While contraceptive use can greatly reduce unwanted pregnancies, it cannot eliminate them (60). An estimated 25 million women become pregnant each year due to failure of their contraceptive method (31). Many women, especially young women, become pregnant as the result of forced sexual intercourse. A smaller number of women develop health conditions that make continued pregnancy unsafe. Many of these women will choose an unsafe abortion if they do not have access to a safe procedure.

Even less is known about the extent of maternal illnesses in developing countries. A frequently cited estimate is 16 illnesses for each maternal death—a figure based on a 1980 study of one village in India (71). Applying this ratio to the entire developing world yields an estimate of eight million cases of nonfatal maternal complications every year (42, 191). Such complications are often chronic and debilitating.

Maternal mortality is usually expressed as the maternal mortality ratio—the number of maternal deaths per 100,000 live births. The maternal mortality ratio measures the risk of dying that a woman faces each time that she becomes pregnant (99, 318, 363). This ratio is often mistakenly called the maternal mortality rate. (A ratio compares the numbers of two differing events; a rate compares a part to the whole.)

Maternal mortality ratios range widely, from an estimated 12 maternal deaths per 100,000 live births in North America to more than 700 per 100,000 in some parts of sub-Saharan Africa (123, 312). For the developing world as a whole, maternal mortality is estimated at more than 400 deaths per 100,000 live births, while the ratio is below 30 per 100,000 in the developed world (312, 380) (see Table 1).

Contraception and psychosocial stress. Lack of control over one's own life is a major cause of stress (75). Thus the use of contraception can improve women's emotional health by providing more reproductive control and greater choice about childbearing (74, 75, 129). Also, because using contraception, like other preventive health practices, reflects an orientation to the future, it can be an important step toward overcoming fatalism and lack of self-worth (129).

In some circumstances, however, obtaining and using contraception can itself be stressful, especially where modern contraceptives are not yet widely accepted. A woman may worry about visiting a family planning clinic and undergoing questioning or a physical examination. She may fear disrespectful treatment or negligent care. She may also fear that visiting a clinic or using contraception will provoke her husband's anger or will bring criticism from her family, her in-laws, or others (74). She may experience painful or worrying side effects from using a contraceptive method. She may hear frightening false rumors about the dangers of contraceptive methods. Family planning managers must recognize these possible stresses and develop strategies to relieve them. As contraceptive use becomes the community norm and as services improve, using contraception may become less stressful.

Many women are having their children closer together than they wish. The World Fertility Survey (WFS) and Demographic and Health Surveys (DHS) indicate that 90% of women who plan to become pregnant would like to space their children at intervals longer than 24 months. More than one-third, however, have a second birth within 24 months (137).

Research also shows that children are more likely to die if their mothers are younger than age 18. According to the WFS and DHS, delaying the first birth until the mother is at least 18 years old reduces the risk of the first child's death by an average of 20%. In the Dominican Republic, Egypt, Mexico, and Peru, delaying childbearing at least until the age of 18 would reduce the risk of the first child's death by 30% (137).

Women who can decide if and when they will become pregnant are better able to plan other aspects of their lives. In the short term women who use contraception effectively may have more choice about the use of their time because they have fewer children. Women may be better able to make plans to take new educational, economic, and other opportunities (22). Also, in the long term society in general and women themselves may change their expectations of how women lead their lives. Young women probably benefit most from being able to control their own fertility.

Avoiding unintended pregnancies is critically important to allow women to make these choices, especially in cultures where unplanned pregnancy precipitates marriage or where premarital births have particularly disastrous social or economic consequences (74). In Latin America and the Caribbean, the Young Adult Reproductive Health Surveys (YARHS) document that many women are sexually active before marriage but are not consistently using contraception. For example, in a 1985 survey in Mexico City, 13% of women age 15 to 19 and 44% of men reported premarital intercourse. Only 22% of the women and 31% of the men used contraception at their first sexual experience, however. Among unmarried women ages 15 to 24, half of all first pregnancies were unintended. Among married women in this same age group, 11% of first births were conceived before marriage (216).

Nevertheless, offering contraceptives to unmarried adolescents and young adults remains controversial. Some parents and policy-makers assume that the availability of contraception will lead adolescents to have sexual relations before marriage. This assumption is one reason that, formally or informally, many family planning programs refuse to serve unmarried young people (333).

In fact, data do not suggest that the availability of contraceptives encourages early sex (130, 228). Most research on the subject comes from the US and other developed countries. For example, an international comparison found that sex education and contraceptive services were more available in Europe than in the US. Sexual activity among adolescents, however, was about as prevalent in the UK, France, and the Netherlands as in the US, while the US teenage pregnancy rate was much higher (154). Another US study found that teens who had a sexual education program in their school delayed intercourse and were less likely to become pregnant (379). Still other studies have found no link between the presence of contraceptive clinics in the schools and levels of sexual activity among students (176).

Still, once girls reach puberty, the greatest threat to their staying in school may be pregnancy. Students who become pregnant often drop out of school, or they are expelled by school authorities—a fate that does not befall male students who father children. In many African countries pregnancy is the most common reason that girls leave school and the main reason that the school-leaving rate is higher for girls than for boys (109).

To ensure that girls are not forced to leave school due to unwanted pregnancy, girls need to be able to refuse unwanted sexual intercourse and to have access to contraceptives, information, and counseling if they choose to be sexually active. Also, schools should help young women continue in school, not expel them, even if they are pregnant or have a child.

Policies that help young women avoid pregnancy and stay in school could help change attitudes in the long run. Parents and communities might be more willing to invest in girls' education if they had more confidence that their daughters would not become pregnant and leave school (74). Also, as more women complete an education, and as more women hold paying jobs, the perception of women's potential is likely to change, helping to break the vicious cycle that holds women back.

Some young women recognize that avoiding pregnancy protects their futures. For example, in a Kenyan study female students of high socioeconomic status viewed contraception favorably. Those who ranked in the top quarter of their class were nearly four times more likely than other female students to have used contraception at their most recent act of intercourse. These young women could afford contraceptives and recognized that an early pregnancy would endanger their chances for academic success and economic security (173).

Children benefit in various ways from their parents' use of contraception. Education appears to be one area in which women pass on the benefit to their daughters: Both sons and daughters from small families have better educational opportunities than children from large families. In a Thai community, in families with three or fewer children, 44% of the children went to lower secondary school, and 31% went to upper secondary school. By comparison, in families with four or more children, 24% went to lower secondary school, and 14% went to upper secondary school. In this study couples with small and large families were matched for wealth, religion, residence, parents' educational attainment, and parents' ambitions for their children's education. All couples had had access to modern contraceptive methods throughout their reproductive years (131, 178). Similarly, in Matlab, Bangladesh, children in small families stayed in school longer because they did not need to care for younger siblings at home (100, 101). Still, in both Thailand and Bangladesh parents provided more education for their sons than for their daughters.

While statistical research into women's labor-force participation and women's use of contraception has not produced clear findings, the conceptual links are clear. With effective contraception, women are better able to work when they need to without the interruption of unplanned childbearing. Women also may find the burden of household work somewhat lightened. In addition to caring for children, women nurse the sick. Women in developing countries raise 50% to 90% of their families' food (340). In most rural areas women spend long hours carrying water, gathering fuel, and preparing and cooking food. How spacing and limiting births influence the daily lives of women working in the home also deserves research.

