PRB

(April 2010) This year’s World Health Day (April 7) focuses on the importance of urban health. Urbanization is occurring so rapidly in some parts of the world that cities are not able to keep up with increased demand for environmental, health, and educational services, not to mention the employment, housing, and transportation needs of a population that may double in size in less than 25 years. Three-quarters of those living in the cities of the developing world live in slums or slum-like conditions, often without access to sanitation and safe drinking water. Because of these unhealthy conditions, rapid population growth in urban areas is especially associated with increased health problems. Urban slums have much higher rates of illness than nonslum areas of the same cities and health and social problems related to the environment, violence, injury, and noncommunicable diseases are more common.¹

As one of the least expensive, most cost-effective interventions with the most lasting impact on health, family planning is often overlooked as an essential strategy to improve urban health. Even though family planning services are less available in rural and remote parts of least developed countries, the poor who live in urban areas have more difficulty, for a variety of financial, social, and cultural reasons, accessing family planning services than do wealthier residents. With half of the world’s residents now living in urban areas, improving the access of the poor to family planning services in urban areas should be a high priority, especially since the majority of urban residents in many countries live on less than US$2 per day.

Rapid Rise in Unintended Births

The majority of urban population growth (60 percent) is due not to the in-migration of people from rural areas, but because births among urban residents outpace deaths. As infant and child mortality has declined, this rate of “natural increase” has become especially high in urban areas of sub-Saharan Africa, some of which are growing at 4 percent per year. This phenomenal growth has proven difficult for governments and the environment to accommodate. In addition, urban families face the higher costs and greater complexities of city living and want to have fewer children than rural residents. Many urban women report that they have more children than they intended to have. While most wealthier urban women have access to contraception, poor women have less physical and financial access to high-quality reproductive health services and to an affordable range of contraceptives that meets their needs. As the growth of urban areas continues unabated, the value of reducing unwanted and unplanned births by enabling equitable access to contraception should not be underestimated. It is one of the most sensible and cost-effective investments that urban planners can make.

The Number of Women of Reproductive Age Is Rapidly Increasing

Because of past high fertility, rapid urbanization is likely to continue. In sub-Saharan Africa for example, the number of women of reproductive age will grow by 35 percent in the next 10 years. Unless women are able to limit their family size to the number of children they want to have, the number of births over this same period will increase by 33 percent. This will fuel even more rapid population growth in urban areas and make the provision of health and other services more challenging.

Poor women who desire to delay a pregnancy or stop having children but are not using a modern method of contraception have an especially high “unmet need” for family planning. In Senegal and Ethiopia, for example, one in every three women ages 15 to 49 who live in urban areas has an unmet need for contraception. Nigeria has one of the lowest levels of unmet need in sub-Saharan Africa—13 percent among urban women and 17 percent among the poorest women. However, because Nigeria is by far the largest country in Africa, the number of women with unmet need, 4 million, is large and it is growing as the demand for family planning increases. The millions of women with unmet need for contraception contribute directly to rapid population growth as well as to high rates of maternal and infant death.

Family Planning Prevents Abortion and Maternal Deaths

Women in sub-Saharan Africa have a one in 22 lifetime risk of dying of causes related to pregnancy and delivery. While maternal mortality has declined since 1990, by 26 percent in Latin America and 20 percent in Asia, it has only fallen by 2 percent in sub-Saharan Africa.² Women who give birth before age 18 or after age 35, or who have closely spaced pregnancies are at a greater risk of death. In many countries of sub-Saharan Africa, early marriage and childbearing is common. In Mali, Malawi, Mozambique, and Niger, for example, half of all women have given birth by age 18.³ Women who give birth before age 20 are twice as likely to die of pregnancy-related causes as are older mothers. Family planning can avert these deaths by enabling young, sexually active women to delay their first pregnancy until they are older and more physically and emotionally mature. However, contraceptive use among sexually active women, whether married or unmarried, is very low in most countries of sub-Saharan Africa. In Nigeria, just 3 percent of married women and 37 percent of unmarried women ages 15 to 19 use a modern method of contraception.⁴

In selected sub-Saharan African countries, including Nigeria and Kenya, between 25 percent and 41 percent of unwanted pregnancies are aborted, and in sub-Saharan Africa as a whole, 99 percent of the nearly 5 million abortions that occur each year are conducted by persons lacking the necessary medical skills or under unsafe conditions or both. Sub-Saharan Africa has the world’s highest proportion of abortions performed among young women ages 15 to 19 (about one in four). As a consequence, abortion is a leading cause of death among young African women. In East Africa, including Kenya, unsafe abortions account for 17 percent of maternal deaths. Assuring that young people have the family planning information and services they need could significantly reduce deaths due to abortion as well as deaths from other maternal causes. Globally, fulfilling unmet need for contraception is estimated to prevent 50,000 deaths due to abortion and 90,000 deaths due to other maternal causes each year. Fifty-five percent of the lives saved would be of women in sub-Saharan Africa.⁵

