Can family planning help the world? Lessons from Indonesia.

Indonesia, the world's fourth most populous country, cut its fertility rate in half over a 30-year period. Now its program faces pushback from conservatives, mirroring global trends in family planning. 

The well-kept village of Wonosari, nestled in the tropical hills above the central Javanese city of Yogyakarta, is experiencing a baby boom.

Infants wail and coo in several of the tile-roofed, one-story houses lining the main dirt road. In one of the homes, 19-year-old bride Wadianti listens as a midwife from a Yogyakarta health clinic explains to her and her 21-year-old husband Anggit Bayu how to prepare for the birth of their first child, only weeks away.

The young couple hadn’t planned to become parents so soon after marrying – Anggit had hoped to wait until he was 26 and had finished his studies at Islamic University in Yogyakarta, while Wadianti had wanted to complete her studies as well. But the couple, devout Muslims, were suspicious of most contraceptive methods, convinced they could cause disease and make getting pregnant more difficult later on.

“So I decided we’d try following her menstrual cycle,” Anggit says with a sigh and a grin. “Now we’re going to have a baby.”

Wadianti and Anggit’s story is hardly a tragedy, but it speaks to the challenge Indonesia's government faces as it seeks to shore up its globally admired family-planning program.

Over the course of an aggressive 30-year policy that aimed to limit families to two children, Indonesia cut its fertility rate by more than half, to 2.37 births per woman in 2012. The centralized policy extended maternal health and family planning clinics across this nation of 255 million people, leading to a sharp dip in maternal mortality.

But now Indonesia is seeing its progress slow, and in some areas of the country even reversed, mirroring a trend that demographers and international health experts say can be seen in other regions, such as sub-Saharan Africa. And any setback to reducing fertility and maternal mortality rates could have a significant impact in some developing countries.

Tool for development

After nearly five decades of international efforts administered by the United Nations, development experts concur that family planning programs have been a key tool in reducing global poverty and in empowering women – an undisputed path to development for poor countries.

“Family planning is the most effective human development intervention there is today – it’s a point we don’t make often enough,” says Babatunde Osotimehin, executive director of the United Nations Population Fund, UNFPA. “Women who have access [to family planning services] are able to make choices – about spacing their children, about education, about their economic activity,” he adds. “That adds up to increased development and well-being.”

Despite that, nearly 250 million married women worldwide still lack access to such services, Dr. Osotimehin says – a point he intends to underscore at an international family planning conference this week in Bali, Indonesia. A key challenge, he adds, is to “encourage more developing countries to committing their own resources to family planning programs.”

The need for local funding for domestic programs has become all the more urgent as Planned Parenthood in particular and family-planning budgets in general have come under attack from conservative political forces in the United States, a major source of international funding. Some of those same forces are also working with conservative political and religious parties and organizations in developing countries, particularly in Africa, to reject international family-planning funding as pro-abortion and anti-family.

At the same time, other high-profile policy decisions and global trends – from China’s easing of its longtime one-child policy to heightened concern over the economic impact of graying populations – are putting family-planning advocates on the defensive.

Are individual rights at stake?

“The international family planning movement, or at least certain elements within it, have a lot to answer for,” says Nicholas Eberstadt, a political economist and development policy specialist at the conservative American Enterprise Institute in Washington.

“What do they have to say about China and coercive birth control, and how that fits with respect for basic human rights?” Mr. Eberstadt says. “Then there is the challenge of aging populations and the fact that aside from sub-Saharan Africa, the rest of the world is pretty much below replacement [rate].”

He also criticizes what he calls the contradiction between top-down family-planning mandates and individual rights. “It’s just an amazingly condescending notion that experts know better than parents how many children they should have,” he says.

Experts like Osotimehin counter that family planning is about enhancing not denying individual rights – and in particular women’s rights. Still, he acknowledges that Eberstadt’s concerns reflect growing challenges to family-planning policies around the world.

“The conservative wave you see in Indonesia is something we’ve seen many places before; in Africa right now the Evangelicals are pushing back on us,” says Osotimehin. “But we are pushing back with the evidence that family planning is one of the best development tools a country can utilize. That’s something women and girls around the world understand.”

Policy faces many challenges

In Indonesia, an established family-planning policy that other developing countries have sought to replicate is facing pushback on several sides.

Political decentralization over the past decade means that regional governments are less interested in taking their cues from the national government. In some cases that has meant de-emphasizing family planning in favor of other priorities.

A wave of religious conservatism is challenging adherence to the secular policy designed to limit family size. Meanwhile, urban middle-class families are increasingly opting to have a third or fourth child because they can afford to.

And among young people, shifting attitudes toward sex are leading to more unintended pregnancies, experts say, even as strict policies mean many young people have little or no access to either contraceptives or family-planning information. That combination helps to explain what some experts say is an unacknowledged rise in maternal mortality.

“The government tries to limit reproductive health programs to married couples, so even information to adolescents remains controversial,” says Martha Santoso Ismail, UNFPA’s assistant representative in Jakarta. Many unmarried women try to hide their pregnancy and don’t consider pre-natal care, she says, while many women in rural areas continue to favor local, often untrained birth attendants over government-authorized midwives.

To revitalize Indonesia’s family-planning efforts, the government is focused on expanding access to services and on sending out more health-care workers – like the midwives who showed up in this village to visit Wadianti and Anggit. 

Back to basics

But others say that given Indonesia's heightened religious conservatism, it would do well to return to the roots of its family-planning success.

“Right now our fertility rate is stuck, and to address that I think we need to remember what made Indonesia’s effort successful in the first place,” says Amin Abdullah, rector of Sunan Kalijaga Islamic State University in Yogyakarta and a professor of Islamic studies.

“Our program was a success story [because] the government and UNFPA worked together with … people with an Islamic worldview,” he says. “They introduced a program with a religious approach,” something he says was “important in a country with strong religious beliefs.”

Looking more globally, UNFPA’s Osotimehin says he sees a key to success in framing family planning policies as a central factor in addressing inequality – both the gender and economic varieties.

Countries at all levels of economic development are trying to address inequality, he says. In that context family planning policy can play a “central role,” he adds, because it “allows people at all income levels to plan family size, and it empowers women to choose a brighter economic path.”

Mr. LaFranchi reported this story in Indonesia as a fellow of the UN Foundation.