Behind the Numbers: The PRB blog on population, health, and the environment

by Charlotte Feldman-Jacobs, program director, Gender 

Secretary of State Hillary Clinton’s speech on Friday, Jan. 8 commemorated the 15th anniversary of the International Conference on Population and Development (ICPD) in Cairo but could reasonably be called the “No Woman Left Behind” speech.

The Secretary extolled the Cairo Conference as a milestone in proclaiming that “women’s health is essential to the prosperity and opportunity of all, to the stability of families and communities, and the sustainability and development of nations.”  She reminded us that the 1994 Conference set specific targets to be met by 2015—to provide evidence of improvement in women’s health care; reductions in infant, child, and maternal mortality; of education for all, but especially for girls and women. These improvements will lead to sustainable development and economic growth — all the while contributing to gender equality, equity, and the empowerment of women. It’s a short time frame with a tall order, especially given the lack of progress in reducing maternal mortality in the last 15 years.

Secretary Clinton listed some of the great achievements that have been made towards these 2015 targets in the increased use of contraceptives, in reducing the spread of HIV/AIDS from mother to child, in improving neonatal and child health, in the number of girls in school, and in the widespread realization that gender needs to be mainstreamed into the entire range of global programs.

However, she rightly pointed out, “vast inequities remain:” Women and girls are the majority of the world’s poor - too many unschooled, unhealthy, underfed, and bearing the brunt of gender-based domestic abuse as well as brutally violent national and regional conflicts.

The statistics Clinton threw down to illustrate that woman are the downtrodden of the earth are very familiar to many of us: one woman dies every minute of every day in pregnancy or childbirth, and “for every woman who dies, another 20 suffer from injury, infection, or disease every minute;”  215 million women lack access to modern contraceptives to prevent unplanned and unwanted pregnancies, a contributing factor in “the nearly 20 million unsafe abortions that take place very year.”  And she noted that millions of women and girls suffer the pain and indignity of such crippling conditions as obstetric fistula and of sexually transmitted infections which they have neither the power nor the information to prevent. Calling specific attention to Female Genital Mutilation (by its “gentler” term Female Genital Cutting), Clinton noted the resulting serious infections and injuries during child birth, but she might have added that it also robs women of their sexual pleasure and indeed  has been outlawed in many countries where it occurs. But, Madame Secretary, far more than 70 million girls and women have been subjected to this cruel tradition. The latest figures show that 100-140 million girls and women worldwide have undergone FGM/C and more than 3 million girls are at risk for cutting each year on the African continent alone.

Moving from the problems to the solutions, Secretary Clinton emphasized “Investing in the health of women, adolescents, and girls is not only the right thing to do; it is also the smart thing to do.” She said the Administration’s commitment and actions will be guided by Cairo’s excellent “roadmap” through:

• New funding to achieve Millennium Development Goal Five (improving maternal health and achieving universal access to contraception)
• The re-funding of UNFPA
• Working with the Congress to appropriate nearly $650 million to family planning and reproductive health programs worldwide
• The Global Health Initiative (GHI), the crown jewel in this administration’s “women-centered approach.”

While the exact strategy of the GHI has not been revealed, $63 billion will be committed over the next six years to prevent millions of new HIV infections; reduce maternal and child mortality; avert millions of unintended pregnancies; eliminate some neglected tropical diseases, and integrate women and girls into all health programs.

If this blogger were to change just one thing about this important speech, it would be to elevate the one sentence that came near the end about the importance of engaging men and boys in the societal changes that will need to take place to achieve better health and equity for women and the world.  “Men are presented as the abusers and HIV vectors,” the Secretary said, adding that we need to reach out to men and boys to encourage them to be active partners in working toward better reproductive health and equality.  This important point deserves to have been made more than once; lack of progress over the last decade in achieving gender equity shows it needs to be raised early and often if our work is to be successful.

Nevertheless, even though I was watching the speech on a TV monitor, I wanted to stand up and cheer her statements that:

• It is a national security issue to pay attention to women and girls.
• It is a matter of equity and fairness.
• It is not just the elite women in societies but also “ the women who live down the street or care for their children or clean their homes or plant their crops” that need our attention.”  Rights must be protected for women everywhere.

