PRB

(July 2009) Every year in sub-Saharan Africa, 265,000 mothers die in childbirth and 4.5 million children die before the age of 5 from preventable causes. One important way to reduce maternal mortality and improve child health is through family planning, which helps women avoid unintended pregnancies and allows them to choose the timing and number of pregnancies they have. The rapid population growth that Africa continues to experience is because women have many children (5.4 children per woman on average in the regions), and this sustained growth in population adversely affects many aspects of national development, including environmental sustainability, economic well-being, health status, and governance.

During a PRB Discuss Online, John Bongaarts, vice president and distinguished scholar at the Population Council; and Nafissatou Diop, country director of the Population Council in Senegal, answered participants’ questions about population growth and policy options in sub-Saharan Africa; factors that contribute to increasing maternal mortality; and programmatic experiences—including family planning—that contribute to reducing maternal mortality.
Africa’s Future: Improving the Health of Mothers and Children 

July 30, 2009 11 AM EST

Transcript of Questions and Answers

Raymond G. Dogore, MD, MPH, Director: What are the obstacles and where are the gaps in the current subsaharan countries prevention interventions targeting maternal and new born mortality reduction?
Nafissatou Diop: While Sub Saharan Africa is experiencing fertility rates among the highest in the world, the prevention interventions targeting maternal and new born mortality in this part of the world focus mainly on antenatal care and undermine family planning as an effective means for the reduction of maternal and child mortality. A major obstacle is at the policy level, which in most sub saharan africa, do not allow task shifting from the upper to the lower level of the health care system. There is a medicalization of prevention interventions and there is not enough involvement of community actors and other sectors of development. To make these programs more successful, a holistic approach to address the social and economic conditions that cause maternal and child mortality need also to be considered. Causes of maternal mortality such as women’s hard domestic work, malnutrition and nutrition deficiencies, malaria, low access to primary health care need to be taken seriously into account. As Kishore said, women empowerment is of paramount importance if we want to improve women and child health.

Dr. Anima Sharma: The Mother-Child Healthcare has always been a matter of concern from every perspective but still there are few gap areas, which need to be addressed. I am an Indian Anthropologist, having lot of experience in studying the indigenous rituals and practices but not having any first hand information about Africa still through secondary text I have come to know that African culture also has rich tradition of folk practices related to every phase of life. My question is that while making health policies for them do we take their ethnic practices into consideration or in other words do make use of their ethnic knowledge?
Nafissatou Diop: I share your point of view that mother-child health care needs to integrate ethnic practices. Unfortunately, health policies are too often based on research from the western world and they do not always use research results from ethno/anthropologic in africa. There is a lot of ehtnographic research done by university scholars but they are not well disseminated among the public health community in Africa. In addition funding for MCH/FP programs comes from outsiders and concepts are not enough adapted to the african context by african public health program managers. There is a need to use more ethnic evidenced-based information to develop appropriate policies and programs.

El Bachir SOW: Dr Diop, pour m’en tenir seulement à la région ouest africaine, que gagneraient les programmes de PF (et sans doute aussi les pays concernés) en faisant davantage la promotion des méthodes de longue durée et en s’intéressant beaucoup plus aux besoins des couches désavantagées dans des sociétés où, il faut le souligner, la pauvreté touche de grandes parties de la population ? Merci.
Nafissatou Diop: La litterature montre que les methodes de longue duree sont le moyen le plus efficace de relever la prevalence contraceptive. Cependant si l’on observe le programme de PF des pays ouest africains, on se rend compte que les taux d’utilisation du DIU (2% ), des implants (1% ), de la sterilization (0,3% )sont tres bas (donnees de l’EDS Senegal). Or ces methodes de longue duree ne sont disponibles qu’au niveau le plus eleve de la pyramide sanitaire (hopital, centre de sante, ou cliniques privees). Si l’on regarde les besoins non satisfaits selon le quintile de bien etre, on voit que les pauvres et les plus pauvres (Quintiles Q1, Q2, Q3) ont plus de besoins non satisfaits que les populations les plus riches (Quintiles Q4, Q5). L’acces a l’information sur la PF est plus faible chez les couches desavantagees (radio 41% pauvre vs 49%; TV 10% pauvre vs 52%riche;…). Donc les pauvres ne sont pas touches. Ainsi dans la plupart des pays ouest africain les programmes de PF gagneraient a se reorienter vers les couches desavantagees du mileu urbain et rural, pour accroitre rapidement la prevalence contraceptive et reduire les inequites dans l’acces aux services de sante.

