# I. Introduction

Family planning services in sub-Saharan Africa are developing slowly<sup>for reasons</sup> embedded in social and cultural patterns that reward high fertility, as well as<sup>for lack of human</sup> and material resources. International agencies and a few countries spent large sums<sup>in the 1980s</sup> to increase family planning services in the region, with little effect on contraceptive<sup>prevalence</sup> rates. Yet there are hopeful signs-programs here and there that suggest<sup>that changes are</sup> occurring or are imminent. This paper reports on three such programs<sup>which were undertaken</sup> in collaboration with the Columbia University Operations Research Program conducted<sup>from 1984</sup> to 1990.1 The Ghana Registered Midwives Association Project, the Ruhengeri<sup>Project in</sup> Rwanda, and the Community Based Family Health Project in the Sudan<sup>were new efforts in</sup> countries with substantial impediments to development of family planning programs.<sup>The</sup> discussion of factors which appear to have influenced their acceptability,<sup>evidence of their success</sup> over the short term, and assessments of their potential for continuation are<sup>based on the</sup> operations research.

The environment for family planning in sub-Saharan Africa, as described by Frank<sup>(1990)</sup> and by Caldwell and Caldwell (1990a; 1990b), is not promising. According<sup>to these observers,</sup> programs fail because demand for children is so strongly rooted in sub-Saharan institutions,<sup>and</sup> demand will not abate unless there are changes in economic, social<sup>or cultural conditions. In</sup> brief, social and family patterns that are resistant to famnily limitation include obsession<sup>with</sup> fertility to continue the (husband's) lineage, weak marital bonds (Caldwell),<sup>fear of child</sup> mortality, abhorrence of sterility, and the custom of fostering children in the extended<sup>family</sup> system (Frank).

The World Fertility Surveys (WFS) conducted in sub-Saharan Africa<sup>in the late 1970s</sup> and early 1980s generally confirmed the absence of signs of fertility<sup>decline. Possible initial</sup> stages were noted in Ghana, Kenya, Senegal, and the Sudan, but they were<sup>not sufficiently strong</sup> or methodologically convincing to remove doubts as to a sustained decline (van<sup>de Walle and</sup> Foster, 1990). Recent Demographic and Health Surveys (DHS) have detected<sup>fertility declines</sup> among women up to age 34 in Botswana and Zimbabwe, and a smaller<sup>decline in Kenya (Arnold</sup> and Blanc, 1990). The DHS repon for Botswana links the timing of the<sup>fertility decline to the</sup> introduction of the national family planning program some 10 to 15<sup>years before the survey</sup> (Lesetedi et al., 1989). From this it could be inferred that in Botswana<sup>there were women who</sup> did not want additional children, who were ready for family planning<sup>and, once contraceptives</sup> were made available, accepted in sufficient numbers to affect the<sup>overall fertility rate.</sup> The premise of an existing demand among women who do not<sup>want more children, or</sup> who would prefer a substitute for postpartum abstinence for child spacing,<sup>and the belief that</sup> additional demand can be stimulated by accessible services, undergirds policy<sup>and operational</sup> strategies of agencies that fund family planning programs. This more optimistic viewpoint is

**'The Operations** Research Program was funded under **Cooperative**<sup>**Agreement DPE-03-A-004049**</sup> **between** Columbia University **and the** United **States Agency for International Development, Office of Population, Research** DiPision. **It was** conducted **by** the **Center for Population and Family Health, School of Public Health of** Columbia **University.**