columnBy Janet Fleischman and Alisha Kramer
Billboards in Ethiopia's capital announce the 2013 International Conference on Family Planning from November 12-15, under the theme "Full Access, Full Choice". The conference participants from around the world should draw lessons from Ethiopia's own experience that family planning is central to broader women's health and development, contributing to the empowerment of women and girls and more stable and prosperous families. U.S. Secretary of State John Kerry's video message to the conference offers a unique opportunity for the United States to strategically reposition family planning as key to sustainable development, and to re-double U.S. commitment to national family planning programs.
We saw first-hand some of the remarkable health and development progress attributed to increased access to family planning information and services around Ethiopia. According to the 2011 Demographic and Health Survey (DHS), the contraceptive prevalence rate in Ethiopia has almost doubled since 2005, from 15 percent to 29 percent. The government's health extension program (HEP), comprising 38,000 predominantly young women health extension workers (HEWs), is unparalleled in Africa; the HEP has contributed directly to rising awareness about the importance of delaying first births, birth spacing, and the availability of modern contraceptive methods. Another impressive result of the HEP has been the sharp reduction of under-five child mortality, which has enabled Ethiopia to meet Millennium Development Goal 4.
Yet Ethiopia faces daunting challenges. It is a vast, diverse country, with a population of 85 million, making it the second most populous country in Africa. It is also one of the world's poorest countries, with limited resources to address a myriad of health, nutrition and development problems. Maternal mortality remains stubbornly high, partly because only 10 percent of pregnant women deliver at health facilities. Unmet need for family planning also remains very high, especially among young women and married adolescents. Cultural practices such as child marriage and female genital mutilation/cutting (FGM) put girls at escalated risk of adverse health outcomes when they begin to have children. Once pregnant, most of these girls will drop out of school, furthering their social isolation and limiting their opportunity to gain knowledge and skills that could empower them economically and socially. Ethiopia's dominant, single-party government has driven impressive improvements in many health and development indicators, but its constraints on civil society and the private sector risk undermining the sustainability of health programs.
The HEP is a hallmark of Ethiopia's health response. In 2003, the government launched an unprecedented program to bring basic primary and preventive health services to the entire country, including hard-to-reach rural areas. Health extension workers are selected from local communities; they are trained, paid by the government, and deployed back to their communities. The government's goal was to have two HEWs per kebele, the smallest administrative unit in Ethiopia. Family planning information and services have been key components of the HEP, and demonstrated that providing more opportunities for services leads to escalating demand. Especially important was the decision to allow HEWs to deliver a range of family planning services; they have been trained to provide injectable contraceptives (depo provera) and to insert long-acting methods, such as the contraceptive implant, Implanon, which remains effective for up to three years.
At a rural health post in the Tigray region, we spoke to a young woman named Meheret, who has been a HEW for eight years, and had received training through the USAID-funded Integrated Family Health Program implemented by Pathfinder International. She has seen many changes during that time but remembers well the tough challenges at the outset. After gaining the support of local administrators and religious leaders, she has found that the community better understands the benefits of healthy timing and spacing. "If you get pregnant or married in school, you have to discontinue your education," she said. "Even if you can continue, having a child means you're not as active as the others... it affects your achievement." Meheret was married at age 12, and had her first child at 17. "In my time, we didn't know where to get family planning," she said.
The important role of religious leaders in supporting family planning cannot be underestimated. Concerted efforts have been undertaken by health workers, nongovernmental organizations, and the government to engage religious leaders from the Orthodox Church and Islamic communities on family planning and safe motherhood.
We met a priest named Gebretsadkan on a rocky hillside in Tigray. He said that there used to be resistance to many health activities, including those related to family planning and HIV/Aids. But after participating in information programs, he began to teach his followers about the benefits of spacing children. "To space children is not a sin," he explained. "What is a sin is to be hungry, to have hungry children."
At a health center down a narrow path from the main road in the Amhara region, we met a deacon who worked as a family planning provider. "Women are happy when they hear I'm a deacon," he told us. "Women are afraid it will conflict with religious matters. I tell them there's no conflict, that they can use the service freely. I tell husbands that using family planning reduces children's and mothers' health problems." He went on to describe the improvements in his community: many women have smaller families and are better able to care for their children. In addition, young married girls are not dropping out of school due to repeated pregnancies.
Reaching adolescent girls with family planning information, especially married adolescents, remains extremely difficult. In the Amhara region, where child marriage is still widespread, we met many girls who had been married at ages 12, 13 or 14, and who were 13 or 14 at their first pregnancy. These girls described the barriers they faced in accessing family planning: husbands who refused to allow it, which left them no choice but to seek services secretly; mothers-in-law who found their pills and threw them out; and families and communities that saw no value in allowing them to stay in school. These girls knew well the possible health consequences of giving birth at such a young age. Sitting under a tree, a girl wrapped in a black scarf told us that she was 14 when she experienced a prolonged and difficult labor: "I was not ready to give birth. My bones were not ready to give birth." Another girl told us about her friend who had been married at 12 and died in childbirth, and others described cases of fistula, resulting from giving birth at such a young age.
The girls we met were the fortunate ones. They had participated in unique programs, one organized by CARE and another by the Population Council, designed to help married adolescents gain knowledge and skills, including information on health and family planning. One of the girls in the Population Council's program explained: "Before the program, we followed the culture of our mothers - no child spacing. Year after year, we'd give birth. Now we understand the effect. We have a different understanding from our mothers."
The Ethiopian government recognizes the value of incorporating family planning into its development agenda. Dr. Kesete Birhan, the minister of health, told us the ways that family planning has an impact on development, by allowing women to participate in microfinance and savings schemes, improving the nutritional status of their children, and enabling them to send their children to school. "Family planning isn't about limiting the family or population size," he told us. "It's about giving voice and choice to women in Ethiopia to decide when and whether to have children."
The important gains made in Ethiopia remain vulnerable. Despite increased financial commitments by the government, the public sector family planning program relies heavily on external funding. The government's uneasy attitude toward the private sector leaves a gap, given data that cost recovery could contribute to greater sustainability for family planning services. And while important changes have been registered in improving the status of women and girls, long-standing social and cultural barriers still stand in the way of equitable access to education, economic assets and leadership positions.
Despite the many challenges, Ethiopia exemplifies why access to family planning is inextricably intertwined with achieving broader health and development goals, and why this should be a strategic priority for the United States. The International Conference on Family Planning provides an opportunity to showcase these successes, identify approaches to ongoing challenges, and re-commit the global community to these critical goals. As Ethiopia's First Lady, Roman Tesfaye, told us: "To be engaged in the economic sphere, to create income, to contribute to family health and well-being and to the country's development, we must have family planning services."
Janet Fleischman is a senior associate with the CSIS Global Health Policy Center, and Alisha Kramer is a research assistant and program coordinator with the CSIS Global Health Policy Center. They traveled to Ethiopia in October 2013.