**2. Brief history of population policies and family planning programs**

An abundant literature covers the history of population policies and family planning programs in the world since 1950. A synthesis book edited by the World Bank summarizes the major stages of these programs, focusing mainly on Asia and America Latin [9]. A review published by the Rand Corporation provides a detailed analysis of family planning programs and their problems [10]. A recent article presents the challenges for the 21st century [11]. This section presents the main stages of this construction, important for understanding the African context.

#### **2.1. Awareness and organization**

couples. To give a classic example, that of Sweden, the level of fertility has not exceeded 4.7 children per woman since the 18th century, began to decline rapidly around 1870, reaching 2 children per woman around 1930, a date that can be taken as that of the end of fertility transition. After this date, fertility followed several cycles, up and down, around this average level. The fertility transition itself lasted about 60 years or two generations. The number of births balanced approximately the number of deaths by 1800 and this balance was practically restored around 1980, about 50 years after the end of the fertility transition. This model is fairly general for European countries, with the notable exception of France, where fertility decline occurred much earlier, beginning in the 18th century, and was very slow, since it lasted nearly two centuries. Historical demographic studies in Europe showed that the fertility transition was virtually unrelated to short-term socio-economic indicators and that it affected different countries at different levels of development, as measured by income per

Russia presents a different case because the state has begun to play an active role in the decline in fertility in this country. Available evidence suggests a small decline in fertility at the end of the 19th century, probably restricted to large cities. Then, after the troubled period of the Bolshevik revolution, fertility reached a peak in 1924. After this date, fertility started a steady decline, reaching a level of 2 children per woman in 1970, some 45 years after the beginning of the transition, after which it fluctuated upwards and downwards. What is important in the case of Russia is the voluntarist policy of the Soviet state, which authorized medical abortion as early as 1921, induced abortion being the main form of birth control in the USSR until 1990. This policy was above all a social and feminist policy aimed at ensuring greater freedom for women and encouraging them to work in industrial and agricultural production, and not a policy of population control in the Western sense. It was however interrupted at the time of

In the Third World, fertility decline began most often after 1960, and is mainly the result of public policies, that is family planning programs. According to United Nations estimates, fertility in Asia fell from 5.67 to 2.24 children per woman between 1960 and 2010 and in Latin America from 5.95 to 2.20 children per woman during the same period, thus realizing the essential part of the transition of fertility in half a century. In sub-Saharan Africa as a whole, fertility declined only slightly during the same period of time, from 6.62 to 5.26 children per woman between 1960 and 2010 [6]. Africa is the last continent where the transition was delayed and remained largely unfinished by 2010. The consequences of this persistent high fertility are incalculable and will lead some countries to situations very difficult to manage,

The purpose of this study is to trace the history of family planning policies and programs and their impact on fertility and contraception in Africa, to highlight what worked and what did not work, and to document the reasons of successes and failures. The emphasis here is on rural areas, because demographic dynamics are different in urban areas which are much more advanced in the fertility transition. This study is intended for social scientists and policy makers, and therefore provides only few details on the demographic and statistical techniques that underlie the tables and graphs. These technical details are amply covered in other publi-

capita, level of education level or level of urbanization [1, 2].

the Second World War, in this case for demographic purposes [3–5].

especially countries located in the Sahel and in Central Africa [7, 8].

cations cited in text.

120 Family Planning

The first voluntarist movements of birth planning, initially private initiatives, appeared in the United States and in England at the beginning of the 20th century, with activist women, most notably Margaret and Ethel Sanger and Marie Stopes, who installed the first clinics promoting birth control in New York City (1916) and in London (1921).

Awareness of the world population problem dates back to the years following the end of the Second World War, especially in the United States and in some European countries (England, Sweden), and it was from 1950 on that concerted efforts to develop and disseminate contraception and limit population growth were made.

Initially, extensive research was funded to develop modern contraceptives with maximum efficacy and minimal side effects, and best suited to the needs of couples. This research produced a long series of important technological innovations: contraceptive pills (1960), Intra-Uterine Devices or IUDs (1958, 1962, 1968), spermicides (numerous products), injectable hormonal contraceptives (1969), implants (1983), abortion pills (1988), morning-after-pills (1999), non-surgical sterilization (2002), etc. These innovations enabled the development of family planning programs and the spread of modern contraception worldwide. These new methods complemented previously known methods (abstinence, interrupted coitus or withdrawal, condom, diaphragm, sterilization, induced abortion, etc.) and facilitated the adoption of new behaviors. It should be noted here that these new contraceptive methods are the most widely used methods in Africa: five modern methods (injectable, pill, implant, IUD, condom) account for 90% of contraceptive methods used, among which almost half (42% of total) are injectables (source: Demographic and Health Surveys, or DHS).

