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Population Foundation of India
2013
Repositioning Family Planning:
A review of evidence on effective interventions
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
rates the imperative to position family
planning as more than a means of popula-
tion control has become increasingly evi-
dent. ‘Repositioning family planning’ was
a multilateral initiative launched almost
a decade ago to increase political com-
mitment and funding for strengthening
family planning services in sub-Saharan
Africa [1]. The 2012 Summit on Family
Planning in London put the ‘reposition-
ing’ approach firmly on the global map by
winning the support of national govern-
ments, 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 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.
In India, the National Population Policy,
2000 (NPP 2000) affirmed the govern-
ment’s commitment to voluntary and in-
formed 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 na-
tional consultation on repositioning fam-
ily 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 con-
text that the Population Foundation of
India’s (PFI) Strategic Plan (2011-2016),
attempts to reposition family planning
within a women’s empowerment and hu-
man rights framework within India’s de-
velopment and Maternal and child health
(MCH) policies and programs. This system-
atic review is a part of PFI’s ‘repositioning
family planning’ initiative.
Why reposition family planning in India?
There are several reasons why ‘Reposi-
tioning family planning’ is especially im-
portant in the Indian context.
To begin with, nine Indian states have al-
ready achieved replacement level fertility.
However, low fertility has not resulted in
improved maternal health, because of ear-
ly marriage and childbearing, and closely
spaced births. For example in Andhra
Pradesh, which had a below replace-
ment level of fertility of 1.79 children per
woman in 2005-06, 55% of young wom-
en age 20-24 years were married before
they were 18 years old, 18% of women
age 15-19 had already begun childbear-
ing 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 develop-
ment issue could contribute to designing
programs that addressed women’s other
reproductive health needs alongside fer-
tility control.
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2013
Population Foundation of India
Even with de-
clining average
annual growth
rates, India con-
tinues to add
approximately
18 million peo-
ple annually to
its population
Secondly, population momentum is an
important contributor to India’s popula-
tion growth. Even with declining average
annual growth rates, India continues to
add approximately 18 million people an-
nually to its population, because the pro-
portion 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 birth and by spac-
ing subsequent births by 2-4 years. Ac-
cording to the UNFPA, raising a mother’s
age at first birth from 18 to 23 could re-
duce population momentum by over 40
per cent [5]. The Indian version of Family
Planning 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
the government’s way of doing things –
i.e. upholding voluntary acceptance and
informed choice.
The third reason why repositioning fam-
ily planning is important is related to the
Indian Family Planning Program’s long
legacy of being driven by a 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 pro-
gram seemed to have lost its fulcrum. There
is a need to infuse the program with a new
‘raison d’etre’ – 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 plan-
ning into MCH policies and development
programs in Bihar and at the national lev-
el. Four focus areas of intervention were
indentified in view of the Indian context.
These were i) delaying age at first marriage
ii) delaying age at first birth iii) promoting
spacing between births iv) improving the
quality of family planning services
Context
i) Delaying age at 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-quar-
ter (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 NFHS-1 to 17.1 years in NFHS-3 [6].
Early marriages
are still prevalent
among a size-
able population
of Indian wom-
en. 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
ii) Delaying age at first birth
There is an urgent need to reorient fam-
ily planning programs so that young mar-
ried women and men are able to achieve
their reproductive intentions. Early mar-
riage 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
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Population Foundation of India
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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].
iii) Promoting birth spacing
Promoting birth spacing and the use of
effective spacing methods of contraception
is a major challenge confronting the Indian
family planning program. Nationally, the
median interval between subsequent
births 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 revers-
ible methods of contraception may un-
derlie poorly spaced births in the country.
Of the three modern reversible methods
available free of cost in India’s family plan-
ning 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 margin-
ally better. In fact, use of IUD has declined
between NFHS-1 and NFHS-3 [4].
iv) Improving the quality of care in family
planning services
The Indian Family Planning Program, am-
bitious in scale and coverage, has been
successful in achieving steep reductions
in fertility across several states. However,
many of its early achievements were at
the cost of providing quality services to
the user.
