Introduction to FP program and its history

1. Family Planning Policies and Programs

2. LEARNING OBJECTIVES
At the end of the course the students will be able to:
• Analyze the national population policy in terms of goals, objectives,
strategies, and major priorities relevant to family planning.
• Evaluate the rationale for FP in terms of health, social/economic,
demographic, human right, and HIV/AIDS impact
• Discuss components of family planning and evidence-based guidance on FP.
• Recognize the role of IEC and counseling in Family planning.
• Identify different methods to evaluate family planning programs.
• Recognize major issues in delivering high quality, cost effective family
planning services in low resource settings.
• Analyze the current family planning practice in Ethiopia in terms of the
available guideline and strategy.

3. CHAPTER ONE: INTRODUCTION TO FAMILY PLANNING
Contents
 Definition of Family Planning
 Concepts and principles of of family planning
 Historical Background of family planning
 Rationale of family planning
 Global and national situation of family planning

4. Population size and growth
 Population size is a measurement of existing population at any point in time,
while the population growth rate tells us what is happening to the
population in terms of whether it is growing, getting smaller, or remaining
constant.
 As the population is growing very rapidly, the need for food, schools, jobs
and health services is also increasing.
 Family planning is one of the leading strategies to improve family life and
welfare, control unwanted population growth, and aid the development of
the nation.

5. Population is affected by
 Fertility,
 Mortality and
 Migration rates
Final population = Initial population + (Births – Deaths) + (Immigration –
Emigration)

6. Cont….
Based on UN Data -2020
• Total Pop ~ 114,963,588 people
• Pop. Growth Rate = 2.6%
• Global Share = 1.47%
• Global Rank = 12
• Urban Population= 21.3%
• Pop. Under 15 = 45%
• Median age = 19.5 years.
• TFR = 4.3
6

7. Ethiopian Population 1900-2020
(Past, Present, Future)
0
20
40
60
80
100
120
1900 1925 1940 1955 1960 1970 1980 1990 2000 2005 2010 2015 2020
Millions
7

8. Definition - family planning
• It is the process of enabling individuals or couples to attain their desired
number of children & the spacing & timing of their births.
• Is regulating the number and spacing of children through the practice of
contraception or other methods of birth control
• Achieved through use of contraceptive methods & the treatment of
involuntary infertility. (WHO,, Dep’t of RH and Research)
• The practice of controlling the number of children in a family and the
interval b/n their births (Wikipedia)

9. Cont…
The practice of controlling the number of children one has and the
interval b/n their births , particularly by means of contraception or
voluntary sterilization (Oxford Definition)
Planning intended to determine the number and spacing of one’s
children through birth control (Merriam Webster)
What is the definition of contraception?
Contraception is the intentional prevention of pregnancy by artificial
or natural means.
Birth Control
• is also known as contraception and fertility control - is a method or
device used to prevent pregnancy (Wikipedia)
• The voluntary limiting of human reproduction using means such as
sexual abstinence, contraception, induced abortion, or forced
sterilization (Encyclopedia Britannica)

10. Components of RH
Understanding
, enjoying
sexuality
Bearing and
raising
children
Fertility
regulation
Remaining free
of disease from
sexual relations
and reproduction

12. Principles of FP Services
A sound FP program is one that incorporates the following principles:
 Autonomy
 Individuals have the ability to decide freely the number and spacing of
their children
 Voluntarism
 A client has the right to make an unpressured, voluntary decision on a
contraceptive method, assuming it is medically safe
 Full choice of FP methods possible/Method Mix
 individuals should have a choose among a full range of safe, effective and
available contraceptive methods

13. FP principles…
 Free and Informed choice
 FP programs that respect an individual’s ability to decide whether or not to
use contraception and to choose a contraceptive method that fits with her
lifestyle, beliefs, needs, preferences, and reproductive intentions
 A decision based on complete, accurate, unbiased information about all FP
options
• Ensuring Privacy and Confidentiality
Privacy and confidentiality of information make women and families feel
respected at all times, protect them from any stigma associated with their
problems and build trust in healthcare providers.
 Preservation of dignity and respect
 Women and newborns receive care with respect and maintain their dignity
and throughout their stay in the health facility.