Wherever unplanned pregnancy would limit the types of work available to women, effective contraceptive use may help provide women with broader opportunities to obtain the economic security of a job. When a woman cannot be sure of avoiding pregnancy, her occupational choices often are limited. She may have to find employment that can be combined with childcare, that permits flexible hours, and that is easy to enter and leave frequently. Such jobs typically earn low, static wages. Most such jobs are in the informal sector of developing economies--for example, agriculture and petty trade. Even in the formal sector of developed countries, such jobs as nursing and teaching have been held mostly by women since employers did not care if pregnancy forced teachers or nurses to leave after a few years on the job. Seen as jobs that young women held until they had a family, these professions have commonly been paid less and offered less opportunity for advancement and less status (22).

More detailed studies, rather than large-scale statistical analyses of fertility levels and labor force participation, may offer a clearer view of how contraceptive use and employment are linked. For example, in Nigeria researchers found that young unmarried women out of school were using contraception in order to work longer before marriage. In one area studied, 75% of single women ages 18 to 25 were using contraception, more than five times the contraceptive prevalence of married women in the same age group (40).

Of course, many factors other than contraception affect women's employment. Women's autonomy within the family is one such factor (194). In some countries cultural norms call for women to remain at home no matter what their own preferences are. Also, some employers discriminate against women, partly because employers assume that women's commitment to their jobs is weaker than men's. Nevertheless, in modernizing economies women are an increasingly important part of the labor force (340). Where contraception is widely available and its use is accepted, employers can be more confident that female workers will not be forced to leave because of unplanned pregnancies. At the same time, however, the possibility that a woman may become pregnant is not legitimate grounds for denying her a job.

When women have access to contraception and new economic opportunities, many take advantage of both. In Bangladesh the Grameen Bank offers poor women small loans for income-generating projects. The women attend regular meetings at which they receive advice on their projects. They also learn the "Sixteen Decisions"—resolutions to make changes in their lives including planting vegetables, educating their children, and having small families. Women who have taken advantage of this new economic opportunity are more likely to be using contraception than women who are not receiving loans (293).

• Encourage respect for women,
• Provide a range of reproductive health care, and
• Design program activities to strengthen the skills that enable women to take new opportunities.

Family planning programs have an excellent opportunity to promote respect for women. Unfortunately, some programs have missed that opportunity—perhaps because program personnel share widespread social attitudes that denigrate women, because a program focuses on enrolling more clients rather than meeting clients' needs, because personnel are simply not aware that courtesy is important, or because service providers have too little time for each client.

Program managers can encourage respect for clients in several ways:

• Ensure informed choice. Programs that help women make their own informed choices about their fertility show respect for their clients' right and ability to make decisions. To ensure informed choice, managers can see that clients are (1) offered a choice of methods, (2) given the information they want about each method, and (3) allowed to choose the method that they want, provided there is no medical reason to withhold it (67).
• Communicate respectfully. All personnel, no matter what their function, can act politely and in a respectful, friendly manner with all clients at all times. Program personnel demonstrate their respect for clients by paying attention to what clients say, answering their questions fully, never belittling their concerns and questions, and understanding and honoring their clients wishes (294, 344). Also, programs must be sensitive to clients' modesty and preserve client-provider confidentiality (186).
• Train staff. Program managers can train staff to think of clients' needs and to communicate with clients. Staff also can learn how to communicate respect.
• Reward respect. Managers can reward personnel who treat female clients respectfully. They can measure the success of programs and providers by client satisfaction rather than just by numbers of clients. To measure client satisfaction, managers can survey clients about the care that they received (see Chapter 7.3 Involving Clients in Program Design). Whether clients return for further services when needed also indicates whether they are satisfied.
• Improve staff morale. Family planning personnel may treat clients poorly if personnel themselves have to work with insufficient time, supplies, space, or pay. If so, managers can acknowledge the problems, remedy them if possible, and at the same time make clear that the staff's frustrations are not an excuse for treating clients disrespectfully. Also, public promotion that enhances the image of providers, along with training, improves morale and inspires staff to live up to their new image (259).
• Set an example. Managers are role-models for other program personnel. If they do not treat clients and staff with respect, they cannot expect their staff to do so.

People who are treated with respect develop self-respect. Brief contacts with a family planning program are not likely to revolutionize women's lives. Still, for some women, contact with high-quality family planning services can be a start; for others, a step forward; and perhaps for a few, a big step. A young mother in Chile credited a family planning service with improving her self-esteem: "I am valuing myself more. I am realizing that I am really worth something. I am a person, and I should take care of myself..." (344).

To attain high quality, family planning services require two components: respectful, helpful interaction between provider and client (see Chapter 4.1, Encouraging Respect for All Women) and technically skilled personnel. To assure high quality, family planning programs can (1) determine the services that they can offer, (2) develop locally defined standards of care, and (3) establish quality-monitoring procedures (31). For example, those who counsel clients about contraceptive use must be trained to explain whichever methods are offered, to understand clients' needs, and to help them consider their options. Those who perform medical procedures need technical training. All training should raise providers' skills to a demonstrated standard of competence. Monitoring and supervision reinforce quality standards to assure that programs offer an informed choice of methods, hygienic care, and safe medical procedures. AVSC International has developed the COPE technique and the Population Council has developed the Situational Analysis approach to evaluate the quality of both client-provider interaction and providers' technical skills (200, 213).

Many medical professionals favor a reproductive health approach because they see a visit to a family planning clinic as a rare opportunity to inform, screen, and treat women for a variety of reproductive health conditions, such as certain common sexually transmitted diseases (STDs) (87, 114, 362) and conditions of pregnancy (156, 167). Also, girls and adolescent women can be counseled about nutrition, anemia, and general health to help prevent later pregnancy-related morbidity and mortality (115, 288, 362). Some programs, too, may want the convenience of dealing with multiple health needs on one clinic visit (33, 87).

Women often see little distinction among family planning, other reproductive health needs, and still other health needs, including their children's. When family planning personnel cannot help, some women feel that program personnel are not really interested in their health (301). In the ICMER clinic in Peru, women wanted a clinic visit to be an opportunity to learn more about their reproductive health and how to protect it. They preferred to discuss all their health problems with one provider (344).

Meeting a variety of needs encourages women to use services. For example, in Tunisia a family planning program recognized that new mothers have multiple concerns—about their new infants' health, their own health, and their ability to breastfeed (59). Therefore a clinic in Sfax began to offer neonatal, postpartum, and family planning services on one visit. Women are encouraged to come to the clinic on the fortieth day after giving birth, the traditional day on which a new mother first leaves the house. In 1987, 83% of postpartum women came for this visit, and 56% of these women adopted a family planning method (59). The approach is now being applied nationwide.

Not all women want all services, however. For example, some women may want a contraceptive method but not a pelvic exam or Papanicolaou smear. Requiring clients to accept services that they do not want could discourage them from getting any services at all (61).

In counseling women, programs also might broaden their focus beyond preventing pregnancy and disease (76, 91, 94). For example, women have a right to refuse unwanted sexual intercourse but often cannot do so. Helping women with such matters requires learning more about their private lives. Ruth Dixon-Mueller argues that providers cannot truly meet women's needs for contraception, disease prevention, or safety from violence without knowing something about how each client is sexually active (76). Providers may need to find out, for example, if a client has multiple sexual partners or is forced into unwanted sexual acts. Few family planning providers are prepared to elicit such information, which must be discussed in a sympathetic and reassuring manner. Training and a new way of thinking about the providers' role will be required. Of course, clients should not be required to disclose intimate information if they choose not to.

Weighing program options. Each program must determine its own ability to offer new services. Some programs may be strained to capacity, already serving as many clients as possible. For such programs, the scarcity of resources limits how much more they can offer. Other programs may want to attract more clients. For these programs, broadening services—and improving quality—may help. In choosing which services to add, each program has to assess clients' needs as well as program resources.

