
mentioned by the Senegal program for
improving quality of care and use of
contraceptives. Staff received specific
training in MIS, space was allocated
for MIS where client records were
maintained, and a strategy was evolved
to track clients using MIS. Users who
did not revisit the clinic in time for the
next appointment and drop-outs were
identified and followed-up at home by
clinic staff [25].
8) Integrating family planning with post-
abortion services
We have included in this review eight
programs in which family planning
services were integrated with post-
abortion care. They include the Urban
Family Planning Program in UP, India
[17]; public-hospital based programs in
Kenya, Egypt (2 settings), Zimbabwe,
Burkina Faso, Bolivia and Mexico [30-
33,36,38-39]. Integration of services often
included improvement of the quality
of post-abortion care and adding on
the contraceptive service component
to it. For example in Oaxaca, Mexico,
and in three hospital settings in Bolivia
the integration of FP services into
post-abortion care in a public hospital
included training providers in Manual
Vacuum Aspiration (MVA) to remove
products of pregnancy, improving the
content and quality of post abortion
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family planning counseling, increasing
the choice of available contraceptives
and sensitizing providers to treat patients
humanely [38-39].
Two settings- Kenya and Egypt -
experimented with different models of
integrating family planning services
and post-abortion care. In Kenya, three
models were tried. In the first, women
were provided family planning services
post-abortion in the gynecology ward
(where they had been admitted for
post-abortion care) by ward staff. In the
second model, women were provided
family planning services post-abortion
in the gynecology ward, but providers
were from the MCH/FP clinic of the same
hospital. In the third model, post-abortion
patients were referred to the MCH/FP
clinic for obtaining FP services [30].
In Egypt, two models were tried
consecutively. Model A consisted of
referring women post-abortion to the
MCH/FP clinics within the same health
facility, while Model B, implemented
after a few months, involved making
FP services available in the gynecology
ward and provided by ward staff [32].
In both Egypt and Kenya, provision
of family planning services in the
gynecology ward, by ward staff, was
a better model in terms of patient
preference and satisfaction.
9) Integrating family planning with
maternal health and delivery care
In three programs of the 27 reviewed,
family planning services were integrated
with maternal health and delivery- care
[17, 21, 29]. Of these, the program based
in a hospital in Kathmandu, Nepal has
been described as part of strategy 3
above [21]. The remaining two were based
in India and Kenya respectively [17, 29].
In Kenya, the program was implemented
in one hospital and three health centers
in the eastern Province. A Post-Natal
Care- Family Planning Package was
designed, consisting of facility-based
assessment and counseling at four
time points. The first contact was made
pre-discharge after delivery or within
48 hours if delivery had taken place
at home. Healthy Timing and Spacing
of Pregnancy (HTSP) was given to the
mothers along with information on self-
care and neonatal care. They were also
told about the lactational amenorrhea
method. At the second contact two
weeks later, maternal and child health
concerns were addressed; advice was
given on return to sexual activity and
fertility; birth spacing message was
reinforced; and in addition, family
planning counseling and services were
provided. The third contact was six
weeks after delivery, the same messages
were repeated and in addition, users of
lactational amenorrhea method were
counseled on introducing weaning
foods as well as on the use of a modern
contraceptive method because they
would no longer be protected. The
fourth contact was four-to-six months
after delivery where all the messages
related to contraception were reinforced,
family planning counseling and services
provided and referrals made for clinical
methods of contraception [29].
In India, the Urban Family planning
program in UP provided women with
FP counseling during antenatal care
visits, and immediately after delivery.
Contraceptive services were also
provided in the immediate post-partum
period and within the first few months
after delivery [17].
10) Community mobilization
Community mobilization has been
used mainly as a demand-generating
mechanism. However, many
interventions to improve quality of family
planning care also have a community-
mobilization component, probably as
a means to create a supportive social
environment that would encourage
users to continue with use and to
sustain demand among those who need
to resume use following delivery or
abortion/miscarriage.