14.  Equity and non-discrimination
Individuals have the ability to access quality, comprehensive contraceptive
information and services free from discrimination, mistreatment, coercion
and violence.
 Integration within other MCH services
 Missed opportunities for FP service persist, with corresponding increase in
unplanned and unwanted pregnancies
FP principles…

15. Historical Background/Origins of family planning
• Attempts to control human reproduction is not entirely a modern
phenomenon.
• Throughout history, human beings have engaged in both pro-and antinatalist
practices directed at enhancing social welfare.
• In many foraging and agricultural societies a variety of method, such as
prolonged breast-feeding were used to space births and maintain an
equilibrium between resources and population size.
• Birth control has been used since ancient times, but effective and safe birth
control methods become only available in the 20th century.
• Thomas Malthus an English man in 1978 wrote an ‘Essay on principles of
Population’ that has huge influence on policies o control population size.
• The idea of Malthus become very popular and are the basis for FP
programmess across the World even today

17. FP History …
• The earlier methods used by men and women to regulate their
fertility included coitus interrupts, abstinence, herbs and amulets
(Planned Parenthood Federation of America,2006).
• The condom appeared in the 17th century.
• Modern methods of family planning have a more recent history
since about 1960 when both the oral contraceptive pill and the
intrauterine device became available

18. FP History …
 As a result of the first two inter-governmental conferences concerning
population issues,
World Population Conference held in Bucharest (1974), and
International Population Conference (1984) in Mexico City,
 Many developing countries concluded that a rapid population
increase created a strain on resources, hampered economic
development and hindered their affluence, leading them to introduce
government-led family planning programs as a means of limiting
population growth.
 Since family planning programs are closely involved with personal
lifestyles, countries are often unable to achieve satisfactory results
even if they adapted FP program

19.  The International Conference on Population and Development (ICPD) in
Cairo in 1994, reproductive health/reproductive rights became the
central concept
 Shifted the focus of Macro/national level population policy to the
micro/individual level, in other words, individual women
 The transition of the aims of from family planning from population control
to a reproductive health/reproductive rights program
 Many countries have not fulfilled the needs of women who want to use
contraception or defer pregnancy
FP History …

21. FP History ….
Pre-war and Wartime (1920~1945)
 Birth Control movement
socialists began to urge the need for birth control as part of a program
to improve the life of workers
Margaret Sanger, the runner of the birth control movement, aiming for
health and happiness at the individual level
Magaret Sanger Coined the term birth control and in 1916 opened the
first Birth Control Clinic in USA and in 1935 Sanger Visited India and
popularized the Birth Control.

22. Family planning programs in developing countries
• Until 1970s, African countries had not viewed population growth as a major
factor in their development strategies given the small size of most of the
populations (34 of 48 African countries had populations under 5 million in
1978)
• While the trends in contraceptive prevalence demonstrate that unmet need
for FP remains an important challenge in many countries.
• Governments provide substantial support for family planning, and most users
of contraception in developing countries rely on their governments for
contraceptive supplies and services, although the private sector, including
pharmacies and private organizations, is also an important source of such
services.
• Many of the family planning programs in developing countries have been
carried out with considerable support from international donors

23. History of FP in developing Countries…
• Over the years, proponents of family planning programs have seen the
benefits of these programs as similar to those of other development efforts—
e.g., in education, or disease prevention through immunizations—in helping
to bring about improvements in the wellbeing of individuals and societies.
• However, the international movement to promote and support family
planning in developing countries as a way to meet the demand for fertility
regulation and as a way to lower fertility and population growth has also
generated criticism and controversy.
• The critics have included, at varying times, representatives of developing
countries, social scientists, interest groups such as feminists and women’s
rights and health advocates, the Catholic Church and other religious
organizations, political conservatives, and representatives of the right-to-life
movement.
• Critics of family planning programs have raised a range of political, ideological,
ethical, cultural, and scientific issues.