Secretary Clinton exhorted the leaders in the august Ben Franklin Room of the State Department (and maybe even those watching on the ICPD2015 simulcast), “Do Not Grow Weary.” She might have borrowed a line from Robert Frost:  For we have promises to keep, and miles to go before we sleep.”?

by Jason Bremner, program director, Population, Health, and Environment

I was recently asked whether I thought Optimum Population Trust’s Carbon Offsets Program was akin to “population control” by rich countries on poor countries. I felt the question mischaracterized the program and population and climate change relationships in general, and this was my response:

Optimum Population Trust’s (OPT) carbon offsets program as well as a recent study they commissioned from the London School of Economics on population and climate change advocate for increased financial support for family planning programs that meet the needs of women regardless of their location in the context of climate change. Some have argued that this amounts to “population control” of developing countries. 

The idea of “Population control” referred to ideas and programs that were being implemented from the 1960’s to the early 1990’s that largely argued that national governments should address high fertility for various developmental, economic, and environmental reasons. The 1994 International Conference on Population and Development (ICPD), however, led to a transformative change in the views, goals, and approaches to family planning, and all efforts since then have been focused on the individual needs of women, their reproductive desires and rights, and voluntary access to family planning for those who wish to space births or limit their number of children. Currently, there are approximately 200 million women worldwide who want to space their births or not have more children but are not using a modern method of contraception. Research indicates that this large “unmet need for family planning” is primarily due to inadequately financed voluntary family planning and girls education.   

The most recent research available from OPT and others indicates that adequately financing voluntary family planning programs and therefore meeting the existing need of 200 million women would benefit individual women and reduce future carbon emissions – a potential win-win. Unintended pregnancies occur throughout the world in both developing and developed countries and thus efforts should be focused where there is a recognized need by individual women (the U.S. for example has a very high rate of unintended pregnancies). 

Efforts to reduce emissions must start with developed or rich nations changing their energy and consumption patterns.  The amount of emissions reductions that are needed to avert the worst climate change scenarios, however, is daunting and will require efforts beyond anything we’ve yet seen. Adequately financing voluntary family planning programs is not a panacea but rather is a contribution to these efforts. 

The Intergovernmental Panel on Climate Change’s (IPCC) climate change models depend on population size in their emissions scenarios. The research that I have read, including some very well done and sophisticated research that should come out sometime later this year, indicates that reducing unintended pregnancies through voluntary programs would result in reductions of at least 1 billion tons of carbon annually by 2050. For those of you familiar with the idea of carbon stabilization wedges, you’ll note that 1 billion tons annually is significant.     

I’d like end by pointing out the just-released UNFPA State of World Population 2009 report that deals with family planning and climate change from the perspective of women’s rights: Facing a changing world: Women, Population, and Climate.

by Jay Gribble, vice president, International Programs 

Over the past few days, I’ve had the opportunity to attend the International Family Planning Conference, held at the Speke Conference Center in Uganda.  This meeting has given me the chance to learn a lot about Uganda and get updated on what has been happening in the field.  While the selection of Uganda as the venue for this meeting of approximately 1,200 participants has focused the eyes of the world on the country’s need to better address the reproductive health of its women, Uganda is not alone in needing to increase its commitment—both political and financial. 

A few statistics about Uganda have really stuck in my head: Ugandan women have on average about 6 to 7 births per women, which is not much less that it was 25 years ago. Only about 18 percent of women of reproductive age use a modern family planning method and more than 40 percent of women don’t want to have any more children in the next two years – or at all – but are not using a family planning method.  Maternal death and disability robs the country of its women as well as hundreds of millions of dollars of lost productivity.  As seen in many countries, provider attitudes can undermine women’s interest and willingness to use family planning, and poor women are again at an inherent disadvantage because of they have limited access to services, poorer understanding of family planning methods, and hold on to traditional beliefs and values that undermine gender equity.

