Family planning

Combined oral contraceptives. Introduced in 1960, "the Pill" has played an instrumental role in family planning for decades.

Family planning is the practice of controlling the number of children in a family and the intervals between their births, particularly by means of artificial contraception or voluntary sterilization. Because "family" is included in the concept's name, consideration of a couple's desire to bear children, in the context of a family unit, is often considered primarily. Contemporary notions of family planning, however, tend to place a woman and her childbearing decisions at the center of the discussion, as notions of women's empowerment and reproductive autonomy have gained traction in many parts of the world. Family planning may involve consideration of the number of children a woman wishes to have, including the choice to have no children, as well as the age at which she wishes to have them. These matters are obviously influenced by external factors such as marital situation, career considerations, financial position, any disabilities that may affect their ability to have children and raise them, besides many other considerations. If sexually active, family planning may involve the use of contraception and other techniques to control the timing of reproduction. Other techniques commonly used include sexuality education, prevention and management of sexually transmitted infections, pre-conception counseling and management, and infertility management.

Family planning is sometimes used as a synonym or euphemism for access to and the use of contraception. However, it often involves methods and practices in addition to contraception. Additionally, there are many who might wish to use contraception but are not, necessarily, planning a family (e.g., unmarried adolescents, young married couples delaying childbearing while building a career); family planning has become a catch-all phrase for much of the work undertaken in this realm. It is most usually applied to a female-male couple who wish to limit the number of children they have and/or to control the timing of pregnancy (also known as spacing children). Family planning may encompass sterilization, as well as abortion.

Family planning services are defined as "educational, comprehensive medical or social activities which enable individuals, including minors, to determine freely the number and spacing of their children and to select the means by which this may be achieved".

Purposes

"Raising" a child requires significant amounts of resources: time, social, financial, and environmental. Planning can help assure that resources are available. The purpose of family planning is to make sure that any couple, man, or woman who has the desire to have a child has the resources that are needed in order to complete this goal. With these resources a couple, man or women can explore the options of natural birth, surrogacy, artificial insemination, or adoption. In the other case, if the person does not wish to have a child at the specific time, they can investigate the resources that are needed to prevent pregnancy, such as birth control, contraceptives, or physical protection and prevention.

Health

See also: Maternal health, Maternal death, and teenage pregnancy

The WHO states about maternal health that:

"Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period. While motherhood is often a positive and fulfilling experience, for too many women it is associated with suffering, ill-health and even death."

About 99% of maternal deaths occur in less developed countries; > ½ occur in sub-Saharan Africa and almost ⅓ in South Asia.

Both early and late motherhood have increased risks. Young teenagers face a higher risk of complications and death as a result of pregnancy. Waiting until the mother is at least 18 years old before trying to have children improves maternal and child health.

Also, if additional children are desired after a child is born, it is healthier for the mother and the child to wait at least 2 years after the previous birth before attempting to conceive (but not more than 5 years). After a miscarriage or abortion, it is healthier to wait at least 6 months.

When planning a family, women should be aware that reproductive risks increase with the age of the woman. Like older men, older women have a higher chance of having a child with autism or Down syndrome, the chances of having multiple births increases, which cause further late-pregnancy risks, they have an increased chance of developing gestational diabetes, the need for a Caesarian section is greater, older women's bodies are not as well-suited for delivering a baby. The risk of prolonged labor is higher. Older mothers have a higher risk of a long labor, putting the baby in distress.

"Family planning benefits the health and well-being of women and families throughout the world. Using contraception can help to avoid unwanted pregnancies and space births; protect against STDs, including HIV/AIDS; and provide other health benefits."

Placard showing negative effects of lack of family planning and having too many children and infants (Ethiopia)

Modern methods

Modern methods of family planning include birth control, assisted reproductive technology and family planning programs.

The use of modern methods of contraception is an important basis for improving the long-term health of adolescent girls. The United Nations Population Fund (UNFPA) says that, “Contraceptives prevent unintended pregnancies, reduce the number of abortions, and lower the incidence of death and disability related to complications of pregnancy and childbirth.” UNFPA states that, “If all women with an unmet need for contraceptives were able to use modern methods, an additional 24 million abortions (14 million of which would be unsafe), 6 million miscarriages, 70,000 maternal deaths and 500,000 infant deaths would be prevented.”

In cases where couples may not want to have children just yet, family planning programs help a lot. Federal family planning programs reduced childbearing among poor women by as much as 29 percent, according to a University of Michigan study.

Adoption is sometimes used to build a family. There are seven steps that one must make towards adoption. You must decide to pursue an adoption, apply to adopt, complete an adoption home study, get approved to adopt, be matched with a child, receive an adoptive placement, and then legalize the adoption.

