FAMILY PLANNING

Dessalegn Wirtu( phD)

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 Course objectives

• Describe the evolution & rationale for FP programs

• Describe contraceptive methods and access to FP services
• Describe the key FP service delivery approaches
• Identify elements of quality FP service programs
• Describe the levels, trends & determinants of unmet need for
contraception
• Describe methods for monitoring & evaluating FP programs

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 Historical development of the concept of
RH/FP
In ancient societies, due to :
• Rampant childhood infectious diseases:
TBc, measles, whooping cough, Rubella,
• Poor or no maternal care,
( poor/no ANC, delivery and postnatal care, poor maternal
nutrition,)
• Maternal infections like TSI ( syphilis),
As a result, toll of death occurs in babies

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 Historical development…
• Only less than 50% of the babies born alive survived to
adulthood
• The need for special attention for children noted in the early
days by Hippocrates (400 – 375 BC).
• Hippocrates described the conditions at that times found in
small babies (observable conditions)
• Galen (130 – 200 AD) wrote about the importance of cleanliness
and salting in health the care
• The first pediatrics book was written by Thomas Phyre in 1545
• That listed a number of conditions (symptoms) in children but
not a specific dx

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 Historical development…
• The days of the Roman Empire was a sad time in the history of child
care: - Infanticide was widely practiced
• poor-babies were considered as burdens & nuisance
• Again the Industrial Revolution in Europe created a new problems in
the history of child care
•More mothers were working outside home
•High migration to the cities and towns;
•that caused a breakdown in the roles of extended family
•leading to limiting children care by extended family
members

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 Historical development…
• UNFPA (international NGO) was established in 1960s
• with a mandate to raise awareness about population
“ problems” &
• to assist developing countries in addressing these problems
At that time, the focus was of :
• “population booms (demographic expansion)”,
• “the world becomes an standing room only”, and
• “scarcity of food, water and renewable resources”
• To restrain this demographic expansion, fertility control
methods were invented

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 Historical development…
• Contraceptive pill became available during the 1960s along
with the IUD and long acting hormonal methods
• Population policies were formulated in d/t developing
countries during the 1970s and 1980s and
• were supported by UN agencies and a variety of NGOs
• The Motto was: “Rapid population growth would not only
hinder development, but causes of poverty and
underdevelopment’’
• Hence population policies were focused on restraining
population growth; “Using FP program”

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 Historical development…
–In 1972, WHO established the Special Program of Research,
Development and Research Training in Human Reproduction (HRP)
HRP mandated to:
• research to develop new and improved methods of fertility
regulation &
• improve safety and efficacy of existing methods
• At that time, modern contraceptive methods were seen as
reliable & independent means of controlling fertility

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 The concept of MCH/RH
The establishment of WHO (1948)
Following its establishment, four vertical priority areas were
identified.
These vertical programmes were:
– Tuberculosis
– Malaria
– MCH
– Venereal Diseases
• Later, the significance of MCH was also restated at Alma-Ata
in 1978, when MCH was identified as one of the essential
components of PHC.

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 The concept of MCH in Ethiopia

post 1978
• MCH coordinating office was established at the Ministry of
Health (in 1979 )
 MCH coordinators were assigned to the then administrative
regions
 At present the MCH/RH activities are coordinated by the
Family Health Department at MOH
 Family Health Teams and experts, were established at
regions, zones and Districts respectively,
 They were responsible for managing and coordinating
MCH/RH services.

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 The concept of MCH in Ethiopia

In 1978, primary health care was declared

MCH services started with more emphasis on:

• child survival
(immunization,U5clinic)- well/sick baby clinic &
• Family planning (the main focus for mothers’ health)

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 Family planning-Traditional FP (pre-Cairo)

The focus were:

• on control Demographic impact
• on married women
• on availability of services
• Number of contraception adoption (new users)

 Basically targeting demographic control

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 The paradigm shift of the concept of
MCH( post Cairo)

• The 1994 ICPD has marked a key event in the history of RH

• It has made the world to think of other ways of approach to RH
• During 1994, ICPD, a new strategy, was emerged & endorsed by
179/180 states
• Its emphasis was to link population issues with development &

• To help couples and individuals meet their reproductive

goals

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 Population and development are inseparably
related

Population issues

Development

• ICPD reflected the growing awareness that population could

not be considered in isolation from poverty, education, health,
the environment & human rights

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 The paradigm shift...
Focus of the paradigm was on:
– Meeting the needs of individual women and men/ couples
– Providing integrated service for all (women, men
adolescents and those beyond child bearing age) i.e..RH as a
life–cycle approach

 A paradigm shift from demographic control to human right (RH

as a basic human right) and development

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 The paradigm shift...
Reproductive Health
• Health: is a state of complete physical, mental and
social well being and not merely the absence of
disease or infirmity.
• Reproductive Health: is a state of complete
physical, mental and social well being and not merely
the absence of disease or infirmity, in all matters
related to the reproductive system and its functions
and processes.

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 Post Cairo,1994
RH Rights:
Includes certain human rights recognized in international &
national legal & human right documents:
– The rights of couples & individuals to freely & responsibly:
– decide the number of their children
– space their children,
 to have the information and the means to do so;
 The right to attain the highest standard of SRH care
 The right to choose whom & when to marry
 Equality and equity for men and women in all spheres of life
 To access quality SRH care throughout the life cycle

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 Post Cairo,1994
• The right of individuals to :
• access sexual & reproductive health services
• access services with privacy & confidentiality &
• be treated with dignity and respect,
• These were explicitly recognized at the UN (ICPD-1994),
programme of action

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 Components of RH
• RH components include the following:
– Quality FP and, IEC services;
– promoting safe motherhood (ANC, safe delivery
& postnatal care, Breast feeding);
– Prevention and treatment of infertility;
– Prevention and management of complications of
unsafe abortion;
• Safe abortion services; where not against the law;

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 Components of …
• Family planning services began in the 1966 in Ethiopia with
the establishment of the Family Guidance Association of
Ethiopia (FGAE),
(An International Planned Parenthood Federation affiliate)