Still, some general principles apply to making these decisions. Elizabeth Maguire, Acting Director of the Office of Population, United States Agency for International Development, urges that family planning programs consider adding other reproductive health services "that will benefit the most women at an affordable cost and have the highest public health impact" (201). Under these criteria a common, serious condition that is easily treated or prevented would have highest priority. Providers and other public health experts should involve clients in deciding which conditions are deemed serious (14, 33, 161, 344), but without abandoning their professional judgement.

Many family planning managers are considering whether to offer services for sexually transmitted diseases. Adding STD services to family planning services can be appropriate because (1) many people need care, (2) combined services would be convenient for clients, (3) most STDs can be treated, (4) counseling could help women avoid STDs, and (5) most family planning programs offer condoms in any case. Also, STDs are spreading and have serious health consequences. It is now known that infection with the AIDS-causing human immunodeficiency virus (HIV) is more likely in those with other STDs (see Popoulation Reports, Controlling Sexually Transmitted Diseases, June 1993). Some family planning programs may find it difficult, however, to add STD services. Of course, family planning program managers can choose among several different levels of STD services: (1) prevention-information, counseling, and providing condoms and spermicides; or (2) in addition, initial screening and referral of suspected STD cases for diagnosis and treatment elsewhere; or (3) diagnosis and treatment as well as prevention and initial screening. The potential for impact and costs differs at each level.

Treatment after a septic abortion is also a serious need because so many women die from unsafe procedures (see Deaths from unsafe abortion in Chapter 2.1). At the 1984 International Conference on Population in Mexico City, delegates urged governments to help women avoid abortion and to treat them humanely if they have had an abortion (368). Policy-makers can reduce the number of abortion deaths by improving treatment for septic abortion and by linking postabortion care with contraceptive counseling and services (361). While offering contraception to all who want it, family planning programs can reduce abortion by reaching out especially to women at high risk of unwanted pregnancy, including adolescents, and by providing postabortion counseling and family planning services in hospitals where women receive postabortion treatment.

Around the world a variety of reproductive health programs are developing. For example, some affiliates of the International Planned Parenthood Federation (IPPF) in Africa and Latin America provide counseling and referrals for clients with STD symptoms (185). In Colombia the Asociación Pro-Bienestar de la Familia (Profamilia) offers contraceptive methods, screening for sexually transmitted diseases, sex counseling, clinics for men, AIDS prevention, and even legal services to low-income men and women (316, 345).

In Bolivia a coalition of 18 public and private health institutions recently launched a national campaign to promote reproductive health services. The Bolivian National Reproductive Health Program encourages couples to use services that will improve family health including reducing the high maternal mortality rate. These services include family planning, prenatal care, safe delivery and postdelivery care, breastfeeding promotion, and abortion prevention. To inform people about these services, the organizations, with technical assistance from Johns Hopkins Population Communication Services (JHU/PCS), have developed a campaign logo, clinic signs, posters, radio and television spots, in-clinic videos, client-provider materials, and audio cassettes for play on buses (285). The campaign tells couples that they have the right and responsibility to protect the health of women and children.

• Helping women learn to make informed choices in new areas of their lives,
• Supporting women's choices,
• Encouraging women to recognize their strengths and to build on them,
• Improving women's skills at communicating with their husbands and with people outside their families, and
• Creating new images and models of competent women and caring men.

Self-awareness can be the first step. Whether services meet women's needs can depend on providers' most basic assumptions about women and men (see Table 4). For example, if providers assume that women are solely responsible for contraceptive use, they may design services that make it difficult for men to obtain information and services. If, instead, providers assume that both men and women need services, they are more likely to design services that both men and women can use easily.

Making informed choices. Women make many decisions throughout their lives, but they may need to gain confidence in making new kinds of decisions, such as decisions to control their fertility or to seek new social roles. In a Mexican study young women with unplanned pregnancies seemed to be women with little awareness that they could make decisions for themselves. They were less likely than nonpregnant young women to know about contraceptives, to have discussed sex with their girlfriends, and to have aspirations and plans for the future (249). Women surveyed in parts of such countries as Bangladesh, Ghana, Jordan, Mali, Nigeria, Pakistan, and Tanzania say that they do not participate in decisions about having children. Many say that they obey their husbands' wishes or the will of God (88, 184, 205, 231, 242, 317, 384) (see side-bar, Who Makes Reproductive Decisions?).

Reproductive health programs can help women make wider choices. By discussing reproductive needs and goals with clients, providers can give women practice in assessing a situation and making thoughtful decisions. Since making fertility decisions may be unfamiliar to some clients, the process requires skill and patience on the part of the provider. Ideally, the provider imparts information, listens attentively, encourages discussion, helps clients recognize their own needs, and answers clients' questions. The clients themselves make the decisions about whether and when to have children and how to carry out their plans (186).

Supporting women's choices. Respecting clients' wishes builds women's confidence in their own decision-making and their right to make decisions. For example, many women already know what contraceptive methods they want before they come to a family planning provider (68, 82). Honoring a woman's preference is important to her satisfaction with family planning (32). In Indonesia, for example, 91% of women who were given the method that they chose were still using that contraceptive method after one year compared with only 28% of women who were given a method that was not their first choice (244). A 6-country IPPF study also found that women were more likely to continue contraceptive use when they received the method that they wanted (142).

Women's choices reflect their own needs. Providers cannot assume what women need or want. For example, in Peru some women in focus groups said that they preferred the rhythm method because it gave them the right to make choices about when to have sex. Also, its use implied the intelligence to take charge of one's life. Women chose this method because it requires cooperation between sexual partners, and that cooperation enhanced the relationship (247).

Therefore, to create the best services, managers can ask clients what they want and design programs and train staff accordingly. Even better, they can directly involve female clients and community members and groups in planning and monitoring services (see Chapter 7.3 Involving Clients in Program Design). Such a client-oriented approach is rare. Indeed, providers' biases often block access to contraception and to a choice of methods (299). Often because of misinformation about methods, providers may favor one method over all others or shun certain methods. Because of negative assumptions about clients, particularly about women, providers may deny clients a choice of methods or discourage use of methods that require clients to act—for example, using barrier methods at each act of coitus or taking an oral contraceptive tablet daily.

Recognizing women's strengths. Successful counseling helps women identify their strengths and build upon them in planning their lives. In India group leaders from the Institute of Health Management ask groups of women who is the most important person in their homes. At first, the women never mention themselves. Then the group leaders recite a list of household chores and ask the women who does each chore in their homes. The women repeatedly answer that they do the chores. When the leaders ask again who is the most important person in their house, the women laughingly answer that they are most important (386). Good counseling can help women recognize that they already plan their time, save money or grain, and care for their families and homes. Building on these skills, women may learn to plan other aspects of their lives, including their reproductive lives, in which they may have depended previously on others. Recognizing their own managerial role in the home, women can have more confidence applying these skills elsewhere. A manual prepared by the United Nations Educational, Scientific, and Cultural Organization (UNESCO) suggests an exercise to help women build their self-esteem: Women list their skills, such as planning their time and organizing their families. Then they say how those skills would help them in a business situation (336).

Improving communication skills. Family planning programs can help women speak up on matters that concern them. In particular, programs can encourage and enable women, and men, to talk about contraceptive use and reproductive health. Women's discussion groups have been the approach most widely used to help women bring up and discuss these issues.

To help women learn to talk about family planning, a program in rural Bangladesh designed with assistance from JHU/PCS organizes volunteer discussion groups. The program was set up to reach more people than family planning field workers could reach in home visits and because women were isolated and unaccustomed to discussing family planning with each other or with their husbands. The discussion groups, called Jiggasha ("to enquire" in Bangla), are formed for men and women separately. Leaders and meeting places are chosen to take advantage of the existing networks of communication in the community (see side-bar, Family Planning Field Worker Helps Create New Rules for Women).