Contraception

Main article: Birth control

Placard showing positive effects of family planning (Ethiopia)

A number of contraceptive methods are available to prevent unwanted pregnancy. There are a range of contraceptive methods, each with particular advantages and disadvantages. Behavioral methods to avoid pregnancy that involve vaginal intercourse include the withdrawal and calendar-based methods, which have little up front cost and are readily available, but are much less effective in typical use than most other methods. Long-acting reversible contraceptive methods, such as intrauterine device (IUD) and implant are highly effective and convenient, requiring little user action. When cost of failure is included, IUDs and vasectomy are much less costly than other methods. In addition to providing birth control, male and/or female condoms protect against sexually transmitted diseases (STD). Condoms may be used alone, or in addition to other methods, as backup or to prevent STD. Surgical methods (tubal ligation, vasectomy) provide long-term contraception for those who have completed their families.

Assisted reproductive technology

Main article: Assisted reproductive technology

When, for any reason, a woman is unable to conceive by natural means, she may seek assisted conception. For example, some families or women seek assistance through surrogacy, in which a woman agrees to become pregnant and deliver a child for another couple or person.

There are two types of surrogacy: traditional and gestational. In traditional surrogacy, the surrogate uses her own eggs and carries the child for her intended parents. This procedure is done in a doctor's office through IUI. This type of surrogacy obviously includes a genetic connection between the surrogate and the child. Legally, the surrogate will have to disclaim any interest in the child to complete the transfer to the intended parents. A gestational surrogacy occurs when the intended mother's or a donor egg is fertilized outside the body and then the embryos are transferred into the uterus. The woman who carries the child is often referred to as a gestational carrier. The legal steps to confirm parentage with the intended parents are generally easier than in a traditional because there is no genetic connection between child and carrier.

Sperm donation is another form of assisted conception. It involves donated sperm being used to fertilise a woman's ova by artificial insemination (either by intracervical insemination or intrauterine insemination) and less commonly by invitro fertilization (IVF), but insemination may also be achieved by a donor having sexual intercourse with a woman for the purpose of achieving conception. This method is known as natural insemination (NI).

Mapping of a woman's ovarian reserve, follicular dynamics and associated biomarkers can give an individual prognosis about future chances of pregnancy, facilitating an informed choice of when to have children.

Finances

See also: Family economics and Cost of raising a child

Family planning is among the most cost-effective of all health interventions. "The cost savings stem from a reduction in unintended pregnancy, as well as a reduction in transmission of sexually transmitted infections, including HIV".

Childbirth and prenatal health care cost averaged $7,090 for normal delivery in the United States in 1996. U.S. Department of Agriculture estimates that for a child born in 2007, a U.S. family will spend an average of $11,000 to $23,000 per year for the first 17 years of child's life. (Total inflation-adjusted estimated expenditure: $196,000 to $393,000, depending on household income.) Breaks down cost by age, type of expense, region of country. Adjustments for number of children (one child — spend 24% more, 3 or more spend less on each child.)

Investing in family planning has clear economic benefits and can also help countries to achieve their “demographic dividend,” which means that countries productivity is able to increase when there are more people in the workforce and less dependents. UNFPA says that, “For every dollar invested in contraception, the cost of pregnancy-related care is reduced by $1.47.”

UNFPA states that,

“The lifetime opportunity cost related to adolescent pregnancy – a measure of the annual income a young mother misses out on over her lifetime – ranges from 1 per cent of annual gross domestic product in a large country such as China to 30 per cent of annual GDP in a small economy such as Uganda. If adolescent girls in Brazil and India were able to wait until their early twenties to have children, the increased economic productivity would equal more than $3.5 billion and $7.7 billion, respectively.”

International oversight

See also: International Planned Parenthood Federation, Marie Stopes International, and United States Agency for International Development

The world's largest international source of funding for population and reproductive health programs is the United Nations Population Fund (UNFPA). In 1994, the International Conference on Population and Development set the main goals of its Program of Action as:

• Universal access to reproductive health services by 2015
• Universal primary education and ending the gender gap in education by 2015
• Reducing maternal mortality by 75% by 2015
• Reducing infant mortality
• Increasing life expectancy at birth
• Reducing HIV infection rates in persons aged 15–24 years by 25% in the most-affected countries by 2005, and by 25% globally by 2010

The World Health Organization (WHO) and World Bank estimate that $3 per person per year would provide basic family planning, maternal and neonatal health care to women in developing countries. This would include contraception, prenatal, delivery, and post-natal care in addition to postpartum family planning and the promotion of condoms to prevent sexually transmitted infections.