• Not until the 1980s did the Federal Ministry of Health

(FMOH) add family planning to its maternal and child health
program

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 Family Planning
Definition
Family planning programs are organized efforts in the
public and private sectors:
• to provide information,
• contraceptive supplies and
• Other health services to couples & individuals
who want to space or to limit the number of their
children

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 Family Planning
• FP Refers to the use of various methods of fertility
control that will help individuals or couples to have
the number of children they want and when they want
them in order to assure the well being of children and
the parents
• It is a means to preventing unwanted pregnancies by
safe methods of prevention
 This is a basic human rights of all individuals or
couples as it is endorsed by ICPD 1994

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 Family Planning
FP helps people achieve:
• The number of children they desire when they want them
• Reduce the number of unwanted pregnancies
• Reduce the risk of sexually transmitted infection (condom),
and
• Improve the health of women and children by spacing birth or
limiting
• Reduces maternal mortality and morbidity by avoiding:
• unwanted pregnancies,
• unsafe abortions &
• high risk pregnancies

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 Family Planning
• Timing & intervals between pregnancies are strongly
related to:
• personal preference &
• social custom /norms
• Age of the mother, family desires for children,
• family supports to use FP,
• economic and social circumstances, &
• access to health care may all play a role in birth spacing

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 Components of…
• The length of time between a woman’s pregnancies
can have significant impact on health outcomes for
both the woman and her baby
• Adequate rest for mothers & regain health
• Nutrition
• Adequate time for breast feeding for baby
• Baby care ( health care nutrition)
(There should be: At least 2 yrs after a live birth)
• At least 6 month after a miscarriage or abortion (WHO
2005)

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 Rationale for family planning
• sexual rights were acknowledged in ICPD PoA as:
“to have a safe & satisfying sex life,
• men & women should have the capability to reproduce
& the freedom to decide, if, when & how often to do
so...”
• The interpretation of what constitutes a “safe &
satisfying sex life” include key aspects of sexual rights
such as:
• consensual sexual relations,
• the choice of sexual partners, and
• the achievement of sexual pleasure

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 Rationale for family planning
Implicit in this are the rights of men and women to :
• be informed of FP
• to have access to safe,
• effective, affordable &
• acceptable methods of fertility regulation of their choice &
• to appropriate health care services
• that will enable women to go safely through pregnancy and
childbirth &
• provide couples with the best chance of having a healthy infant
(WHO) (ICPD,1994)

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 FP as Human Rights

• This rationale became eminent in the 1990s, in part because of

the excesses reactions to the demographic rationale
• It rests on the belief that individuals and couples have a
fundamental right to:
• control their fertility
• make decisions,
• including family size and the timing of births
• This rationale found its strongest articulation at the ICPD, held in
Cairo, in 1994

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 Fertility and the proximate determinants

• Bongaarts’ model of the proximate determinants of fertility

( Bong. 1978, 1982) & Potter (1983) refined Davis & Blake’s
framework into 7 important factors,
• These are termed as the proximate determinants of fertility,
• These proximate determinants are:
1. Proportion of married women among all women of reproductive
age( marriage as risk factor for fertility)
2.Prevalence of contraceptive use & effectiveness
3. Duration of postpartum infecundability (or postpartum
insusceptibility)-delay return of mens s fertility rate

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 Proximate determinants of…
4.Proportion of induced abortion
5.Level of fecundability (including frequency & timing of
intercourse)
6. prevalence of permanent sterility
7. Prevalence of spontaneous intrauterine mortality

• Out of the 7 proximate determinants of fertility, Bongaarts

(1982) showed that 4 determinants are most important in
terms of explaining variations in fertility levels

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 Bonggard’s aggregate model of the proximate
These are:
1. Proportions of women married or in sexual union (as proxy of
% of women exposed to sexual intercourse)
2. Contraceptive use and effectiveness
3. Duration of postpartum infecundability (or postpartum
insusceptibility)
4. Induced abortion
• These 4 proximate determinants are of most importance both
because they differ greatly between populations

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 The Bongaarts Model
TFR = TF x Cm x Cc x Ca x Ci
where: TFR = Total Fertility Rate
• TF = Total natural Fertility rate
• Cm = index of non-marriage
• Cc = index of contraception
• Ca = index of induced abortion
• Ci = index of lactational infecundability
• The value of each index ranges between 0 &1
• Each of these indices can be estimated from survey data to
assess the relative contribution of each of these proximate
• determinants to the level of fertility.

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Chapter 2. FP Methods, Accessibility and Quality

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 Methods of FP

1.Abstinence
• Description: No sex or intimate contact until marriage or
mature enough to handle what happens with sexual intimacy

• EFFECTIVENESS: 100% effective if no semen enters the vagina

2.Natural Family Planning

Description: Natural methods that require a lot of self-control
from both partners

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 Methods of FP
The Billings Method: checking cervical mucus to determine
women’s fertile period based on changes in vaginal discharge that
occur just before she’s fertile
Effectiveness: 85%-97%. Pretty risky. Rhythm or calendar method.
Side effects: no protection against STI/HIV
 Natural Family Planning demands trust, communication, and a
supportive relationship

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 Methods of FP
3. Breast feeding
Period of infertility longer with only/exclusive breastfeeding:
– Likelihood of menses and ovulation is low during first
six
months
– After six months, even if her period has not returned, she
is
at risk of pregnancy
– Women can ovulate before menses if she is on longer only
breastfeeding or the baby is more than six months old

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 Methods of FP
• However, return of fertility is unpredictable
• If she doesn’t want to get pregnant, she needs contraception.
• Counsel women about return of fertility and risk of pregnancy
during antenatal, postpartum, newborn and child care
4. Coitus interruptus
• Coitus interruptus or withdrawal is an ancient method which is
still widely used

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 Methods of FP
5. Male Condom
Description: Thin latex or polyurethane disposable sheath worn over the
penis during sex
Effectiveness:
• 86%-98% if used correctly every time
• More effective if used with foam
Side effects: some people are allergic latex

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 Methods of FP
6.Female condom
• Description: Pre-lubricated pouch with open ring at
one end, closed ring at other.
• Closed ring anchored between cervix and vagina,
open ring just outside body.
• Effectiveness: 79%-95% effective if used perfectly.

