A Measure of Equity
-Maternal Death and Disability
-The Feminization of HIV/AIDS
-Reaping the Rewards of Family Planning
Reaping the Rewards of Family Planning
The freedom to choose how many children, and when, is a fundamental human right. Better access to safe and affordable contraceptive methods is key to achieving the MDGs. Family planning has proven benefits in terms of gender equality, maternal health, child survival, and preventing HIV. Family planning can also reduce poverty and promote economic growth by improving family well-being, raising female productivity and lowering fertility (see Chapter 2).(68) It is one of the wisest and most costeffective investments any country can make towards a better quality of life. Limited access to contraception, on the other hand, constrains women's opportunities to pull themselves and their families out of poverty.
Drawing on earlier human rights conventions, the 1994 ICPD and the 1995 Fourth World Conference on Women placed reproductive health, including voluntary family planning, at the centre of initiatives to promote the human rights of women. This was a departure from earlier efforts that focused more on curbing rapid population growth, in some cases at the expense of women's rights. Citing ethical values and human rights principles, both conferences asserted that freedom to make reproductive decisions is essential for achieving gender equality and sustainable development.
"Gender inequality and gender roles are
in many settings the most important
underlying influences on vulnerability to
HIV. In fact, the AIDS epidemic cannot be
understood, nor can effective responses be
developed, without taking into account the
fundamental ways that gender influences
the spread of the disease, its impact, and
the success of prevention efforts."
- UN Millennium Project, Combating AIDS in the Developing World
BARRIERS TO ACCESS: POVERTY AND GENDER DISCRIMINATION. Since reliable methods became available in the 1960s, the use of modern contraception has risen steadily to 54 per cent of all women currently married or in union. The figure rises to 61 per cent when traditional methods are taken into account.(69) As a result, fertility rates continue to fall. In the developing world, the total fertility rate-average number of births per woman-has fallen from over six in the 1960s to under three per woman today. However, fertility remains high in the least-developed countries, at five children per woman.(70)
The combination of high fertility and pervasive poverty in developing countries intensifies the latter by slowing economic growth and increasing costs for health, education and other basic needs, lowering female productivity, and reducing income and savings. Falling fertility, on the other hand, can accelerate poverty reduction, especially when combined with supportive social and economic policies.(71) Some of the world's poorest countries have made slow or only halting progress over the past 30 years in increasing contraceptive access. In 21 of the poorest countries in sub-Saharan Africa, the total fertility rate has remained high, or declined only slightly, since the 1970s.(72)
Contraceptive use is uneven both among and within countries. It varies according to income, education, ethnicity, proximity to clinics and the strength of family planning programmes. In Africa, only 27 per cent of married women are using any method of contraception, and only 20 per cent are relying on more effective modern methods. And in some parts of the continent, the proportion drops to under 5 per cent for modern methods.(73) The wealthiest women are four times more likely to use contraception than the poorest: In some countries, the rate is 12 times higher (see Figure 3). Globally, some 201 million women lack access to effective contraceptives but many would practise family planning if given the option.(74)
Figure 3: Contraceptive Use According to Wealth
Source: World Bank, 2004, Round II Country Reports on Health, Nutrition, and Population Conditions Among the Poor and the Better-Off in 56 Countries.
In addition to the macro-level social and economic benefits of family planning, studies have found that women who plan their families reap personal, psychological and economic rewards. In Bolivia, contraceptive use was associated with working for pay outside the home. In Cebu, the Philippines, the average income growth for women with one to three pregnancies was twice that of women who had undergone more than seven pregnancies.(75) Family planning programmes also produce tangible and sizeable savings for governments.
Several factors affect demand for contraception. Social, cultural and gender-related obstacles can prevent a woman from realizing her childbearing preferences (see Box 15). Women who cannot read or have limited education may know little about their own bodies, much less about family planning. Misconceptions and myths about pregnancy and contraceptive methods abound.(76) Men tend to want more children and to want them earlier than women do, and in many cases have greater decision-making power to determine family size.(77) Social norms surrounding fertility and virility, and the overall low status of women, keep many women and men from seeking family planning.
15 | COMMON GENDER-BASED BARRIERS TO CONTRACEPTIVE USE
- At the policy and legal level, decisionmakers may not place high priority on funding contraceptive services because they view family planning as a "women's programme". Some countries restrict certain methods. Laws may require a woman to have her husband's permission to use some methods, and adolescents under a certain age may be required to get parental consent.
- In health facilities, biased service providers may fail to offer a range of contraceptive options, on the basis that a woman will not understand them or would choose "wrongly". Some providers incorrectly believe that certain contraceptive methods cause infertility and only provide them to women who have already had children.