Four programs included in this review
have a community mobilization
component. Two of these are programs
implemented in rural Jharkhand and
urban Uttar Pradesh in India [17-18].
In the Uttar Pradesh Project, besides
community-based theatre and other
events using local media, a “happy
dampati (couple)” contest was held
each year in which the community
identified and celebrated couples
who had successfully accepted family
planning. This has the potential to
promote contraception as a social
norm [17]. In Jharkhand, Village Health
Committees were formed which were
actively involved in the improvement
and monitoring of health sub-centers.
The Village Health Committees also
advocated for and promoted social
marketing of contraceptives such as
condoms and oral contraceptive pills.
These Committees also appointed
watchdogs to monitor the quality of
services in health sub-centers [18].
In Madagascar, a modest investment
was made in promoting “mothers’
clubs” of satisfied contraceptive users,
as part of the community mobilization
strategy [34]. The Navarango Project in
Ghana used community mobilization as
a key strategy in improving quality of
contraceptive services. The project used
traditional social co-operation, called
zurugelu, to mobilize support for health
and family planning services. Traditional
meetings of men were used as a venue
for disseminating family planning
information and distributing supplies
of contraceptives. While the traditional
meetings were typically ‘all-male’ spaces,
the project sought to find support for
women’s participation in these [26].
Effectiveness of strategies
One or both of the following indicators
have been used by studies as indicators
of effectiveness of programs: statistically
significant increase in contraceptive use
and in client satisfaction, before and
after the intervention; and a statistically
significant positive difference between
intervention and control groups in
these indicators.
Community-based female and male
health workers providing family
planning services
Interventions using the strategy of using
community-based female and/or male
workers were effective, although the
strength of evidence was moderate.
It should however be borne in mind
that there were many variations across
programs in the profile of community
workers, the extent of training they
received, their conditions of work, and
breadth of services provided.
In seven of 11 studies (6 programs)
using the strategy of community-
based service delivery through female
health workers exclusively, the strategy
successfully increased contraceptive
prevalence rates. Of these seven, five
were “before-after” studies, one was a
qualitative end-line study (of a program
evaluated by a ‘before-after’ study)
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and one was a quasi-experimental
study. In one study the strategy was
one of many simultaneously used, and
this quasi-experimental study found
the intervention to be effective. In yet
another quasi-experimental study, it
was a strategy used alongside use
of community-based services using
male health workers, and was again,
found to be effective. In two instances,
where the strategy was used along side
community-mobilization, the strategy
was again found to be effective.
Both programs with male health workers
providing family planning services - an
experimental study from Malawi and a
quasi-experimental study from Mali –
found the strategy to be effective. While
the strength of evidence of effectiveness is
high, the number of studies is too small.
Some lessons for effective community-
based contraceptive distribution
programs are offered by a 1999 review
of programs in Africa. The review
emphasizes that alongside deployment of
community-health workers, community
mobilization and involvement played
an important role in the success of
the strategy. The review suggests
that the choice of workers be guided
by community opinion and further,
that community structures be used
as a basis for reaching client groups.
Also, successful programs offered a
broader range of services beyond just
contraception, and offered remuneration
or incentives to workers [42].
Drawing on these lessons, approaches
where community-based health
workers do more than just distribute
contraceptives appear to be worth
further scrutiny. This includes, for
example, the “empowerment” of female
community health workers, use of the
“social networks” approach where
women meet satisfied contraceptive
users to discuss family planning and
the ”male motivator” approach wherein
a satisfied and enthusiastic male
contraceptive user motivates his peers to
become contraceptive users.
Targeted contraceptive counseling
and education of women and men
More experimentation is needed with
these approaches to be able to come to
any definitive conclusions.
One experimental study, which used
targeted counseling of post-partum
women as a single strategy, found the
strategy to result in an improved uptake
of contraception. More such studies
are needed in other settings before any
firm conclusions can be reached. Given
the feasibility of integrating such an
approach in health facilities providing
delivery and postpartum care, this would
certainly be worth a try.