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 Methods of FP

7. Spermicides (Foam/Suppositories)
• Description: Sperm-killing foam OR suppository
inserted into vagina before having sex
• Effectiveness: 71% effective if foam is used alone
(Not good)
• 98% effective if partner uses a condom too

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 Methods of FP

8.Diaphragm Cervical Cap

• Description: The diaphragm and cervical cap are
barrier birth control devices tailored to fit over the
cervix to prevent sperm from entering the uterus.
Effectiveness:
• Cervical Cap: 60%-80% effective
• Diaphragm: 80%-94% if used perfectly

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 Methods of FP
9.The Pill
• Description: The pill is made of synthetic hormones almost
like those produced by the ovaries
• the pill should be taken at the same time every day whether or
not a woman have sex
• Effectiveness: 95%-99% effective if used perfectly
Side effects:
• Positive- Regular periods, less anemia, less cramping, less
benign breast disease. May protect against some forms of
cancer

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 Methods of FP
• Negative- May include nausea, spotting, missed
periods, headaches, mood changes, dark skin areas
(Normally disappear within 3 months)
• Major but rare:
• blood clots, high blood pressure,
• gall bladder disease,
• heart attacks, liver tumors

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 Methods of FP
10. IUD (Intrauterine Device)
• Description: Small plastic or metal device inserted in uterus
by a medical professional. Nylon thread attached for easy
checking
• Effectiveness: 97.4%-99% effective
• Side effects: Irregular menstrual bleeding at first, then
little or no menstruation, with longer periods, spotting
between periods or skipped periods
• , headaches, nausea and weight gain

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 Methods of FP
• Check with your health provider if you experience
any unusual symptoms
Major but rare:
 blood clots, depression.
 Some IUDs may cause heavy menstrual flow (the
first few months)
 May cause cramps or other irritation as body tries to
reject IUD

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 Methods of FP

11. Injectable (Depo)

Effectiveness:- 99-99.7%
Side effects:
• Irregular menstrual bleeding at first, then little or no
menstruation, with longer periods
• spotting between periods or skipped periods,
• headaches, and weight gain.

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 Methods of FP

12. sterilization
• Sterilization is a procedure that permanently ends the
reproductive function
• Sterilization is a permanent and effective
contraceptive method.

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 FP service out lets

All possible options should be used to bring FP

information and services to the clients :
• Health Institution- Based Services
• Out reach services
• Community–based distribution (through HEW)
• Social marketing-Private out lets
• Work place (factories, Schools)

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 Benefits of FP
• Family planning can help the couples to reduce the factors that
place the health of women and children at most risk:
• Age at pregnancy (prevents too young/too old age at of
pregnancy)
• Prevents too many pregnancies
• Prevents pregnancies spaced too shortly
• Improve the future by allowing parents plan their lives
• Reduces poverty ( decrease family share, allow mothers to
economic activities)
• Opens a chance of education for mothers
• Decreases maternal & infant morbidity & mortality
• Decrease the risk of unsafe abortion

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 Benefits of FP
Social and economic benefits
• Individual:
• Pregnancy and childbirth poses a risk to the life of the
woman
• Repeated pregnancies & childbirth restrict women from
• education,
• employment & productivity
• resulting in poor status of women in the community
• Family planning helps women to pursue their education for a
better employment opportunities and payment

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 Benefits of FP
Family:
• Increased family size leads to income & resource
sharing
• Repeated & too many pregnancies entail early
weaning with the consequent of:
• high infant morbidity & mortality
• as well as the high cost of alternative infant feeding
options

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 Benefits of FP
Community:
• Increase in population size leads to increased man/land ratio
reduced
• production & income with consequent urban migration
• increase in population size results in
• poor social services,
• poor education,
• compromised increased non-productive segment of the
population,
• Deforestation, &
• over consumption of resources that aggravates poverty

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 Benefits of FP
Global:
• Uncontrolled population growth intensifies famine,
war & migration which are collectively termed
‘demographic entrapment”
• Moreover, deforestation, erosion & resource
depletion and global warming are consequences of
population explosion

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 Quality of Care & informed choice in FP
• Quality is often defined as ‘providing client-centered services
and meeting clients’ needs (Berwick et al., 1990) or consistent
with accepted standards and guidelines.
• Program is said to be of a quality if it is:
• Customer focused
• consistently involves clients in defining their needs &
• Satisfy clients’ needs
• Providing quality services is fundamental to sustain services

• Maintaining quality services can only be accomplished through

continuous problem solving and quality improvement

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 Quality of Care & informed choice in FP

Indicators of Quality FP services (Bruce-Jain Framework)

• Choice of contraceptive methods offered

• Information given to users

• clinical competence of the provider

• client/provider relations

• re-contact and follow-up mechanisms

• appropriate constellation of services-appropriate mix

• Measurement of quality should ideally address all 6 of these dimensions

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 Quality of…
Choice of method
• Offering the right to the client to choose the method means
giving confidence to the individual

• The client feels more comfortable in using the method for

which he/she has been provided with:
• clear,
• accurate
• specific information and
• which is the best for his/her needs

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 Quality of…
Information given to users
• It helps in conveying the right message and to build a rapport
with the client
• The language should be simple enough, without any technical
terms so to put the clients at ease
• It is a tool to understand client’s knowledge, attitude,
perceptions and feelings about the subject
• Providing all the necessary information helps the clients
using the selected method correctly, without no fear
• Right information clears the myths and rumors about FP

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 Quality of…

Follow-up

Correct and continuous follow up of the users is indispensable to:

• monitor the possible complications with the use of FP

methods

• It ensures continuation rate among the users

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 Quality of…

Constellation of services/ integration

• Adding family planning services along with the routine ones
under the same roof may attract more clientele

