WHY FAMILY PLANNING?
Dr Nuriye OrtayliRHR, WHO
Health Concerns
Relation of higher fertility with high maternal mortalityRelation of frequent birth intervals with adverse pregnancy outcomesRelation of frequent deliveries and large families with higher under five morbidity and mortality
MATERNAL MORTALITY
If birth to pregnancy intervals are shorter than 12 months maternal mortality is likely to riseMaternal morbidity (PIH,PROM, anemia) is likely to rise with intervals shorter than 6 months
Infant and Child Health
When birth to pregnancy interval is shorter than 18 months:
Fetal deathLow birthweight RISKS INCREASEPrematurity
Infant Mortality Rate and Total Fertility Rate by Region
Annual deaths to infants under age 1 per 1,000 live births
Average number of children per woman
6
27
51
88 Africa
Asia
LAC*
MDR** 1,6
2,6
2,5
5,1
* LAC=Latin America and the Caribbean; ** MDR=More Developed Regions.Source: Population Reference Bureau, 2005 World Population Data Sheet.
Under 5 Mortality
Each year 11 million children under 5 years of age die1 million deaths of children under 5 years of age can be prevented if birth intervals of less than 2 years are eliminated
Projections based on Matlab and DHS data
Wanted Births, Worldwide
Not Wanted11%
Wanted Later16%
Wanted73%
Recent Births, by Mother’s Attitude, Late 1990s
Note: Estimates based on approximately 60 percent of births worldwide.Source: Population Reference Bureau, Family Planning Worldwide 2002 Data Sheet.
Unintended Births
Births Reported by Women as Either Unwanted or Wanted LaterPercent
54
30
44
16
45
22
Cameroon2004
Kenya 2003
Madagascar2003/2004
Philippines2003
Morocco2003/2004
Columbia2005
Source: DHS STATcompiler: accessed online at www.measuredhs.com/statcompiler on June 14, 2006.
Abortions as a Share of Pregnancy Outcomes, Estimates for 1999
Miscarriages and Stillbirths
15%
Induced Abortions
22%Live Births
63%
Note: The percentages are based on a 1996 UN projection of 210 million pregnancies for 1999.Source: Alan Guttmacher Institute, Sharing Responsibility: Women, Society, and Abortion Worldwide, 1999.
If Unmet Need could have been met
90% of abortion-related20% of obstetric-related mortality and morbidity could have been averted
150,000 maternal deaths annually could have been prevented
Why Family Planning
It is a developmental factor
Why Family Planning?
It is a human right
ICPD, CAIRO
Enable couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so and to ensure informed choices and make available a full range of safe and effective methods. (ICPD, Cairo, 1994)
The core ICPD Goal
"All countries should strive to make accessible through the primary healthcare systems, reproductive health services to all individuals of appropriate ages as soon as possible and no later than the year 2015."
(ICPD Programme of Action, para 7)
Why Family Planning?
Population concerns
World Population Growth Through HistoryBillions
A.D.2000
A.D.1000
A.D.1
1000B.C.
2000B.C.
3000B.C.
4000B.C.
5000B.C.
6000B.C.
7000B.C.
1+ million years
8
7
6
5
2
1
4
3
OldStoneAge New Stone Age
BronzeAge
IronAge
MiddleAges
ModernAge
Black Death —The Plague
9
10
11
12
A.D.3000
A.D.4000
A.D.5000
18001900
1950
1975
2000
2100
Future
Source: Population Reference Bureau; and United Nations, World Population Projections to 2100 (1998).
World Population Growth, in BillionsNumber of years to add each billion (year)
Ninth
Eighth
Seventh
Sixth
Fifth
Fourth
Third
Second
First Billion All of Human History (1800)
130 (1930)
30 (1960)
15 (1975)
12 (1987)
12 (1999)
14 (2013)
14 (2027)
21 (2048)
Sources: First and second billion: Population Reference Bureau. Third through ninth billion: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005.
Growth in More, Less Developed Countries
Billions
0
1
2
3
4
5
6
7
8
9
10
1950 1970 1990 2010 2030 2050
Less Developed Regions
More Developed Regions
Source: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005.
Rates of birth, death, and natural increase per 1,000 populationBirth and Death Rates, Worldwide
0
5
10
15
20
25
30
35
40
1950-1955
1955-1960
1960-1965
1965-1970
1970-1975
1975-1980
1980-1985
1985-1990
1990-1995
1995-2000
2000-2005
Birth rate Death rate
Natural Increase
Source: United Nations, World Population Prospects: The 2004 Revision, 2005.
The Classic Stages of Demographic Transition
Time
Stage 1 Stage 2 Stage 3 Stage 4
Naturalincrease
Birth rate
Death rate
Note: Natural increase is produced from the excess of births over deaths.
First Interventions
0
1
2
3
4
5
6
7
1600 1700 1800 1900 2000 2100
Bill
ions
Bill
ions WHA 18.49WHA 18.49
1999
1987
1974
1960
19271804
2013...................................................................
