FAMILY PLANNING BEHAVIOR

Reproductive health is defined in the Programme of Action of the International Conference on Population and Development (ICPD), held in Cairo, Egypt, in September 1994, as:

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 to 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 right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.

Sexual health was also defined in this resolution, "the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases." In 1999, the United Nations General Assembly adopted its Key Actions for Further Implementation of the Programme of Action. This document focused on population and development concerns; gender equality, equity and empowerment of women; reproductive rights and reproductive health; and partnerships and collaboration.

Reproductive health has widely been interpreted to focus more specifically on providing access and choice in family planning; caring for women before, during, and after pregnancy; preventing and controlling sexually transmitted infections, including HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome); preventing and treating cervical cancer and breast disease; promoting the health of adolescents; promoting positive communication between sexual partners; promoting special services (i.e., counseling, care, and education) to women that decrease the disparity of services between genders; and supporting positive reproductive health–related practices. The Programme of Action has helped nations throughout the world to understand that, in the everyday lives of people, family planning is an integral part of daily living and overall health.

The World Health Organisation (WHO) has outlined four basic goals that should be met for people to achieve reproductive health. These goals were established in order to focus attention on the community at large—how people live, work, and play—and to get people thinking more broadly about the treatment services available at health care delivery centers. These goals provide a basis for reproductive health promotion, prevention, and intervention initiatives. The overall design aspires to create a safe environment where people may: (1) be free from violence and other harmful practices related to sexuality and reproduction; (2) avoid illness, disease, and disability related to sexuality and reproduction, and receive appropriate care when needed; (3) achieve their desired number of children safely and healthily, when and if they decide to have them; and (4) experience healthy sexual development and maturation and have the capacity for equitable and responsible relationships and sexual fulfilment.

Implicit in these goals is the expectation that people should be safe from violations of their human rights, as well as from discrimination based on sex, race, religion, or culture. Women, in particular, should be free from all forms of sexual and physical violence. Both men and women should be seen as equal and responsible contributors to a healthy society.

Family planning enables couples and individuals to decide freely and responsibly the number and spacing of their children, and to have the information and means to do so. It also means that people have ongoing availability of a full range of safe and effective contraceptive methods that enable them to take action according to these decisions. This ability to take action is also based upon the cost of contraceptives, ideas (sometimes correct and sometimes erroneous) people have about the different methods, and the support or lack thereof of the partners, extended family members, and wider community. People are deciding to have families at both younger and older ages, and contraceptive technology is enabling them to do so. It is important that these decisions be made not only freely but also with full information about the long-term consequences for both the parents and the children. Unfortunately, there are still many women in the world who die each year from pregnancy-related services. A considerable number of these women want to limit or space their pregnancies but are without the means to do so effectively.

Reproductive rights include all the elements mentioned above related to family planning. They also include the rights of couples and individuals to make decisions about family size and spacing and about which contraceptives will be used, without being coerced or otherwise being subject to violence and other outside pressures to behave in ways contrary to what they would like. Implicit in these rights is the idea of gender equity in decisionmaking, including meeting the educational and service needs of both sexes, and addressing negative attitudes toward women and girls that often result in their having little control over their own sexual and reproductive lives.

FACTORS INFLUENCING REPRODUCTIVE HEALTH BEHAVIOR

In most countries of the world today, couples have concluded that it is in their best interest (and that of their children) to plan and limit the numbers of births. Most families are having fewer children than families did in the past. In industrialized countries this trend has been happening gradually since about 1900, while in developing countries, for the most part, the change has happened relatively swiftly beginning about 1970 and the average desired family size has dropped from six children to three. Unfortunately in some situations, particularly in sub-Saharan Africa, extreme poverty, profound inequalities between men and women, and early marriage severely limit women's ability to achieve their childbearing goals. A gap frequently exists between the number of children women say they want and the number they have. More than 50 percent of women in some countries report that they would have preferred to postpone their most recent birth or not have had it at all. More than 50 million of 190 million women who become pregnant each year have abortions, many of them clandestinely performed under unsafe conditions.

Identifying factors that affect family planning behaviors helps in understanding effective ways of promoting such behaviors. It is widely accepted that simply providing information to people does not make them change their behaviors. Information is only one of the factors that contribute to behavior change. Particularly in the complex area of family planning, where there is a tremendous influence exerted by culture, tradition, taboos, sex-role definitions, and a reluctance to openly discuss these matters, it is important to understand contributing and inhibiting elements that will support or block healthy family planning behaviors.