Of the two interventions that targeted
men with contraceptive counseling and
education of men, the quasi-experimental
study from Delhi that worked with
men who accompanied their wives to
the antenatal clinic was found to be
effective.The second, an experimental
study targeting husbands of women
admitted for post-abortion care did not
have the same results. This study found
that while acceptance of contraception
before discharge was higher among
the experimental group, the difference
in contraceptive use at 12 weeks was
not significantly different between
experimental and control groups
Expanding contraceptive choice,
training of providers and organiza-
tional changes to improve quality
Overall, interventions to improve quality
of care need further experimentation and
rigorous evaluation.
There were four programs that used
these as main strategies for improving
quality of care. Two of these were
‘before-after’ studies while two were
quasi-experimental studies. One of the
studies showed the interventions to be
effective in increasing contraceptive
prevalence rates, and is a ‘before-after’
study. Two other studies show the
interventions to be effective in increasing
client-satisfaction with quality of care.
One of these is a ‘before-after’ study
while the other is a quasi-experimental
study. The fourth, a quasi-experimental
study shows the intervention to be
ineffective in increasing contraceptive
prevalence but effective in increasing
client-satisfaction.
Integration of FP with post-abortion
and maternal health/delivery care
Overall, the evidence on effectiveness of
integration with post-abortion care may
be considered moderately positive; that
on effectiveness of integrating services
with maternal health and delivery-
related care is promising, but the number
of studies is small.
Seven of eight programs integrating family
planning services with post-abortion care
were found to be effective in increasing
adoption of post-abortion contraception
and in ensuring its continuance after a
period of 3-6 months. However, six of
these were ‘before-after’ studies and
only one was a quasi-experimental
study. One experimental study whose
focus was counseling and education of
husbands of post-abortion care clients
showed no significant difference between
experimental and control groups in
adoption of contraception.
Of the three programs integrating family
planning services with maternal health
and delivery care, all three reported
the intervention to be effective. One
each was an experimental and a quasi-
experimental study, while the third was a
‘before-after’ study.
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Community mobilization
The evidence on community mobilization
shows the strategy to be effective when
used alongside other strategies for
improving quality of care. In the only
instance when it was used as a single
strategy – the Navarango project in
Ghana – it was not found to be effective.
In conclusion
Only a few dimensions of the six
elements of quality of care have been
examined by studies. For example,
while several studies have examined
integration of family planning services,
very few have looked at interventions
to improve client-provider interactions.
It is not clear whether this is a reflection
of the kinds of innovations that were
implemented at the ground level.
Many studies have evaluated programs
that have employed multiple strategies
simultaneously. Of such programs,
integration of services with post
abortion care and maternal health-
delivery care offer most promise
in terms of their ability to improve
contraceptive use.
Of interventions using only one or
two strategies, use of female health
workers for community-based education
and counseling and distribution of
contraceptives appear to offer more
promise than interventions that focus
on other aspects of quality of care. Here
again, innovative and participatory
approaches such as the ‘empowerment’
training of female health workers and use
of social networks for reaching women
in the community with contraceptive
messages, seem to be worth examining
further. Use of male health workers
alongside female health workers or by
themselves also appears to be effective
in motivating men for contraceptive use
in the few settings where this has been
systematically studied.
In addition, there are instances of
effective interventions that need
further exploration, such as the
Nepal health education program for
post-partum women and the Men in
Maternity program offering targeted
counseling and education to women
and their husbands during pregnancy
and postpartum. These strategies are
particularly attractive for their simplicity
and feasibility with modest investment
of resources.
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Chapter 6
Conclusions and
Policy Implications
As part of PFI’s move towards
“Repositioning Family Planning” as a
health and rights issue, this review
sought to identify strategies or
combinations of strategies that have been
effective in delaying age at marriage and
at first birth, in increasing birth spacing
and in improving quality of family
planning services.
Through a systematic search of literature,
intervention studies which adopted an
experimental, quasi-experimental or
‘before-after’4 study design and satisfied
a set of ‘quality’ criteria were identified
for each of four focus areas: i) delaying
age at marriage ii) delaying age at
first pregnancy iii) promoting spacing
between births and (iv) improving quality
of care of FP programs.