The Jiggasha meetings have encouraged women to discuss and use family planning. About 65% of participants report that, after attending several meetings, they have discussed family planning with their husbands or with other women in the group, and about 50% report talking to people outside the group or to a family planning field worker. Some 30% of the women began to use a modern contraceptive method, and 20% visited a health clinic (169).

In Bolivia in the early 1990s client-provider materials produced to improve the quality of reproductive health services and counseling contributed to communication between spouses. Before-and-after surveys found that significantly more clients had talked with their spouses about family planning after seeing and receiving the materials--95% compared with 84% before they had seen the materials in clinics. By comparison, the increase among those who had not seen the materials—from 83% to 88%—was not statistically significant (343). Later a video drama entitled Hablemos en Pareja (Let's Talk Together) was produced and shown in clinic waiting areas to help clients overcome barriers to communication between spouses.

Couples may find talking about family planning and reproductive health easier if they have discussed the subject first with someone of their own sex. Programs such as Jiggasha can help. For example, women in a rural area of northern India could not talk to their husbands about sexually transmitted diseases, even though they feared that their husbands might infect them. Health advisors organized the women into groups that discussed the problem and decided how to approach their husbands. After practicing the conversation in groups, the women were better able to talk with their husbands (332).

Family planning providers can help couples communicate better if they are aware of social conventions. For example, in Mexico a survey revealed that couples thought it immodest for the wife to start a discussion of family planning. These couples said that husbands should start such discussions and decide whether the couple uses a family planning method. In response, family planning providers designed counseling services for men and women advocating that women start discussion and that the couple make a decision together (256).

Women's situation will improve faster if men help. Protecting reproductive health particularly requires commitment from both men and women. While a woman can control her fertility without a man's cooperation—and many do—men's understanding and help make contraception and family planning easier and widen the choice of methods that a couple can use. Also, to prevent sexually transmitted disease, a woman must have the cooperation of her male sexual partner, who must remain faithful to her or use condoms. What can family planning and reproductive health programs do to encourage men's cooperation?

Still, many men have negative attitudes about women choosing and using contraception. Some men fear that contraceptive use will make their wives independent of their control (98). They fear that their wives will have sex with other men if they no longer risk pregnancy (84, 98, 241). Some men may be unwilling to have their wives adopt family planning because they themselves know little about it. Some do not want their wives talking with strangers about sex and reproduction. Some worry that contraceptive use will harm their wives' health or their own (3). Some oppose contraceptive use for religious reasons (84, 155). Some men think that large families reflect their masculinity or their wives' faithfulness in serving them (84, 98).

These male attitudes about contraceptive use are part of some men's broader fears. Traditional social norms often have required men to maintain the honor and position of their extended family, village, religious group, or other social organization. Therefore men feel responsible for the behavior of their wives and children and think that women have no right to make decisions for themselves (88, 132, 295).

• Inform men about family planning, reproductive health, and contraceptive methods,
• Encourage and improve communication between spouses,
• Design convenient services for men,
• Provide contraceptive choices for men, and
• Promote images of male role-models who cooperate with women both in the family and in the community and who share the burden of ensuring reproductive health.

Women, too, want men to have information. In Chile women asked that men be allowed to come to the classes at the clinic. One woman said that her husband did not always believe her and that she would "love to have him come to some of the talks" (344).

Men need information about contraceptive methods for women as well as about those for men. Well-informed men can use a method themselves or support their partners in using a method. Well-informed men also can talk with their wives and cooperate in assessing their needs and choosing a family planning method.

Men especially need information about sexually transmitted diseases since men play a big role in the spread of sexually transmitted diseases including AIDS (23). Although there is much variation among cultures, except for female prostitutes men are likely to have more sexual partners than women. Men have more control over condom use. Men are more likely to control the frequency of sexual relations and the possibility of abstinence within a relationship. To reduce risk, men can: (1) reduce the number of sexual partners, (2) use condoms, and/or (3) practice sexual fidelity or abstinence (271).

Encouraging communication between spouses. Men can support women's choices better when couples can talk about reproductive health and family planning (see Chapter 5, Encouraging Men's Cooperation). But surveys show that even men who approve of family planning do not always discuss it with their wives. For example, in Burundi 94% of surveyed men approved of contraceptive use, but only 48% had discussed it with their wives in the preceding year (see Table 7). Family planning communication campaigns can change men's role in contraceptive decision-making. The Zimbabwe Male Motivation Project in 1988 and 1989 sought to inform men, promote more favorable attitudes, increase contraceptive use, and promote male involvement and joint decision-making. The project appeared to increase condom use particularly. Its impact on men's attitudes about decision-making was ambiguous, however. Men who heard the campaign radio soap opera, attended a lecture, or saw a pamphlet were more likely to say that the man alone should make the decision to practice family planning. At the same time, these men also were more likely to say that the couple should decide jointly how many children to have. Researchers concluded that future campaigns should put more emphasis on joint decision-making and discussion between spouses (254).

Some family planning programs welcome husbands and wives who seek family planning counseling and services together. While counseling a couple, a provider can encourage the woman to ask her own questions and express her own opinions. The provider also can encourage the man to understand and respect the woman's opinions and choices. Program managers seeking to improve women's situation need to make clear, however, that the program also welcomes women and men who come alone, does not require a husband's permission before serving a woman, and keeps the names of clients and all information about clients confidential, even from spouses.

Designing convenient, appealing services. Men cannot share responsibility for reproductive health and family planning if services and information do not reach them. Few men go to facilities that offer services primarily for women. Men must be reached in other ways. There are five main approaches:

• Separate clinics. Male-only clinics can inform men about all family planning methods and provide condoms and vasectomy. Separate male clinics have been successful in Asia and particularly in Latin America, including Brazil, Colombia, Guatemala, Honduras, Mexico, and Peru (111, 124, 279). Some offer a range of reproductive health services including care for sexually transmitted diseases and infertility.
• Better service for men at existing clinics. Some conventional family planning clinics have hired male staff, offered hours convenient for men, and offered additional reproductive health services for men. In Colombia Profamilia serves men at its women-oriented family planning clinics as well as in clinics for men only.
• Workplace services. In India, Kenya, the Philippines, Turkey, and elsewhere, employers or trade unions provide family planning services to workers, often as part of broader health services (274). Other possibilities include working with male-oriented educational or fraternal organizations, cooperatives, or the military (111).
• Community-based services. Male community-based distributors can provide men with condoms and information about family planning. For example, in 1987 the Katibougou Family Health Project in Mali recruited men from the community who distributed condoms from stocks kept in their homes, just as female community health workers distributed supplies to women (158).
• Commercial and social marketing. Commercial sales have long been men's chief source of condoms. To make supplies more affordable and to increase promotion, social marketing programs, which sell contraceptives at subsidized prices through established commercial outlets, operate in more than 20 countries. Men can buy social-marketing condoms along with other goods. In many Muslim countries particularly, men do the household shopping.

In most developing countries neither condoms nor vasectomies are widely used. Just under 5% of married couples in developing countries use each of these methods. Condoms probably are more widely used outside marriage than in marriage, however, and use may be growing because of concern about AIDS (190). Neglect by policy-makers and providers may help explain the low prevalence of vasectomy. Where the procedure is accessible and promoted, men use it. For example, in Colombia the annual number of vasectomies performed by Profamilia rose by 77%, to more than 1,000, after the organization opened its first two men-only clinics in 1985. In 1991 Profamilia's eight men-only clinics performed about 5,000 vasectomies (189).

