The Long-Term Fertility Impact of the Navrongo Project in Northern Ghana

Studies in Family Planning (Impact Factor: 1.28). 08/2012; DOI: 10.1111/j.1728-4465.2012.00316.x

ABSTRACT Total fertility rates in Africa's Sahelian region are double the levels prevailing elsewhere in the developing world, and the Sahel has the lowest contraceptive prevalence in Africa and in any region worldwide. This type of setting has long been viewed as challenging for family planning programs (Van de Walle and Foster 1990). Although survey data from the Sahel suggest that unmet need for contraception exists, demand for fertility regulation is focused on desire to space rather than limit childbear-ing (Westoff and Bankole 1995; Biddlecom, Tagoe, and Adazu 1997; Casterline and Sinding 2001). Traditional child-spacing practices arise from spousal separation and prolonged breastfeeding, constraining the prospects of incremental demographic effects from family planning practice (Bledsoe et al. 1994 and 1998). The Sahel is the last frontier in the long-standing policy debate concerning the demographic potential of family planning programs in high-fertility settings. Recent evidence of the stagnation of fertility transitions in Africa has generated renewed interest in the popula-tion debate (Bongaarts and Sinding 2009). Prospects for family planning programs to induce and sustain demo-graphic transition remain the subject of challenge on theoretical and empirical grounds, however. Various researchers have questioned whether demand for family planning in Africa is sufficient to justify policies promot-ing organized family planning programs in the region (Frank 1987; Frank and McNicoll 1987; van de Walle and Foster 1990). Others have noted that public invest-ment in family planning service delivery is intrinsically inefficient because demand for services is constrained (Pritchett 1994). Qualitative research on marriage and family-building customs in West Africa has suggested that African reproductive beliefs and customs promote traditional child-spacing practices that will continue to impede fertility transition (Caldwell and Caldwell 1987, 1988, and 1990). A study from the Gambia has shown that contraceptive use can increase without affecting fer-tility levels (Bledsoe et al. 1994).

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    ABSTRACT: In Ghana, despite a 38 percent decline in the total fertility rate from 1988 to 2008, unmet need for family planning among married women exposed to pregnancy risk declined only modestly in this period: from 50 percent to 42 percent. Examining data from the five DHS surveys conducted in Ghana during these years, we find that the relative contribution to unmet need of lack of access to contraceptive methods has diminished, whereas attitudinal resistance has grown. In 2008, 45 percent of women with unmet need experienced no apparent obstacles associated with access or attitude, 32 percent had access but an unfavorable attitude, and 23 percent had no access. Concerns regarding health as a reason for nonuse have been reported in greater numbers over these years and are now the dominant reason, followed by infrequent sex. An enduring resistance to hormonal methods, much of it based on prior experience of side effects, may lead many Ghanaian women, particularly the educated in urban areas, to use periodic abstinence or reduced coital frequency as an alternative to modern contraception.
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    ABSTRACT: The original CHPS model deployed nurses to the community and engaged local leaders, reducing child mortality and fertility substantially. Key scaling-up lessons: (1) place nurses in home districts but not home villages, (2) adapt uniquely to each district, (3) mobilize local resources, (4) develop a shared project vision, and (5) conduct ''exchanges'' so that staff who are initiating operations can observe the model working in another setting, pilot the approach locally, and expand based on lessons learned. ABSTRACT Ghana's Community-Based Health Planning and Service (CHPS) initiative is envisioned to be a national program to relocate primary health care services from subdistrict health centers to convenient community locations. The initiative was launched in 4 phases. First, it was piloted in 3 villages to develop appropriate strategies. Second, the approach was tested in a factorial trial, which showed that community-based care could reduce childhood mortality by half in only 3 years. Then, a replication experiment was launched to clarify appropriate activities for implementing the fourth and final phase—national scale up. This paper discusses CHPS progress in the Upper East Region (UER) of Ghana, where the pace of scale up has been much more rapid than in the other 9 regions of the country despite exceedingly challenging economic, ecological, and social circumstances. The UER employed 5 strategies that facilitated scale up: (1) nurse recruitment from their home districts to improve worker morale and cultural grounding, balanced with some social distance from the village community to ensure client confidentiality, particularly regarding family planning use; (2) prioritization of CHPS planning and continuous review in management meetings to make necessary modifications to the initiative's approach; (3) community engagement and advocacy to local politicians to mobilize resources for financing start-up costs; (4) a shared and consistent vision about CHPS among health administration leaders to ensure appropriate resources and commitment to the initiative; and (5) knowledge exchange visits between new and advanced CHPS implementers to facilitate learning and scale up within and between districts.
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    ABSTRACT: Evidence-based behavior change interventions addressing gender dynamics must be identified and disseminated to improve child health outcomes. Interventions were identified from systematic searches of the published literature and a web-based search (Google and implementer's websites). Studies were eligible if an intervention addressed gender dynamics (i.e., norms, unequal access to resources), measured relevant behavioral outcomes (e.g., family planning, antenatal care, nutrition), used at least a moderate evaluation design, and were implemented in low- or middle-income countries. Of the 23 interventions identified, 22 addressed reproductive and maternal-child health behaviors (e.g., birth spacing, antenatal care, breastfeeding) that improve child health. Eight interventions were accommodating (i.e., acknowledged, but did not seek to change gender dynamics), and 15 were transformative (i.e., sought to change gender dynamics). The majority of evaluations (n = 12), including interventions that engaged men and women to modify gender norms, had mixed effects. Evidence was most compelling for empowerment approaches (i.e., participatory action for maternal-child health; increase educational and economic resources, and modify norms to reduce child marriage). Two empowerment approaches had sufficient evidence to warrant scaling-up. Research is needed to assess promising approaches, particularly those that engage men and women to modify gender norms around communication and decision making between spouses.
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Jun 3, 2014