Coercive interfering with family planning

Forced sterilization

Main article: Forced sterilization

Compulsory or forced sterilization programs or government policy attempt to force people to undergo surgical sterilization without their freely given consent. People from marginalized communities are at most risk of forced sterilization. Forced sterilization has occurred in recent years in Eastern Europe (against Roma women), and in Peru (during the 1990s against indigenous women). China's one-child policy was intended to limit the rise in population numbers, but in some situations involved forced sterilisation.

Sexual violence

Main article: Pregnancy from rape

Rape can result in a pregnancy. Rape can occur in a variety of situations, including war rape, forced prostitution and marital rape, and those that result in pregnancy add to the long-term psychological and economic anguish of the victim, besides other things, disturbing her plans for creating a family of her choosing.

In Rwanda, the National Population Office has estimated that between 2,000 and 5,000 children were born as a result of sexual violence perpetrated during the genocide, but victims' groups gave a higher estimated number of over 10,000 children.

Family planning, human rights & development

Access to safe, voluntary family planning is a human right and is central to gender equality, women’s empowerment and poverty reduction. The United Nations Population Fund (UNFPA) says that, “Some 225 million women who want to avoid pregnancy are not using safe and effective family planning methods, for reasons ranging from lack access to information or services to lack of support from their partners or communities.” UNFPA says that, “Most of these women with an unmet need for contraceptives live in 69 of the poorest countries on earth.”

Over the past 50 years, right-based family planning has enabled the cycle of poverty to be broken resulting in millions of women and children’s lives being saved.

UNFPA says that, “Global consensus that family planning is a human right was secured at the 1994 International Conference on Population and Development, in Principle 8 of the Programme of Action: All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so.”

As part of the United Nations Millennium Development Goals (MDGs) universal access to family planning is one of the key factors contributing to development and reducing poverty. Family planning creates benefits in areas such as, gender quality and women's health, access to sexual education and higher education, and improvements in maternal and child health.

UNFPA and the Guttmacher Institute say that,

"Serving all women in developing countries that currently have an unmet need for modern contraceptives would prevent an additional 54 million unintended pregnancies, including 21 million unplanned births, 26 million abortions (of which 16 million would have been unsafe) and seven million miscarriages; this would also prevent 79,000 maternal deaths and 1.1 million infant deaths."

Regional variations

A family planning facility in Kuala Terengganu, Malaysia

Africa

Main article: Birth control in Africa

Most of the countries with lowest rates of contraceptive use, highest maternal, infant, and child mortality rates, and highest fertility rates are in Africa. Only about 30% of all women use birth control, although over half of all African women would like to use birth control if it was available to them. The main problems that preventing access to and use of birth control are unavailability, poor health care services, spousal disapproval, religious concerns, and misinformation about the effects of birth control. The most available type of birth control is condoms. A rapidly growing population coupled with an increase in preventable diseases means countries in Sub-Saharan Africa face an increasingly younger population.

China

Main article: Family planning policy

China's Family planning policy forced couples to have no more than one child. Beginning in 1979 and being officially phased out in 2015, the policy was instated to control the rapid population growth that was occurring in the nation at that time. With the rapid change in population, China was facing many impacts, including poverty and homelessness. As a developing nation, the Chinese government was concerned that a continuation of the rapid population growth that had been occurring would hinder their development as a nation. The process of family planning varied throughout China, as people differed in their responsiveness to the one-child policy, based on location and socioeconomic status. For example, many families in the cities accepted the policy more readily based on the lack of space, money, and resources that often occurs in the cities. Another example can be found in the enforcement of this rule; people living in rural areas of China were, in some cases, permitted to have more than one child, but had to wait several years after the birth of the first one. However, the people in rural areas of China were more hesitant in accepting this policy. China's population policy has been credited with a very significant slowing of China's population growth which had been higher before the policy was implemented. However, the policy has come under criticism that it has resulted in the abuse of women. Often implementation of the policy has involved forced abortions, forced sterilization, and infanticides. That families desired a male child had a part to play in the number of infanticides. The number of girls that die within their first year of birth is twice that of boys. Another drawback of the policy is that China’s elderly population is now increasing rapidly. However, while the punishment of "unplanned" pregnancy is a large fine, both forced abortion and forced sterilization can be charged with intentional assault, which is punished with up to ten years' imprisonment. Another issue that is raised in the one-child policy in China is the information in regards to naturally giving birth to twins or triplets. If this situation arises, the family is allowed to keep the children because of the natural causes of this impregnation.