Promoting male methods and men's services. Promoting men's family planning methods and services boosts their use. For example, in Turkey a social marketing campaign to promote condoms involved a television comedy, video tapes, sponsorship of a soccer team and tournament, billboards, and gift packs to medical schools (377). The program sold 4.5 million condoms in 1991, its first year of sales (319). Men's response suggests that some men are willing to take responsibility for contraception if programs make the effort to reach out to them.

Social marketing programs have been directed more to men than to women. They have emphasized the economic value of small families. They also depict men as the protectors of their families (314). While most promotion has touted condoms, some social marketing programs now address advertisements for oral contraceptives to men as members of the "contraceptive decision-making team." In Morocco radio and print advertising, display boxes, and posters depict condoms as offering men the opportunity to share responsibility for reproductive decision-making (314).

Promotion also has brought men to clinics. In Colombia Profamilia has promoted its men's services in the mass media and through field workers (189). In Brazil Pro-Pater increased the number of vasectomies performed monthly in 1989 at its Sao Paulo clinic by nearly 80% with television spots, billboards proclaiming that "vasectomy is an act of love," and resulting press coverage (171).

Promoting positive images. Family planning communication can depict new images of men as well as of women (see side-bar, Competent Women and Caring Men). Also mass-media depictions of couples discussing family planning and making joint decisions suggest to the public that such discussions are appropriate. They also suggest to both men and women how to discuss family planning and sex and can even provide an occasion to start discussion.

Men's organizations are involved, too. In Jamaica, Fathers Incorporated assists men who want to help children. The group points out that in the past men have been seen solely as providers of goods for their children. To change that image, group members are holding workshops to promote men as care-givers as well (8).

The United States Agency for International Development estimates that currently about 500,000 women work in family planning programs in developing countries—about half of the nearly one million family planning workers estimated by the World Bank to be employed in both developed and developing countries (139, 385). Jobs held by women range from community-based distributors to program administrators to doctors, nurses, and midwives.

Income. The salaries, honoraria, or fees for service paid to family planning workers can make a difference to their quality of life. In a survey by the Center for Development and Population Activities (CEDPA) of 305 field workers employed in 11 family planning projects in Bangladesh, India, Kenya, Mali, Nepal, Pakistan, and Turkey, 76% reported that the income they received from their jobs improved their economic status (157).

Most of these women use their income to help their families (24, 162, 163). In the CEDPA study 51% used their earnings largely for general household expenditures; 29%, for their children's education; 10%, for themselves; and 6%, for other miscellaneous, unessential expenses. The remaining 4% gave the money to their husbands (157).

By earning money, some women improve their position in the household. Most women in the CEDPA study gained more control over their children's education, medical care, and household expenditures. Many also found that relations with husbands and in-laws improved (157). Just earning money does not guarantee better status at home, however. Some case studies of women earning money in the informal sector (not in family planning) experienced no increase in household influence (126, 193).

Of course, many programs ask women to work as volunteers. Even if women cannot be paid for their work, programs can make special efforts to recognize their contributions and publicly honor their contribution to their communities.

Competence in new skills. Family planning providers can learn new information and skills. In the CEDPA study community-based distributors' reports suggest that their leadership and communications skills improved, as did their knowledge of family planning methods and service delivery (157). For many, this is their first paying job. Unlike physical labor such as sewing, farming, or typing, family planning field work teaches women skills that meet the social needs of the community and that enable women to teach others. Community-based family planning providers often help people obtain medical care at clinics. Some are trained to provide directly and/or to teach oral rehydration therapy, immunization, nutrition services, safe delivery practices, and broader maternity care (302). Professional status and respect. Female family planning workers often win respect for their knowledge. These women become community authorities in family planning and other health matters. In Matlab, Bangladesh, both field workers and community members report that field workers are important community resources not only for family planning services but also for general medical advice and referral. Community members even seek field workers' advice on financial matters and neighborhood disputes (302).

Respect is not always easily earned, however. New roles for women sometimes threaten community norms, and those who break the rules may be scorned. For example, in Muslim countries where purdah is practiced, custom prohibits women from moving about alone in public, and yet family planning field workers must visit homes and clinics.

In the face of initial hostility from the community, female workers often find ways to maintain their self-respect. For example, Bangladeshi family planning workers redefined for themselves the traditional norms of purdah and female modesty (302). They spoke of "inner purdah," shifting emphasis from physical seclusion to an internalized moral code of conduct (302).

In various cultures and countries, female family planning workers have experienced initial rebuke, then gradual acceptance, and eventual respect (157, 188, 302). For example, in Bangladesh the field workers initially scorned for violating purdah eventually regained their prestige and at the same time legitimized family planning services (302). In a few cases female field workers have been unable to win community respect. A study of auxiliary nurse-midwives who provided family planning services in Maharashtra, India, found that many of the women had been abandoned by their husbands or had difficulty finding a husband (152).

In general, women working as community-based distributors feel strengthened by their work. They reported in the CEDPA study that their achievements and value to the community enhanced their self-esteem and sense of autonomy (157). Particularly in cultures that generally isolate women, work in family planning is a gateway to new ideas, new information, and new opportunities (140).

By persevering and winning respect, women working in family planning set an example for other women (see side-bar, Family Planning Field Worker Helps Create New Roles for Women). They legitimize women's employment, and family planning workers can serve as examples that young women can aspire to emulate (140).

Family planning workers can stimulate change in their communities in many ways. Their work can loosen taboos detrimental to women and even help other women assert themselves. For example, after three years of a women-staffed community-based project in Mali, villagers were more willing to discuss such previously taboo topics as family planning and contraceptives (157). In Nairobi, Kenya, female volunteers in a family planning project spoke with confidence in public gatherings (157). In both India and Bangladesh community acceptance has enabled female field workers to intervene in family disputes, rebuking and advising men and providing moral support to women (157, 302).

Workers selected with their communities' input may have a better chance of being accepted than workers chosen by outsiders, as a review of community-based programs in Africa suggests (248). In some cases newly employed family planning workers may displace traditional practitioners, such as traditional birth attendants and midwives, who play a vital social role. Collaboration may be important to win support from traditional practitioners and avoid resistance that could make the task of family planning workers more difficult.

Promoting family planning providers helps women win community respect as qualified, trustworthy professionals. Strengthening both the image and the skills of providers can attract and keep clients. Johns Hopkins Population Communication Services has dubbed this the PRO approach—Promoting Professional Providers (259). A survey in Kenya showed that people who had heard the radio drama in the Haki Yako ("It's Your Right") PRO approach campaign were less likely to have a negative image of family planning providers than people who had not heard it (320).

Visible symbols of family planning employment help, too. In Kenya and Zimbabwe, for example, female community-based distributors wear uniforms and have signs outside their homes signifying official endorsement of their work. Recognized as community leaders and authorities, family planning workers are often the only women who sit on the podium at official village events (188).

How can population policies better reflect women's interests? Improving the quality of care and protecting women's health have long been concerns of family planning advocates. The United Nations has declared that the goal of family planning should be "the enrichment of human life, not its restriction," pointing out that women in developing countries need a broad range of economic, health, and social rights and services (47, 322). Many family planning programs are still struggling to meet more modest goals, however. As demand for contraception has risen rapidly in developing countries over the past two decades, programs often have not been able to serve all the people who want family planning.

Recognition is growing that population policies--and development policies in general—must pay attention to their clients' needs and preferences if they are to succeed. J. Brian Atwood, Administrator of the United States Agency for International Development, describes the need in this way (14):

Attention to gender roles is fundamental to the success of programs we assist. We must support full participation of women at all levels of family planning and—indeed—all health and development programs. We must help women overcome the obstacles they face in obtaining services or using contraceptive methods. We must see that programs are designed to benefit women. And, we must help programs strengthen men's support and participation.

