Learning from success cases: ecological analysis of potential pathways to universal access to family planning care in low- and middle-income countries.

Selected geographies

Based on previously published literature^7,8,26,27, we sought countries from each of the UNICEF world regions with successful stories of increasing contraceptive use and reducing inequalities. Within each region, we looked up for the countries that presented the largest progress in increasing coverage or the ones that managed to rapidly increase it in the last years. We also considered countries that managed to increase coverage among disadvantaged women, such as the youngest, poorest, least educated, and rural residents. To present a broad picture while limiting the total number of countries in the study, we did not include more than two countries per region. We selected one country from the Middle East and North Africa (Egypt), two from Eastern and Southern Africa (Ethiopia and Rwanda), one from Asia (Afghanistan), and two countries from Latin America and the Caribbean (Brazil and Ecuador).

Study design and data collection

We used data from publicly available national health surveys, including Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), and Reproductive and Health Surveys (RHS) carried out since 1986. These surveys are: Afghanistan 2010, 2015; Brazil 1986, 1996, 2006, 2013; Ecuador 1994, 1999, 2004, 2012; Egypt 1995, 2000, 2005, 2008, 2014; Ethiopia 2000, 2005, 2011, 2016, 2019; Rwanda 2000, 2005, 2010, 2014. All surveys included use standardized data collection procedures²⁹.

To increase the amount of information for each selected country we also used estimates provided by the World Bank (https://data.worldbank.org/) based on other sources of data. To check the consistency of these estimates with the ones based on surveys, we compared existing survey estimates with those published by the World Bank and found no difference in most cases. The comparisons are presented in the supplementary material. A complete list of surveys used in the analyses is presented in Table 1 and underlying data is published at Harvard Dataverse²⁹.

Study population

We evaluated demand for family planning satisfied by modern methods (mDFPS) among women who were married or in a relationship. mDFPS is defined as the proportion of women in need of contraception that were using (or whose partner was using) a modern contraceptive method. Women were considered in need of contraception if they were fecund and did not want to become pregnant within two years or were unsure if or when they wanted to become pregnant. Those who were pregnant at the time of the survey and declared the pregnancy was unintended were also considered in need of contraception. Women were classified as infecund if they were menopausal; had had a hysterectomy; had never menstruated; had had their last period more than six months ago and were not postpartum amenorrhoeic; said they cannot get pregnant; or if they had been married for at least five years, had never used contraception and not become pregnant in the previous five years³⁰.

Different definitions of modern contraceptives have been proposed in the last years^31,32. In this analysis, modern contraceptive methods were defined as medical procedures or technological products³¹ and included short-acting reversible methods (oral contraceptive pills, injections, spermicides, and male and female condoms); long-acting reversible contraceptives (intrauterine devices (IUD) and implants); and permanent methods (female and male sterilization). This definition does not consider lactational amenorrhea nor any calendar-based method as modern. Although they can be as effective as the methods we are considering as modern, they were not included here since they require a recent pregnancy or couples avoid sex.

Ethical approval

Ethical clearance was responsibility of the institutions that conducted the surveys, all of them were approved by the national committee of each country. All survey data are anonymized.

Data analysis

For some surveys, information to identify women in need of contraception was not available. Given the high correlation between demand for family planning satisfied and contraceptive use prevalence, we estimated mDFPS using the following predictive equation³³:

where mDFPS is demand for family planning satisfied by modern methods and CPMO is the modern contraceptive use prevalence.

CPMO was estimated for all countries without information to estimate mDFPS, considering it as the proportion of women 15-49 years of age currently using a modern contraceptive method. As mDFPS, CPMO was restricted to women who were married or in a union.