First interventions
“REQUESTS the Director-General to develop further the programme proposed:
(a) in the fields of reference services, studies on medical aspects of sterility and fertility control methods and health aspects of population dynamics; …”
(WHA Resolution 18.49; 1965)
NATIONAL FP PROGRAMS
1960: 2 countries1975: 74 countries1996: 116 countries
INTERNATIONAL FUNDING1971: $168 million1985: $512 million1995: $560 million2003: $460 million
Synergies worked
Scientific communityHealth advocates (woman and child health)Women's advocatesDevelopment workersEnvironmentalistsDonorsNational governments
9
24
38
53
60
1960 1970 1980 1990 Late 1990s
Rising Family Planning Use, Developing Countries
Married Women 15 to 49 Using Any MethodPercent
Source: Population Reference Bureau, Family Planning Worldwide 2002 Data Sheet.
Trends in Childbearing, by Region
Average number of children per woman
4,9
6,8
5,7 5,6
2,42,7
5
2,5 2,6
1,6
World Africa Asia Latin Americaand the
Caribbean
More DevelopedCountries
1965-1970 2000-2005
Source: United Nations, World Population Prospects: The 2004 Revision, 2005.
Reaching Replacement FertilityAverage number of children per woman
5,6
7.0
5,4
6.4
5,7
7,3
1,9 2,0 2.1 2,0 1,9 2,0
Azerbaijan Chile Iran Mauritius Thailand Tunisia
1960-1965 2000-2005
Source: United Nations, World Population Prospects: The 2004 Revision, 2005.
What has been achieved?
During the last four decades:Population in Asia rose by 129% from 1.7 to 3.9 billion, but will increase only 33% till 2050Similar case in Latin America & CaribbeanSimilar in North Africa and Middle-EastWorldwide contraceptive prevalence increased from 9% to 60%.
Diverging Trends in Fertility Reduction
Average number of children per woman
5,75.25,4
6.46,4
8,5
5,3
3,3
6,2
3,12.4 2,1
4,3
2,5
Egypt India Indonesia Iran Pakistan Turkey Yemen
1970-1975 2000-2005
Source: United Nations, World Population Prospects: The 2004 Revision, 2005.
Price paid
Governments, officials, even health care providers acting on demographic targetsInattention to quality of care
ICPD CAIRO
Celebration of successEmphasis on rights and choiceEmphasis on quality of careEmphasis on integrated care
After Cairo
Perception that “population” threat was goneNew challengesInterest decreased /funding decreasedDiffusion of innovation (difficult ones remained)
Can we sit back and ?
Population growth from 1960 to 2050, by region
Growth in More, Less Developed Countries
Billions
0
1
2
3
4
5
6
7
8
9
10
1950 1970 1990 2010 2030 2050
Less Developed Regions
More Developed Regions
Source: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005.
Projected Population Change, by CountryPercent Population Change, 2005-2050
Source: Population Reference Bureau, 2005 World Population Data Sheet.
Modern Contraceptive Use, Developing CountriesMarried Women 15 to 49 Using Modern Methods, Late 1990s, Early 2000sPercent
4
8
20
32
33
43
47
49
57
57
59
64
70
Congo, Dem. Republic of
Nigeria
Pakistan
Kenya
Philippines
India*
Bangladesh
Russia*
Egypt
Indonesia*
Mexico*
Vietnam
Brazil*
* Data prior to 1999.Source: Population Reference Bureau, 2005 World Population Data Sheet.
Family Planning Methods, Developed CountriesMarried or In-Union Women of Reproductive Age Using Family Planning, 1996
Other4%Traditional
Methods13%
Male Sterilization
5%
Female Sterilization
9%
Condom14%
IUD8%
Pill16%
Not Using a Method
31%
Source: United Nations Population Division, World Contraceptive Use 2005..
Family Planning Methods, Developing CountriesMarried or In-Union Women of Reproductive Age Using Family Planning, 1999
Female Sterilization
22%
Pill6%
Injectable or Implant
4%
Male Condom3%
IUD15%
Traditional Methods
6%
Other<1%Male
Sterilization3%
Not Usinga Method
41%
Note: Total exceeds 100 due to rounding.Source: United Nations Population Division, World Contraceptive Use 2005.
Family Planning Methods, Sub-Saharan AfricaMarried Women 15 to 49 Using Family Planning, Late 1990s
Any Method
19%
No Method
82%
Rhythm16%
Female Sterilization
11%
Withdrawal5%
Other Traditional
11%
IUD5%
Condom5% Other
Modern5%
Injectables21%
Pill21%
Note: Total exceeds 100 percent due to rounding.Source: Population Reference Bureau, Family Planning Worldwide 2002 Data Sheet.
Patterns of Fertility DeclineAverage number of children per woman
0
2
4
6
8
10
1950–1955 1960–1965 1970–1975 1980–1985 1990–1995 2000–2005
Source: United Nations, World Population Prospects: The 2004 Revision, 2005.