To accomplish this at the program level, family planning program managers are increasing their efforts to learn from clients. At the same time, women's advocates are seeking more opportunities for women to participate in planning services (38, 220, 313). Thus program managers and women's groups have begun to work together. At the policy level, policy-makers, family planning organizations, women's groups, and other nongovernmental organizations have been building links between population policy-makers and women's advocates (323). This discussion and debate has grown as world attention has focused on the United Nations International Conference on Population and Development (ICPD) in Cairo in September 1994 (see side-bar, Debate Over Policy).

In this discussion diverse policy-makers are recognizing that their various goals can be achieved by the same means—offering services that people want. Policies that serve clients:

• Recognize that reproductive choice is a human right,
• Focus on meeting clients' unmet needs for reproductive health services, and
• Involve clients, especially women, in program design.

Reproductive Choice Is a Basic Human Right

Women's advocates have had to struggle to gain recognition of women's reproductive rights. Early in the 20th century women's advocates established the first programs to provide contraceptive information and services so that women could exercise their rights to protect their own health and control their own fertility (121, 143, 212, 263). Often religious, medical, and government leaders stood in their way (121, 214). It was not until the 1940s that contraception began to be accepted in developed countries as a medical service and become more widely available (212, 221, 270).

In recent years international organizations have recognized the right of all individuals and couples to make reproductive choices. In 1968 the International Conference on Human Rights in Teheran affirmed the right of reproductive choice. This right was reaffirmed at the first UN World Population Conference, held in Bucharest in 1974, and again at the second such conference, in Mexico City in 1984. In the words of the report of the Bucharest conference, "All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children, and to have the information, education, and means to do so" (327).

International institutions consider securing reproductive choice to be an important part of improving women's well-being. For example, the Committee on the Elimination of Discrimination Against Women (CEDAW), established by the United Nations to gauge progress toward ending discrimination against women, monitors access to family planning as an important indication of women's situation (see side-bar, Efforts for Legal Change).

The declarations of international institutions and global conferences put governments on notice that women should have the right to control their fertility and their own lives—and that family planning programs can help women to achieve these rights. Governments and reproductive health programs face the challenge of turning these broad principles into policies and programs.

Such statistics imply large potential demand for family planning services. Even though contraceptive use has risen substantially in recent years, in most surveyed countries between 20% and 30% of married women of reproductive age report that they are not using contraception but do not want any more children or else want to delay their next birth at least two years (357). Rates of abortion, even where abortion is illegal and unsafe (see Chapter 2, Family Planning Saves Lives), also testify to women's strong desire to control their own fertility.

Demographers describe women who are not using contraception but want to space or limit births as having an unmet need for family planning. Using this definition, Population Reports has estimated, based on DHS data, that 120 million married women of reproductive age in developing countries have an unmet need for contraception (see Population Reports, The Reproductive Revolution: New Survey Findings, M-11, 1992). Ruth Dixon-Mueller and Adrienne Germain suggest widening the definition of unmet need to include unmarried women, women who need better or more suitable contraceptive methods, women who need abortion services, and women who need more comprehensive reproductive health services than are currently available (78). These numbers cannot be easily estimated, but they would surely add substantially to the 120 million figure.

Men also have unmet needs for family planning. In DHS in Burundi, Egypt, Ghana, Kenya, and Pakistan, over half of men approve of family planning, but very few are using a contraceptive method (see Table 7). In smaller, qualitative studies as well, men have asked for more information about reproductive health services including both contraception and treatment for sexually transmitted diseases (see Chapter 5.2, Encouraging Male Responsibility).

Effectively serving all who want to avoid pregnancy but are not using contraception could help reconcile the dual goals of (1) serving individual clients and (2) slowing global population growth (74, 303). Steven Sinding has suggested that family planning programs replace demographic objectives with the objective of meeting unmet need. In 9 of 12 countries studied, levels of contraceptive use would be higher if all unmet need were met than if current demographic objectives were reached (303).

To translate this unmet need to control fertility into utilization of reproductive health services, policy makers must let clients know that these services are a safe and effective way to achieve their personal goals. Reproductive health programs can identify the obstacles that prevent women from using services and can design services and communication that will help overcome some of those obstacles. Obstacles may range from lack of supplies and services to dissatisfaction with current services to fears of contraceptive side effects, to social limits on women's mobility or decision-making. Beyond the need to control their own fertility, women also need other reproductive health services, and family planning programs may be able to meet these needs, as well (see Chapter 4.2, Offering Other Reproductive Health Care).

Policy-makers can use various means to learn what clients and the public want. A recent review has identified a range of approaches (33). Many of these approaches are routinely used in the audience research that is part of designing and monitoring family planning communication programs (255):

• Observation of client-provider interactions,
• Feedback from "mystery" or "simulated" clients—people who use services and then report on their experience,
• Patient flow studies to determine how long patients spend in such activities as waiting and talking to providers,
• Focus-group discussions with clients and potential clients about their experience and their preferences,
• Exit interviews or other postservice interviews with clients,
• Interviews with service personnel about what they think would constitute a good client visit and what they see as difficulties,
• Involving women directly in program design as program administrators or on advisory groups,
• Working with women's health advocacy groups to benefit from their analyses of women's health needs,
• Open discussion meetings in the community, sometimes specifically for women or for men, and
• Learning from other programs with services that clients like.

Some women's grass-roots organizations have identified their own reproductive needs and responded to them. For example, the Working Women's Forum in India and the Mothers' Clubs in South Korea offer family planning services that complement the economic help and other services that they provide to members (5, 49, 53). The seven clinics run by the Bangladesh Women's Health Coalition each have a local advisory committee to ensure that the clinics meets local needs (161).

Some women's organizations have focused on informing other women. In 1991 a collective of Egyptian women wrote a nontechnical book on women's reproductive health (145). In Peru women in focus groups helped Peru Mujer, a nongovernmental organization, design educational materials for nonliterate women like themselves (96). Women in Fiji made videos for women's groups on topics that they wanted discussed, such as sexually transmitted diseases and women's attitudes toward menstruation and family planning (364). Other family planning organizations can learn from such groups and perhaps collaborate with them.

Involving women more deeply in program design should not mean excluding men. Men and women share responsibility for reproductive health. Policies and programs will work best if they are planned by, and for, both women and men. Ideally, the insight and experiences of both women and men will create better programs that improve the lives of all clients.

Improving the lives of women and men should be a primary goal of population policy. Reproductive health care programs contribute by enabling men and women to live healthier lives and to plan when they will have children. Women, and men who enjoy better health and more control over their reproductive lives can have more opportunity to fulfill their hopes for their children, themselves, their families, and their communities.