• The clients do not have to go to some other service specialized

in family planning only

• Clients discuss their problems with more openness with their

own physician in a friendly ambiance

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 Quality of …
clinical competence of the provider:
• Quality needs command on the subject
• It is inevitable to acquire all the essential knowledge and
to polish one’s technical competence regarding family
planning services
• Improve staff technical competence with training-
pre-service/in service training –continuous
professional development

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 Quality of …
• The adequacy of family planning services is measured in terms
of service output
• Service output can be classified and evaluated on three
dimensions:
• accessibility of family planning services;
• quality of services; &
• image/acceptability of the program
• service utilization important because it is closely linked with
the key behavioral change sought:
 increased contraceptive practice among the target population

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 Conceptual Framework of FP Supply Factors

External Operations
Development Management
Service
Assistance and
FP Organizational Outputs
Supervision
Structure Access
• Service infrastructure Quality
• Sectoral Integration • Training
Image/
• Delivery Strategies: • Commodity
Political and Accepta
• public–Private Acquisition/
Administrative bility
• Partnership Distribution
System
•I–E–C
Political Support
•Research &
Resource
Evaluation
Allocations
Legal Code/
Regulations

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 Global prevalence of FP use

• Globally, the prevalence of contraception of any

method among women of reproductive age (15–49),
who were married or in a cohabiting union, was 63%
in 2007
• The use of a modern method was 56%.
• Contraceptive prevalence remains low in Africa, at
28% for all methods and 22% for modern methods

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 Global prevalence of…
• The prevalence is even lower in sub-Saharan Africa,
• where, the use of any contraceptive method was 21%,
while the use of modern methods was 15%. in 2007
• In contrast, contraceptive prevalence of any method
was over 66% in Europe, North America, Asia, and
Latin America and the Caribbean
(United Nations, 2009)

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FP demand of HIV positive couples

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 Family planning demand of HIV...
• Preventing unintended pregnancy among HIV-
positive women is an effective approach to:
• reducing pediatric HIV infection and
• vital to meeting HIV-positive women’s sexual and
SRH needs (WHO 2002, 2004; UNFPA 2004).
• A review of PMTCT programs found that implementers have
not prioritized family planning (Rutenberg & Baek 2004).

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• HIV positive people need comprehensive services
• They need to know how to prevent infection & to
have easy access to condoms;
• HIV positive women may want to have children
• Prevention of mother-to-child transmission services
should not neglect other needs of the pregnant woman

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Chapter 3: The supply-demand framework for
family planning and unmet need

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 Unmet needs for family planning
• More than 100 million(17%) of married women in
developing countries, need to avoid a pregnancy
• but are not using any form of family planning
• In sub-Saharan African countries, unmet need for
family planning is reported by 25% of women in the
reproductive age group(15–49) (MDG 2010)
• Women will continue to face unintended pregnancies as
long as their family planning needs are not met

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 Unmet needs for…

• Demographers and health specialists refer to these

women as having an “unmet need” for FP
• Over the past decade, increasing rates of contraceptive
use have reduced unmet need for FP in most countries
• In some countries, however, unmet need remains
persistently high

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 Unmet Need for …
Definition:
• Women are defined as having an unmet need if
they are:
• Fecund (physiological capability of producing
offspring)
• Married or living in union,
• Do not want any more children, OR
• Want to postpone for at least two years &
• Not currently using any contraception
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 The concept of Unmet needs
The concept of unmet need was developed a long a go
(Westoff, 1978) and
Has been refined several times over the years (Westoff
and Pebley, 1981;
• The basic objective is to estimate the proportion of
women not using contraception who:
• either want to cease further childbearing (unmet need
for limiting) or
• who want to postpone the next birth at least two more
years (unmet need for spacing)

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 The concept unmet ...
• This concept has been used in the international population
field since the 1960s
• Unmet need for contraception is one of several indicators
for monitoring of FP programs, and
• Recently added to the MDG goal of improving maternal
health
• Unmet need estimates the proportion of potential users of
contraception among women
• Women who are using contraceptives are said to have met
need for family planning

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 Demand for family planning

• Demand for family planning may be divided into two

components:
• demand for limiting and
• demand for spacing.
• Women or couples who desire to terminate childbearing
are said to have a demand for limiting,
• while those who wish to postpone future births are said to
have a demand for spacing

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 The concept unmet ...
• The total demand for family planning is:
• the proportion of married women with unmet need &
• the proportion of married women with met need for
family planning
• Unmet need is sometimes interpreted as lack of access
to a source of contraceptive supplies
• However, there are many reasons why women do not
use contraception,

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 The concept unmet ..
• unmet need should not be equated with the lack of
access to contraception due to:
• supply constraints (such as distance, stock outs of
contraceptives or legal obstacles), or
• to financial costs associated with FP
• Women with unmet need may still not have
intention to use contraception while it is accessible
& of good quality

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 The concept unmet ...
• Non-use of contraception may be due to:
• cultural issues
• religious objections to contraception,
• objections from a spouse,
• lack of knowledge, or fear of side effects

• Non pregnant Women in union for at least five years

who have not used any contraception and who not
been fertile are classified as infecund
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 he concept unmet ...
The following categories of women are considered to be not in
need for FP:
• Women who are currently in union
• Women who are currently using contraception
• Women who are currently pregnant or amenorrheic who were
using contraception at the time of conception
• Women who are currently pregnant or amenorrheic and whose
last pregnancy was reported as intentional
• Infecund women
• fecund women who reported that they want the next child in
less than two years

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 The concept unmet ...
• Unmet need also includes women who are currently
pregnant or with post-partum amenorrhea:
• If she was not using contraception at time of last
conception it might be unwanted or mistimed
pregnancies/births,
• The “need” for FP services in a population cannot be
measured directly
• What is actually measured is the “unmet need for FP”

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 Measurement of of Unmet Need

In-

No unmet need
No unmet need
No unmet need

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 Unmet need…
Unmet need for spacing includes:
A pregnant women:
• whose current pregnancy is mistimed,
• Who are amenorrhoeic & not using FP
• whose last birth was mistimed or unwanted
• but now want more children, &
• fecund women who are neither pregnant nor amenorrhoeic,
• Who are not using any FP method but want to delay next
pregnancy/ birth

