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Contrary to conventional wisdom, many sub-Saharan African women—often at young ages—have an unmet need for family planning to limit future births, and many current limiters do not use the most effective contraceptive methods. Family planning programs must improve access to a wide range of modern contraceptive methods and address attitudinal and knowledge barriers if they are to meet women's needs.

International Perspectives on Sexual and Reproductive Health 206 quality of care and human rights since the 1970s. The literature for this article is supplemented by a wider review of literature conducted on voluntary, human rights-based family planning by Rodriguez et al. 17 While Rodriguez et al.'s literature review focused on the years 1995-2012, this article includes literature from family planning programming dating back to the 1960s, because some instances and allegations of coercive practices included here occurred at that time. What Constitutes Coercion?To inform this article, we looked for existing definitions and descriptions of coercion in family planning. 18,19 There is no commonly held definition, although instances of coercion are linked to violations of human rights and there is broad consensus that coercion is morally wrong and should be avoided by family planning programs. 18,[20][21][22] To develop a definition of coercion, we found it instructive to review the three broad categories of reproductive rights described by Erdman and Cook-the right to reproductive self-determination; rights to sexual and reproductive health services, information and education; and rights to equality and nondiscrimination. 23Defining coercion or coercive actions too broadly could incriminate all family planning programs, becoming a catchall term applied to poorly implemented programs that neglect or are unable to reach quality of care standards. We contend that for the term coercion to be useful for advocacy and accountability purposes, it should not be conflated with broader issues of quality of care or equity, which deserve equal, if not more, attention and are also linked with human rights violations. Considering these factors, we propose the following definition: Coercion in family planning consists of actions or factors that compromise individual autonomy, agency or liberty in relation to contraceptive use or reproductive decision making through force, violence, intimidation or manipulation.Under this definition, coercion is a violation of the right to reproductive self-determination, including the right to bodily integrity (autonomy over one's own body). It is important to note that coercion is not the only way in which the right to reproductive self-determination can be violated; denying services to individuals also violates their rights. To illustrate actions and factors that may fit under this definition, this article focuses on policies and program management that explicitly foster practices that compromise, or have the potential to compromise, autonomy, agency or liberty when implemented.The 2012 London Summit on Family Planning refocused attention on family planning, garnering much-needed support for the goal of reenergizing and expanding programs in 69 low-and medium-income countries "to enable 120 million more women…to use contraceptives by 2020."1 Although the response to the summit's initiative (referred to as "FP2020") was generally positive, reproductive health and rights advocates expressed conce...

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The Association for Voluntary Surgical Contraception retrospectively examined the impact of funding decreases on access to sterilization services at 20 nongovernmental family planning clinics in Mexico, the Dominican Republic, and Brazil. Clinic staff were asked questions about client fees, caseloads, availability of comparable low-cost or free services nearby, cost-recovery activities, and the socioeconomic profile of clients before, during the time, and after subsidies were lowered or eliminated. Funding reductions were followed by decreased caseloads at 14 of the 20 sites studied. Of the six others, four experienced an increase in caseloads, one saw no perceptible change, and one experienced a decrease only as a result of management policy to cut the caseload to improve quality. The most common response to the decrease in funding (shared by 17 sites) was an increase in client fees. In all but three of the 17 clinics, the increase in fees was met with a decline in caseloads. Moreover, at nine of these 17 sites, the fee increase effected a change in client mix; anecdotal evidence suggests that more middle-income and fewer lower-income clients were using sterilization services. Four lessons can be drawn from this study: Donors need to plan funding phase-outs carefully, in conjunction with grantees; grantees need to assess the costs of the procedure realistically, and assign fees accordingly; management needs to seek alternative funding sources in lieu of, or in addition to, increasing fees; and caseloads can be increased and costs recovered by diversifying services.