We Have Family Planning Now
Thinking about Family Planning and Women's Lives
The Death of Sadie Sachs
Meeting Women's Needs: What Should Be Done?
A Better Life
Son Preference, Daughter Neglect
Changes in Woman's Lives: Profiles from Surveys
Learning More About Family Planning and Woman's Lives
Who Makes Reproductive Decisions?
My Husband...Was a Great Help
Efforts for Legal Change
Family Planning Field Worker Helps Create New Roles for Woman
Ten Program Strategies To Meet Woman's Needs
Debate Over Policy

"We Have Family Planning Now" "I was given in marriage at age 13. I hadn't even reached puberty. My father was dead, so my uncle arranged the marriage with a neighbor. Now it is better; there is a law that says girls mustn't marry before the age of 17. That is good. You know, I hadn't had my period when I married. A month later it came—and a month after that I was pregnant. I had five children—three boys and two girls—but one daughter was stillborn. "My children go to school, and I want them, both sons and daughters, to go as far as their ability lets them. I want them to have a good future, a profession, a happy life. I don't want them working in the fields, picking up straws and leftovers as I do. I would like so much to have gone to school. I would like to have opened my mind. I would have taught other people about things. I want to know everything—everything you can learn if you have an education. I won't let my daughters marry earlier than 17. I want them to have time to finish their studies, prepare their trousseau, and prepare themselves for marriage. "Men are much better these days than they were before. They respect women more. Now they learn things, they are more understanding, they understand the rights of men and of women, too. And now a man can no longer divorce a wife he tires of. Before, a woman could be divorced, beaten, and poorly treated. That kind of thing doesn't exist anymore, thanks to President Bourguiba. Thanks to him and the laws, women are much better off today. "We have family planning now, and you can take better care of your children. That, too, is different. You can't imagine how many things I tried to swallow to prevent myself from having more children. I even used to eat mothballs, thinking that would help. I am only 36 years old, and I have planned my family now for five years. I have a loop. I don't want any more children. Life is too difficult. "Before the new laws, all women lived the lives of beasts." —Bedouin woman in Sfax, Tunisia (144)

Thinking about Family Planning and Women's Lives How can family planning help women meet their needs? Thinking about this question requires making some basic distinctions. Women's Practical and Strategic Needs Women's needs can be grouped into two categories—practical needs and strategic needs. Caroline Moser, writing about women and development (218), defines practical needs as what women need to perform their conventional roles more effectively, such as good child care, better agricultural technology, and better housing. To help meet women's practical needs, women and program planners first analyze women's current activities and then develop ways to help women undertake those activities more effectively and with less burden. In contrast, strategic needs are what women need to broaden their choices and opportunities. Although circumstances vary in different societies, strategic needs often include training for new jobs, enforcement of equal legal rights, and access to more education. Program planners try to help women meet their strategic needs by looking at the social factors that limit women's choices and then developing opportunities for women to assume new roles and responsibilities. Practical and strategic needs are not mutually exclusive. Some new opportunities, such as the opportunity to control one's own fertility, help women meet both kinds of needs. Contraceptive Use and Family Planning Services The term "family planning" often encompasses two distinct concepts—contraceptive use and family planning services: Contraceptive use, of course, is use by an individual or couple of a means to avoid pregnancy. Contraceptive use helps women meet their practical and strategic needs by enabling women to control when and how many children to have. Family planning services are organized sources of contraceptive methods. Such services include family planning programs of various types, retail sales of contraceptive supplies, and private practitioners' services. The foremost way that family planning services help to meet women's needs is by providing contraceptive methods safely and effectively, thereby enabling women to control when and how many children to have. In the course of providing contraception, however, family planning programs can do more. Program planners can deliberately design services to help meet women's strategic needs (see Chapter 4).

THE DEATH OF SADIE SACHS One stifling mid-July day in 1912, I was summoned to a Grand Street tenement, wrote Margaret Sanger, then a nurse in New York City. Margaret Sanger arrived at the apartment building to find 28-year-old Sadie Sachs unconscious from complications of a self-induced abortion, with three crying, under-nourished children around her. Her husband Jake spent the last of his meager earnings to pay Sanger and a doctor, who worked together for hours to defeat the infection that had set in. After three weeks under Sanger's care, Sadie Sachs recovered. Mrs. Sachs then begged the doctor for some way to prevent further pregnancies. "Tell Jake to sleep on the roof!" was his reply. She then turned to Sanger for help. "Please tell me the secret. I'll never breathe it to a soul! Please!" I did not know what to say or how to convince her of my own ignorance.... I promised to come back in a few days to talk with her [but] I was helpless to avert such monstrosities. Time rolled by and I did nothing. The telephone rang one evening three months later. Mr. Sachs begged me to come at once. Mrs. Sachs was sick again from the same cause.... I hurried into my uniform...and started out.... I turned into the dingy doorway and climbed the familiar stairs once more... Mrs. Sachs was in a coma and died within 10 minutes. I folded her still hands across her breast, remembering how they had pleaded with me, begging so humbly for the knowledge which was her right.... Jake was sobbing.... Over and over again he wailed, "My God! My God!" When I finally arrived home...I looked out my window upon the dimly lit city.... I could bear it no longer... I went to bed, knowing that no matter what it might cost, I was finished with palliatives and superficial cures. I was resolved...to do something to change the destiny of mothers whose miseries were vast as the sky. Margaret Sanger, nurse, US family planning pioneer, founder of Planned Parenthood Federation of America (290).

Meeting Women's Needs: What Should Be Done? Women confront many obstacles to better lives. Women need change in many areas simultaneously. Thus the agenda for policies to give women more opportunities must be broad. In addition to assuring women's ability to control their own fertility, important elements include efforts to: Improve health. In the nations with the best health care, the life expectancy of women is 10% longer than that of men (243, 331, 347). In developing countries, however, women's life expectancy is closer to or shorter than men's (203, 331). This occurs because women receive less than their fair share of health care and food, often beginning in childhood (57) (see side-bar, Son Preference, Daughter Neglect). As adults, many women do not get the food and health care needed for healthy childbearing (306, 371, 374, 380). Encourage education. Over the last 20 years more and more girls have been going to school, but boys still get more education than girls. An estimated two-thirds of the 300 million children without access to education are girls. Two-thirds of the 960 million nonliterate adults are women (329). Ensure job opportunities and fair pay. Most women work long and hard, and they earn less for it than men do (341). Even in developed countries, for example, women earn 75% or less of what men earn (326). Much of women's work is unpaid. Women's unpaid household labor accounts for about one-third of the world's economic production (306). When unpaid agricultural work and housework are considered along with wage labor, women work more hours than men (196, 326). Guarantee legal protection. Legal codes often sanction inequality between husband and wife (341). They may allow marriage of very young women, marriage without the woman's consent, unequal ownership and control over family assets including land and other property, unequal inheritance rights, and unequal access to divorce and to support after divorce (103, 105, 146, 287). In many cases the law does not recognize women as adults with the same capacities and right to make decisions as their husbands (105, 106). Laws that do protect women's rights often are not enforced (127). Permit access to reproductive health care. The International Planned Parenthood Federation (IPPF) has reported that 46 of 94 surveyed countries require spousal consent for contraception, abortion, or voluntary sterilization—services used primarily or exclusively by women (147). Worldwide, 54 countries require a woman to obtain her husband's approval before voluntary sterilization, but only 20 of these countries also require a man to have his wife's approval (283). Young women and unmarried women often have little or no access to reproductive health services. Yet surveys in eight sub-Saharan countries, for example, find that 20% to 47% of adolescent women become pregnant before marriage (73). Prevent violence against women. Many women live every day in fear of violence, often from their husbands (341). In surveys in Chile, Colombia, Kenya, India, Mexico, Pakistan, Papua New Guinea, San Salvador, South Korea, and Thailand, 40% to 99% of women reported physical abuse by their husbands (43, 133, 264). Most of these women have no choice but to live with this abuse and fear. Leaving the marriage is often not a realistic option when women, denied education, jobs, and inheritance rights, are economically dependent on their husbands (43). Unwanted sexual intercourse is a major form of violence against women (326). In a US national sample survey, 13% of women reported that they had been raped at some time in their lives, not counting marital rape (229). This amounts to one woman raped every minute (133). Half of these women were under age 18 when raped, and 75% knew the man who raped them (229). Detailed data on rape are not available from developing countries. Fear of desertion or violence prevents women from acting in their own best interests. For example, in Egypt many women do not seek care for gynecological problems such as vaginal discharge or fistula because they fear that their husbands will divorce them for spending time and money on their own health (167). Threats of violence prevent some women even from participating in development projects (43, 150). Increase respect for women. Since most societies value females less than males, many women grow up believing that they are inferior to males. Such perceptions are difficult to change. For example, China has promoted equal roles and rights for women for 40 years. Still, 30% of Chinese women surveyed in 1990 thought that men are born to be more important than women, and 33% agreed that women should hold back so that they are not more successful than their husbands (52). Programs to Improve Women's Lives Programs to help women often focus on their economic or legal position. Women themselves have started many of these programs. For example, women in India formed the Self-Employed Women's Association (SEWA) in 1972 and the Working Women's Forum (WWF) in 1977 to change local ordinances that interfered with their ability to work as market traders (49, 282). Both groups broadened their agendas as members began to request help with health, education, and other needs. In Tunisia in the 1970s President Habib Bourguiba led the government to legislate better legal protection of women (see side-bar Efforts for Legal Change). In Bangladesh university professor Mohammed Yunus convinced the Grameen Bank, a private bank, to give poor women small loans (108). Development planners have developed two broad approaches to assessing women's needs and designing programs to address them: The status of women approach compares the positions of women and men in a society or cross-nationally. After identifying the areas in which women are disadvantaged, planners design programs to address the problems. The empowerment of women approach aims to help women gain more control of their lives. This approach often begins with women identifying and prioritizing their own needs. Program organizers then help women to design programs that meet those needs. Both approaches have advantages. Focusing on objective measures of women's status documents the problem for top-level policy-makers and helps motivate their support for policy changes. The United Nations has based its efforts to eliminate discrimination against women on status measures such as years of education and hourly wages. The empowerment approach may bring faster results for individual women, although usually on a smaller scale. Involving women in solving their own problems builds their skills and self-confidence and finds solutions that are locally appropriate (113, 166, 352). Using both approaches could speed improvements for women, and in practice the two approaches are not always distinct. Program organizers can use the status-of-women approach to influence policy nationally and to evaluate its impact and at the same time can use community-based empowerment programs to begin change locally. Some of the most successful community programs at first address a need that women clearly recognize, such as the need for income, and then build skills that women can use in many areas of life. Women's advocates are asking that development plans pay more attention to the effects of planned changes on women's lives. Some development plans have required, for example, male labor migration or female volunteer labor, which place additional burdens on women (26, 37, 223). "Gender planning," as the approach is called, considers the impact of a proposed program on women, men, and their relationship (198, 217, 245, 268). Its goals are to ensure that development programs do not inadvertently harm the lives of men or women and to see that women's situation is improved.