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 Unmet Need…
Unmet need for limiting:

Refers to pregnant women

• whose pregnancy was unwanted,
• who are amenorrhoeic but are not using FP,
• whose last child was unwanted
• who do not want any more children, and
• fecund women who are neither pregnant nor amenorrhoeic,
• but not using any method of FP & who want no more
children
• Pregnant or amenorrhoeic women who became pregnant while
using a method (these women are in need of a better method of
contraception) not in unmet need category
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 Covariates to Unmet needs
• The magnitudes of unmet needs for FP varies both across a
countries and within a country based on
• Maternal age:
• women younger (< 35 years) have a higher unmet need for
spacing,
• while older women ( >35yrs) have a higher unmet need for
limiting
• Level of education( unmet needs decreases with increasing education)
• Number of living children( the more the No. of children, the more the
unmet need for limiting)
• Urban-rural residence ( rural have more total unmet need for FP)

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 Trends of Unmet need for FP in Ethiopia
• Use of any contraceptive methods among currently
married women has increased nearly six fold in the last
20 years, from 5% in 1990 to 29% in 2011 EDHS
• The increase is especially pronounced between the years
of 2000 and 2011
• The increase in modern method use is attributed
primarily to the sharp increase in the use of injectables,
from 3% in 2000 to 21% ( seven fold) in 2011

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Trends of Unmet need for FP in Ethiopia

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 unmet need
Total unmet need 25% (Urban: 15 % & Rural: 27.5%)
Unmet need for both spacing & limiting differs by
women’s age:
• women younger (< 35 years) have a higher unmet
need for spacing,
• while older women ( >35yrs) have a higher unmet
need for limiting

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unmet need for spacing & limiting (%) by age among
currently married women age 15-49 (EDHS,2011)

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 Causes of Unmet Need
• Lack of access
• “costs” such as monetary & time
• Geographical inaccessibility
• Religion
Poor quality services:
• Provider competence( knowledge, skill)
• Quality of information given to the clients
• Provider-client relationships(judgmental attitude,)
• Gender of the providers

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 Causes of Unmet Need

•Rumors (perceived side effects)

•Quality of follow-up care
Lack of information and misinformation about:
• Available methods(variety)
• Mode of action
• Side effects
• Less perceived risk of pregnancy
• Ambivalence about fertility preferences

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 How unmet need is measured
• Unmet need for contraception is generally measured with
household surveys(DHS),
• In the DHS, women ages 15 to 49 are asked :
• whether they would like to have a child (or another child)
• & if so, how soon, or
• whether they would prefer not to have any (more) children
• If a woman is using any method of contraception,
• whether for limiting or spacing purpose
• If a woman is using contraception, including traditional
methods, she is considered to be a contraceptive user, and
therefore does not have unmet need.

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 How unmet need is measured
• Women who are not using contraception are then asked whether
they are pregnant or amenorrheic ( due to a recent pregnancy or
lactation).
• Crrently pregnant or amenorrheic women whose pregnancy was
mistimed or unwanted are added to the proportion of unmet
need,

• Women who are currently not pregnant or amenorrheic and are

infecund or
• women who want to become pregnant soon do not have unmet
need,

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 Data sources on family planning

– Facility inventory
– Client exit interviews
– Demographic and Health Survey(DHS)
– Program evaluation

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Why Are Policy makers Concerned About
Unmet Need?
• Unmet need for contraception can lead to unintended
pregnancies, which pose risks for women, their
families, and societies
• In developing countries, about 1/4th of pregnancies
are unintended-that is, either unwanted or mistimed
• One of the harmful consequence of unintended
pregnancies is unsafe abortion;
• leading to: infection, infertility, cervical
incompetency, bleeding, anemia & death

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 Why Are Policy makers…
• An estimated 18 million unsafe abortions take place each year
in developing regions, contributing to high rates of maternal
injury and death in these regions
In addition, unwanted births pose risks:
• on children’s health & wellbeing and
• contribute to rapid population growth in resource-poor
countries

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 Why Are Policy makers…
• Studies report that a significant number of women do
not want another child but are not using any method of
contraception

• This gap inspired many governments to

initiate/expand FP programs to:
• reduce unintended pregnancies and
• lower their countries’ fertility rates- rapid
population growth

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 What Are the Implications for Policies & Programs?
understanding the size of unmet need can help planners:
• To identify overall problems in the society and
• weaknesses in services that need to be overcome
• From a policy perspective, it is important for both achieving
demographic goals and enhancing individual rights

From a demographic point of view, reducing unmet need can lower

fertility that results in rapid population growth

Reducing unmet need is also important for helping couples achieve

their reproductive goals ( to space or limit)

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Importance of knowing level of Unmet need for
FP
• Knowing why women have unmet need is
useful for planning for:
• information,
• education,
• communication (IEC) campaigns and
• behavioral change communication(BCC)
programs to generate demand for FP services

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 Range of Services to be offered In Family
Planning Services
• The services shall be offered at each level of the health
system
• Counseling
• Provision of contraceptives
• At levels above a health post Screening for reproductive
organ cancers
• Prevention, screening and management for sexually
transmitted infections including HIV
• Prevention and management of infertility

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 Range of FP Services…
Provision of Contraceptives
• The contraceptive mix in Ethiopia will consist of the following
commodities and methods:
• Natural Family Planning Methods,
• Abstinence
• Fertility awareness based methods: Standard Days Method
• (SDM),Rhythm(Calendar) Method, two-days method, Cervical
mucus (Billings
• ovulation) method, Sympto-thermal method
• Lactation amenorrhea method (LAM),
• Withdrawal method
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 Ranges of FP services
Modern Family Planning Methods
• Male and Female Condoms/Diaphragms and other barrier
methods
• Vaginal Contraceptive Foam Tablet and jellies
• Emergency Contraceptives
• Progestin-Only Pills
• Combined Oral Contraceptives
• Injectables contraceptives
• Implants
• Intra-Uterine Contraceptive Devices
• Bilateral tubal ligation & Vasectomy

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 Integration of FP and other RH services
• Integration should be considered at all levels of health care
delivery system.
• Integration of FP with other RH service delivery is cost effective
and enables maximum utilization of health care services in one
visit
• HIV Counseling and Testing (HCT) services can be good entry
points to FP services and vice versa.
• Both HIV and unwanted pregnancy are consequences of
unprotected sex
• Hence clients attending HCT clinics and clients seeking FP
services are sexually active people

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 Integrating…
• With minimum input both types of providers can provide
service to clients seeking HCT and FP services at one stop
• The HIV/AIDS Policy and Guidelines for VCT for HIV,
• The PMTCT, and ART &,
• The opportunistic infections treatment in Ethiopia
• All recommend that basic FP information and services should
be incorporated into the services for all clients regardless of
their HIV serostatus.