Adrienne Allison: World Vision found that when FP was related to rapid population growth or national development, communities absolutely rejected FP. For the past two years, WV has discussed FP only in terms of Healthy timing and Spacing of Pregnancy. The data showing the relationships between birth-to pregnancy intervals and infant, child and maternal mortality are compelling. As a result, WV is now adding FP, in terms of HTSP, to its health programs that include about 70 million people in Africa. This is the only message that most communities understand, appreciate and request.How can HTSP messages become part of the fabric of all FP programs?
Nafissatou Diop: I agree with you that the HTSP arguments is more acceptable to both policy and community levels. From my experience in West Africa, this argument is used since the 80s as program managers quickly understood that the population rapid growth justification couldn’t work. However what is new is that there is data from several research that shows this benefit. So we should take advantage of these recent data to reinforce our programs. However we should keep in mind that this element alone may not be sufficient to increase CPR.

Birungi Beatrice: As we are trying to improve the health of mothers and children, what programes do you have for school going children since they are the ones suffering during birth at an early age. And remember here in Africa there is still gender imbalances that hinder women to decide even on issues concerning their lives like family planning. Again many children are being sexually abused and end up being impregnated, where is the law. I think as we plan for family planning to reduce on the number of children let us look at those other factors causing death to our children during birth.
Nafissatou Diop: There are many programs that seek to fight against illiteracy by giving education to kids especially to girls. Many studies have shown that keeping girls at school reduces their vulnerability to early marriage, early sexual activities and pregnancies which have a positive correlation with maternal mortality and morbidity. But we need to recognize that we do not have good RH/FP programs for schools, due to several socio-cultural and religious barriers. And unfortunately an unnacceptable number of school girls are getting pregnant which jeopardize their future. I aggree with you that we need also to address some current trends on sexual abuse, rape and incest and discrimination against girls and women. Gender based violence (GBV)programs are also better structured these days but a lot of work still need to be done. A better integration of GBV issues into FP and FP into GBV programs is key. Emergency contraception (EC) is one FP method that needs to be promoted within anti-GBV interventions. Several countries are succeeding in making EC available in post rape services (e.g Zambia, Mexico, Guatemala..). Specialized centers staff, police staff, social services personnel, and health facilities providers need to be trained to provide quickly EC to girls and women that have been raped.

charlie teller: In order to influence policymakers in SSA, shouldn’t we distinguish between the mortality reduction/family health approaches to reducing the high demand for children, and more macro socio-eco. development and cultural change approaches to reducing pop. growth and resource/environ/food pressures. In the latter, raising early age at marriage, girl’s education and off-farm migration are the types of effective pop-related policies needed. In this light, Ms Diop, why has a country like Senegal progressed more in its demographic transition than other neighboring Sahelian countries (Mali, Niger, BF, etc.)?
Nafissatou Diop: Senegal demographic transition is mainly due to the increase of the age of marriage due to the improvement in girls education and also urbanization. Senegal is more urbanized than Mali, BF, Niger with about 50% of the population living in urban cities.

J Kishore: Dear John Bongaarts, Population growth in Africa is a symptom of bigger problem of illiteracy, poor nutrition and development. Our focus should be on raising education and development by stablising political and economic crisis in the region that can be very well done through United Nations involvement. Women empowerment (Political, economical, education and health) would improve mother and child health.
John Bongaarts: There is no doubt that education, women’s empowerment and human development in general are powerful forces that bring about development and move countries through their demographic transitions. However some poor countries are stuck in a poverty trap in which rapid population growth and high fertility contribute to poverty and vice versa. Breaking out of this trap is difficult and requires investments in human development, women’s empowerment and family planning/reproductive health

Marcel Reyners: Method choice is a quality indicator of a FP program. But most couples do not have access to methods as IUD and sterilization because of lack of providers and high costs. In your opinion, should RH/FP programs not tackle those issues of access as priority of all priorities??
John Bongaarts: Past studies have shown that greater choice of methods leads to higher contraceptive prevalence, lower unmet need and greater user satisfaction. The problem is that many poor countries lack the resources to provide wide access to many methods.