A Better Life "The main thing that makes the times different, I think, is the control women have over the number of children in a family. A family can be planned now; it can live a better life. Women have more facilities for everything because of this. I began to take contraceptives when the last child was eight months old. I take the pill." "...we were very poor when I was a child. We were six children, and my father didn't earn much. That is why I want just two or three children. I don't want my children [two daughters] to grow up like me—without an education. I feel very ashamed and bad about not having any education. I want my children to go to school and learn many, many things.... I want them to be independent and proud of themselves." —19-year-old Mexican woman using contraception without her husband's knowledge (144).

Son Preference, Daughter Neglect In some countries parents tend to prefer sons and to treat them better than daughters. Boys sometimes get more to eat and more medical care, while girls are slighted in education and jobs and in some cases are neglected, abused, and even killed. While the majority of studies on son preference come from countries in South Asia and North Africa, where son preference is believed to be strongest, son preference appears to exist to some degree in other regions of the world as well. The preference for sons is both a symptom and a cause of limited opportunities for women. Extent of Son Preference A common index of preference for sons comes from survey responses: the ratio of the number of parents who say that they prefer their next child to be male to the number who prefer their next child to be female (374). A ratio also can be derived from survey responses about desire for additional children among women with different numbers of living daughters and sons (12). Among countries surveyed, those with strong preference for sons—indices of 1.6 or above—are Bangladesh, Jordan, Nepal, Pakistan, South Korea, and Syria. Moderate preference for sons (indices of 1.2 to 1.5) has been documented in many other countries, including the Dominican Republic, Egypt, Mexico, Senegal, Sudan, Turkey, Nigeria, Tunisia, and Yemen. Some countries, such as Colombia, Ghana, and Indonesia, show no preference, and two—Jamaica and Venezuela—show a slight preference for daughters (12, 284, 374). In most countries parents desire at least one daughter as well as sons. Reasons for Son Preference Why do many parents favor boys? Often the reasons are both economic and cultural. Economic security. In many developing countries sons are their parents' only source of security in old age. Particularly where women have little economic independence or cannot inherit property, sons are insurance for a mother against the loss of her husband's support due to death or desertion (39, 267). Where women have few opportunities to earn income, investing household resources in female children, who will marry and leave the family, is likely to have little pay-off, and so poor families tend to invest what little they have in sons (177, 193). In cultures with dowry systems, such as India's, daughters are more expensive to marry off than sons (80). Cultural factors. In many countries kinship systems, tradition, and religion value males over females. In parts of Bangladesh, China, Egypt, India, and Tanzania, for example, traditional patrilineal kinship systems require women to marry out of their families of origin and then not to provide financial or even emotional support to their own parents (126, 177, 211). In both Hindu and Confucian traditions, practiced throughout Asia, only sons can pray for and release the souls of dead parents, and only males can perform birth, death, and marriage rituals (21, 284). Effects of Son Preference on Female Children Although females are thought to be genetically more resistant to respiratory and other infectious diseases than males and more likely to survive infancy, in some developing countries this advantage rapidly disappears as female babies grow up (347). Females are more likely than males to die in early childhood (ages 1 to 4), particularly in South Asia, the Near East, and North Africa (4, 12, 17, 79, 117, 292, 328, 337, 338, 374). Poorer nutrition and health care are important reasons (80). Nutrition. In some places boys get more and better food than girls (44, 48, 69, 72). Breastfeeding and weaning practices also seem to favor boys in some countries (44, 330). In the Indian state of Punjab, for example, boys from both wealthy and poor households are better nourished than girls (374). An analysis of DHS data from 18 countries, however, found few significant differences in the nutritional status of boys and girls (12). Medical care. Girls are sick as often as boys, but boys sometimes receive more treatment and more medicine. For example, boys were seen 66% more often than girls at a diarrhea treatment center in Bangladesh even though the center provided free ambulance transport and treatment (48). Parents bought drugs and sought medical care three times more often for boys than for girls (141). Girls often receive less preventive health care, as well. Studies in Latin America and India show that girls often are immunized later than boys or not at all (119, 296). Female infanticide. Some unwanted female children are killed or abandoned soon after birth. It is not clear how common or widespread the practice is, but some demographers have long suspected its existence. They base their conclusions largely on reported sex ratios at birth (310). Others argue that underreporting explains the discrepancy. In China, where sex ratios show that 5% of all infant girls born are unaccounted for, some observers suspect that female infanticide accounts for at least some of these missing girls, although informal adoptions, sending girls to faraway relatives, or raising the girls covertly probably explain most of the cases (10, 382, 383). Abortion of female fetuses. Selective abortion of female fetuses reportedly is widespread in such Asian countries as China, India, and South Korea (11). Increasing use of prenatal ultrasound and amniocentesis procedures, which make selective abortion possible by revealing the sex of a fetus, may be contributing to a growing gap in the number of males and females born in some countries (153, 181). Although governments in China, South Korea, and three Indian states have banned prenatal gender tests to prevent selective abortions, illegal tests are available, and females are more often aborted than males (10, 11, 21, 181, 225, 382, 383). Son Preference, Fertility, and Contraceptive Use Does a preference for sons result in higher fertility? Do more couples adopt family planni