Family planning in China had its benefits, and its drawbacks. For example, it helped reduce the population by about 300 million people in its first 20 years. A drawback is that there are now millions of sibling-fewer people, and in China siblings are very important. Once the parent generation gets older, the children help take care of them, and the work is usually equally split among the siblings. Another benefit of the implementation of the one-child law is that it reduced the fertility rate from about 2.75 children born per woman, to about 1.8 children born per woman in the 1979.

Hong Kong

Main article: The Family Planning Association of Hong Kong

See also: Two-child policy

In Hong Kong, the Eugenics League was found in 1936, which became The Family Planning Association of Hong Kong in 1950. The organisation provides family planning advice, sex education, birth control services to the general public of Hong Kong. In the 1970s, due to the rapidly rising population, it launched the "Two Is Enough" campaign, which reduced the general birth rate through educational means.

The Family Planning Association of Hong Kong, Hong Kong's national family planning association, founded the International Planned Parenthood Federation with its counterparts in seven other countries.

India

Main article: Family planning in India

Family planning in India is based on efforts largely sponsored by the Indian government. In the 1965-2009 period, contraceptive usage has more than tripled (from 13% of married women in 1970 to 48% in 2009) and the fertility rate has more than halved (from 5.7 in 1966 to 2.6 in 2009), but the national fertility rate is still high enough to cause long-term population growth. India adds up to 1,000,000 people to its population every 15 days.

Iran

Main article: Family planning in Iran

While Iran's population grew at a rate of more than 3% per year between 1956 and 1986, the growth rate began to decline in the late 1980s and early 1990s after the government initiated a major population control program. By 2007 the growth rate had declined to 0.7 percent per year, with a birth rate of 17 per 1,000 persons and a death rate of 6 per 1,000. Reports by the UN show birth control policies in Iran to be effective with the country topping the list of greatest fertility decreases. UN's Population Division of the Department of Economic and Social Affairs says that between 1975 and 1980, the total fertility number was 6.5. The projected level for Iran's 2005 to 2010 birth rate is fewer than two.

In late July 2012, Supreme Leader Ali Khamenei described Iran's contraceptive services as "wrong," and Iranian authorities are slashing birth-control programs in what one Western newspaper (USA Today) describes as a "major reversal" of its long standing policy. Whether program cuts and high-level appeals for bigger families will be successful is still unclear.

Ireland

Main article: Contraception in the Republic of Ireland

The sale of contraceptives was illegal in Ireland from 1935 until 1980, when it was legalized with strong restrictions, later loosened. It has been argued that the resulting demographic dividend played a role in the economic boom in Ireland that began in the 1990s and ended abruptly in 2008 (the Celtic tiger) was in part due to the legalisation of contraception in 1979 and subsequent decline in the fertility rate. In Ireland the ratio of workers to dependents increased due to lower fertility — the reality of which has been questioned — but was raised further by increased female labor market participation.

Pakistan

Main article: Family planning in Pakistan

In agreement with the 1994 International Conference on Population and Development in Cairo, Pakistan pledged that by 2010 it would provide universal access to family planning. Additionally, Pakistan’s Poverty Reduction Strategy Paper has set specific national goals for increases in family planning and contraceptive use. In 2011 just one in five Pakistani women ages 15 to 49 uses modern birth control. Contraception is shunned under traditional social mores that are fiercely defended as fundamentalist Islam gains strength.

Russia

See also: Demographics of Russia

According to a 2004 study, current pregnancies were termed "desired and timely" by 58% of respondents, while 23% described them as "desired, but untimely", and 19% said they were "undesired". As of 2004, the share of women of reproductive age using hormonal or intrauterine birth control methods was about 46% (29% intrauterine, 17% hormonal). During the soviet era high quality contraceptives were difficult to obtain, and abortion became the most common way of preventing unwanted births. Since the dissolution of the Soviet Union abortion rates have fallen considerably, but they are still higher than rates in many developed countries.

Philippines

In the Philippines, the Responsible Parenthood and Reproductive Health Act of 2012 guarantees universal access to methods on contraception, fertility control, sexual education, and maternal care. While there is general agreement about its provisions on maternal and child health, there is great debate on its mandate that the Philippine government and the private sector will fund and undertake widespread distribution of family planning devices such as condoms, birth control pills, and IUDs, as the government continues to disseminate information on their use through all health care centers.

Singapore

In the 1970s the Singaporean government encouraged much smaller families.

Main article: Family planning in Singapore

Population control in Singapore spans two distinct phases: first to slow and reverse the boom in births that started after World War II; and then, from the 1980s onwards, to encourage parents to have more children because birth numbers had fallen below replacement levels.