It was also during this period that were founded the leading organizations responsible for disseminating modern contraception and monitoring its effects, such as the Population Council (1952), the International Planned Parenthood Federation (IPPF, 1952), the PathFinder Fund (1957), as well as the specialized programs of large American foundations (Ford, Rockefeller, Hewlett-Packard, etc.) and of the American government (USAID). At the level of international organizations, the United Nations created in 1967 an agency specialized in population issues: the United Nations Fund for Population Activities (UNFPA). Other UN agencies will also participate in this movement in various ways: World Health Organization (WHO), UNICEF, World Bank, etc.

With the development of major family planning programs worldwide, many consulting firms and consulting groups, mostly American and financed by USAID, were created since the 1970s, which played an important role in the establishment, management and evaluation of family planning programs, such as: Family Health International, Futures Group, PSI, JSI, MSH, Abt Associates, World Vision, etc. The programs were monitored mainly through demographic sample surveys, firstly the Contraceptive Prevalence Surveys (CPS) in the 1960s, then through more elaborate surveys: the World Fertility Surveys, or WFS (1972-1984), and especially the Demographic and Health Surveys (DHS), which have been in place since 1985 to date.

a minority represented by some Third World countries like Algeria and Argentina and some communist countries, supported the slogan: "the best pill is development." Their argument was that economic development was a prerequisite for declining fertility, that is, economic growth must create the necessary and sufficient conditions for fertility control. In the following years, the experience of many Third World countries showed the opposite, that is that family planning programs could work well in very poor countries with low economic growth. However, this meeting resulted in the adoption of a global action plan (World Population Action Plan), a reference document used extensively thereafter. This very comprehensive document contains 109 recommendations covering all aspects of population, health and development policies which were later implemented in the world, including technical details such as

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123

• The International Conference on Population held in Mexico in 1984: this conference was the first to express an almost unanimous consensus on the need to limit the number of births globally, and received the strong support of Western countries for family planning programs. On one hand, this meeting was an important step forward, because African countries endorsed the "Kilimanjaro Declaration," which affirmed their support for family planning programs in the continent. On the other hand, the United States of President Ronald Reagan expressed opposition to induced abortion and to programs supporting

• The International Conference on Population and Development (ICPD) held in Cairo in 1994, emphasized the public health aspects of contraception, introduced the concepts of "Reproductive Health" and "Sexual Health", in the context of the fight against HIV/AIDS and other sexually transmitted infections. The conference insisted on the rights of women to control their reproduction and on their autonomy of decision. By focusing on the individual, this approach was closer to that of the pioneers of contraception, and avoided the pitfalls of the so-called population control approach that was dominant in the 1950s.

• The International Parliamentarians' Conference on the Implementation of the ICPD, held in Strasbourg in 2004, continued along the same lines and saw a solemn commitment by parliamentarians from all over the world to continue to implement the ICPD Plan of Action.

• The Family Planning Summit held in London in 2012, under the aegis of the British government and the Gates Foundation, proposed to continue along the same lines, and to focus efforts on the lagging countries (69 countries were selected, including the poorest countries and many African countries), with the goal of universal access to contraception by year 2020.

• This conference was followed 5 years later (10–11 July 2017), also in London, by a new sum-

Of course, these large international meetings were complemented by a myriad of small con-

The development of modern contraception and family planning in Africa follows overall the

mit with the same actors, focusing on the needs of adolescent girls.

**2.5. Development of family planning policies and programs**

same patterns in most countries, with some local variants:

ferences, seminars, scientific and political meetings on the subject since 1950.

data collection, assessment, training and research.

abortion (Global Gag Rule).

#### **2.2. Major international programs**

The first population intervention trial was conducted in the 1950s, in the form of a clinical trial with an intervention area and a control area, in the Punjab province of India, around the village of Khanna, in 1954–1959 [12]. India was the first country to officially adopt a family planning program in 1952. Following this trial, many family planning programs were implemented in most Third World countries, in Asia, Latin America, the Middle-East, North Africa and later in sub-Saharan Africa.

