Institute for Reproductive Health, Georgetown University, Washington, DC, USA.
Independent consultant, Amman, Jordan.
Glob Health Sci Pract. 2017 Dec 28;5(4):617-629. doi: 10.9745/GHSP-D-17-00191.
Health practitioners, researchers, and donors are stumped about Jordan's stalled fertility rate, which has stagnated between 3.7 and 3.5 children per woman from 2002 to 2012, above the national replacement level of 2.1. This stall paralleled United States Agency for International Development (USAID) funding investments in family planning in Jordan, triggering an assessment of USAID family planning programming in Jordan. This article describes the methods, results, and implications of the programmatic assessment. Methods included an extensive desk review of USAID programs in Jordan and 69 interviews with reproductive health stakeholders. We explored reasons for fertility stagnation in Jordan's total fertility rate (TFR) and assessed the effects of USAID programming on family planning outcomes over the same time period. The assessment results suggest that the increased use of less effective methods, in particular withdrawal and condoms, are contributing to Jordan's TFR stall. Jordan's limited method mix, combined with strong sociocultural determinants around reproduction and fertility desires, have contributed to low contraceptive effectiveness in Jordan. Over the same time period, USAID contributions toward increasing family planning access and use, largely focused on service delivery programs, were extensive. Examples of effective initiatives, among others, include task shifting of IUD insertion services to midwives due to a shortage of female physicians. However, key challenges to improved use of family planning services include limited government investments in family planning programs, influential service provider behaviors and biases that limit informed counseling and choice, pervasive strong social norms of family size and fertility, and limited availability of different contraceptive methods. In contexts where sociocultural norms and a limited method mix are the dominant barriers toward improved family planning use, increased national government investments toward synchronized service delivery and social and behavior change activities may be needed to catalyze national-level improvements in family planning outcomes.
卫生从业者、研究人员和捐赠者对约旦停滞不前的生育率感到困惑，从 2002 年到 2012 年，约旦每名妇女生育率一直徘徊在 3.7 到 3.5 个孩子之间，高于 2.1 的国家更替水平。这种停滞与美国国际开发署（USAID）在约旦计划生育方面的资金投入相吻合，这引发了对 USAID 约旦计划生育方案的评估。本文描述了该方案评估的方法、结果和意义。方法包括对 USAID 在约旦的方案进行广泛的案头审查，并对 69 名生殖健康利益攸关方进行访谈。我们探讨了约旦总生育率（TFR）停滞不前的原因，并评估了同一时期 USAID 方案对计划生育结果的影响。评估结果表明，使用效果较差的方法（尤其是体外排精和避孕套）的增加是导致约旦 TFR 停滞不前的原因之一。约旦有限的方法组合，加上生殖和生育愿望方面强烈的社会文化决定因素，导致约旦的避孕效果不佳。在同一时期，USAID 为增加计划生育服务的获取和使用做出了广泛的贡献，主要集中在服务提供方案上。除其他外，其中一些有效的举措包括由于女医生短缺，将宫内节育器插入服务移交给助产士。然而，改善计划生育服务利用方面的关键挑战包括政府对计划生育方案的投资有限、服务提供者的行为和偏见限制了知情咨询和选择、强烈的社会规范普遍限制了家庭规模和生育、以及不同避孕方法的可用性有限。在社会文化规范和有限的方法组合是改善计划生育利用的主要障碍的情况下，可能需要增加国家政府对同步服务提供和社会及行为改变活动的投资，以促进国家一级计划生育结果的改善。