There was a serious dearth of studies
that evaluated interventions for all four
focus areas. This was especially the case
for interventions to delay age at first
pregnancy in married women, for which
we could identify only two studies. A
total of 61 studies were included in the
review. Most of the studies were from
Africa and South Asia, and a few from
other developing countries.
The effectiveness of interventions was
gauged based on whether interventions
achieved their intended objectives. In
addition, the strength of the evidence was
also taken into account, with experimental
studies ranking as the strongest, quasi-
experimental studies ranking next,
followed by ‘before-after’ studies.
Given the small number of studies
overall and the limited strength of
evidence in many of these, it is difficult
to draw firm conclusions regarding
effectiveness. Similar interventions
would need to be implemented in
diverse settings using rigorous study
designs before we will be able to do this.
Nevertheless, the results we have do
point us in the direction of ‘promising’
strategies/combination of strategies.
Delaying age at marriage
Financial incentives/support to prevent
adolescent girls from dropping out
from school was found to be the ‘single’
strategy that helped delay age at
marriage in two rigorous evaluations.
Keeping girls in school and also carrying
out intensive community mobilization
helped prevent very early marriages in
Ethiopia, but not marriages under 18
years of age.
Another effective combination of
strategies was of life-skills education
for young women or for young people
of both sexes, together with intensive
engagement of the community. Life
skills education was broad-based,
included ‘empowerment’ education
alongside information on sexuality and
reproduction, and also skill-development.
Interventions with gate-keepers
such as parents, religious leaders
and community elders with specific
messages and at the same time carrying
4 In instances where the total number of studies identified was small (less than 10), studies
using cross-sectional designs were also included
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out media campaigns raising visibility
of the issue within the community were
both important.
Delaying age at marriage for girls was an
especially challenging goal to achieve.
Community norms on appropriate age of
marriage for girls was in some instances
well below 18 years, and even with
success in changing attitudes towards
early marriage, only very early marriages
(age 15 and below) could be prevented.
In most instances, however, even when
the community became aware of the
negative health consequences of early
marriage, they were unable to change
the practice. This was because there was
immense pressure from the community
on parents of young women to get them
married at the earliest opportunity. There
was fear of pregnancy in an unmarried
girl, which would bring shame on her
family. Also, in South Asian societies
in particular, an older girl would find it
more difficult to find a groom and may
have to pay a higher dowry.
These findings have important
implications in the Indian context.
India has several conditional cash
transfer schemes operated by the
central government and various state
governments aimed at improving
the status of the girl child. Delaying
age at marriage till completion of 18
years of age is one of the conditions
for cash transfer in more than 10 of
these schemes. The Dhanalakshmi
Scheme and Balika Samridhi Yojana
of the government of India, Girl Child
Protection Schemes of Tamil Nadu and
Andhra Pradesh, Ladli Schemes of
Delhi, the Apni Beti Apna Dhan Scheme
in Haryana, Ladli Lakshmi scheme of
Madhya Pradesh and Beti Hai Anmol
Scheme of Himachal Pradesh are some
examples. It would be important to
evaluate the effectiveness of these
schemes in delaying age at marriage,
and to suitably redesign them based on
the evaluation, to better achieve
this objective.
The Kishori Shakti Yojana education and
empowerment program for adolescent
girls implemented through the Integrated
Child Development Scheme (ICDS) offers
scope for implementing the combined
strategy of life skills education for girls
alongside community-mobilization. At
the same time, we need to design, pilot
and evaluate the third strategy - life skills
programs which include not only girls and
young women but also adolescent boys
and young men, alongside community
mobilization. Special effort is needed
towards changing mindsets and making
early discontinuation of schooling and
early marriages socially unacceptable
through community mobilization
programs using multiple media resources.
Delaying early pregnancy
The vast majority of intervention studies
related to delaying early pregnancy deal
with preventing pregnancy in unmarried
adolescents in high-income countries
such as the US and the UK, and sub-
Saharan Africa.