Tope Akintunde: I agree with you that improving the health of mothers and children will go a long way to improve national development in Africa. But do you think that family planning will help in bringing about such improvement when there are still many people in Africa who still don’t believe in the use of contraceptives? May be because of religious or cultural beliefs What are the possible policies that can work in Africa?
John Bongaarts: There are three general reasons why married women don’t use contraception. The first is that they still want more children. This is an important reason in sub-Saharan Africa where desired family size is typically around five. Second some women are not exposed to the risk of pregnancy (e.g husband away, infecund). Third are women with an unmet need i.e. they are not using even though they don’t want to get pregnant. Among the main reasons for this are fear of side effects, lack of knowledge and access, costs and opposition from self, spouse or others). Well designed FP programs attempt to address all these obbstacles by providing quality care and counceling and through appropriate media messages.

M.B.Malik: Can any country improve its economy condition if it controls its population growth?
John Bongaarts: Reductions in fertilty can make important contributions to economic growth
through several mechanisms: First, according a recent UN report ” For every dollar spent in family planning, between 2 and 6 dollars can be saved in interventions aimed at achieving other development goals. Second, as women spend less time on childcare they can become wage earners outside the family thus boosting income and reducing poverty. Third, fertility decline leads to a so-called demographic dividend which refers to a rise in the rate of economic growth due to a rising share of working age people in a population. Reduced fertility also increases expenditures on children’s education and health, and encourages savings thus giving economic growth a further boost.

Sara Yeatman: Most people in sub-Saharan Africa know methods of modern and traditional family planning. Many have reasonable access to free or subsidized services. What do you propose as the next step?
John Bongaarts: It is true that many people know about methods of family planning, but access at low cost and/or method choice is still limited in many parts of Africa. The next step is to address the reasons women give for their unmet need in particular fear of side effects and opposition from self or others. See answer to question from Akintunde

Richard Cincotta: One way to look at persistent high fertility in the western, central and eastern regions of SSA is to hypothesize that these regions harbor the least favorable conditions for a decline in desired family size and for accessing, disseminating and adopting modern contraception. Thus, such regions (and a few others in Asia) were bound to lag in the fertility transition the longest. Is this a general hypothesis to which you would subscribe? If so, what are the conditions particular to countries in these 3 regions that have most deterred their fertility transition?
John Bongaarts: I agree that conditions in western central and eastern regions of SSA are particularly unfavorable to fertility decline. High child mortality, low literacy, low status of women and pervasive poverty all support desires for large families. Nevertheless there are reasons to believe that such high preferences can be changes rapidly once the right messages and conditions are put in place. For example the implementation of the family planning program (and its IEC component) in Kenya since the 1960s coincided with a large decline in desired family size from 7.2 in the 1970s to less than 3.8 in 2003.

Ernest Nettey: Have any new strategies emerged to tackle the problem of unmet need for FP in Africa recently? If so, what are they and how do they differ in practice across the various sub-regions? Again, how does FP success vary across sub-regions by male involvement? What is the future of FP in Africa, considering that HIV/AIDS often receives more attention than FP?
John Bongaarts: On unmet need, see answers to questions by Yeatman and Akintunde. The HIV/AIDS epidemic has indeed received more attention than FP. In the past many governments believed the dire predictions that the AIDS epidemic would result in a decline in population and therefore gave lower priority to FP. In fact however the epidemic has peaked and in many countries it has had only a minor impact on population growth. The population of SSA is expected to increase by 1 billion by 2050. It is increasingly clear that the neglect of FP has been a mistake.

Yinka Shokunbi: Nigeria’s population is no doubt huge while the acceptance of family planning methods is low; what options remain un-explored to ensure aceptance among a people with diverse beliefs and culture as well as high illiteracy level which is fueled by bad governance?
John Bongaarts: See earlier answers to Yeatman and Akintunde

Danjuma Jise: Q1 Has a carrying capacity been established for our planet yet? Q2. Is Africa’s population improving towards stability, if yes when is the projected time for this?
John Bongaarts: Q1: No one has established a credible carrying capacity for our planet and the concept is now considered problematic, because the number depends on the consumption level, the development of new technologies etc. In general however fewer people is better. Q2 Africa is one of the fastest growing regions in the world. Population growth is expected to continue throughout this century adding well over a billion. See projections made by the UN population division

Tope Akintunde: I believe that the issue of mass poverty with gross inequalities and the problem of high level of illiteracy should be tackled first in SSA and other things like the use of family planning in order to improve mothers’ health will fall in place
John Bongaarts: I think that we should do all these things. In particular I see FP not only as a health but also as an economic investment.