Uganda
Kenya
Columbia
South Korea
Population Increase
From now on will be concentrated in the poorest region of the world:
Sub-Saharan Africa (was 0.225 billion in 1960 and 0.75 billion now) will increase 200 million/year and will reach 1 billion in 2020 and 1.69 billion in 2050.Weakest economies in that region (Burkino Faso, Mali, Niger, Somalia will triple)Uganda's population will quadruple.Fertility rate still around 6
An example: Niger
Is it possible to achieve MDGs ?
Eradicate extreme poverty and hungerAchieve universal primary educationPromote gender equality and empower womenReduce child mortalityImprove maternal healthCombat HIV/AIDS, Malaria and otherEnsure environmental sustainabilityDevelop a global partnership for development
What are the options?
It’s their choice!
OROR
Unmet Need
Proportion of fecund, married women who wish to avoid further childbearing alltogether or postpone for at least 2 years but who are not using contraception
Unmet Need for Family Planning
11
6
5
18
20
34
29
25
23
17
11
Ghana 2003
Burkina Faso 2003
Kenya 2003
Bolivia 2003
Cameroon 2004
Mozambique 2003
Philippines 2003
Bangladesh 2004
Jordan 2002
Columbia 2005
Vietnam 2002
Married Women 15 to 49 Not Using Family PlanningPercent
Source: DHS STATcompiler: accessed online at www.measuredhs.com/statcompiler on June 8, 2006.
2223
5045
11
36
50
60
49
38
Bangladesh2004
Egypt 2005
Bolivia 2003
Malawi 2004
Tanzania2004/2005
Poorest Fifth Richest Fifth
Disparities Within CountriesMarried Women 15 to 49 Using a Modern Method, by Wealth CategoryPercent
Source: ORC Macro, Demographic and Health Surveys.
Wanted Births, Worldwide
Not Wanted11%
Wanted Later16%
Wanted73%
Recent Births, by Mother’s Attitude, Late 1990s
Note: Estimates based on approximately 60 percent of births worldwide.Source: Population Reference Bureau, Family Planning Worldwide 2002 Data Sheet.
Unintended BirthsBirths Reported by Women as Either Unwanted or Wanted LaterPercent
54
30
44
16
45
22
Cameroon2004
Kenya 2003
Madagascar2003/2004
Philippines2003
Morocco2003/2004
Columbia2005
Source: DHS STATcompiler: accessed online at www.measuredhs.com/statcompiler on June 14, 2006.
Pregnancy Outcomes Worldwide
Miscarriages and Stillbirths
15%
Induced Abortions
22%Live Births
63%
Abortions as a Share of Pregnancy Outcomes, Estimates for 1999
Note: The percentages are based on a 1996 UN projection of 210 million pregnancies for 1999.Source: Alan Guttmacher Institute, Sharing Responsibility: Women, Society, and Abortion Worldwide, 1999.
Has all been done?
120 million unmet needAn estimated 38% of all pregnancies that occur around the world every year are unintended, Around 6 out of 10 unplanned pregnancies result in an induced abortion 300 million users unsatisfied
What are the reasons behind UNMET NEED?
Lack of information about contraceptionSocial pressuresDifficulty in access to servicesDissatisfaction with servicesDissatisfaction with contraceptives
WHAT CAN BE DONE??
WE KNOW WHAT WORKS
Improve Quality of Care in FP Services
The Four Cornerstones of evidence-based guidance
Medical Eligibility Criteria for
Contraceptive Use
Selected Practice Recommendations for
Contraceptive Use
Guidelines for policy-makers
and programme managers
The Handbook for Family Planning Providers
Handbook forHandbook for
Family Family Planning Planning ProvidersProvidersSuccessor to Successor to The Essentials of Contraceptive TechnologyThe Essentials of Contraceptive Technology
A WHO FAMILY PLANNING CORNERSTONE
Tools for health-care providers
Handbook for Family Planning
Providers
Decision-Making Tool for Family Planning Clients and
Providers
Evidence-based information to providers and users
Potential and current users need to have informationProviders must have up-to-date and correct information:Four cornerstones of FP
Strategic Approach for Identifying Problems and Developing Solutions
Quality of care in FP:Choice of methodsInformation provided, Personal interactionTechnical competence of staffPhysical infrastructureConstellation of services
Appropriate Services
Social science research looking into users/providers/managers perspectives
Developing New Contraceptives and Studying safety of existing ones
Collect data on long term safety of contraceptivesCollect safety data for different subgroups Develop new contraceptives
Summary
FP programmes all over the world is among the most prominent success stories of 20th centuryIt is not complete yetWe need to improve FP programs to achieve MDGs
To improve FP services
Overcome the neglectRemove policy barriersRemove medical barriersIncrease funding for FPIncrease contraceptive rangeUse appropriate IECSupport provider training and supervisionSupport research and monitoring
THANK YOUTHANK YOU
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