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 Integrating…
• CAC, ANC, delivery care, postpartum care
• A woman seeks abortion or post abortion care largely because
of unwanted pregnancy
• One of the elements of comprehensive abortion and post
abortion care is provision of FP, counseling & services based
on free and informed choice
• Abortion and post abortion care can be the first encounter of a
woman with the health system.
• So, this opportunity shall be utilized to counsel and provide FP
services

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• FP counseling should be part of focused ANC services
• Though institutional delivery and postpartum care is less than
10% of all deliveries,
• it is imperative that all women who give birth at health
facilities should be counseled on FP and informed about the
availability of FP services.
• Child health and immunization services create a good
opportunity for provision of FP information and counseling

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 Family Planning Service Strategies
• Currently it is estimated that 90% of the population has access
to modern health services
• Currently the health service delivery system has introduced a
the following tier system characterized by
• a Primary health care unit (PHCU) comprising of five satellite
Health Posts, one Health Centre, and a Primary Hospital to serve
5 000, 25 000 & 100 000 population respectively;
• A General Hospital that serves 1 million people;
• and a Specialized Hospital that serves 5 million population
• All shall provide Family Planning services

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 Family Planning Service Strategies

• Family Planning services shall be delivered through the

following service delivery modalities:
• Community based services
• Facility based Family Planning services
• Social marketing
• Outreach services

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 FP Services for clients with special needs

1.Adolescents and youth

• Limited knowledge of sexual physiology, early marriage,
• limited use of contraceptives,
• limited access to RH information, and
• girl’s limited agency over her sex lives all contribute to the high
rate of unwanted pregnancy.’
Considering these facts FP services need to be youth-friendly, i.e.,
• Friendly procedures to facilitate easy and confidential
registration, short waiting time, swift referral, consultation with
or without appointment

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 FP Services for clients with special…

2.PLWH
• Dual protection is critical in reducing transmission of STIs and
HIV.
• For PLWH dual use helps to prevent transmission of the virus
to uninfected partner
• For the HIV negative client, it prevents the sexual
transmission of HIV and other STIs from an infected partner
7.3 Survivors of Sexual Violence
• Unwanted pregnancy is one of the complications of sexual
violence.
• Hence, emergency contraception shall be provided for all
victims of completed rape who are at risk of pregnancy

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 FP Services for clients with special…

• IUCD can be used as emergency contraception if the woman

presents within
• seven days of the sexual assault or chooses IUCD as a long
term option of family planning
4.Persons with disability including Mental disability
• The ability of the Persons with disability
• including mental disability to use the FP method
timely should also be considered

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Advocacy, communication & social mobilization for
FP

• Information, education and communication (IEC) combines

strategies, approaches and methods that
• enable individuals, families, groups, organizations and
communities to play active roles in achieving, protecting and
sustaining their own health
The aims of the IEC /BCC in family planning are:
• To increase awareness and use of family planning /child
spacing methods and
• other relevant reproductive health services
• Promote client-provider interaction

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 Communication channels
• Newspapers, Magazines
• Radio, Television ,sonic screens
• Leaflets, Brochures, Posters
• Banners, Billboards
• Schools
• Market places
• Home visits
• Youth and anti HIV/AIDS clubs
• Work places
• Kebele, Community meetings etc

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 Communication…
The target group shall include:
• Policy makers
• Health care providers
• Opinion leaders, religious bodies
• Women
• Men
• Adolescents and youth
• Communities
• Media personnel, partner organizations

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 HEALTH MANAGEMENT INFORMATION
SYSTEM
• Family planning records and reports are important tools for
strategic planning, supervision and monitoring.
• The Health Management Information System (HMIS) is put in
place as of 2009
1.Client Card
• The client card provides information on past and current use
of a FP method and method switch (if any).
• It is an important tool for monitoring the quality of services as
it provides information on socio-demographic and health
history,

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 HEALTH MANAGEMENT INFORMATION…

2. Family Planning Register

• Provides information on the contraceptive use in a specified
geographical area
• Useful tool for tracking clients, especially defaulters
• Provides information on supplies of contraceptives.
3. Referral form
• Records of clients referred are obtained from the referral
records
4. Supplies records
• Records of contraceptive supplies are described in section on
contraceptive logistics

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 HEALTH MANAGEMENT INFORMATION…

5. Reports
• Family planning reports provide information on the progress
of the various indicators that have been identified by the
Federal Ministry of Health.
• The reports shall include complications with use of methods
and are important tools for monitoring

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 Challenges in FP

• Inadequate funding – there has been major decline of funding

to RH services from the mid 1990’s
• Lack of funding to subsidize FP/RH services & support
outreach activities
• Lack of security for contraceptive commodities leading:
• to irregular supply to the service delivery points
• to lack of sustained demand creation for family planning
services

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 Challenges in FP
• Inadequate family planning training for service
providers
• Shortage of health workers and frequent migration
• Low level of integration of family planning with
HIV&AIDS and other health services
• Relatively low community and private sector
participation

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 To address unmet
1.Improve communication about FP
• Relevant information on FP
• Clear misinformation & rumors regarding
• side-effects
• Risks of pregnancy
2. Improve access to good quality services
• Adequate & quality supplies
• Offer choice of methods ( diversity of methods)
• Eliminate medical barriers
3. Expand service delivery points
• Home delivery ( home-to- home provision)
• Social marketing
• Provide confidentiality and privacy