Mbagnick DIOUF: Dr. Diop. Si la plupart des produits contraceptifs utilisés au Sénégal nous viennent des bailleurs. Pensez vous que si ces derniers retirent la relance de la PF n’aboutira pas?
Nafissatou Diop: Mbagnick, je suis d’accord avec vous que les produits contraceptifs sont supportes par les bailleurs de fonds. C’est du a ce constat que l’alerte a ete donnee en 2005 pour repositionner la PF. C’etait non seulement pour lui redonner de l’importance dans les programmes de sante publiques, mais c’etait surtout pour que le sgouvernements s’impliquent plus dans l’achat des contraceptifs, puisque la tendance au niveau international etait a la reduction des financements pour la PF. Je ne peux pas envisager pour le moment un retrait des partenaires au developpement. Au contraire, avec le changement d’administration aux Etats Unis et les initiatives telles que celle-ci pour attirer l’attention des politiques, et des populations, on assiste a une augmentation des financements alloues a la PF. Le congres americains a recemment accorde plus de financements. Je susi persuade que cette tendance va continuer, afin que les pays puissent mettre en oeuvre leur programme de relance de la PF. Cependant les gouvernements doivent aussi allouer des lignes budgetaires, si ils sont convaincus que l’utilisation de la contraception par les populations contribue aussi au developpement economique de leur pays.

Mohamed ElMouldi CHERIF: I don’t have a question, but i think the world need a strategic vision to arrive to a tactic targets,but this need beside the civil societies, [it needs] a truly and an honest will to upgrade to these situations and others in the world. [In] this new century we need really more and more collaborations without politics or economic challanges.
John Bongaarts: Thanks for your thoughtful comment

Roger Rochat: Death during or after traditional abortion remains important contributor to maternal deaths in Africa. some countries,e.g. SA, Zambia, Ethiopia have changed their laws to permit legal and safer abortions. Has this led to a reduction in maternal mortality from abortion?
John Bongaarts: Yes unsafe abortion remains a major cause of maternal deaths. I am not aware of studies that have measured declines in maternal deaths after the changes in the laws in SA Zambia and Ethiopia, but I would expect the impact to be substantial.

Hazel Denton: PEPFAR: Billions of US dollars are being pumped into SSAfrica to address AIDS, in a ‘stovepipe’ approach. Do you see any prospect – under the new Administration – of shifting the focus toward using these funds for strengthening health care systems in general, and integrating Family Planning into health care?
John Bongaarts: There is increasing concern that the huge amounts of funding for AIDS are overburdening the health care system and are taking attention away from other more cost-effective health interventions. The FY 2010 budget includes a substantial increase for international family planning so that is step in the right direction.

Dr. Josephine Alumanah: Some women in a relationship because of their economic standing more than culture may not be able to access some forms of family planning and taking advantage of some safe motherhood practices. What should be done to help such women?
Nafissatou Diop: I agree with you that there is a huge inequity in terms of access to family planning services. In most african countries DHS data shows that poor and very poor women (quintile 1,2,3) have a higher unmet need than wealthy women (quintile 4,5). This means that our safe motherhood programs are not reaching the poor. Only countries like Bangladesh were able to reduce these inequities. Recently I read that the Brazilian MOH is also reorienting the program to reach disadvantaged groups. I think that the first step is to draw governement attention to these facts, using research results that show what are the gaps in their program coverage. the second step will be to develop and implement interventions that will reach the poor in urban slums, and poor remote areas.

Jason Bremner: Wow, I’m really impressed with the many thoughtful questions. Do you think that our key term “unmet need” for family planning realistically measures latent demand for FP services? It seems there are many women who want to space or limit their births and aren’t using contraception, but won’t use a method if we improve access to FP due to various additional barriers. Is there a better measure for immediate need?
John Bongaarts: You are right simple access is only one of many reasons for having an unmet need. For women who are exposed, fear of side effcts and opposition from others are key factors.

Edith Mbatia: Most of FP services in Sub-Sahara Africa are provided in the health services, where the accessibility and utilization of services is very low and some areas no services. What will be the best ways to convince the government to increase the health budgets and monitor the utilization of funds towards improving health services? Most of deaths of under-fives and mothers occur outside the health services as community have no trust with the services provided. Is there any of the country which manages to increases the utilization of health services and reduce the deaths?
Nafissatou Diop: You can look at the recent exemple of Rwanda who is really operating an incredible shift and improving the use of services. Madagascar is another example. I encourage you to look at the litterature on these 2 countries