Though there is much work to be done to improve access to and use of family planning, this opportunity to bring together representatives of the global family planning movement has had some real benefits.  Over the couple of decades I’ve been working in this field, I don’t remember attending a meeting that has reenergized people with new evidence, new messages, and new acquaintances. Could the funds used to support the conference have been channeled into the field to support efforts? No doubt it could have been.  Yet just as people who attend a global AIDS conference look forward to learning the new science and being recharged to go back to work, this meeting has given those of us who work in family planning a new, broader perspective on what’s going on and what needs to be done. Through learning new information, sharing what PRB has to offer to the field, and  meeting new people from around the world, I am recharged—and I think many others are, too.  Will things change tomorrow?  Probably not.  But by bringing ministers of finance, health, and planning together; by exposing Ugandan parliamentarians to some of the lost opportunities to national health and development because of inadequate political and financial commitments; by sharing evidence-based research results to better figure out what else needs to be done—I am optimistic about getting things on track and moving forward.

As I leave Uganda and look back on what has happened over the past few days, I think the global family planning movement has been galvanized in a way that hasn’t happened before. Driving forward, the way will certainly have its bumps, but I am optimistic that we are on the right road.

by Jay Gribble, vice president, International Programs

As the International Family Planning Conference, held in Uganda, comes to a close, Dr. Ward Cates, president of Family Health International, summarized the content, tenor, and tone of the conference in 10 “pearls.” I found his reference to pearls to be an appropriate comparison; while Uganda is referred to as the “Pearl of Africa,”pearls are formed by a grain on sand creating an irritation within an oyster.

1. Policies related to family planning need to be better implemented so that they reach those women who either don’t want any more children or want to postpone having children for a few years, but are not using family planning.  Linked to meeting this need is the importance of family planning in achieving the Millennium Development Goals.
2. Long acting and permanent methods are increasingly playing a more important role in programs because short-acting methods pose challenges in correct use and are subject so supply shortages.
3. New contraceptive technologies are needed—including low-cost methods and products that provide dual protection from HIV/AIDS and unplanned pregnancy.
4. Service delivery needs to gain better community buy-in and involvement in distribution, including community-based participation and increased awareness through media.
5. Commodities are in stock more often because of better collaboration between partners—and this results in better service delivery; creative multi-tier pricing strategies are also contributing to a wider range of service delivery points to meet the need of women and couples.
6. The integration of family planning and HIV services appears to be reaching a tipping point in some countries as local, national, and international decisionmakers recognize its value. 
7. The integration of family planning into other types of services—postpartum care, immunizations clinics, and primary health care—provide important strategies for expanding access to family planning services.
8. The financing and costs associated with family planning programs remains a challenge.  However, the total cost of addressing family planning and reproductive health on a global basis is less that what is spent over 10 days on military actions worldwide. 
9. Youth and men need to be addressed more explicitly. Vasectomy is becoming more popular, but there are still many taboos to overcome for it to be accepted more broadly. Similarly, language associate with family planning needs to be reconsidered so that it better appeals to men’s ways of looking at issues.
10. We know what we need to do—we need to do more of it.  Better collaboration, better harmonization, and less duplication of efforts are all part of the way forward.

Ward’s pearls resonate with what has been discussed at the conference.  His comments came at the beginning of last day of the conference, which focuses on using research findings to improve programs.  For many of these pearls to come to fruition, advocates, program manages, policy makers, media, and the public will need to be vocal, use evidence to make their case, and hold governments accountable. Just like the grain of sand in the oyster, we need to better raise awareness about the health and development benefits of family planning to make sure these pearls fully develop.

by Jay Gribble, vice president, International Programs 

On the first day of the International Family Planning Conference, held at the Speke Conference Center outside of Kampala, Uganda, ministers of health, finance, and planning assembled to discuss financing the health-related Millennium Development Goals.  The day-long session included representatives from more than a dozen countries and raised a number of interesting and relevant questions.  The first question, perhaps asked rhetorically, was “Is family planning back?”

As competing priorities for scarce resources have led to less attention being paid to family planning, this question is relevant also because of the stagnation in contraceptive use in many countries throughout sub-Saharan Africa.  HIV/AIDS has taken both the spotlight and the majority of funds.  Even though the region continues to struggle with the epidemic, ministers discussed the need to focus on family planning, especially as a way of reducing maternal mortality.

The speaker who posed this question, Dr. Khama Rogo of the World Bank, acknowledged the challenges to getting family planning back as a priority: country leadership, donor coordination, overcoming the inadequacies of government budgets to address family planning, the large out-of-pocket expenditures that individuals pay for services and commodities, and innovations in policies, strategies, and financing—which require finding new ways to get family planning into national development priorities. 