#### **2.3. African family planning programs**

With respect to modern contraception, very little was happening in Africa during the colonial period, that is, before 1960. At that time, the dominant doctrine was that the continent was under-populated, and that demographic growth, already strong at that time, though little documented, was conducive to economic development.

Awareness of the population problem began to change in the 1960s and 1970s with the emergence of the first population censuses, which showed an extremely high population growth, often between 30 and 40 per 1000, which clearly could not last for a long time. Let us recall that with a growth of 35 per 1000, a population doubles every 20 years, producing a multiplication by 32 within a century. The first population projections made by the United Nations Population Division (UNPD) and subsequent studies of the Futures Group (RAPID project) made it possible to ring the bell: it was clear that the continent would run to catastrophe if fertility remained at a very high level, or even increased, while mortality declined rapidly. Let us recall here that it takes almost a century to stop the devil engine of population growth. It was at this time that the first family planning programs were set up in Africa [13].

#### **2.4. Major international conferences**

Another factor that led to awareness and changes in the attitude of governments from pronatalist to neo-Malthusian was the holding of major international population conferences, held approximately every 10 years by the United Nations agencies, by major American foundations, or by other organizations [14, 15].


a minority represented by some Third World countries like Algeria and Argentina and some communist countries, supported the slogan: "the best pill is development." Their argument was that economic development was a prerequisite for declining fertility, that is, economic growth must create the necessary and sufficient conditions for fertility control. In the following years, the experience of many Third World countries showed the opposite, that is that family planning programs could work well in very poor countries with low economic growth. However, this meeting resulted in the adoption of a global action plan (World Population Action Plan), a reference document used extensively thereafter. This very comprehensive document contains 109 recommendations covering all aspects of population, health and development policies which were later implemented in the world, including technical details such as data collection, assessment, training and research.

which played an important role in the establishment, management and evaluation of family planning programs, such as: Family Health International, Futures Group, PSI, JSI, MSH, Abt Associates, World Vision, etc. The programs were monitored mainly through demographic sample surveys, firstly the Contraceptive Prevalence Surveys (CPS) in the 1960s, then through more elaborate surveys: the World Fertility Surveys, or WFS (1972-1984), and especially the

The first population intervention trial was conducted in the 1950s, in the form of a clinical trial with an intervention area and a control area, in the Punjab province of India, around the village of Khanna, in 1954–1959 [12]. India was the first country to officially adopt a family planning program in 1952. Following this trial, many family planning programs were implemented in most Third World countries, in Asia, Latin America, the Middle-East, North Africa

With respect to modern contraception, very little was happening in Africa during the colonial period, that is, before 1960. At that time, the dominant doctrine was that the continent was under-populated, and that demographic growth, already strong at that time, though little

Awareness of the population problem began to change in the 1960s and 1970s with the emergence of the first population censuses, which showed an extremely high population growth, often between 30 and 40 per 1000, which clearly could not last for a long time. Let us recall that with a growth of 35 per 1000, a population doubles every 20 years, producing a multiplication by 32 within a century. The first population projections made by the United Nations Population Division (UNPD) and subsequent studies of the Futures Group (RAPID project) made it possible to ring the bell: it was clear that the continent would run to catastrophe if fertility remained at a very high level, or even increased, while mortality declined rapidly. Let us recall here that it takes almost a century to stop the devil engine of population growth. It

Another factor that led to awareness and changes in the attitude of governments from pronatalist to neo-Malthusian was the holding of major international population conferences, held approximately every 10 years by the United Nations agencies, by major American foun-

• The International Conference on Family Planning Programs held in Geneva in 1965 was the first to show the impact of modern contraception on fertility trends in some Asian countries

• The World Population Conference held in Bucharest in 1974: this conference was the first arena of struggle between supporters and opponents of family planning policies. The opponents,

was at this time that the first family planning programs were set up in Africa [13].

Demographic and Health Surveys (DHS), which have been in place since 1985 to date.

**2.2. Major international programs**

122 Family Planning

and later in sub-Saharan Africa.

**2.3. African family planning programs**

**2.4. Major international conferences**

dations, or by other organizations [14, 15].

(South Korea, Taiwan), and to seek consensus on the issue.

documented, was conducive to economic development.


Of course, these large international meetings were complemented by a myriad of small conferences, seminars, scientific and political meetings on the subject since 1950.