"[The nurse] told me that if I did not want the pill, then she would not recommend anything."
- Zambian woman
- At the community level, contraceptives may be frowned upon as contributing to female promiscuity, a concern not expressed for men.
- At the level of individuals and couples, some women may fear their husbands' disapproval, or even retribution for contraceptive use. Many couples have difficulty discussing the subject.
"My husband knew about the pills. I told him, and he was always against them. We almost
broke up over it."
- Guatemalan woman
- Young women, if married, may be expected to "prove" childbearing ability to their husbands and families; if unmarried, they may be expected to remain abstinent.
"I tried to get some tablets, but I was chased from the clinic. I think it was because I looked
- Zimbabwean secondary school student
- Men are often excluded from family planning programmes because they are designed for women and operate as part of maternal and child health services.
GROWING DEMAND, GROWING SHORTAGES. Many developing countries face critical shortfalls of contraceptives and condoms. Reasons include rising numbers of users (from population growth), growing demand (from a desire for smaller families), the spread of HIV/AIDS (requiring substantial resources), and declining levels of donor funding.(78)
A number of developing countries are able to cover contraceptive costs, but most lack the foreign exchange and manufacturing capacity to meet their own needs without donor support. The cost of contraceptives and condoms is estimated to rise from $1 billion to $1.6 billion between 2004 and 2015, with a large gap still existing between projected costs and donor funding. Meanwhile, the AIDS epidemic means that shortfalls-not only in male and female condoms, but in other reproductive health supplies such as STI treatments and HIV test kits-have become all the more pressing.
16 | WHERE ARE THE CONDOMS?
Approximately five billion condoms were distributed in 2003 for HIV prevention. But many more-an estimated 13 billion-were needed to help halt the spread of HIV and other sexually transmitted infections. In 2003, donor support paid for the equivalent of one condom a year for each man of reproductive age living in the developing world. In sub-Saharan Africa, the region receiving the largest share of support, donor contributions provided six condoms a year for each man.
The shortage of condoms is alarming. They are the only effective means of protecting sexually active people from HIV infection. If used consistently and correctly, condoms also serve as a means of contraception for people with limited access to health care and more effective methods. The projected cost of the number of condoms that will be required to halt the AIDS epidemic is expected to reach $590 million by 2015. This is about three times current condom costs. Brazil, China and India are self-sufficient in contraceptives, but other developing countries must import them, paying with scarce foreign exchange required for food, medicine and other necessities.
EXPANDING CONTRACEPTIVE CHOICE. The ICPD called for universal access to "a full range" of family planning methods. However, in most countries, one or two methods dominate. Three methods-female sterilization, intrauterine devices, and oral contraceptives- account for most contraception worldwide.(79) Contraceptives under development, including a male hormonal method, may soon add to the mix of choices available in wealthier nations. But it will be many years before these become available in developing countries.(80) Until an HIV vaccine and microbicides become available, expanding access to the female condom offers the only female-controlled alternative protection from HIV. As it still requires male cooperation, men need to be informed and sensitized to its use.(81)
17 | CHANGING LIVES IN COMMUNITIES OF ZIMBABWE
Zimbabwe has one of the highest HIV prevalence rates in the world: 25 per cent of the population. Close to one million women are HIV-positive. Young women represent two thirds of all new HIV infections among young people 15 to 24. UNFPA Zimbabwe is working to improve the social and economic status of women as a way to give them greater power to protect themselves.
In Ruheri District, women are trained in communication and negotiation skills, and spread the gender equality message at weddings, parties, schools, food distribution points and public forums. Men's initial resistance, based on concerns that changes would promote promiscuity, was overcome through dialogue with key groups and traditional leaders. In 2004, the project exceeded expectations with a 50 and 20 per cent increase in the distribution of male and female condoms, respectively, reaching a total of 47,423 people.
In Mutare, commercial sex work is a fact of life. Authorities decided 13 years ago to train sex workers as peer educators on the prevention of HIV and sexually transmitted infections (STIs). They are encouraged to use and distribute condoms to their clients and fellow workers, inform the larger community about prevention and refer people to treatment. In 2003, the project reached 1,177,128 women and 736,981 men. Clinic nurses report a steady decline in STIs-of between 6 to 50 per cent, varying by neighbourhood-with more than 5.7 million condoms distributed. This initiative has changed lives: the majority of peer educators have left sex work for entrepreneurial activities. As Caroline, a former sex worker, said, "If it were not for this project, I would have died of AIDS a long time ago."