In order to engage in safe family planning practices, individuals must feel that they are capable of what is needed. Self-efficacy, or having the appropriate skills, means, and confidence, is a critical factor in any person's decision to try to adopt a new behavior. To be effective in family planning, people need to know what contraceptives are available, how to use them, where to go to get them and how often they should be used. Being skilled, however, is only part of the process of developing capabilities for effective family planning behavior. Real or perceived barriers to obtaining contraceptives (including cost, accessibility, and lack of reinforcing and enabling support) can deter individuals. Some may find that despite their knowledge or skills, they may not be able to follow through on their desired practices due to the fact that there are elements of the system that block, deter, or discourage them. For example, some health policies may require that a woman have permission from her husband before she can be given contraceptives. Even though she may know that it is dangerous to her health to have more children, she may not seek family planning services for fear of a violent reaction from her spouse. Many people who go to health facilities are further discouraged because they feel that the health workers humiliate them, ask them difficult questions, and conduct unpleasant procedures. Costs, some of them recurring on a monthly basis, may be yet another deterrent.

Globally, and particularly in the United States, unwanted pregnancies and high levels of sexually transmitted diseases (STDs) are extremely prevalent in young people between the ages of ten and twenty-four. These are problems that are preventable through contraception and safe sexual practices. Therefore it is important to begin to reach young people early in their lives, when they are feeling the influence of many different pressures, to help them decide when and if they will have sexual intercourse, and, if so, whether they will make it a point to protect themselves from unwanted pregnancy and STDs. In order that they may plan the size and timing of their families, it is also important for young people to understand the potential consequences of pregnancies that occur too early in their lives or are too closely spaced together.

In some situations, young girls think it would be wonderful to have a child, someone to care for and someone who will give love unconditionally. At one time, young girls who became pregnant and were not married were forced to either get married, not have the child, or not keep the child. In the United States today, with a prevailing culture and social support system that is supportive of single mothers, many young girls are looking forward to getting pregnant and having and keeping their children. What is important is that they understand the long-term consequences of making this decision—economically, socially, educationally, and in terms of their future opportunities.

Although some people do not believe that their family planning behaviors put them at risk, in other cases individuals will weigh the expected positive and negative outcomes. A woman who is considering using the female condom during each act of sexual intercourse may anticipate that she will have to choose between being embarrassed at having to discuss this with her partner and reducing her risk for unwanted pregnancy and diminishing her chance of contracting STDs. (Many women also have to take into account the possible harm her partner might inflict upon her in a violent attack.) Her decision may be based upon what she feels most comfortable doing.

The prevailing peer and social norms and expectations are also going to have an impact on whether or not a person decides to have a child or how early and how often to have children. Individuals will conform to different social norms depending on age, income, sex, experience, and culture. A very strong ethical or religious culture in the home will possibly exert greater influence on the decision whether to use contraceptives or not than will that of their peer group. In the end, individuals may act according to which pressures are dominant in their lives, and which ones they feel they are the most competent to resist.

Other factors that will influence a person's decision whether or not to use effective family planning or STD protection include the media, current events, life events, social policy and legislation, and general information exchange. Private life events, such as supporting a friend through an abortion, may also produce a marked behavior change in the future decisions of an individual. Individuals are exposed to a considerable amount of information on a daily basis. Certain images and ideas may affect a behavior change, while others will be sifted and discarded by the end of the day. Repeated dissemination of information will have more of an impact than random images and messages. A well-publicized health campaign may influence an individual to adopt new behaviors, and repeated messages on public transport billboards, television, and radio may act to reinforce such a behavior change. When new behaviors are unfamiliar, other cues and associations can also act as reminders, or triggers, to individuals of their new or changed behavior. For example, if a woman associates taking a daily contraceptive pill with something she does as part of her daily routine, such as drinking orange juice or coffee in the morning, it will be a helpful reminder for her to continue this daily behavior. Behaviors can be reinforced when an individual receives positive feedback from someone whose opinion the person values. Reinforcement is a key element of behavior change and maintenance.

Marilyn Rice

(see also: Behavior, Health-Related; Contraception; Family Health; Planned Parenthood; Preventive Health Behavior; Women's Health )

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