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 To address unmet…
Increase male’s involvement)
Link FP services to other services( programmes)
• Prenatal care
• Post-partum care/breastfeeding
• Immunization
• Post-abortion care
• Child health services (MCH) and
• HIV services

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 Address Provider’s needs
• Training will certainly help the provider to do a better
counseling.
• It is needed to polish one’s skills to pass the right information,
to help the client in decision making,
• Information about all the FP methods/RH services: about the
local community like: social, cultural and religious beliefs is
always helpful in dealing with the FP clients
• Update knowledge about the FP methods & the new
developments in the reproductive health

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 Address Provider’s needs

• Outlet- adequately equipped service outlets for a provider is

an essential requirement for the FP/RH services
• There should be a logo / sign to show the availability of FP
services in that particular outlet
• Supplies -continuous & adequate supplies are needed at the
outlet to ensure sustainable service for the users & potential
clients
• Backup & referral for the complicated cases should be there,
where and when needed

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 Address Provider’s needs

• Feedback about the services provided in a certain outlet helps

the provider to amend and ameliorate his/her services

• Acknowledgement in the shape of certification or some

incentives to be encouraged to continue with the same
motivation and involvement

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 Supportive environments for FP in Ethiopia

Policy Environment
• The Ethiopian Government is a signatory to several
International Conventions/Charters including:
• the 1987 Safe Motherhood Conference(Nairobi),
• the 1990 World Summit for Children;
• the 1994 International Conference on Population and
Development (ICPD) and
• the 1995 Fourth World Conference for Women & other
significant int’l declarations
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 Supportive environments for FP…
Ethiopian population policy clearly states
• “… women have the right of access to family planning
information education and capacity”

• The National Health Policy also emphasizes inter-

sectoral collaboration, particularly with regards to
family health and population planning
• health and population planning.

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 Supportive environments for FP…
Service Eligibility
• The National population policy states that “Any
reproductive age person, male or female regardless
marital status is eligible for Family Planning services
including information, education and counseling” .

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 Role of Men in Family planning

Men play key roles

They can advocate for good reproductive health
• Men play dominant roles in decisions
• Couples who talk to each other reach better, healthier
decisions
• reaching men is a winning strategy
• to encourage sexual responsibility
• to foster men’s support of their partners’ contraceptive
choices
• to address the reproductive health care of couples

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 Role of Men in Family planning
 slow the spread of HIV/AIDS and other STDs
 prevent unintended pregnancies
 reduce unmet need for family planning
 foster safe motherhood
 practice responsible fatherhood
 stop abuse of women
 Their decisions and actions make a difference during:
• pregnancy
• Delivery & postpartum period

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 Role of Men in Family planning
• help mothers to take plenty of rest
• to go safely in pregnancies & childbirth
• care for babies
• for early referral for help
• ensure proper antenatal and early care

• Male participation has become especially important due to

the HIV/AIDS pandemic, the increasing prevalence of
STDs, and the problem of unwanted pregnancies

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 Thank you

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 Reading assignment:
Family planning and Population
Policy Environment in Ethiopia

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 Approaches and methods for monitoring and
evaluating family planning programs

• Evaluation is the application of social science

research procedures to judge and improve the ways
in which social policies and programs are
conducted,
• It starts from the earliest stages of defining and
designing programs through their development and
implementation (Rossi and Freeman,1993).
• Evaluation results should inform program
management, strategic planning, the design of new
projects or initiatives, and resource allocation
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• The evaluation of family planning programs includes
both program monitoring and impact assessment
• Monitoring is used to determine how well the
program is carried out at different levels and at what
cost;
• it tracks change that occurs over time in the resource
inputs, production/process, and use of services

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• Impact assessment measures the extent
to which this change can be attributed to the
program intervention (cause and effect)
• The results of program monitoring are indispensable
for program management because they inform the
manager whether the program is on track, where the
problems are, and what unexpected results have
occurred

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• Evaluation results are also important inputs into
strategic planning and program design
• Measures of program performance, output, and
population outcomes describe the current state of the
demand for services and the program environment
• Results linking inputs and activities to program
outputs and changes at the population level serve to
demonstrate what has worked in the past and to
suggest potential directions for the FUTURE ACTIONS

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• Successful interventions can be scaled up or
replicated in new program or project phases,
• whereas activities that do not produce results
can be phased out
• Moreover, evaluation can be used to explore
why certain interventions did not work

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 SCOPE AND FOCUS OF EVALUATION

• Evaluations vary greatly in scope and focus.

For example, the target area may be defined as:
• the entire country;
• an entire region or state; or
• a specific city or location
Evaluation can focus on different program components:
• on inputs,
• On Processes,
• on outputs, and outcomes.
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• Measurements can be taken at:
• At the population level (e.g., among a random
sample of the general population), or
• At the program level (e.g., among clients or
participants in a given program).
• Different techniques are used to collect and analyze
the data:
quantitative, or
qualitative

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• The specific target population will vary in different
settings and for different types of interventions:
e.g. For family planning: all women of reproductive age
For integrated family planning (STD/HIV prevention)
all sexually active adults or
For adolescent programs: Adolescent aged 10 –
19

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• The adequacy of family planning services is
measured in terms of service output
• The term output refers to results achieved at the
program level;
• service refers to the objective of improving the
service delivery system
• Service output can be classified and evaluated on
three dimensions:

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• accessibility of family planning services;
• quality of services; and
• image/acceptability of the program
• By making services more accessible and satisfactory
to potential clients, national family planning
programs strive to achieve the second key output: an
increase in the utilization of these services

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• In the case of family planning, service utilization is important
because it is closely linked with the key behavioral change
sought: (increased contraceptive practice among the target
population)
Contraceptive prevalence refers to the percentage
of women of reproductive age in the target population (or
their partners) using a contraceptive method at a given point
in time

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• Contraceptive use directly affects fertility.
• In analyses of the factors responsible for recent fertility
decline in developing countries, contraceptive use emerged
as the most important.
• Other inter-mediate variables (or proximate determinants
of fertility) include
• the percentage of women of reproductive age in sexual
unions,
• the percentage of women in the non–susceptible post–
partum period, and
• the prevalence of abortion (Bongaarts, 1978).

