versão impressa ISSN 0042-9686
Bull World Health Organ vol.89 no.11 Genebra Nov. 2011
Once a taboo subject, family planning is increasingly being recognized as essential for social and economic development in countries in WHO's Eastern Mediterranean Region. Dale Gavlak reports from Jordan.
Women, some carrying crying children, form a long queue in the clinic's brightly-coloured corridor adorned with posters of babies and cartoon characters. Some wearing traditional long black abaya, others clad in jeans and T-shirts, wait to see a female doctor. The occasional husband can be spotted among them.
They are among some 300 women who come seeking family planning advice from the all-female team of doctors each month at the Princess Basma Health Clinic in the city centre of the Jordanian capital, Amman. One of scores dotting this desert kingdom, the clinic offers free advice, treatment and education to Jordanian women and their families.
"We explain to the women that we are not forcing them to limit the size of their families", says Mervat Famour, section chief at the clinic. "We don't tell a woman that she should give birth to only one or two children. That is up to her. Yet, she should leave space between one pregnancy and the next for the sake of her and the baby's health. In the past, they used to call this haram or forbidden, but now they understand the purpose of our work", she added.
Spurred by the 2004 World Health Assembly endorsement of the first WHO global strategy on reproductive health, the governments of Jordan and other countries in the World Health Organization's (WHO's) Eastern Mediterranean region, such as Afghanistan and Iraq, are promoting family planning more actively. Increasingly they are recognizing the key role that family planning plays in achieving the United Nations Millennium Development Goals. Many countries have developed national strategies based on the global strategy and some are working to introduce family planning and reproductive health topics into the medical and nursing curricula.
"WHO's main focus is on preventing pregnancy-related health risks in women by allowing them to space and limit their pregnancies", says Heli Bathija, WHO's reproductive health and research manager for the Eastern Mediterranean Region. "Closely-spaced and ill-timed pregnancies and births also place babies and children at greater risk of dying or poor development."
"One of Jordan's most recent successes has been the acceptance of family planning by policy-makers and the public", says Raeda al-Qutob, who heads the Higher Population Council, a specialized agency that deals with population and development policy and is chaired by Jordan's prime minister. "Before, many thought such programmes came from foreign funding agencies trying to impose their views, but more and more see family planning as a tool to reduce fertility to help us achieve social and economic development", she says. "Decision-makers are aware of the relationship between large family size and poverty." She adds that, increasingly, Jordanians are recognizing the importance of family planning for women's and children's health.
Jordan has seen a remarkable decline in its total fertility rate, from 7.4 children per woman in 1976 to 3.7 in 2002. Since then, this rate has remained unchanged at 3.8 children per woman, according to the Higher Population Council. At this current rate, Jordan's population of 6.5 million is set to double in 30 years, putting even greater pressure on food security, housing, employment, scarce water resources, health and education services.
According to al-Qutob, challenges for providers of family planning services include overcoming women's concerns about the side-effects of contraceptives, fears of becoming infertile and concerns over the reliability of long-term contraceptives, such as the intrauterine device (IUD) - the preferred method in Jordan - and the contraceptive pill.
Asma Fashho, who assists al-Qutob at the Council, adds that another challenge is a strong cultural preference for a male child. "People believe that they must have a baby boy as soon as possible", she says. She cites a Johns Hopkins University study that found that women in Jordan sometimes start to use contraceptives only after the birth of their fourth girl or second boy.
Fashho adds that the higher her level of education, the more likely a woman is to use contraception. "Most educated women have fewer children because they tend to marry later and continue to work after marriage", Fashho says. "If you empower women, they will space [the birth of their children] themselves. More female-empowerment projects are needed." But women from all sectors of society may still feel cultural pressure to produce a male child, adds Fashho: "Even if a woman is educated and lives in the capital's wealthiest district, her mother-in-law, mother and the rest of her community could be pushing her to have more children, especially if she only has girls."