#### **2.5. Development of family planning policies and programs**

The development of modern contraception and family planning in Africa follows overall the same patterns in most countries, with some local variants:


John-Paul-II (1981), and speech of Pope Benedict-XVI (2008). The position of the Catholic Church is essentially philosophical, therefore subject to adjustments, such as for example about the use of condoms. However, the Catholic Church allows certain forms of traditional contraception, defined as "observing the natural rhythms of woman's fertility", such as:

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125

*The position of certain Islamist groups*: Islam generally favors contraception for two reasons: to improve the health of mother and children, and to take account of economic constraints of the family. However, many Muslim schools of thought are opposed to sterilization and abortion. Moreover, some highly politicized groups are hostile to any population policy aimed at reducing the number of Muslims. These positions vary widely between countries, schools of thought, and periods [17].

The spread of modern contraception and the introduction of family planning programs raised many ethical issues around the world, which have evolved considerably over the years [10]. The most important debates have been on induced abortion, on male and female sterilization, and on the side effects of hormonal contraceptives (pills and injectables in particular). These debates were fierce in countries where population policies were restrictive or even coercive (China, Indonesia), and in countries where financial incentives for sterilization were important relative to income levels (India, Bangladesh). These issues have little affected African countries, because induced abortion is still largely illegal (except in South Africa and Ghana) and because sterilization is still rare, whereas it is the most frequent method in Asia. In Africa, questions have been raised about injectable contraceptives (Depo-Provera), because they

Furthermore, the 1960s and 1970s saw many debates and polemics on the question of the role of the developed countries, in particular the United States, in the promotion of family planning in the countries of the Third World. These actions were sometimes perceived as a form of "imperialist plot" or "cultural intrusion" in Asia, Latin America and Africa. These discussions virtually disappeared after the 1984 conference, the adoption of a broad consensus at the

This section revisits previous studies and provides a general overview of fertility trends in African countries, separating urban and rural areas, because their population dynamics are different. There are even countries in Africa where fertility continued to increase in rural

It should first be recalled that no country in sub-Saharan Africa maintains a complete civil registration of births and deaths necessary for monitoring precisely changes in birth and death rates. For the purpose of estimating fertility levels and trends, sample demographic surveys,

areas, while it was declining in urban areas for decades, such as Congo-Kinshasa.

periodic abstinence, cervical mucus, temperature method, etc.

increase the susceptibility to the HIV virus causing AIDS [18, 19].

global level, and the paradigm shift toward reproductive health in 1994.

**3. Trends in fertility and family planning in Africa**

**2.7. Ethical and political debates**

**3.1. Data and methods**


Thus, there is a wide range of situations in African countries, from countries who adopted a population policy and developed a family planning program early on, who were successful in funding and managing their programs, and who reached the whole population thanks to a good coverage of the fixed posts and of the mobile teams, to countries who started later, who invested little in the program or who mismanaged it, and who reached only a fraction of the national population. There is therefore a wide range of situations in fertility declines, which are presented below.

#### **2.6. Legal and religious barriers**

There are many ideological, legal and political obstacles to family planning programs, as will be illustrated in the case studies presented below. But there are a few specific obstacles that need to be mentioned with respect to African countries:

*The French law of 1920*: This law, passed on July 31, 1920, following the First World War and the demographic deficit that followed, prohibited "any propaganda on contraception or against the birthrate" and severely repressed induced abortion and its promotion. It was voted in the hope of raising the birthrate in order to have more soldiers in case of war, and to regain the numerical superiority of France as in the previous centuries. This law applied not only in metropolitan France but also in Algeria and in all the French colonies, where it remained in application after independence. This law was abolished only on December 28, 1967 in France (*Loi Neuwirth*). In Africa, countries concerned had to revoke this law before undertaking information and awareness campaigns on family planning. In many francophone African countries, it was not until the 1980s or 1990s that this law was abolished. The project to harmonize legislations in Francophone West Africa came even later. The model law on Sexual and Reproductive Health was adopted at the Abidjan Symposium on June 9, 1999 and subsequently implemented in the 10 countries concerned [16].

*The position of the Catholic Church*: in response to the secular movements and to the positions taken by the Anglican Church, the Catholic Church condemned modern contraception very early on, and on several occasions: encyclical *Casti Connubii* of Pope Pius-XI (1930), encyclical *Humanae Vitae* of Pope Paul-VI (1968), apostolic exhortation *Familiaris Consortio* of Pope John-Paul-II (1981), and speech of Pope Benedict-XVI (2008). The position of the Catholic Church is essentially philosophical, therefore subject to adjustments, such as for example about the use of condoms. However, the Catholic Church allows certain forms of traditional contraception, defined as "observing the natural rhythms of woman's fertility", such as: periodic abstinence, cervical mucus, temperature method, etc.