The bulk of this study consists of a descriptive analysis of changes in family planning coverage and contextual factors. We used scatter plots to explore changes over time in mDFPS along with changes in the proportion of total population living in extreme poverty (less than US$ 1.90 a day), and in levels of gender inequality. This was measured by the Gender Inequality Index (GII), a composite measure reflecting inequality in achievement between women and men in three dimensions: reproductive health, empowerment, and labor market. A complete description of the index is available elsewhere³⁴. Using survey data, we also evaluated changes over time in mDFPS against changes in the mix of contraceptive methods used in each country and inequalities according to wealth, women’s age, and women’s education. Visual representation of absolute inequalities by each factor was accessed using equiplot graphs (equidade.org/equiplot) while changes in method mix were presented in stacked bar charts.

Wealth was measured based on an asset index obtained from information on household assets, presence of electricity, water supply, sanitary facilities, and building materials of the dwelling, among other variables^35,36. The wealth score was obtained through principal component analyses, estimated separately according to area of residence, since relevant assets may vary in each area, and were later combined into a single score using a regression-based scaling procedure³⁵. The scores assigned to the households were then used to divide them, weighted by the number of residents, into five equally sized groups. Women’s age was categorized in three groups: 15–17 years, 18–19 years, and 20–49 years. Women’s education was classified according to the highest level achieved (none, primary, or secondary/higher).

All analyses were conducted in Stata 16.0 (StataCorp, College Station, TX, USA), always considering the multi-stage survey design, including sampling weights and clustering.

Country cases

Egypt. Egypt, an Arab country with historical cultural norms regarding early marriage and large families, began its commitment with family planning practices aiming to control population growth due to the narrative of its negative effects on availability of resources and national development⁴⁶. Egypt started to limit its population growth in the 1930s and in the 1950s the government started its endorsement of birth control and modern contraceptives were increasingly available^46,47. With a high level of coverage since the 1980s, part of the Egyptian success in increasing contraceptive use was due to an early agreement between Western donors, national health professionals and female activists who managed to increase public trust and women’s demand for family planning⁴⁶. The involvement of different leaders led to the promotion of family planning in community contexts and health facilities, integrating family planning with both health and social services⁴⁶. Another differential of Egyptian family planning policies was that family planning messages were not designed in favor of couples’ choices regarding family size, but were in favor of smaller families⁴⁸.

Egypt decreased its total fertility rate of 5.6 births per women in 1976 to 2.8 in 2007^46,49. Between the 1970s and the early 2000s, in a context of political instability, the number of health facilities have increased over 50 percent and the resources allocated by national government to family planning services have increased by 400 percent, contributing to an increase in the contraceptive use prevalence from 19% in 1976 to 59% in 2005^49,50. The reduction in fertility rate was largely credited to the increased use of contraception, and in a smaller measure to the increase in the number of induced abortions and the increase in the age of marriage^48,49.

In the family context, factors identified as important determinants of contraceptive use were the desire for less children, the number of living children, place of residence, woman’s work after marriage, and the level of education of the woman and her husband⁵⁰. Although we found a high level of gender inequality until the 2010s, previous studies indicated that Egyptian families have been built upon more equitable standards. In 1992, men and women already had similar fertility preferences, with an ideal family size of three children on average⁵⁰. While in 1992, only 29% of Egyptians declared that there was an agreement in fertility preferences⁵⁰, in 2008, already more than 85% of women using modern contraceptives had declared that this decision was made jointly with their husbands⁴⁸. Despite the progress in women’s education, female employment and wife’s opportunity cost did not lead to a significant lower number of wanted children during the peak of increase in modern contraception⁴⁸. More recent studies have found a significant effect among women with secondary level or higher⁵¹, however, the early adoption of family planning policies seems to be a stronger factor in the desire for smaller families and modern contraceptive use among women of all socioeconomic groups in Egypt⁴⁸.

Ethiopia. Ethiopia is one of the most populous countries in Africa, which had been exposed to huge political instability in the second half of the 20^th century, with the abolishment of the parliament, domain of an authoritarian revolutionary regime, suspension of the constitution, and land expropriation^52,53. Since the 1980s, Ethiopians have been facing water scarcity and repeated famine episodes. The critical scenario naturally affected the desired family size in Ethiopia. Following this increased demand for contraceptives and in partnership with international donors, Ethiopia managed to increase provision of contraceptive methods and, consequently, the national coverage raised. Modern contraceptive use prevalence increased from 2.9% in 1990 to 27.3% in 2011, and total fertility rate declined from 7 children per woman to 4.8, respectively⁵⁴.

