Repositioning Family Planning in Africa Africa SOTA Nairobi June 10-15, 2002

Population Priorities Maximizing access and quality Contraceptive security Post-abortion care Youth reproductive health Population and environment Family planning and HIV integration Reemphasizing family planning in Africa

Population Increases: 2000 to 2025

Africa Population Pyramid: 2000 and 2005 Source: U.S. Bureau of Census. Male Female Age group 10 – 19 represents 24% of the total population

TFR Trends: Africa Source: DHS for years indicated. Total Fertility Rate Zimbabwe Ghana Kenya

TFR Trends: All Countries Source: Demographic and Health Surveys African Non-African

CPR Trends: Africa * Percent of married women ages 15 to 49 using modern contraception. Source: Demographic and Health Surveys Contraceptive Prevalence Rate Zimbabwe Malawi Kenya

CPR Trends: All Countries Percent of married women ages 15 to 49 using modern contraception. Source: Demographic and Health Surveys African Non-African

Contraceptive Prevalence and Adult HIV Prevalence Source: UNAIDS/WHO; DHS; UN. Hill K, et al. Estimates of maternal mortality for 1995, Bulletin of the World Health Organization 79(3), WHO 2001:

HIV and CPR Relationship Adult HIV/AIDS Prevalence CPR (modern methods) Botswana* Kenya Lesotho* Malawi Burundi* CAR* Cote dIvoire Ethiopia Mozambique Higher (>8%) HIV Lower (<8%) HIV Higher (>20%) CPR Lower (<20%) CPR Namibia South Africa Swaziland* Zimbabwe Rwanda Tanzania Uganda Zambia Angola Benin Burkina Faso Cameroon Chad* Comoros* Congo DR Congo Eritrea Gabon* Gambia* Ghana Guinea Guinea Bissau* Liberia Madagascar Mali Mauritania* Niger* Nigeria Senegal Sierra Leone* Sudan* Togo * Denotes countries where USAID does not work. Lower HIV and Higher CPR Higher HIV and Higher CPR 98 million people No SSA countries fall in this category Lower HIV and Lower CPR 340 million people Higher HIV and Lower CPR 175 million people

HIV and CPR Relationship Note: USAID does not work in the following countries: Botswana, Burundi, Cameroon, CAR, Chad, Gabon, Gambia, Guinea Bissau, Lesotho, Mauritania, Niger, Sierra Leone, Sudan, and Swaziland. Higher HIV/Higher CPR 98 million Higher HIV/Lower CPR 175 million Lower HIV/Lower CPR 340 million Lower HIV/Higher CPR Nil

FP Use and Unmet Need

Unmet Need for Women: Age Source: DHS, Data re-produced from PRB, Women in need of contraception(%) * Senegal and Zimbabwe have data only regarding married women using modern methods.

Uganda: Unmet Need By Education

Uganda: Unmet Need by Residence

Optimal Birth Interval: Three year birth intervals, or longer, are associated with the lowest infant mortality rates.

Under Five Mortality: Three year birth intervals, or longer, are associated with the lowest mortality risk for the under five age group Source: Shea Rutstein, Effect of Birth Intervals on Mortality and Health: Multivariate Cross-Country Analyses, Presentation to USAID, July 27, 2000.

Nutrition Status: Three year birth intervals, or longer: lowest risk of stunting and underweight. Source: Shea Rutstein, Effect of Birth Intervals on Mortality and Health: Multivariate Cross-Country Analyses, Presentation to USAID, July 27, 2000.

Maternal Deaths: Short birth intervals <14 months significantly increase the risk of maternal death. (one study, sample - 450,000 women) Source: Conde-Agudel and Belizán, Maternal Morbidity and Mortality Associated with Interpregnancy Inteval: Cross Sectional Study, British Medical Journal, 18 November 2000.

Magnitude of the Problem: 50% - 70% of births in developing countries occur after too short intervals. Source: Shea Rutstein, Effect of Birth Intervals on Mortality and Health: Multivariate Cross-Country Analyses, Presentation to USAID, July 27, 2000.

Maternal Mortality Summary Unacceptably high (2-3 times higher than elsewhere) Most deaths due to: oComplications during delivery and unsafe abortions oInadequate obstetrical care oClosely-spaced births Family planning could reduce maternal mortality by 20% or more.

Summary High fertility, but glimmers of hope High population growth overall, slowed somewhat by HIV and in some countries will reverse Low contraceptive use, under 20% in most countries High unmet need, over 20% in most countries resulting in Unwanted, mistimed pregnancies & abortion Child health impacts Maternal health impacts

Challenge Maintain priority in face of HIV Large cohorts entering reproductive age Resource crunch due to AIDS crisis

Opportunities High unmet need Successful models Capitalize on synergy with HIV (social marketing, BCC, youth, policy, etc.)

Repositioning FP in Mali Lessons Learned Need for policy champions Lack of government coordination Contraceptive complacency Need for focused FP intervention Start with FP basics Encouraging NGO results, but high cost/limited coverage Social marketing success

Repositioning FP in Mali Actions Long-term contraceptive planning Assessment of FP context Advocacy Strengthen national coordination capacity Relaunch CBD FP a major CSP axis

Repositioning FP in Mali Next Steps Design of intervention based on findings training service providers equip service delivery points Operations research IEC strategies Policy dialogue

Repositioning FP in Malawi: History 1964 FP failed to take off 1982 child spacing program launched 1984 USAID provided TA and funding 1992 National Family Welfare Council est 1993 name changed to FP Council 1999 MOHP takes over FP activities

Repositioning FP in Malawi: Achievements CPR increases from 7-26% between Injectables up from 6-16% between Modern method knowledge up to 90% by 96 CBDAs trained and serving communities Contraceptive logistics mgt system Contraceptive supply assured GOM launched RH strategy in 01

Repositioning FP in Malawi: Critical Ingredients for Success Government commitment and support Training of FP service providers training and retention of CBDAs Availability of contraceptive mix Contraceptive logistics management Proximity of health facilities/outreach Injectables Coordinated donor support