Each of these challenges can be addressed through the efforts of skilled advocates and committed policymakers.  However, as Dr. Rogo pointed out, if family planning is an “externally funded mandate, then it is not back at all.”  While donors and outside organizations have a role to play in addressing family planning needs, unless the issue is owned by local stakeholders and governments, family planning will not get the traction that it needs to move forward.

He went on to suggest recommendations to help ensure that family planning is back—including having national governments follow through with their commitment to allocate 15 percent of national budgets to the health sector; the development of country-led strategies that respond to local issues and that do not rely on donors; increasing community participation in family planning service delivery—especially through community-based distribution; a policy environment that promotes public-private partnerships so that the challenge for responding to family planning needs is spread throughout other sectors; and improving stewardship—national and local leadership—in addressing the family planning needs of women and couples.

Dr. Rogo made a comparison that was perhaps the most memorable line from the ministers’ seminar: family planning is to maternal health what vaccination programs are to child health.  This insight places family planning squarely where it belongs: as a health intervention, family planning is central to reducing maternal mortality and disability.  Given the importance of this way of looking at family planning within sub-Saharan Africa, Rogo’s insight should  be used by advocates to refocus attention on family planning and make sure that it is back to stay.

by Jay Gribble, vice president, International Programs 

More than 1,000 people have gathered on the shore of Lake Victoria at the Speke Conference Center outside of Kampala, Uganda, to discuss family planning—what we have learned from research and how to expand the implementation of best practices.

The opening plenary included a range of speakers, including the First Lady of Uganda. Many speakers have focused on family planning as a strategy to reduce maternal mortality. For years, family planning has been couched in terms of its health benefits to women and children. The idea of “too young, too old, too close, and too many” is familiar to family planning advocates because through helping avoid unplanned pregnancies, family planning is able to contribute to lower maternal and child mortality. These are critical to addressing the Millennium Development Goals, which aim to reduce poverty and improve the quality of life among the poor.

Yet there are other benefits of family planning that should not be overlooked. Not only is family planning a health strategy, but it is also a poverty reduction strategy. Evidence demonstrates that when women use family planning and have smaller families, their families are better off. Research from Bangladesh shows that through the long-term commitment to family planning and maternal-child health, families are healthier; they have greater assets; they live in more valuable houses; their children are better educated and have lower mortality rates. These benefits reinforce the importance of family planning as both a health strategy as well as one to reduce poverty and improve economic development.

We should also remember that family planning is intrinsically linked to women’s empowerment. When women can decide the timing, spacing, and number of children that they want to have, they and their children are healthier, but they are also more empowered. Recognizing that there are important gender aspects of health and development, family planning helps women better care for themselves, for their children, their families. It allows them to work and earn an income, to continue their education, and to have a say about their own lives and futures.

The conference theme makes an important statement: family planning—family health—family wealth. Let’s not limit the discussion of family planning to only one area of benefit. Good health is important, but family planning also reduces poverty and promotes gender equity.

by Charlotte Feldman-Jacobs, program director, Gender

Last week, I visited ground zero of hope and it wasn’t in Washington, London, or Geneva.  It was 60 kilometers outside of Nairobi, in a small town called Kajiado.

With 15 journalists in a workshop funded by USAID and organized by PRB, I went to the AIC Girls’ Primary School and Rescue Center and although we were hot, dusty, and grumpy from the traffic jams and rough roads when we arrived, we left hopeful and inspired.

While we were there we heard from the headmaster, Nicholas Muniu, and a dedicated staff member named Catherine that change is happening: that girls named Emily and Beatrice were among the girls who had come to the school escaping from certain early marriage and female genital mutilation (FGM); that among the 706 girls now at the school, 217 were rescued from early marriage and FGM; that some were brought by uncles, fathers, and mothers who wanted something better for these daughters. Even more amazing, many came by themselves.

The school began in 1959 with 20 girls and now has more than 700, with a waiting list of girls who want to come. While some of the girls were only rescued after they had already been subjected to FGM or early marriages, the school is now rescuing many before this happens. While the school was formerly viewed with suspicion—and even met with spear-carrying husbands and fathers—the school is gaining respect quickly.  The graduates of Kajiado graduate with top academic skills, according to headmaster Muniu.  And more importantly, the thinking among chiefs in the region has changed dramatically. “Chiefs now accept that educating girls is more important than getting two cows for them in early marriages,” Muniu says.