In his introduction to a compilation of
studies on quality of care in India’s fam-
ily planning program, Koenig (1999) noted
that the program had been characterized
Promoting birth
spacing and the
use of effective
spacing
methods of
contraception
is a major
challenge
confronting
the Indian
family planning
program
Less than a
third (32.2%)
of current us-
ers of contra-
ception were
informed about
side effects or
problems of the
method they
were to adopt,
or were using
by an “overriding concern for numbers”
– in terms of acceptors of contraception
and specifically, sterilization. The entire
program was driven by targets which ser-
vice providers had to meet under threat
of punitive action. This shaped provid-
ers’ 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 infrastruc-
ture and equipment, limited choice of meth-
ods, 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 Pro-
gram that was launched in 1997 prom-
ised a paradigm shift towards addressing
broader reproductive health needs of
the family. Quality of Care was an explicit
focus, and targets for contraceptive ac-
ceptance were to be replaced by a “Com-
munity-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, NGOs collabo-
rating with government were not allowed
to adopt Community-Needs Assessment
approaches and were given targets to
achieve [9].
There have been few recent studies on
quality of care in family planning servic-
es. Data from the National Family Health
Survey-3 gives 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 in-
formed 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 plan-
ning worker about other methods that
could be used [4]. Yet another paradigm
shift may be needed to alter the program
ethos to respect and uphold clients’ rights in
the provision of family planning services.
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Population Foundation of India
Yet another
paradigm shift
may be needed
to alter the
program ethos
to respect and
uphold clients’
rights in the
provision of
family planning
services
Objectives
The review aims to answer the following
questions:
I) Are interventions in developing
country settings related to (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 effective?
II) 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 develop-
ing countries pertaining to the four focus
areas, viz., interventions to delay age at
marriage; to delay age at first pregnancy;
to promote spacing between births; and
to improve the quality of family plan-
ning services. Identified published as well
as unpublished articles in English were
further scrutinised for quality as well as
strength of evidence, and those that met
a set of clear inclusion and exclusion crite-
ria 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. The effectiveness of inter-
ventions were gauged based on whether
they achieved their intended objectives.
In addition, the strength of the evidence
was also taken into account, with experi-
mental 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 61 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 over-
all and the limited strength of evidence in
many of these, it is difficult to draw firm
conclusions regarding effectiveness. Simi-
lar interventions would need to be imple-
mented 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
Interventions
that combined
multiple strate-
gies - 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.
2) Life skills education and empowerment
programs 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) Community 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 mar-
riage, only very early marriages (age 15
and below) could be prevented. In most in-
stances, however, even when the commu-
nity 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
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2013
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 commu-
nity, 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 effec-
tive in delaying age at marriage. Life skills
education was broad-based, included
‘empowerment’ education alongside in-
formation on sexuality and reproduction,
and also skill-development. Of equal or
more importance was to simultaneously
engage gate-keepers such as parents, reli-
gious leaders and community elders with
specific messages, while the same time
carrying out media campaigns raising vis-
ibility of the issue within the community.
Of these, the PRACHAR project from India
which carried out life skills education for
boys and girls alongside intensive com-
munity engagement has been successfully
up-scaled 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 to-
gether with intensive community mobili-
zation helped prevent very early marriag-
es (age 15 or 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 up-scaled 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
The key to mak-
ing these work
is to combine
them with
broad-based
community
mobilization
as well as tar-
geted efforts
to change at-
titudes of par-
ents and other
gate-keepers.
This is crucial
for changing
mindsets and
making early
discontinuation
of schooling
and early mar-
riages socially
unacceptable.
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 con-
ditional cash transfer schemes operated
by the central and various state govern-
ments 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 Protec-
tion Schemes of Tamil Nadu and Andhra
Pradesh, Ladli Schemes of Delhi and Hary-
ana, Ladli Lakshmi scheme of Madhya
Pradesh and Beti Hai Anmol Scheme of
Himachal Pradesh are some examples. It
would be important to evaluate the effec-
tiveness of these schemes in preventing
girls from dropping out from school and in
turn, delaying age at marriage. The evalu-
ations may provide directions for suitably
redesigning these conditional cash trans-
fer schemes to better achieve the objec-
tive of delaying age at marriage for girls.
Delaying early pregnancy
The systematic search yielded three stud-
ies (on two programs) from India, 23 sys-
tematic 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 oc-
curring 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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Systematic reviews of intervention stud-
ies from the US and the UK show that sex-
education programs by themselves are in-
effective in preventing teenage pregnan-
cy. Comprehensive youth development
programs which start with interventions
from early childhood and address the so-
cial determinants of teenage (unmarried)
pregnancy – educational opportunities,
skill development for livelihood, together
with sexuality and relationships educa-
tion- 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 pregnan-
cy out-of-wedlock.