Systematic reviews of intervention studies
from the US and the UK show that sex-
education programs by themselves
are ineffective in preventing teenage
pregnancy. Comprehensive youth
development programs which start with
interventions from early childhood and
address the social determinants of teenage
(unmarried) pregnancy – educational
opportunities, skill development for
livelihood, together with sexuality and
relationships education- were found to
most effective.
Financial incentives/support to prevent
drop-outs and keeping girls in school,
found to be effective in delaying age
at marriage in two studies from Africa,
were also effective in preventing teen
pregnancy out-of-wedlock.
Two studies evaluated interventions
to delay first birth in married young
women, and found these to be effective.
In both instances multiple strategies
were used. Three main strategies could
be discerned. One strategy aimed at
social environment building through
interventions with key gatekeepers as
well as with the larger community. The
second strategy was providing sexual
and reproductive health education –
jointly to young married couples and
also separately for women and men. The
third strategy was increasing access to
contraceptive and other reproductive
health services. Thus, both demand and
supply side factors were simultaneously
addressed, and a serious attempt at
changing social norms was made.
Both these studies are from India. One of
the evaluated interventions is no longer
operational, while the second effective
intervention is being implemented
in Bihar. The scope for upscaling this
intervention in other states on a much
wider scale needs to be examined.
Promoting spacing between births
Nine intervention studies were included
in the review. As with interventions
to delay early marriage, many of the
evaluated interventions to promote
spacing between births used two or more
of six specific strategies simultaneously.
These six strategies included: i) Targeted
messages for young married women ii)
Targeted messages for young married
men iii) Community mobilization – from
targeted meetings with gate keepers to
broader community awareness building
and attitude shaping iv) Engagement
with health and allied service providers
within the public and private sectors v)
Mainstreaming the optimal pregnancy/
birth spacing messages within the
government health system; and vi)
High level advocacy with policy makers
to integrate optimal pregnancy/birth
spacing as a policy and program goal.
Working intensively with women and
their husbands, alongside building
community support plus building health
worker capacity in providing suitable
services seems to be a promising
combination of strategies. Four Indian
programs adopted this combination of
strategies and all of them were found
to be effective, three of four being
experimental or quasi-experimental
studies. This is an approach that tackled
demand and supply-related factors
simultaneously.
Within the above combination of
strategies, approaches to working
with men need further exploration.
Interventions that did not intensively
target husbands but worked with men
in the community also seem to have
achieved good results.
Another combination of strategies worth
further experimentation and study is
clinic-based intensive counseling of
antenatal women and their husbands.
This approach appears to be able to
achieve effective results with a relatively
modest investment of resources.
In the Indian context, mainstreaming
the “healthy timing and spacing of
pregnancy” within policies and programs
would be an important first step.
Spacing of births, although mentioned
as a priority in policy documents,
has not been adequately emphasized
within the Indian family planning
program. Much work needs to be done
in making providers more conscious
of prioritizing birth spacing and in
enhancing their knowledge on modern
as well as traditional methods of spacing
pregnancy. Two Indian programs, in UP
and Bihar/Jharkhand respectively have
attempted to mainstream promotion
of birth spacing within the government
health sector, including provider training
and community mobilization. These
models have the potential for sustainable
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and affordable upscale, and need to be
explored further.
Making spacing methods acceptable to
potential users is yet another challenge
to be overcome. Currently, contraceptive
use is tilted overwhelmingly towards
sterilization. Research is needed to
identify barriers to acceptance of spacing
methods in different parts of India, and
to build context-specific communication
and behavior-change strategies based
on these. Clinic-based interventions with
pregnant women and their husbands
offer one major window-of-opportunity
to influence attitudes and behavior
related to spacing births.
The studies show that targeted
interventions with young married
women need to be complemented
with interventions with their husbands
or with groups of young married
men. While ASHAs and ANMs could
be trained to promote birth spacing
with women, it would be important to
identify a suitable male cadre to work
with young married men.
