Meeting Objectives Present data on the status and trends of FP needs and programs in sub-Saharan Africa. Identify effective strategies to demonstrate the importance of strong FP programs within the context of health and development priorities in SSA. Identify next steps to effectively mobilize existing resources to strengthen FP programs to address current health and development priorities in SSA.

Status and Trends of Family Planning in Sub-Saharan Africa USAID Africa Bureau and Global Bureau for Health October 30, 2002

FP in Sub-Saharan Africa Task Force Khadijat Mojidi Nomi Fuchs Daniel Kabira Katharine Kreis Daniel Halperin Jyoti Schlesinger Kendra Phillips Adrienne Cox Dana Vogel*

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

Fertility Decline in Selected World Regions, Early 1960s to 2002 Children per woman* * The average total number of children a woman will have given current birth rates. Source: US Bureau of the Census, International Data Base, September 23, 2002.

African Contraceptive Prevalence Rate Compared to Other Regions Source: Population Reference Bureau, Rate of Modern Contraceptive Prevalence among Married Women Women using contraception (%)

Family Planning Data

Population/Family Planning Programs in Africa – 25 Programs Ongoing Programs West Africa Regional Benin Program DR CongoBurkina Faso EritreaCameroon EthiopiaCote d’Ivoire GhanaTogo Guinea Kenya Liberia Madagascar Malawi Mali Mozambique Nigeria REDSO/ESA Rwanda Senegal South Africa Tanzania Uganda Zambia Zimbabwe Strategic Objective in Population and Family Planning

Trends in Contraceptive Prevalence Rates: Select Countries * Percent of married women ages 15 to 49 using modern contraception. Source: Demographic and Health Surveys Women using contraception (%)*

Representative Contraceptive Prevalence Rates* (population in millions) Source: Demographic and Health Surveys, most recent available data. No recent data available for Angola, DR Congo, Lesotho, and Swaziland. Total population, mid World Population Data Sheet, PRB, * Married women, Modern Methods

Contraceptive Prevalence and Adult HIV Prevalence Source: Report on the global HIV/AIDS epidemic. UNAIDS, July 2002; DHS; UN. Hill K, et al. Estimates of maternal mortality for 1995, Bulletin of the World Health Organization 79(3), WHO 2001: % - 9.9% 10% % 1% - 2.9% Over 15% 0% - 0.9%

Comparison of Total Fertility Rates for Selected African Countries: Source: DHS for years indicated. Total Fertility Rate (children/woman)

Use and Total Unmet Need* Women Source: Demographic and Health Surveys. *All women 15-49, modern methods. **Currently married women 15-49, modern methods.

Unmet Need for Contraception Among Adolescent Women Ages 15-19, by Marital Status Source: DHS, Data re-produced from PRB, Women in need of contraception(%) * Senegal and Zimbabwe have data only regarding married women using modern methods.

FP Summary Africa’s high fertility will ensure continued rapid growth throughout most of the region and will surpass 1 billion in 25 years. Twenty-one of the 25 countries that USAID supports has CPRs of less than 20%--with most under 10%. High unmet need for family planning among all of reproductive age, especially adolescents who are risk for both pregnancy and HIV. Data suggests need to revisit USAID programming in responding to country FP and HIV needs.

Maternal and Child Health Data

Western Africa 1,040 Eastern Africa 1,340 North Africa 460 Central Africa 1,020 Southern Africa 360 *Maternal deaths per 100,000 live births Maternal Mortality Ratio* Source: Kenneth Hill, Carla Abou Zahr, & Tessa Wardlaw: Estimates of maternal mortality for Bulletin of the World Health Organization, vol.79, no.3, Sub-Saharan Africa1,100 South Asia430 East Asia/Pac.140 LAC 190 Developing Countries 440

Maternal Mortality and Adult HIV Prevalence Source: Report on the global HIV/AIDS epidemic. UNAIDS, July 2002; DHS; UN. Hill K, et al. Estimates of maternal mortality for 1995, Bulletin of the World Health Organization 79(3), WHO 2001: Adult HIV Prevalence % - 9.9% 10% % 1% - 2.9% Over 15% 0% - 0.9%

CPR and Maternal Mortality Ratio by Country Source: Demographic and Health Surveys for CPR. Hill K, et al. Estimates of maternal mortality for 1995, Bulletin of the World Health Organization 79(3), WHO 2001: Percentage of women using modern methods Death per 100,000 births

Maternal Mortality Summary Maternal mortality rates in SSA are unacceptably high, ranging from 341 (South Africa) to 1841 (Ethiopia) per 100,000 women, nearly two to three times that of the rest of the developing world. Most maternal deaths are due to: Closely-spaced births Complications during delivery and unsafe abortions Inadequate obstetrical care Family planning could reduce maternal mortality by 20% or more.

Under 5 Mortality and Adult HIV Prevalence Source: UNAIDS/WHO; U.S. Census Bureau Adult HIV Prevalence % - 9.9% 10% % 1% - 2.9% Over 15% 0% - 0.9%

Source: Demographic and Health Surveys of indicated years. UNIICEF for regional U5 mortality rates for Under-Five Mortality Rates in Selected African Countries : two points in time Note: Mortality rates given are for the five-year period prior to the survey. * In Ethiopia’s 2000 survey, the previous period is based on recall. U5M Regional Averages: SSA 172 South Asia101 East Asia/Pac.44 LAC 38 Dev. Countries90

Infant Mortality by Birth Interval On average, infants born after short birth intervals are twice as likely to die as those born after intervals of two or more years. Source: Country DHS Reports. * Figures here are only for a 2 year birth interval instead of a 2-3 year interval.