The first movement related to family planning policies in Ethiopia occurred in 1966, with the foundation of the Family Guidance Association of Ethiopia, affiliated with the International Planned Parenthood Federation. The first national policy was implemented in the early 1990s and, as in Egypt, its primary concern was to reduce the population growth to promote socioeconomic development. Aspects addressed in this policy were the elimination of legal barriers to socioeconomic rights for women and family planning propaganda advising in favor of smaller families. The following policies expanded the sources of contraceptives and proposed new plans to end poverty and expand the number of health providers and sources of contraceptives^54,55. Structural factors such as the number of modern contraceptive methods available and distance to health facilities have been identified as significant factors associated with increased use of contraception among Ethiopian women⁵⁶. Family planning was also included in HIV, postabortion and postpartum services^54,57. Later on, in the early 2000s, the national government launched the Health Extension Plan, which delivers primary health care and family planning services in the more vulnerable settings, and has removed import taxes to contraceptive methods^54,57. Since 2009, health extension workers were allowed to provide implants and midwives to insert IUDs^58,59. It was a successful strategy, which was fundamental for the increase of long-acting reversible methods. In the 2012 London Family Planning Summit, Ethiopia put family planning in the core of its health system, aiming to address aspects related to supply of contraceptives, increase of the family planning budget, reduce early marriage, and improve its strategy to meet the needs of adolescents^54,60. Complementary to the health extension workers, school-based family planning programs have being providing sexual and reproductive education to girls and reinforcing the importance to use contraception and continue education⁶⁰.

Among the selected countries, Ethiopia was the leading country in reductions in the proportion of the population living in extreme poverty and managed to increase mDFPS among women from all groups of age, wealth, and education. The progress made in Ethiopia was also made possible by the international donor support and by the support provided by nongovernmental organizations, improving service delivery and promoting behavior-change campaigns. Because of its delicate situation and the national government commitment with family planning, Ethiopia was the African country that received most international funding for family planning. In addition to monetary resources, Ethiopia has been receiving technical and management resources from the Global Health Initiative⁵⁴.

Rwanda. Between 2005 and 2015, Rwanda increased its modern contraceptive use from 17% to 53%⁶¹ and decreased its total fertility rate from 6.1 to 4.6 births per woman⁶². The major factor that possibly contributed its success was the government commitment, who increased the family planning budget and made family planning services available^54,61–63. Family planning services in Rwanda are still being funded mostly by international organizations⁶¹, but the national government made them a national priority and, with collaboration of different sectors, innovation and evidence-based strategies, have been implementing and supporting family planning policies^63,64.

The discussion on promotion of contraception started in Rwanda much later than in Egypt and Ethiopia, in the early 1980s, with the creation of the National Office of Population⁶⁴. National family planning policies in Rwanda have been built upon strong campaigns with training of providers, increase of the range of methods available, and mass media campaigns⁶². Aiming to improve reproductive health outcomes and endeavor national development, the creation of the National Reproductive Health Policy in 2003 addressed issues related to women’s, adolescent’s and child’s health, prevention of sexually transmitted infections, family planning, and women’s decision-making power^63,65. With the 2005 National Policy for Family Planning and the 5-year strategy, other important aspects were addressed in order to increase family planning coverage, such as the encouragement of the participation of men and the whole community in family planning discussions, increased efficiency in the provision of family planning services, construction of more health posts, facilitated distribution of short-acting reversible methods by community health workers, and the promotion of training to insertion of long-acting reversible methods and male permanent contraception^61,62. These policies are aligned with our findings that between 2005 and 2010 Rwanda achieved not only important increases in mDFPS, but also reductions in gaps in coverage and a more balanced mix of methods, with a reduction in the role of sterilization and an increase in the share of long-acting methods. Another potential contributor for this improvement was the decentralization of health services, with increased access to health services for those living in rural areas^61,63.