It quickly becomes apparent that the school, which runs through grade 8, is more than a shelter for these girls, it’s a doorway to a brighter future. While customs and laws change slowly in this part of the world, these girls quickly grasp that they can be anything they want.  They study hard, they live without many of the amenities expected in the West, they sometimes say goodbye forever to families who would force them to undergo old customs and harmful traditional practices. But they have dreams, these girls. When asked what they want to be, they answer doctors and lawyers and pilots. Though they may never have been on an airplane, I know that some day they will be.  For this school has given them wings to fly.

by Yordanos Goushe, senior reporter,  Ethiopia Radio TV Agency

The most effective way of saving young girls from FGM, rape, and early marriage is strengthening the optional center of care that functions within the society. Women in the society remain the vanguard to take actions against the impairing conditions for young girls through a most supporting structure.        

On Saturday, April 25, 2009 we Women’s Edition journalists visited the Kajiado AIC Rescue Center, a center that was created by people who were committed to educating young girls. The girls in the center have stories to tell about Female Genital Mutilation (FGM), early marriage, and rape.  These stories make you wonder how such things are done by a parent to his/her own offspring in the name of culture.  However, there are also beautiful and rare stories of hope. If we ask the young girls in the rescue center, they will tell us they want to be a lawyer, politician, public figure, and a journalist. 

Taking these and other difficulties of Kajiado girls into consideration, the AIC Rescue Center has taken the step of working with the chiefs, fathers, and mothers of the community. Now the chiefs are protecting the young girls who go back to their community for school break and fathers are bringing their daughters before the cutting is done to them.

The AIC Rescue Center receives girls  from all over Kenya, some travelling a long distance after being the victims of rape, others running away from home because they do not want to be cut. The center provides good education, food, and shelter for these young girls who have seen a lot at an early age. The center receives all of them with an open hand even if it has limited capacity; there is always room for one more young girl who comes to the rescue center to have another chance in life.

There is a very important message which comes across from the AIC Rescue Center: there are young girls who are saying “no” to the cultural barriers in their communities and these girls need help, so it’s our duty to help them find a solution.

by Victoria Ebin, news media coordinator

PRB is carrying out three workshops on family planning for West African journalists between January and June of this year. The first workshop, held in Dakar in January, was for 16 print and broadcast journalists; the second, with 19 participants, took place in Ouagadougou in April; and the third workshop will be in Bamako in May. These workshops somewhat resemble a family reunion. They bring together print and broadcast journalists from Burkina Faso, Mali, and Senegal that PRB has worked with for more than a decade. Back in the mid-1990s, many of the editors-in-chief of the current crop of participants were already senior journalists and were part of PRB’s long-running media training project, Pop’Mediafrique, that met regularly until 2005.

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by Chinyere Fred-Adegbulugbe, senior correspondent, The Punch, Lagos, Nigeria and member of PRB’s Women’s Edition

The Women’s Edition training continued on Thursday with a field to a Marie Stopes centre in a Nairobian slum called Kanyemi. There are about 27 Marie Stopes centres throughout Kenya. Though small, the Kayemi centre is already making its presence known in the neighbourhood with the comprehensive reproductive services it offers which includes different family planning methods, pap smear, Voluntary Counselling and testing (VCT), and a host of others. A one-stop reproductive health shop, you might say.

Records from the staff showed that Kenyan women and men are beginning to make the most profitable journey toward that point where they take their sexual and reproductive health seriously; about 15 women have come for tubal litigation in the centre this April and the month isn’t over yet!

The afternoon saw the group back at Fairview hotel where Family Planning in the Africa was analysed using SWOT – Strengths, Weaknesses, Opportunities and Threats. The general feeling was that where there is political will and government commitment in any country, many more people whether rich or poor would be able to access family planning services. While realising that there are indeed real threats to effective family planning programs, there is also the need to grab with both hands opportunities (wherever they are found) that could bring more positive results. Everyone seems to be on the same page here.

The day ended with a dinner at the Carnivore. Did you say the Carnivore? Yes, the Carnivore and it was quite an experience. The most daring of the pack even got and actually ate crocodile meat and some Kenyan native dance steps.  It was fun, fun fun!