Under Five Mortality with and without AIDS: 2002 Source: Stanecki, K. The AIDS Pandemic in the 21 st Century. Draft report XIV International Conference on AIDS, Barcelona, U.S. Bureau of Census, International Database, July 2002.

Infant and Child Mortality Summary African children are 3-4 times more likely to die than children in other regions. Infants are twice as likely to survive if the previous birth interval is at least 2 years. Very few children in SSA are spaced at a birth interval of 3 or more years. Family planning can make a difference.

HIV and CPR Relationship Data

Spread of HIV over time in sub-Saharan Africa, 1984 to 2002 Source: WHO and UNAIDS June Estimated percentage of adults (15–49) infected with HIV 20.0% – 36.0% 10.0% – 20.0% 5.0% – 10.0% 1.0% – 5.0% 0.0% – 1.0%

Adult HIV Prevalence Rates* (Adult population in millions) Source: Report on the global HIV/AIDS epidemic, UNAIDS HIV prevalence data for Gabon, Guinea, Liberia, Mauritania, and Niger is from AIDS in Africa: Country by country, UNAIDS * Adult HIV prevalence and population (15-49).

HIV and CPR Relationship Adult HIV/AIDS Prevalence CPR (modern methods) Botswana* Kenya Lesotho* Malawi Burundi* CAR* Cameroon Cote d’Ivoire Higher (>8%) HIV Lower (<8%) HIV Higher (>20%) CPR Lower (<20%) CPR Namibia South Africa Swaziland* Zimbabwe Mozambique Rwanda Tanzania Zambia Angola Benin Burkina Faso Chad* Comoros* Congo DR Congo Eritrea Ethiopia Gabon* Gambia* Ghana Guinea Guinea Bissau* Liberia Madagascar Mali Mauritania* Niger* Nigeria Senegal Sierra Leone* Somalia* Sudan* Togo Uganda * Denotes countries where USAID does not work. Lower HIV and Higher CPR Higher HIV and Higher CPR 105 million people No SSA countries fall in this category Lower HIV and Lower CPR 466 million people Higher HIV and Lower CPR 118 million people

HIV and CPR Relationship Higher HIV/Higher CPR 105 million Higher HIV/Lower CPR 118 million Lower HIV/Lower CPR 466 million Lower HIV/Higher CPR No SSA countries in this category

Ecological Relationship Between Male Circumcision and Heterosexual HIV Transmission Sources: Halperin D, Bailey R. “Male circumcision and HIV infection: 10 years and counting.” Lancet 1999; 354: Notes: * Countries excluded from table for following reasons: 1) estimated proportion of men circumcised >20%, <80%; 2) similar risk factors for heterosexual HIV not present; 3) insufficient information; 4) very small countries. ** June 1998 UNAIDS/WHO percent estimates. *** If the predominately non-circumcising region of western Kenya, where seroprevalence is approx. 35%, is excluded, national prevalence would be approx. 8%. 80% Circ.Seroprevalence** Zimbabwe25.84Kenya11.64*** Botswana25.10Congo (Braz.)7.64 Namibia19.94Cameroon4.89 Zambia19.07Nigeria4.12 Swaziland18.50Liberia3.65 Malawi14.92Sierra Leone3.1 Rwanda12.75Ghana2.38 Benin2.06 HIV-1 prevalence in African countries with similar risk factors for heterosexual HIV infection.*

World Population Projections by Region or Country Source: PRB World Population Data Sheet, Even with the world’s worst HIV epidemic, the population growth rate in Africa will continue to increase at the most rapid rate.

Summary of HIV and CPR Relationship: SSA countries with the worst HIV epidemics tend to have higher CPR, lower MMR, and lower TFR. While AIDS has exploded in some SSA countries, HIV rates in most of Africa have remained at relatively low levels. Epidemiological data on the male circumcision-HIV relationship suggests there may be limits to the spread of HIV in most West African and some other SSA countries, where male circumcision is widely practiced. Most SSA countries (584 million people out of 688 million total) have very high FP needs, with CPR usually less than 20%. Of these, 466 million people live in countries with both very low CPR and HIV prevalence less than 8%.

Funding Data

USAID Population Funding Trends Source: USAID Agency Funding Data, Global Population Office.

USAID PHN Funding Trends: SSA Population: 673 million Health includes: Child Survival, Infectious Disease, Other Health, and Vulnerable Children (FY00-03) Population HIV/AIDS Health Source: Africa Bureau OYB.

Repositioning Family Planning Africa’s population will continue to increase, averaging about 2.5% increase per annum. While TFR has declined rapidly in other regions, fertility in Sub-Saharan Africa lags far behind - double that of Asia and Latin America. There are 584 million people living in 35 SSA countries with contraceptive prevalence less than 20% (most less than 10%). While HIV/AIDS has exploded in parts of southern and East Africa, West Africa (except Cote d’Ivoire and Cameroon) still has HIV prevalence of less than 8% (usually less than 5 or lower).

Approaches for Resuscitating FP in Sub-Saharan Africa Promoting FP in HIV/AIDS Settings Promoting Child Spacing in Pre-natal Settings Promoting Post Partum FP Addressing Unmet need, especially youth Promoting Male involvement in FP

Questions and Answers