24. WHY HAVE FAMILY PLANNING PROGRAMS BEEN SO CONTROVERSIAL?
• There are two main reasons why family planning programs have been
controversial.
• The first is because they deal with a subject-birth control (and implicitly sexual
activity)—that was a sensitive topic for public consideration for most of the
last century
• The second is because a political movement to promote particular public
policies was spawned out of a growing concern about the negative effects of
rapid population growth on the economic development prospects of many
Third World countries. While this movement had strong support from a
number of quarters, it also generated opposition among a number of groups
and for different reasons

25. Historical background of family planning programs in Ethiopia
 Before the mid 1960s- Not much was known about FP in Ethiopia.
 The first family planning clinic in Ethiopia opened in 1963 at St Paulos Hospital by
FGAE and under the auspices of the Haile Selassie 1st Foundation. A single nurse
was providing the services supported by volunteer doctors. At the time family
planning was illegal and FGAE was not a legally registered organization.
 In 1966, the Family Guidance Association of Ethiopia (FGAE) was formed by a few
health and social workers.
 In 1970- the Association became an associate member of the International
Planned Parenthood Federation (IPPF) and a full member in 1975.
 It did not become involved in active family planning services delivery until about
1975, when FGAE was officially registered with the then Ministry of Interior, Public
Security Department as a non-governmental, non-profit voluntary organization.
 Even after 1975, its services did not expand but were limited to one clinic in Addis
Ababa and services were provided only two afternoons a week

26. Cont…
• Until the 1980s, family planning was perceived as something hostile to the
interest of the country by policy and decision-makers who had strong pro-natal
attitudes.
• Conservative thoughts and opposition towards Population Control and Family
Planning were high among government authorities, religious leaders and the
community at large. This needed wise and careful introduction of family
planning program.
• In 1980, however, the Government made a decision allowing the provision of
family planning services in the context of maternal and child health (MCH)
services.
• In 1996, the MOH released the first Guideline for FP Services in Ethiopia to
guide stakeholders and expand quality FP services

27. Rationales for family planning programs
 FP programs have been a key public health intervention in developing
countries and a component of international development assistance
programs for three reasons:
 Demographic,
 Health,
 Human rights.
 Each of these rationales can also be viewed as goals for family planning
programs because each implied achieving certain changes or improvements

28. Demographic Rationale
• The history of family planning programs in developing countries partly
originates with concern about a “world population problem.”
• In the late 1940s and 1950s, the phenomenon of rapid population growth,
resulting from the gap between declining mortality and continuing high
fertility,
• The demographic rationale for family planning programs was based on
concern with the macro-level consequences of rapid population growth
• The Coale and Hoover (1958) analysis of population growth and economic
development in India and Mexico was influential in framing the
understanding of the macro-consequences of population growth.

29. Cont…
• Was the predominant rationale for much of the late 1960s and 1970s
• The 1974 World Population Conference, held in Bucharest, Romania, was the first
international meeting of governments to address what some called the world
population problem.
• Their analysis and subsequent work contributed to the view that rapid population
growth would impede development, especially in the world’s poor countries.
• This provided the scientific foundation for policies and programs of bilateral and
international donors, particularly support for family planning programs
• By helping to reduce high rates of fertility, family planning programs were
intended to contribute to lower rates of population growth, improved living
standards and human welfare, and lessened impact on natural resources and the
environment.

30. Health Rationale
• During the 1980s, a shift toward the health rationale occurred.
• Pregnancy and childbirth complications are the leading cause of death among
15 to 19 year-old girls globally, with low and middle-income countries
accounting for the majority of global maternal deaths
• High maternal mortality was associated with a high number of pregnancies,
births to older and younger women, and abortions.
• Multicounty studies have shown that accessing family planning can reduce
maternal deaths by as much as 25% (Ahmed S, et al and Cleland, et al , 2012,
Lancet) , infant mortality by 10%, and childhood mortality by 21%.
• This rationale was more appealing to policymakers in many countries,
including those in sub-Saharan Africa.
• The delivery of FP services is also an important strategy for reducing maternal
morbidity and mortality.