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 Levels of Indicators in Family Planning Program
Evaluation

Program–based ( performance) Population based(outcome)

• input • Effect (Intermediate)
Process • Impact (Long–term)
Output

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• Within the program level it is important to
further differentiate the components
• Inputs (program resources) are fed into processes
(program activities), which in turn produce output
(program results) and ultimately outcome
(population–based results),
• as shown in the following sequence
• Input Process Output Outcome

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Inputs are:
• human and financial resources,
physical facilities,
• equipment, and
• Operational policies that enable services to be
delivered

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• Process refers to the multiple activities that
are carried out to achieve the objectives of
the program
• It includes both what is done and how well
it is done
• Output refers to the results of these efforts at
the program level

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• Two types of output, are service output
(that measure the adequacy of the family planning service
delivery system) and
• service utilization (that measures the extent to which the
services are used)
• Within the category of population–based evaluation, it is
important to distinguish between two kinds of outcome:
• intermediate and
• ultimate (long–term)

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• Effect (intermediate outcome):
that which is a relatively direct and immediate
result of program process and output
(e.g. contraceptive prevalence)
Impact (ultimate outcome):
that which is an anticipated result of program
process and output in the long–term
(e.g., change in fertility rates), but also subject to the
influence of many non–program factors (such as
socio–economic conditions or status of women)
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• Many family planning programs are designed
to reduce fertility; however, it often takes years to
produce this impact
• Thus, program evaluations often concentrate
on intermediate level outcome (effects), which are
seen as more directly linked to program effort and
which are expected to reflect change in a shorter
period of time

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• The most widely reported intermediate outcomes of
family planning programs are:
• contraceptive prevalence Rate, and
• the percentage of women of reproductive age
currently using a contraceptive method

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INDICATORSTOMEASUREDEMANDFOR
FAMILYPLANNING

• Demand for family planning refers to the desire or

motivation of women or couples to control their future
fertility
• Demand for family planning is said to exist when the
supply of children exceeds the desired or preferred
number.
Women or couples are assumed to continue (or at
least intend to continue) to bear children until such
time as the desired number of children is reached,
at which time it is assumed that they will be moti-
vated to control future pregnancies
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• Demand for family planning may be divided
into two components: demand for limiting and
demand for spacing.
• Women or couples who desire to terminate
childbearing are said to have a demand for
limiting,
• while those who wish to postpone future births
(but not to terminate childbearing) are said to
have a demand for spacing
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• measures of demand for limiting and spacing
provide valuable information on current and
projected future program needs in terms of
the mix of services and contraceptive methods
• DE M A N D F O R L I M I T I N G
Definition
The number or proportion of women currently
married or in union who are fecund and who
desire not to have additional children

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• The indicator is calculated as follows:
DL = CL + UL + FL
DL= the number or proportion of women currently married
or in union with a demand for limiting,
CL= the number of women currently married or in union desiring no additional
children who are currently using a contraceptive method (i.e., met demand)
UL = the number of women currently married or in union who desire
no additional children but are not currently using a contraceptive
method, plus the number of currently pregnant or amenorrheic
women currently married or in union whose current/last
pregnancy was unwanted and occurred
while not using a contraceptive method (i.e., unmet demand), and

156
FL= the number of currently pregnant or amenorrheic women
married or in union whose current/last pregnancy resulted
from contraceptive failure
Data Requirements ( what?)
Responses to survey questions on:
desire for additional children;
current contraceptive use status;
current fecundity, pregnancy, and amenorrhea
status for women not currently using a contraceptive method;
the wanted status (with respect to number)of the current/ last
pregnancy for women currently pregnant or amenorrheic; and

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• whether a contraceptive method was being used at
the time of the current/last pregnancy among
currently pregnant or amenorrheic women (i.e.,
whether the last/current pregnancy resulted from
contraceptive failure).
Data Source(s)
Population-based surveys

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2. D E M A N D F O R S P A C I N G
Definition
The number or proportion of women currently married or in
union who are fecund and who desire to delay the birth of
their next child for a specified length of time (for example, for
two years from the date of a survey)
he indicator is calculated as follows:
Ds = Cs + Us + Fs
Ds= the number or proportion of women currently married or in
union with a demand for spacing,

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Cs = the number of women currently married or in
union desiring to delay their next pregnancy for a
specified length of time who are currently using a
contraceptive method (i.e., met need),
Us = the number of fecund women currently married or in union who
desire to delay their next pregnancy for a specified length of time but are
not currently using a contraceptive method, plus the number of currently
pregnant or amenorrheic women married or in union whose current/last
pregnancy occurred earlier than desired and who were not using a
contraceptive method at the time of pregnancy (unmet need or demand),
and

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Fs = the number or proportion of currently pregnant or
amenorrheic women married or in union whose current/last
pregnancy occurred earlier than desired as a result of
contraceptive failure
Data Requirements
Responses to survey questions on:
desire for additional children and, among women desiring
additional children, the preferred length of birth interval;
current contraceptive use status;
current fecundity, pregnancy, and amenorrhea
status for women not currently using a contra ceptive method

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• The wanted status (with respect to timing) of the current/last
pregnancy for women currently pregnant or amenorrheic;
and
n whether a contraceptive method was being used at the
time of the current/last pregnancy among currently pregnant
or amenorrheic women
• Data Source(s)
Population-based surveys

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• TOTALDEMAND(FORFAMILYPLANNING)
• Definition
The number or proportion of women currently married or in union who are
fecund and who desire to either terminate childbearing or to post-
pone their next birth for a specified length of time.
• Total demand is calculated as:
D = DL+ Ds
Where:
D = the number or proportion of women currently married or in union
with a demand for family planning,
DL = the number of women currently married or in union with a demand
for limiting, and
• Ds = the number of women currently married or in union with a demand
for spacing.

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• Data Source(s)
Population-based surveys.
UNMETNEEDFORFAMILYPLANNING

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