The increased number of women in the parliament has suggested that part of Rwanda’s success in family planning programs is related to gender-equality issues at a macro level⁶⁵. However, since the start, the main aim of family planning policies in Rwanda has been to reduce population growth, not to tackle gender equality^62,63,65. Pursuing the government aim to transform Rwanda into a middle-income country by 2020, family planning messages have been putting smaller families not only as contributive but as imperative to reduce poverty and promote development^62,63,65. On the other hand, along with the provision of family planning services, education, job opportunities, and empowerment of women were promoted by national policies in order to support behavior changes regarding fertility preferences⁶⁴.

Previous studies indicate that individual factors associated with greater use of contraception among Rwandese women were their level of education, place of residence, agreement with their husband regarding the desired number of children, experience of child mortality, and exposure to family planning information⁶².

Afghanistan. The impressive progress observed for the other selected countries was not observed for Afghanistan. Even so, it was the country with the fastest increase among the Asian countries with available data. The Islamic Republic of Afghanistan is a country with strong religious and strict social norms, and it has been ravaged by war and plagued by political instability under the Taliban from 1996 to 2001^66,67. Despite the issues in its health and education system, the country managed to increase family planning coverage in the past two decades, after the deposition of the Taliban regime, in 2001, with the US led invasion of the country^66,67 and the implementation of important strategies. Important factors associated with this success were the engagement of different members of the community in family planning discussions, the focus on the benefits of birth spacing to the health of children and mothers, literacy programs for women, and the increase in the number of female community health workers⁶⁸.

In the late 1990s, Afghanistan had a total fertility of 7.5 children per woman and one of the highest rates of maternal mortality in the world⁶⁷. With the family planning messages focusing on the importance of larger birth spacing, parity started to decline and the age of first childbearing started to increase in the early 2000s⁶⁶. The first national health policy was implemented in 2003, the Basic Package of Health Services, which aimed to deliver a variety of health services, including family planning⁶⁶. The higher acceptance of family planning among Afghan families is probably due to its specific approach, that was more sensitive to the health benefits of larger birth spacing than to the potential economic benefits of smaller families⁶⁸.

Differences in acceptance of contraception between different ethnic groups in Afghanistan has been documented⁶⁷. Despite the huge heterogeneity, increase in contraceptive use has been documented in regions where religious leaders supported it^68,69. In some settings, they were also providing family planning knowledge to men. This represents a very important advance, since Islam is not only the predominant religion, but the foundation of their culture and their lives⁶⁸. Despite the religious concerns regarding family planning, Islam allows it when pursuing the common good or when the family is very poor^68,69.

Strong cultural gender inequalities are another barrier to contraceptive use, due to the preference of a male child, which tends to increase the number of children, and due to power imbalance between husband and wife^68,69. Another barrier to contraception is the influence of other family members in the desired family size. Life experiences of older family members tend to be passed on to current generations⁶⁹.

Important strategies to deal with these barriers were the promotion of basic education to women, the support from non-government organizations, family planning services working with both men and women, the integration of family planning with other health services, and the implementation of community health workers⁶⁸.

Despite the improvement in family planning coverage starting in 2000 with the end of the Taliban rule, there was much space to increase coverage, which stalled after 2008. Several basic aspects were not addressed, such as the lack of male involvement in family planning counseling, limited method mix offered in public facilities, limitation of health providers to offer specific methods, such as IUD and injectables, and religious prohibition of some contraceptive methods⁶⁹. Unfortunately, the progress that was achieved in the previous decades is now being lost after the Taliban regained power in 2021⁷⁰. Notwithstanding, we opted to keep Afghanistan in our study since our analysis was in an advanced stage in 2021. It is important to note, however, that the country can no longer be considered a success story.

Brazil. Public policies related to population growth started in Brazil in the 1950s, in a context of high fertility rate and fears of a demographic explosion^71,72. Only at the end of the 20th century was the impact of family planning on women’s health included in the official discourse⁷². Contrary to the other countries selected and despite the international pressure for population control, the Brazilian government was not directly involved in the first family planning programs^73,74. The first reproductive health policy from the government, the Program of Integrated Assistance to Women’s Health, was only launched in 1986^74,75.