Fashho says that the Jordanian government is focused on reducing fertility rates through a strong advocacy plan and an awareness campaign to boost and broaden family planning services, including expanding the range of contraceptive methods available. The health ministry has announced that it will increase reproductive health programmes in rural areas, particularly in the south of the country, including home visits to make families more aware of contraceptives.
Engaging the support of religious leaders from Jordan's Muslim and Christian communities is another key factor for success. Female religious leaders and male clerics, who are becoming increasingly supportive of the country's family planning programme, educate women about the benefits of using reproductive health services.
Other countries in the region face similar cultural and religious barriers but prolonged conflict in some places presents even greater hurdles to providing family planning services. "Security is the number one biggest challenge to achieving family planning goals in Afghanistan and Iraq", says Paata Chikvaidze, medical officer for reproductive health and research at WHO's Regional Office for the Eastern Mediterranean in Cairo. "It significantly hampers the delivery of commodities and services, the ability to train service providers at different levels, including community health workers, and to provide necessary supervision", he says.
One of the world's poorest countries, Afghanistan is expected to double its population of almost 30 million in as many years and Iraq's 32 million people face the same prospect. Afghan women have on average 6.3 children, while the average is 5 children in Iraq. In some parts of Afghanistan, male domination in decision-making and lack of female empowerment hamper progress in providing family planning services. Further obstacles include a shortage of female health workers, poor roads, lack of education and a tradition of child marriage. According to a nationwide household survey done in 2007/8, women aged 15-49 years with primary education or higher are twice as likely to use contraception (31%) than women with no school education (14%).
"Despite the enormous challenges, both countries are making headway in family planning efforts", says WHO's Bathija. Afghanistan has ramped up efforts that include training large numbers of health professionals in family planning services and community awareness in the provinces of Kabul, Nangarhar, Balkh and Herat.
The health ministry has adapted WHO family planning guidelines to the Afghan situation, with the support of WHO, and translated them into national languages, Dari and Pashto. WHO is also working with the health ministry to train female community health workers so that they can provide vital counselling to Afghan women to dispel any myths about family planning and to explain the benefits, according to Adela Mubasher, from the WHO Country Office in Kabul. A WHO-led strategic assessment of family planning in 2005 found broad support for family planning and recommended improved education for young people, increased involvement of men and influential women, and more public-private sector collaboration. Some Muslim religious leaders are reaching rural communities on family planning practices and pregnancy spacing, backed up by quotations from Islam's Holy Quran that say "mothers shall suckle their children two years completely", and some of them distribute condoms.
In Iraq, conflict has also taken a heavy toll on the health system, once considered the best in the region. According to Faeza Majeed, a medical officer for the WHO Iraq Country Office based in Amman, obtaining reliable supplies of contraceptives is a problem for private and public family planning clinics. In June, WHO provided training to 32 health workers from Iraq, including the northern Kurdish region, to update them on the latest family planning methods. WHO's Mary Lyn Gaffield, who co-facilitated the course, says that the ministry of health wants to expand services mainly provided by obstetricians and gynaecologists to include nurses, midwives and other health workers. Participants spoke of enormous social challenges posed by an increase in conservative attitudes that question the role of women and their ability to control their own reproductive health.
"The physicians are somewhat held in suspicion and have to practice medicine in a more conservative way because they could be blamed for something inadvertently. There is a tendency to be more restrictive on medical eligibility for contraceptive methods than is actually necessary", Gaffield says. For example, doctors are less likely to prescribe hormonal contraceptives - such as the pill - to women with non-insulin dependent diabetes, even though this is considered safe medical practice under WHO guidelines.
Jordanian mother of three, Aleja Ghanem, who visited the Amman family planning clinic, sums it up best. "I use family planning because each child deserves their full right to good living and adequate care", she says, in the visit accompanied by her husband and 18-month old daughter. "It's better than having children year after year. I come here so that my children can have a better education, sufficient food and better care, instead of having six children that we can't feed and care for."