Understanding ethical challenges of family planning interventions in sub–Saharan Africa: a scoping review

Abstract

BackgroundImproving the design of family planning (FP) interventions is essential to advancing gender equality, maternal health outcomes, and reproductive autonomy for both men and women. While progress has been made towards applying a rights-based approach to FP interventions in sub-Saharan Africa, the ethical implications of FP interventions has been underreported and underexplored. Several ethical challenges persist related to measuring success, choice, and target population.MethodsWe conducted a scoping review to understand if and how FP interventions published between 2000 and 2020 within sub-Saharan Africa address the ethical challenges raised within the literature. We identified a total of 1,652 papers, of which 40 were included in the review.ResultsOur review demonstrated that the majority of family planning interventions in sub-Saharan Africa place a strong emphasis, on measuring success through quantitative indicators such as uptake of modern contraception methods among women, specifically those that are married and visiting healthcare centres. They also tend to bias the provision of family planning by promoting long-acting reversible contraception over other forms of contraception methods potentially undermining individuals' autonomy and choice. The interventions in our review also found most interventions exclusively target women, not recognising the importance of gender norms and social networks on women's choice in using contraception and the need for more equitable FP services.ConclusionThe results of this review highlight how FP interventions measured success through quantitative indicators that focus on uptake of modern contraception methods among women. Utilising these measures makes it difficult to break away from the legacy of FP as a tool for population control as they limit the ability to incorporate autonomy, choice, and rights. Our results are meant to encourage members of the global family planning community to think critically about the ethical implications of their existing interventions and how they may be improved. More public health and policy research is required to assess the effect of applying the new indicators with the FP community as well as explicitly outlining monitoring and evaluation strategies for new interventions to allow for programme improvement and the dissemination of lessons learned.

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“…While this aligns with a substantial body of literature that highlights their high effectiveness and high couple-years of protection, it is important to emphasize that a rights-based approach necessitates giving precedence to women’s preferences ( 224 ). Particularly in resource-limited settings, which often grapple with fragile supply chains, women’s choices may be influenced by the training of healthcare providers, which may prioritize one form of contraception over others ( 224 ). Within a rights-based framework, it is fundamental that policies acknowledge the necessity of making multiple contraceptive options readily available and address issues related to stock-outs of all contraceptive methods.…”

“…In most cases, these aspects were associated with the promotion of long-acting reversible contraceptives. While this aligns with a substantial body of literature that highlights their high effectiveness and high coupleyears of protection, it is important to emphasize that a rights-based approach necessitates giving precedence to women's preferences (224). Particularly in resource-limited settings, which often grapple with fragile supply chains, women's choices may be influenced by the training of healthcare providers, which may prioritize one form of contraception over others (224).…”

“…This narrow focus often falls short of embracing crucial elements of a rights-based approach, such as informed choice and autonomy. Concentrating solely on specific targets may pressure family planning providers to meet those goals at the expense of individual women’s preferences, potentially hindering their ability to make fully informed decisions about family planning ( 224 ). Additionally, this approach often assumes that all women aspire to have smaller families and achieve this through the use of a modern contraceptive method, which may not always align with women’s actual desires ( 224 ).…”