United Kingdom

Contraception has been available for free under the National Health Service since 1974, and 74% of reproductive-age women use some form of contraception. The levonorgestrel intrauterine system has been massively popular. Sterilization is popular in older age groups, among those 45–49, 29% of men and 21% of women have been sterilized. Female sterilization has been declining since 1996, when the intrauterine system was introduced. Emergency contraception has been available since the 1970s, a product was specifically licensed for emergency contraception in 1984, and emergency contraceptives became available over the counter in 2001. Since becoming available over the counter it has not reduced the use of other forms of contraception, as some moralists feared it might. In any year only 5% of women of childbearing age use emergency hormonal contraception.

Despite widespread availability of contraceptives, almost half of pregnancies were unintended in 2005. Abortion was legalized in 1967.

United States

Main article: Birth control in the United States

Despite the availability of highly effective contraceptives, about half of U.S. pregnancies are unintended. Highly effective contraceptives, such as IUD, are underused in the United States. Increasing use of highly effective contraceptives could help meet the goal set forward in Healthy People 2020 to decrease unintended pregnancy by 10%. Cost to the user is one factor preventing many American women from using more effective contraceptives. Making contraceptives available without a copay increases use of highly effective methods, reduces unintended pregnancies, and may be instrumental in achieving the Healthy People 2020 goal.

In the United States, contraceptive use saves about $19 billion in direct medical costs each year. Title X of the Public Health Service Act, is a U.S. government program dedicated to providing family planning services for those in need. But funding for Title X as a percentage of total public funding to family planning client services has steadily declined from 44% of total expenditures in 1980 to 12% in 2006. Medicaid has increased from 20% to 71% in the same time. In 2006, Medicaid contributed $1.3 billion to public family planning. The 1.9 billion spent on publicly funded family planning in 2008 saved an estimated $7 billion in short-term Medicaid costs. Such services helped women prevent an estimated 1.94 million unintended pregnancies and 810,000 abortions.

About 3 out of 10 women in the United States have an abortion by the time they are 45 years old.

Uzbekistan

Main article: Compulsory sterilization in Uzbekistan

In Uzbekistan the government has pushed for uteruses to be removed from women in order to forcibly sterilize them.

Obstacles to family planning

There are many reasons as to why women do not use contraceptives. These reasons include logistical problems, limited access to transportation in order to access health clinics, lack of education and knowledge and opposition by partners, families or communities.

UNFPA says that “efforts to increase access must be sensitive to cultural and national contexts, and must consider economic, geographic and age disparities within countries.”

UNFPA states that, “Poorer women and those in rural areas often have less access to family planning services. Certain groups — including adolescents, unmarried people, the urban poor, rural populations, sex workers and people living with HIV also face a variety of barriers to family planning. This can lead to higher rates of unintended pregnancy, increased risk of HIV and other STIs, limited choice of contraceptive methods, and higher levels of unmet need for family planning.”

World Contraception Day

September 26 is designated as World Contraception Day, devoted to raising awareness of contraception and improving education about sexual and reproductive health, with a vision of "a world where every pregnancy is wanted". It is supported by a group of international NGOs, including:

Asian Pacific Council on Contraception, Centro Latinamericano Salud y Mujer, European Society of Contraception and Reproductive Health, German Foundation for World Population, International Federation of Pediatric and Adolescent Gynecology, International Planned Parenthood Federation, Marie Stopes International, Population Services International, The Population Council, The USAID, Women Deliver.

See also

• Life planning
• Natural family planning
• natalism and antinatalism
• Parental leave
• POPLINE (World's largest reproductive health database)
• Sex selection
• Human overpopulation
• Birth in Sri Lanka
• Women in Bolivia
• Birth in Benin
• Abortion in Panama
• Opata people
• Pledge two or fewer (campaign for smaller families)
• Reproductive coercion

International organizations

• International Planned Parenthood Federation
• Marie Stopes International
• Reproductive Health Supplies Coalition

National organizations

• British Pregnancy Advisory Service
• Family Planning Association (UK)
• Family Planning Association India
• Family Planning Association of Hong Kong
• German Foundation for World Population (DSW)
• National Alliance for Optional Parenthood (USA)
• Planned Parenthood (USA)

External links

• Siedlecky, Stefania; Wyndham, Diana (1990). Populate and perish : Australian women's fight for birth control |. Allen & Unwin. ISBN 978-0-04-442220-4  [1]
• The Environmental Politics of Population and Overpopulation A University of California, Berkeley summary of historical, contemporary and environmental concerns involving women's health, population, and family planning
• A World too Full of People by Mary Fitzgerald, NewStatesman, August 30, 2010
• Reproline-Family Planning JHPIEGO affiliate of Johns Hopkins University