Family Planning Averts the Deaths of Infants and Children

Spacing births at least two years apart is one of the most important and successful strategies for improving birth outcomes and the survival of infants. Infants born less than two years after a previous birth are about twice as likely to die in the first year of life as an infant born three years after a previous birth. Infants and children born to mothers who are under age 20 are also much more likely to die in the first days, months, and years of life. In Senegal, for example, one of every 10 infants born to women under age 20 dies in the first year of life, as opposed to one in 17 among women who give birth between ages 20 and 29. Use of family planning can avert these deaths by enabling young women to avoid pregnancies that occur too early, are unwanted, or too closely spaced. In Senegal alone, family planning could avert 1.3 million unintended pregnancies, 400,000 abortions, and 200,000 deaths to children under 5 over a 10-year period. Filling unmet need for contraception also significantly reduces the cost of providing universal vaccination coverage and other health interventions for children, and facilitates the ability of governments to improve overall societal health.⁶

Family Planning Is a Key but Greatly Underutilized HIV-Prevention Strategy

The importance of family planning to reducing mother-to-child transmission of HIV has not received sufficient attention. Each year, more than 577,200 unintended pregnancies among HIV-infected women in sub-Saharan Africa are prevented through the use of contraception, which already prevents more HIV infections among infants than antiretroviral therapy (ART).⁷ While it is essential that all women in need of ART have access to it, more than half a million additional unintended pregnancies to HIV-positive women could be averted each year if all women in the region who did not wish to become pregnant had access to modern contraception. In South Africa, more than 400,000 annual unintended pregnancies could be averted among HIV-positive women, preventing more than 120,000 HIV-positive births.⁸

Family Planning Promotes Environmental Sustainability and Expansion of Education and Health Services

Investing in family planning not only saves lives but results in large savings to the health, education, and environmental sectors. With fewer children to educate, governments can extend safe water and sanitation services to a greater share of their populations. This will in turn have benefits in terms of reduced water-born illnesses and deaths due to diarrhea. When population growth occurs more slowly, there is also less pressure on scarce land and water resources and less environmental degradation due to deforestation, salinization of soil, and air pollution. In Kenya, for example, meeting unmet need for family planning at a cost of $71 million can be expected to reduce expenditures on education by $115 million, on immunization by $37 million, on water and sanitation by $36 million, on maternal health by $75 million, and on malaria by $8 million. For every dollar spent on family planning, Kenya would recoup $3.79 in savings in these sectors alone.⁹

Equity in Access to Family Planning for the Poor Is a Matter of Health and Human Rights

There is near universal agreement among governments that every child has a right to be wanted and women and couples have a right to decide freely on the number of children they will have. In most societies, poor women are the least likely to be able to exercise the right to use contraception, in part because they are the least able to pay for family planning services. Until poor women have the same ability to exercise that right as wealthier women, urban areas will grow not only in size but in level of inequality. The percentage of people living in poverty will continue to increase and income inequality between rich and poor will grow larger.

Governments and urban planners should ensure that the poor are the recipients of public funds that subsidize and aim to improve the quality of reproductive health services. Without this assurance, subsidies and incentives are more likely to be utilized by those who do not need them as much.¹⁰ And investments in reproductive health and family planning are among the most cost-effective that governments can make. In Kenya and Nigeria, for example, the cost of protecting an urban couple from an unwanted pregnancy for a year through the provision of clinic-based services is only $4.27.¹¹ This small investment is worthwhile for the benefit of individuals and families and for the greater society. World Health Day 2010 is an appropriate time to give family planning the attention it deserves.

Karin Ringheim is senior policy adviser at the Population Reference Bureau.

References

1. African Population and Health Research Center, Population and Health Dynamics in Nairobi’s Informal Settlements, Report of the Nairobi Cross-Sectional Slums Survey (NCSS) (Nairobi: APHRC, 2002).
2. Susheela Singh et al., Adding it Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health (New York: Guttmacher Institute/UNFPA, 2009).
3. ICF Macro, Demographic and Health Surveys, Mozambique, 2003; Malawi, 2004; and Mali, 2006 (Calverton, MD: ICF Macro).
4. National Population Commission and ICF Macro, Nigeria Demographic and Health Survey, 2008 (Abuja, Nigeria: NPC and ICF Macro, 2009).
5. Singh et al., Adding it Up.
6. Scott Moreland and Sandra Talbird, Achieving the Millennium Development Goals: The Contribution of Fulfilling the Unmet Need for Family Planning (Washington DC: The Futures Group/Policy Project, 2007).
7. Heidi Reynolds et al., “The Value of Contraception to Prevent Perinatal HIV Transmission,” Sexually Transmitted Diseases 33 no. 6 (2006): 350-56.
8. Derived from: Heidi W. Reynolds, M.J. Steiner, and Willard Cates Jr., “Contraception’s Proved Potential to Fight HIV,” Sexually Transmitted Infections 81 (2005): 184.
9. Constella Futures, POLICY Project, and Health Policy Initiative, 2005-2007. For more information, see Rhonda Smith et al., Family Planning Saves Lives, 4th ed. (Washington, DC: Population Reference Bureau, 2009).
10. Davidson Gwatkin, Overcoming Global Health Inequalities—Where Next?, Population Reference Bureau Policy Seminar, Dec. 16, 2009.
11. Moreland and Talbird, Achieving the Millennium Development Goals.