Population Indicators: Who is left behind?
In a data collection setting in Cairo, I asked a nurse if any woman could walk into a healthcare unit to get contraceptives, she nodded affirmatively. A perplexed pause, then I asked her about the requirements; she explained that the husband’s ID is required to open a family file at the local healthcare unit. Then it made sense, the healthcare system does not see unmarried women as contraceptive users. All the awareness messaging uplifting access barriers to contraceptives mean to target married women.
Population increase has been a buzzing term in Egypt over the past years; after a decade of being discussed as an opportunity (Sayed, 2011), it has now become development’s biggest challenge, or at least this is how it is presented. Earlier this year, we witnessed public conversations on population increase, accompanied by regressive national policy articulations conveying a message to decrease the number of children per family and increase modern contraceptive uptake. The only cohesive messaging across current awareness raising campaigns rationalizes family planning as nationally convenient, what seems best for the greater good. The question then arises: How can we achieve the greater good if we systematically overlook women?
Notwithstanding the general absence of reliable data in the last six years on reproductive needs and patterns and the fact that analysis of population patterns in Egypt relies solely on the number of births, this commentary pauses to unpack the indicators used to set and realize national strategic goals, by highlighting the inaccuracy of equating marital status with pregnancy risk.
Structural barriers are not only about service availability and accessibility. They are not exclusively about the number of contraceptive options offered to women at any point of sale; they could also be the lens we look through. A barrier could be established prior to data collection, long before the provider-client interaction; it could be what we define and use as evidence along with the baselines we engineer as professionals and policymakers. For example, the Demographic Health Survey (DHS) covering Egypt’s population characteristics between 1988 and 2014 only addressed married women in its standard surveys, resulting in the majority of analyses on reproductive behaviors and patterns excluding unmarried women and men from their sampling. Egypt aims to control population fertility, its target for the total fertility rate (TFR) is 2.4, while it currently stands at 2.9 (Ministry of Planning and Economic Development, 2021). In Egypt and in the majority of countries, the successful achievement of family planning goals is predominantly measured by the TFR, contraceptive prevalence rate (CPR) and unmet needs (Hardee et al., 2014). The subsequent section will explore the efficacy of these indicators.
Family Planning Targets and Indicators
It is essential to read family planning indicators within their historical context; they came to life during the global population control era (Senderowicz, 2020). It is therefore necessary to reassess how reproductive rights can be upheld through population control indicators. Currently, there are a handful of targets of the Sustainable Development Goals (SDGs) which address sexual and reproductive health; these include target 3.7 which aims by 2030 to “ensure universal access to sexual and reproductive health care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.” As available data guiding this target at the national level captures married women, in order to ensure universality as articulated in target 3.7, data should be expanded to include all women of reproductive age regardless of their marital status (Guttmacher Institute, 2015). There are over 90 family planning indicators interchangeably referred to as population based indicators, three of which are listed in SDG 3 Good Health and Wellbeing and SDG 5 Gender Equality. Goal 3, indicator 3.7.1 measures the proportion of women of reproductive age who have their need for family planning satisfied with modern methods; Goal 5, indicator 5.6.1 gauges women’s ability to make their own informed decisions about their sexual and reproductive health. Since Egypt aims to realize SDGs, marital status should not determine availability of and accessibility to sexual and reproductive health knowledge and services. All women are rights holders regardless of their marital status.
In reference to indicator 3.7.1, demand satisfaction is calculated through mCPR and unmet needs. The CPR is the percentage of women of reproductive age using contraceptives while the mCPR is the percentage of said women using modern contraceptives. Unmet Needs is the percentage of sexually active women of reproductive age who want no more children or desire to postpone pregnancy and are not using contraceptive methods. Generally, there is substantially more to dissect when it comes to population based indicators, for example, unmet needs in theory and/or in practice of national and global reproductive health agendas, are centered around married women of reproductive age using modern contraceptives; thereby excluding both married women who use traditional methods and unmarried women using either modern or traditional contraceptives (Kiarie, 2021). Even when global goals are set to include all women, national datasets in many countries are only focusing on married women (Fabic & Becker, 2017). Such population based (read control) indicators not only undermine women’s reproductive rights – by not taking into account their preferences to use traditional contraception methods, or desiring to postpone or prevent pregnancy without using any contraceptives – it also excludes the needs of unmarried women. Not all married women are sexually active and there are unmarried women who are sexually active! It is pressing to understand the various subtle forms of reproductive rights violations, one of which is being overlooked. Reproductive violence is often associated with coerced sterilization, yet it pertains also to such exclusion.
Restructuring Family Planning Indicators
One of the alternative frameworks for family planning was developed in 2014, in response to the London Summit on Family Planning in 2012, where world leaders committed to providing effective family planning and contraceptive services to 120 million additional women and girls by the year 2020 (Hardee et al., 2014). A descriptive study shows that unlike the conventional CPR whose estimates may be somewhat deflated, alternative CPR (ACPR) includes modern and traditional contraceptives and all women of reproductive age who are a) sexually active within a specified retrospective time frame; b) not currently pregnant; and c) fecund. Rereading contraceptive prevalence through this alternative indicator shows that the ACPR is on average 23 points higher than the CPR across sub-Saharan African countries, Asian/Eastern European countries and Latin American/Caribbean countries (Fabic & Becker, 2017). Recently, Leigh Senderowicz (2020) introduced a new indicator named ‘contraceptive autonomy’, which she defines as “the factors necessary for a person to decide for themself what they want in relation to contraception and then to realize that decision”, dividing the indicator into the subdomains of informed choice, full choice and free choice. Figure (1) summarizes Senderowicz’s proposed metrics for operationalizing this indicator.
Stipulating that all of the above indicators should be measured among all women of reproductive age, Senderowicz’s contraceptive autonomy is an example of the necessary shift away from current metrics which are rooted in cultural values, exclude unmarried women and thus erase their needs from the policy agenda. Cultural justifications for these measurement approaches are divorced from the picture on the ground and therefore lead to inadequate data. Reproductive health and family planning policy making and program design should be based on comprehensive data reflecting women's lived realities, collecting and presenting reproductive patterns and needs of all women, rather than normative assumptions rooted in ‘culture’.
The Way Forward
Recently, there have been inconsistent announcements of a national survey replacing the DHS in Egypt, while there is insufficient communication detailing its mandate, its sampling can be inferred from the working title: the Egyptian Family Health Survey (Hendawy, 2020). Now is the right moment to make up for decades of policy and programming blind spots. Instead of leaning towards removing social protection for families that do not adhere to an ideal number of children, policymakers and delegated government bodies should include women in decision making, as they are the main targets of these national strategies. This entails including all women and men, regardless of their marital status, in the sampling criteria of national surveys, through developing newer population based indicators based on the reality that sexual intercourse takes place outside of marriage as well. In order to uphold the constitutional right to health, national policy design and program implementation should address the needs of individuals who are not currently using services by ensuring services are available, accessible, and acceptable to all. Limiting awareness raising campaigns and service availability to married women and occasionally married men does not ensure availability and accessibility of knowledge, quality of service nor informed reproductive decision making.