Three Indian studies pertaining to two
programs, evaluated interventions to de-
lay 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 in-
terventions with key gatekeepers as well
as with the larger community ii) Provid-
ing sexual and reproductive health edu-
cation – 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 proj-
ect, being implemented in three districts
of Bihar. The scope for up-scaling this in-
tervention and for adapting it to the needs
of other Indian states needs to be exam-
ined. There is a need for more innovative
interventions to address the strong pres-
sures that most young Indian women face
to prove their fertility soon after marriage,
and the barriers that adolescent and young
couples face in contacting the health care
system prior to parenthood [10-11].
Working in-
tensively with
women and
their husbands,
alongside build-
ing community
support plus
building health
worker capac-
ity in providing
suitable ser-
vices seems to
be a promising
combination of
strategies.
Promoting spacing between births
Nine intervention studies were included
in the review. As with interventions to
delay early marriage, many of the evalu-
ated interventions to promote spacing
between births used two or more of six
specific strategies simultaneously. These
six strategies included: i) Targeted mes-
sages for young married women ii) Target-
ed messages for young married men iii)
Community mobilization – from targeted
meetings with gate keepers to broader
community awareness building and atti-
tude shaping iv) Engagement with health
and allied service providers within the
public and private sectors v) Mainstream-
ing the optimal pregnancy/birth spacing
messages within the government health
system; and vi) High level advocacy with
policy makers to integrate optimal preg-
nancy/birth spacing as a policy and pro-
gram goal.
Working intensively with women and
their husbands, alongside building com-
munity support plus building health work-
er 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 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 strate-
gies, 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 an-
tenatal 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, al-
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though mentioned as a priority in policy
documents, has not been adequately em-
phasized within the Indian family planning
program. Much work needs to be done
in making providers more conscious of
prioritizing birth spacing and in enhanc-
ing 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 promotion
of birth spacing within the government
health sector, including provider training
and community mobilization. These mod-
els have the potential for sustainable and
affordable upscale, and need to be ex-
plored further.
Making spacing methods acceptable to
potential users is yet another challenge to
be overcome. Currently, contraceptive use
is tilted overwhelmingly towards steriliza-
tion. Research is needed to identify barriers
to acceptance of spacing methods in differ-
ent parts of India, and to build context-spe-
cific 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 interven-
tions 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 impor-
tant to identify a suitable male cadre to
work with young married men.
Improving quality of care in 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
The policy rec-
ommendation
from this review
would be to
provide post-
partum and
post-abortion
family planning
services that are
truly based on
informed choice
following coun-
seling; offer the
full range of
contraceptives
for the woman/
her partner to
choose from,
and come to-
gether with
improvement in
overall quality
including hu-
mane treatment
of the client,
as described
above.
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 cli-
ent satisfaction with services. The first
of these is integration of family planning
services with post abortion care and ma-
ternal health-delivery care, provided this
is not just a mechanical addition of one
additional service. The effective interven-
tions 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-par-
tum and post-abortion sterilization. Also,
imposing sterilization or IUD insertion as a
condition for providing safe abortion ser-
vices 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 ser-
vices 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 to-
gether with improvement in overall qual-
ity including humane treatment of the cli-
ent, 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
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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.
Conclusions
Population Foundation of India
B-28 Qutab Institutional Area
New Delhi - 110 016
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 wom-
en, 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 document-
ed here are yet to be rigorously evaluated.
One of the key tasks ahead is to system-
atically document and evaluate existing
interventions.
The review identifies strategies that are
worthy of further experimentation and
up-scaling from among the pool of inter-
ventions that have been implemented
thus far. However this should preclude
the possibility of innovating what has
not yet been tried. There are other po-
tential 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 fam-
ily planning with post-abortion care. Yet,
any attempt to reposition family plan-
ning would need to include safe abor-
tion services as an important dimension
of upholding women’s health and rights.
We hope future reviews will examine ‘ef-
fective’ safe abortion services which have
the woman’s safety and wellbeing as out-
come indicators.
Last but not least, all strategies to ‘reposi-
tion 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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