31. Human Rights Rationale
• The 1968 International Conference on Human Rights brought the Teheran
Proclamation, which affirmed family planning to be a human right; “...parents
have a basic human right to determine freely and responsibly the number and
spacing of their children
• This most recent shift toward reproductive rights as a human right is
associated with the United Nations International Conference on Population
and Development (ICPD), held in Cairo in 1994.
• All individuals and couples have the right:
“…to decide freely and responsibly the number, spacing and timing of
their children and to have the information, education, and means to do so, and
the right to attain the highest standard of sexual and reproductive health...
ICPD Programme of Action

32. Family Planning and Human Rights
 All people deserve the right to determine, as best they can, the course of
their own lives. Whether and when to have children, how many, and with
whom are important parts of this right. Family planning providers have the
privilege and responsibility to help people to make and carry out these
decisions.
Source: United Nations, 1995.

33. Benefits of FP Services
The purpose of family planning is the enrichment of human life, not its restriction; by
assuring greater opportunity to each person, frees people to attain his/her individual
dignity and reach his/her full potential.

34. For All Women
• Lower risk of maternal death
• Lower risk of anemia, poor pregnancy outcomes and complications, and
complications related to miscarriage or unsafe abortion
• Non-contraceptive benefits from some methods such as protection from:
• Disease transmission/acquisition of certain cancers and other
gynecological problems
• Improved educational and economic opportunities
Source: Lloyd, 2008; Wilcher, 2008.
104,000 maternal deaths/year could be prevented if all women who said
they want to avoid pregnancy were able to stop childbearing.

35. For Infants and Children
• Longer breastfeeding:
• Provides nutrition
• Protects from childhood diseases
• Improves mother/child bonding
• Reduces child illness and death
• Promote physical growth and development
• Allows more time and resources for parents to meet the needs of each
child
Source: Rutstein, 2005; Demographic and Health Surveys, various years.

36. For Families and Communities
• Families can devote more resources to providing for each child
• Reduced maternal and child illness reduces economic strain on family
• Reduced maternal deaths strengthen families and communities
• Relieves economic, social, and environmental pressures
• Enhances women’s status and promotes equality between men and
women

37. Benefits of family Planning
The Health,
Population and
Nutrition partners
are fully
committed to
work with the
Government of
Ethiopia and
others to
accelerate
progress towards
FP2020 and Health
Sector
Transformation
Plan Goals.
Individual level
• Empowers women - enables them to plan the size and timing of their
families
• Saves Women’s life – avoids unwanted pregnancies; and, avoids
unsafe abortions
• Improves infant and child health - spacing between births, limits
births to heathier years
Household level
• Increases household savings
• Increases investment in individual children - children in smaller
families are better educated
• Increases work productivity , in particular female work participation
Community/Country level
• Increases size of the labour force , and, domestic savings
• Improves quality and quantity of infrastructure – better schools and
health facilities
• Reduces poverty, and , accelerates demographic transition –
promotes growth
Global level
• Slowing population growth reduces pressure on environment and
natural resources- reduces pressure on water and land; reduces
conflict over natural resources; limits pollution
• Helps progress towards sustainable human population
• Helps in slowing Global Warming

39. Low FP service
Coverage
High rate of
Unwanted pregnancy
Unsafe Abortion
Family/
Population size
Increase
maternal Morbidity
High
MMR
Poverty
Migration CSW
Environmental
Degradation
Ill Health
Ill Health and Social Wellbeing

40. Women with an Increased Risk of Having Problems During
Pregnancy and Delivery
Women who:
• Are under the age of 18, or over age 35 (Avoid Too Young and Too old pregnancy)
• Become pregnant less than 2 years after a previous live birth (Avoid too close
pregnancy)
• Become pregnant less than six months post-abortion or post-miscarriage
• Have too many children (high parity)
• Have certain existing health problems
• Do not have access to skilled health care
Problems are more likely in those with multiple risk factors.