Improving quality of family planning
services
Twenty seven intervention studies were
included in the review. Simultaneous
adoption of multiple strategies was a
feature also of interventions to improve
quality of family planning services.
The programs reviewed adopted one
or more of 10 strategies to improve
access to and quality of family planning
services: i and ii) Community based
service delivery through female/
male health workers respectively iii
and iv) Health facility-based targeted
counseling and education for women/
men v) Expanding contraceptive choice
vi) Provider training for improving
quality of care vii) Strengthening
service provision through improved
organization, equipment and supplies
viii) Integrating family planning with
post-abortion services ix) Integrating
family planning with maternal health
and delivery care, and x) Community
mobilization.
Two combinations of strategies offer
most promise in terms of their ability
to improve contraceptive use as well
in improving client satisfaction with
services. The first of these is integration
of family planning services with post
abortion care and maternal health-
delivery care, provided this is not just a
mechanical addition of one additional
service. The effective interventions
examined also involved reorganizing
service delivery to suit client
convenience, provider training to make
service delivery more client-centered and
targeted family planning counseling for
women, and also their husbands.
Post-partum and post-abortion family
planning is well known in India.
However, much of the focus has been
on post-partum and post-abortion
sterilization. Also, imposing sterilization
or IUD insertion as a condition for
providing safe abortion services has
been reported in the 1990s by many
studies examining quality of care. The
policy recommendation from this review
would be to provide post-partum and
post-abortion family planning services
that are truly based on informed choice
following counseling; offer the full
range of contraceptives for the woman/
her partner to choose from, and come
together with improvement in overall
quality including humane treatment of
the client, as described above.
The other strategy that appears to
offer promise is the use of female and
male health workers for community-
based education and counseling and
distribution of contraceptives. We do
not have a male health worker cadre
who provides community-based family
planning information and services – in
fact, we do not have any mechanism to
systematically reach men with family
planning information. Use of female
community-health workers to deliver
services is again a strategy well-known
in the Indian family planning program,
and the ASHA is now charged with
this responsibility. The main difference
is that in many instances there are in
practice (whatever the official policy
may be)‘targets’ for the community
health worker to fulfill. This transforms
an intervention that could improve
quality of family planning services by
providing information and services
closer to the woman’s home, into one
with coercive overtones. We need
to reorient the role of the female
community health worker and include
male community health workers. Their
role would be to provide information,
facilitate discussion on the pros and
cons of different methods and help
clients make an informed choice of a
method that is acceptable to him/her.
Concluding remarks
This review has identified a range
of ‘promising’ strategies that would
help reposition family planning as a
means of upholding the health and
rights of women, men and children.
The results of the review need to be
interpreted keeping in mind the very
limited evidence on which it is based.
Many interventions have not been
documented, and those documented are
yet to be rigorously evaluated. One of
the key tasks ahead is to systematically
document and evaluate existing
interventions.
The review identifies strategies that
are worthy of further experimentation
and upscaling from among the pool
of interventions that have been
implemented thus far. However this
should preclude the possibility of
innovating what has not yet been tried.
There are other potential interventions
that are as yet to be tried or even
conceived: for example, programs that
uphold reproductive and sexual rights;
programs that provide a comprehensive
range of reproductive health services
of which family planning is an integral
part. It is as much a priority to design
and implement interventions that are
out-of-the box, as it is to have rigorous
evaluations of what already exists.
Safe abortion services have featured
among the strategies examined only as a
part of interventions that integrate family
planning with post-abortion care. Yet, any
attempt to reposition family planning
would need to include safe abortion
services as an important dimension of
upholding women’s health and rights.
We hope future reviews will examine
‘effective’ safe abortion services which
have the woman’s safety and wellbeing
as outcome indicators.
Last but not least, all strategies
to ‘reposition family planning’
recommended above are by definition
guided by a human rights perspective. If
taken out of this context and perspective,
and superimposed with a ‘population
control’ imperative, we may achieve
fertility reduction, but without a
concomitant improvement in population
health and wellbeing.
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