When I first began work in community-based health care in the 1990s, only 3 percent of married women in Ethiopia used a modern method of contraceptive. Family planning was scarce, to say the least.
In 1990, on a visit to a rural community in eastern Ethiopia, I discussed family planning issues with a group of women living there. Most of the women were married as young as 15 years of age or younger, had an average of 7 or 8 children, and believed that pregnancy needed to occur every year in order to prove their fertility to their husbands and the community.
Almost every community member who I met had misconceptions about modern contraceptive methods and very little awareness about family planning.
It was clear that women in the country were in dire need of reproductive health and family planning information and services. Because of the low contraceptive prevalence rate (i.e., most women were not using contraception), fertility was high and Ethiopia’s maternal mortality rate was one of the highest in the world.
With un-spaced pregnancies, the chances of complications occurring during pregnancy, labor, and delivery are very high—contributing to the high level of maternal mortality. Every pregnancy a woman faced was like the game of roulette, with her risk of death increasing as she experienced more pregnancies. In addition, families struggled to support large numbers of children, which strained already struggling families.
But in the last few years, we’ve seen a significant shift.
Newly released, preliminary, data from the 2011 Demographic and Health Survey shows that the contraceptive prevalence rate in Ethiopia has doubled since 2005 and is now at nearly 30 percent.
The increase year over year has, in many ways, been unprecedented. Ethiopia is one of only three countries to see contraceptive prevalence rate double twice in less than a decade. And even more important, few, if any countries that have contraceptive prevalence rates of over 10 percent have seen continued increases of more than one percent. (Basically, it’s a lot easier for countries to see the use of contraception increase when there are fewer women using contraception, but more difficult to realize larger gains once a higher percentage of women are using it).
So the question is: why this sudden change? How did Ethiopia go from just a three percent contraceptive prevalence rate to nearly 30 percent in just 20 years?
The “What” in What Works
I believe Ethiopia’s family planning improvements are due to a rare combination of strong government commitment, solid public-private partnerships, thoughtful international donor support, and a unique community mobilization effort.
Seven years ago, the government of Ethiopia made a commitment to family planning. Following international pledges to improve women’s health, the government focused on mobilizing resources for community outreach—particularly in rural areas—through a network of health extension workers who bring health information and services to areas that have lacked both health care facilities and health workers.
In partnership with local and international NGOs, the government trains these health extension workers to provide health information and services, including family planning counseling and contraception.
We’ve seen great success in particular with access to short-acting contraceptive methods including use of injectable contraceptives, as well as long-acting family planning methods such as implants. Findings from ongoing operational research show that the uptake of Implanon, a one rod implant that health extension workers have been trained to provide, is particularly successful in these rural, hard to reach areas for addressing the unmet need for family planning.
In addition, the government invested in building a network of health posts and improving funding for contraceptive supplies, with the support of the international donor community.
The building of over 15,000 health posts has increased the provision of basic health services and provides a base from which the health extension workers can reach out to communities. Clients in need of other services beyond the level of the health post are linked by the health extension workers to the next level. And with the investment in contraceptive supplies, the health extension workers can meet the needs of clients with a steady supply of family planning methods.
Spreading Family Planning Success
This week, leaders, health providers, researchers, and donors gathered in Dakar, Senegal at the International Conference on Family Planning. We’ve shared and listened to a range of strategies to improve the health of women and families.
My hope is that we can take the lessons learned in Ethiopia—strong government commitment, strategic investments, solid public-private partnerships—and use them as a model for future improvements for family planning everywhere; particularly in other areas of the world where family planning and other basic health services still remain low.
Family planning saves lives. As use of contraception in Ethiopia has increased, maternal mortality has declined and our total fertility rate is now 4.8 children per woman.
Today with the increased level of awareness at the grassroots level compared to the 1990s, communities are demanding better access to quality family planning services. Women, and indeed, all people, have the right to family planning. But to realize that right, we need stronger commitments and investment in strategies that work.