41. Global and National Situation of Family Planning
• In an effort to achieve a better future for all, SDG 3 targeted to reduce the
maternal mortality ratio to less than 70 per 100,000 live births by 2030.
• The SDG plans to ensure universal access to sexual and reproductive health-
care services including for FP, which will be measured by the proportion of
reproductive age women who have their need for FP satisfied with modern
methods of contraception.
• Approximately 218 million women in LMICs have an unmet need for modern
contraception. About half (49%) of pregnancies in LMICs—111 million
annually—are unintended. (Guttmacher Institute, 2020 report) ,
• The ambitious goal announced at the 2012 London Summit on FP of
reaching 120 million additional women and girls as FP users (London
Summit on FP 2012; BMGF and DFID 2012).

42. 218 705 718
1,640 million women of reproductive age, 2019
Have unmet need*
218 705 Have met need 718=not need contraception
923 million want to avoid a pregnancy

43. Family Planning and the Sustainable Development Goals (SDGs)
Source: United Nations, 2016

44. Family Planning and the SDGs Cont.

45. National Family Planning Situation
• Ethiopia as a member of the international community has endorsed and
signed a number of international and regional agreements to promote and
protect the rights of women and children.
Convention on the Political Rights of Women (CPRW),
Convention on Elimination of All Forms of Discrimination against Women (CEDAW),
Universal Declaration of Human Rights,
Convention on the Rights of the Child, and
has endorsed and engaged with the Sustainable Development Goals of 2015
• In 2006, African ministers of health and delegates agreed on the Maputo
Plan of Action
• Ethiopia had signed the London submit in 2012 where the country has
dedicated to increase its contraceptive prevalence rate to 69 %, reduce its
total fertility rate (TFR) to 4 children per woman, and reach an additional
6.2 million women and adolescent girls with family planning (FP) services.

46. HSTP 1 achievements and HSTP targets related to FP
Indicator HSTP 1
Baseline Target Achievement HSTP2 target
Life expectancy at birth (in years) 64 69 65.5 68
Maternal morality ratio (per 100, 000
live births)
420 199 401 277
Under five mortality 64 30 59 43
Infant mortality (per 1,000 live births) 44 20 47 35
Neonatal morality (per 1,000 live
births)
28 10 33 21
Contraceptive prevalence rate 42 55 41 50
Unmet need for FP 24 10 22 -
Teenage pregnancy rate 12.5 10 12.5 7

47. Trends in contraceptive use
6
14
27
35
41
8
15
29
36
42
0
5
10
15
20
25
30
35
40
45
2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHS 2019 MinEDHS
Percentage of women age 15-49
Any Modern Method
Any Method

48. Demand for Family Planning – EDHS 2016
22
36
58
62 61
0
10
20
30
40
50
60
70
Unmet need Met need Total demand Demand satisfied Demand satisfied
by modern
methods
Percentage of women age 15-49

49. Trends in TFR
5.5
5.4
4.8
4.6
4
4.2
4.4
4.6
4.8
5
5.2
5.4
5.6
2000 2005 2011 2016
Number of Children Per Woman

50. 27
9
2
2
Contraceptive method used among currently
married women (Percentage) - EDHS 2016
Injectable
Implant
IUCD
Pills

51. CPR by By residence
Urban – Any method =49.7
- Modern method = 47.7
Rural - Any method = 38.2
- Modern method = 37.7

52. MCPR by Region
 Tigray = 36.3
 Afar = 12.7
 Amhara = 49.5
 Oromia = 38.9
 Ethiopia Somali = 3.4
 Benishangul Gumuz = 36.7
 Snnp =44.6
 Gambela = 33.2
 Harari = 30.3
 Addis Ababa = 47.6
 Dire Dawa = 30.3

53. THANK YOU