During the 1960s, in addition to the rapid population growth and in a time when contraception was considered a taboo in the country, Brazil had a high rate of induced abortions. In a context where promotion of contraception was out of the law, the high occurrence of abortion was a powerful motivator to private health providers to offer contraceptives^71,74. Despite the prohibition of contraception according to the 1941 Act, condoms were allowed to prevent diseases and contraceptive pills were allowed for ovulation control and regularization of the menstrual cycle⁷¹. In a context of industrialization and increasing female insertion in the labor market, the Sociedade Civil Bem-estar Familiar no Brasil (BEMFAM, Society for Family Wellfare) was founded in 1965, with support from the International Planned Parenthood Federation, aiming to open the discussion on reproductive health, increase the provision of family planning services, and provide training to health professionals⁷¹. The press, through news and analysis articles on family planning, the TV generally, and especially through the popular soap operas showing wealthier families with small families may also had a role in behavior change and promotion of family planning in Brazil^71,76.

During the second half of the 20^th century, socioeconomic conditions had improved, social mobility had increased, consumption expectations had raised, and national public health started to migrate from control of diseases to hospital-based curative care, leading to a growing demand for female sterilization, which was mostly performed after a cesarian section and paid out-of-pocket. In the more vulnerable regions, sterilizations were paid by politicians, in exchange for votes^73,77. Between 1978 and 1986, use of sterilization increased more than 100 percent in the Southeast region and almost 80 percent in the Northeast region⁷⁴. In 1986, more than half of the married women were already using a modern contraceptive method, mostly female sterilization or the contraceptive pill⁷⁴. Use of sterilization continued to increase over the 1990s, when it became subsidized by the Brazilian Unified Health System created by the new 1988 constitution⁷⁴. Up to 2013, Brazil managed to increase family planning coverage to 94% and reached all population subgroups. As our initial analysis indicated, there was a reduction in the share of permanent contraception in favor of short-acting methods, but long-acting contraceptives are still little used in the country^75,78.

Ecuador. Aiming to improve maternal and child health and guarantee families’ rights to plan their family size, family planning was made one the highest priorities in Ecuador since the 1970s. Between 1970 and 2015, modern contraceptive prevalence increased from 15% to 61%⁷⁹. The national commitment with the human right of families to choose their family size and space births is demonstrated in the 1998 Ecuadorian constitution and in the National Population Policy of 1987⁸⁰. The USAID played a major role in the initial years of the Ecuadorian reproductive health programs, between 1970 and 1999, working with public and private institutions and getting support from other international organizations. The aim of the policies was to increase use of family planning services and improve maternal and child health with sustainability, aiming to increase the financial sustainability and independence of major local nongovernmental organizations, the Associación Pro-bienestar de la Familia and the Centro Médico de Orientación y Planificación Familiar⁸⁰.

Despite the efforts made in the first decades of family planning policies in Ecuador, more disadvantaged women were not reached. Although mDFPS was already high among the more advantaged groups in 1994, until 2004 coverage was low among the poorest, less educated, and younger women. The scenario changed with the health reform in 2007, when the supply of modern contraceptive methods increased in primary health care facilities and the offer of female sterilization increased, especially after childbirth⁸¹. Trying to reach adolescents, health services for adolescents were first differentiated, with health providers being trained to be more sensitive to adolescents needs and language. Because it was not resolute, in a second stage, the Intersectoral Policy for the Prevention of Pregnancy in Girls and Adolescents was created, aiming to address social and contextual barriers to contraceptive use⁸².

Despite the increase in coverage among those who were poorer and who lived in more remote areas⁸³, there is evidence of the insufficient effect of this increase in the supply of contraceptives on modern contraceptive use, especially among indigenous women, due to lack of cultural sensitivity^81,84. Other persistent barriers to increase coverage among more disadvantaged populations are the gender-based violence and absence of economic opportunity⁸¹.