*The position of certain Islamist groups*: Islam generally favors contraception for two reasons: to improve the health of mother and children, and to take account of economic constraints of the family. However, many Muslim schools of thought are opposed to sterilization and abortion. Moreover, some highly politicized groups are hostile to any population policy aimed at reducing the number of Muslims. These positions vary widely between countries, schools of thought, and periods [17].

#### **2.7. Ethical and political debates**

• Arrival of modern contraceptives, first in pharmacies and among private doctors.

opening of the first specialized clinics.

women at home.

124 Family Planning

cation), etc.

**2.6. Legal and religious barriers**

need to be mentioned with respect to African countries:

• Establishment of private family planning associations, generally affiliated to IPPF, and

• Establishment of a national family planning program, first in urban areas and then in rural areas, usually supported by a strong international technical and financial assistance. At the beginning, these programs are based on fixed structures (hospitals, clinics, family planning centers), then on mobile teams that make home visits or even distribute contraceptives to

• Official adoption of a population policy, often with precise objectives (maximum number

• Development of programs as needed: development of integrated reproductive health programs, development of contraceptive mix, awareness campaigns (information, education, communication, or IEC), sex education in schools, adolescent awareness (peer group edu-

Thus, there is a wide range of situations in African countries, from countries who adopted a population policy and developed a family planning program early on, who were successful in funding and managing their programs, and who reached the whole population thanks to a good coverage of the fixed posts and of the mobile teams, to countries who started later, who invested little in the program or who mismanaged it, and who reached only a fraction of the national population. There is therefore a wide range of situations in fertility declines, which are presented below.

There are many ideological, legal and political obstacles to family planning programs, as will be illustrated in the case studies presented below. But there are a few specific obstacles that

*The French law of 1920*: This law, passed on July 31, 1920, following the First World War and the demographic deficit that followed, prohibited "any propaganda on contraception or against the birthrate" and severely repressed induced abortion and its promotion. It was voted in the hope of raising the birthrate in order to have more soldiers in case of war, and to regain the numerical superiority of France as in the previous centuries. This law applied not only in metropolitan France but also in Algeria and in all the French colonies, where it remained in application after independence. This law was abolished only on December 28, 1967 in France (*Loi Neuwirth*). In Africa, countries concerned had to revoke this law before undertaking information and awareness campaigns on family planning. In many francophone African countries, it was not until the 1980s or 1990s that this law was abolished. The project to harmonize legislations in Francophone West Africa came even later. The model law on Sexual and Reproductive Health was adopted at the Abidjan Symposium on June 9, 1999 and subsequently implemented in the 10 countries concerned [16].

*The position of the Catholic Church*: in response to the secular movements and to the positions taken by the Anglican Church, the Catholic Church condemned modern contraception very early on, and on several occasions: encyclical *Casti Connubii* of Pope Pius-XI (1930), encyclical *Humanae Vitae* of Pope Paul-VI (1968), apostolic exhortation *Familiaris Consortio* of Pope

of children per couple, prevalence of contraception above a threshold, etc.).

The spread of modern contraception and the introduction of family planning programs raised many ethical issues around the world, which have evolved considerably over the years [10]. The most important debates have been on induced abortion, on male and female sterilization, and on the side effects of hormonal contraceptives (pills and injectables in particular). These debates were fierce in countries where population policies were restrictive or even coercive (China, Indonesia), and in countries where financial incentives for sterilization were important relative to income levels (India, Bangladesh). These issues have little affected African countries, because induced abortion is still largely illegal (except in South Africa and Ghana) and because sterilization is still rare, whereas it is the most frequent method in Asia. In Africa, questions have been raised about injectable contraceptives (Depo-Provera), because they increase the susceptibility to the HIV virus causing AIDS [18, 19].

Furthermore, the 1960s and 1970s saw many debates and polemics on the question of the role of the developed countries, in particular the United States, in the promotion of family planning in the countries of the Third World. These actions were sometimes perceived as a form of "imperialist plot" or "cultural intrusion" in Asia, Latin America and Africa. These discussions virtually disappeared after the 1984 conference, the adoption of a broad consensus at the global level, and the paradigm shift toward reproductive health in 1994.
