Women's Voices, Women's Lives: The Impact Of Family Planning

Introduction

A primary purpose of the Women's Studies Project (WSP) at Family Health International (FHI) is to put women's voices at the center of family planning research.

By supporting 26 social and behavioral science field studies, plus five secondary analyses, in 14 countries, the WSP has sought to increase the body of knowledge on women's family planning experiences and to increase understanding of how women perceive the immediate and long-term consequences of family planning programs and methods. The ultimate goal of the Project is to provide new information to policy-makers and providers that can improve reproductive health services and policies.

Begun in October 1993 under a Cooperative Agreement with the U.S. Agency for International Development (USAID), the WSP was designed to explore the impact of family planning programs on women's lives by asking women directly how they felt they had benefited -- or not benefited -- from contraceptive use.

The WSP began at a crucial juncture in the evolution of global population policy. In the early 1990s, donors, women's advocates and public health organizations increasingly called for changes in the population research agenda. The success of family planning programs, they observed, typically had been measured by numbers -- declines in fertility rates, increases in the number of contraceptive users, couple-years of protection, or achievement of country-wide targets. Little consideration had been given to whether family planning programs, in meeting these demographic goals, actually enhanced or improved individuals' lives. Author Ruth Dixon-Mueller noted that "little is known about how family planning clients interpret their sexual lives or what providers can do to help women gain more effective control over their sexuality and reproduction."1

During the five years in which WSP research was conducted, two landmark events occurred. In 1994, the International Conference on Population and Development (ICPD) was held in Cairo, Egypt, and in 1995, the Fourth World Conference on Women was held in Beijing, China. Both conferences reaffirmed the need for a change in perspective -- the need to view family planning not as an end unto itself, but as means to help women and men improve their reproductive health. Reproductive health, in turn, was seen as essential to women's empowerment, as defined by the ICPD Programme of Action:

"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 relating to the reproductive system and its functions and processes. Reproductive health, therefore, implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the rights of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice. ...In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems."2

At the Fourth World Conference on Women, participants reaffirmed the ICPD's recommendation that family planning be placed in the context of reproductive health. The Beijing Programme of Action noted that "women are subject to particular health risks due to inadequate responsiveness and lack of services to meet health needs related to sexuality and reproduction," and the document called for the "mainstreaming of a gender perspective into all policies and programs."3 Other reports called for increased access to family planning, noting that choices about contraceptives and other aspects of life are essential to human dignity.4

The Women's Studies Project anticipated some of the recommendations of the two conferences in developing and implementing research projects. For example, the WSP included women, not only as research respondents, but as principal actors in all phases of the research process -- from study design through information dissemination. Women were included in the triangle of WSP collaborators -- women's advocates, policy-makers and providers, and researchers.

During the course of the five-year project, the WSP sought to promote local ownership of research and to build the capacity of developing country colleagues to conduct research and disseminate information. Consequently, the research process was as important as the research agenda. During initial needs assessment visits to countries that expressed interest in the Project, FHI staff met with members of the triangle. Later, representatives of these groups formed In-country Advisory Committees (IACs), which helped to develop the research agenda in their specific countries, monitor the progress of the studies, and plan efforts to disseminate research results to a wide audience, including study participants. To ensure that women's voices were indeed heard, researchers used both qualitative and quantitative methods. Focus group discussions were used as a guide to help develop research questions and indicators and, along with in-depth interviews, were used to add depth and context to quantitative data. Case studies were written to profile local women-centered health programs, in an attempt to learn how family planning had been integrated with other types of reproductive health services.

The objective of the WSP appeared simple: to assess the impact of family planning on women's lives. However, actually determining that impact is complex and difficult. Family planning use affects numerous aspects of women's lives, including their roles in the family and work place, but aspects of women's lives also affect their family planning use. In implementing studies and analyzing study results, the impact of family planning could not always be easily measured or isolated. For this reason, many of the WSP studies explored family planning in the context of women's lives -- their psychosocial well-being, domestic lives, work lives, and position within the community.

To guide the research process, the WSP staff reviewed various conceptual frameworks and developed a framework of its own to explore the relationships between family planning and women's lives. Originally, the Project was envisioned as comparative research based on similar studies in different countries, and the WSP staff developed a core questionnaire reflecting the conceptual framework. However, as the Project evolved, staff recognized the importance of supporting the needs, interests, and skills of the local colleagues. Consequently, the core questionnaire, when used, was adapted by local researchers to complement their in-country research agenda. A Technical Advisory Group (TAG), comprised of international experts in diverse disciplines, was established to provide WSP staff with feedback on the research process and results. Again, the triangle of providers and policy-makers, women's advocates, and researchers was reflected in the TAG membership (see Appendix 1). Selection of countries to participate in the WSP was based on both country interests and USAID's priorities. After initial visits by FHI staff, conversations with in-country colleagues, and consultation with USAID, six "emphasis" countries were selected. These countries, each of which was the site of multiple WSP studies, were Bolivia, Brazil, Egypt, Indonesia, the Philippines and Zimbabwe. The WSP also supported a single study in the two "associate" countries -- Jamaica and Mali. A grant from the Rockefeller Foundation supported research in China.* Funds from FHI were used for a small pilot project in the Republic of Korea (South Korea). In addition, the WSP supported secondary analyses of existing data in the Philippines, Bangladesh, Nigeria and Malaysia.

In this paper, we discuss the research methodologies used in the WSP in Section II. In Section III, we present crosscutting themes that emerged from the research and some implications for reproductive health policies and programs. In Section IV, we provide an overview of the conceptual framework that guided the research process and data collection. We offer some lessons learned in Section V and suggestions for future directions in Section VI.

This report is a summary of results from 26 field studies finalized in March 1998. The report is intended as a synthesis of findings for a general audience, and therefore, does not include detailed data from the hundreds of analyses carried out by research teams. Instead, illustrative findings, tables and quotes from study participants are presented to support the crosscutting themes that emerged from the WSP. The final reports on which this synthesis is based are will be featured on this web site under Women's Studies as they become available. Further primary and secondary analyses, as well as several longitudinal studies (for example, in Brazil and Mali), are ongoing and will be completed within the next few months. The WSP also will submit its findings in scientific papers to peer-reviewed journals.

The knowledge and insights gained from the WSP can be used in the ongoing discussion among women's advocates, policy-makers and researchers, who share the common goal of improving reproductive health services and women's lives. By taking into account women's perspectives and experiences, family planning programs can help make access to quality reproductive health services not just a goal, but a reality.

*The study in China, which took place in two provinces, South Jiangsu and North Anhui, will be replicated in a third province, Yunnan. Research in Yunnan is supported by the Ford Foundation.

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