The Bangladesh 2011 Demographic and Health Survey (DHS) is the ninth demographic survey taken in the country since 1975. Except for a few very small countries and city-states, Bangladesh is the world’s most densely populated country with about 1,100 people per sq. kilometer. The country’s area is about the same as the U.S. state of Arkansas and a bit more than Greece but is home to over 150 million people. The preliminary 2011 report has just been released and it shows that fertility has continued its decline to a low level. The total fertility rate (TFR) for the three-year period before the survey was 2.3 — 2.0 in urban areas and 2.5 in rural areas. The survey interviewed 17,842 ever-married women ages 12 to 49 and 3,997 ever-married men ages 15 to 54 from July to December 2011.* Rural women accounted for two-thirds of those interviewed. From 1975 to 1993-1994, the TFR in Bangladesh was in continuous decline. But the next three surveys showed a tendency for TFR decline to “stall” at a medium level (see graph). Desired family size has greatly decreased. In the survey, 76.2 percent of women with two living children said that they did not wish to have any more children and an additional 5.3 percent had been sterilized and 1.3 percent said they were incapable of conceiving.
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In the survey, 61.2 percent of currently married women said that they were using some form of family planning, a level comparable to developed countries. The use of modern methods was quite high at 52.1 percent. Unlike neighboring India, where female sterilization predominates, the contraceptive pill is the most widely used modern method at 27.2 percent, followed by injectables (11.2 percent), and the male condom (5.5 percent). Contraceptive use has risen steadily in surveys, up from 7.7 percent in 1975. Family planning use has risen despite the fact that fewer women report a visit from a family planning worker, either government or private. Overall, only 15.5 percent reported contact with a home visitor, which has been an important part of the country’s family planning program. The report notes that this may be due to workers deciding to provide services from community clinics for three days a week.
The Mozambique 2011 Demographic and Health Survey (DHS) is the third DHS in a series that began in 1997. The preliminary report has just been released. A major finding of the survey is that there has been no perceived decline in the total fertility rate (TFR) since the first DHS, and that the TFR may actually have risen. The survey interviewed 13,745 women ages 15 to 49 and 4,035 men ages 15 to 59 from May to November 2011. The TFR obtained in the survey was 5.9 for the three-year period preceding the survey. For urban women, the TFR was 4.5 and, for rural women, who were 65.3 percent of the sample, 6.6. The reported TFR in the 2011 DHS was higher than that obtained in both the 1997 and 2003 DHS (see figure). The 2011 DHS TFR can also be compared with a TFR of 6.1 obtained in the 2008 Multiple Indicator Cluster Survey (MICS) conducted by UNICEF. In the survey, 46 percent of women with five living children said that did not wish to have any additional children and 59.4 percent of those with six or more children also said that they wished to cease childbearing. Of those two groups, the percentage who declared themselves to be sterile or who had been sterilized was 7.6 and 7.2, respectively. It would seem that the desire for small families is largely absent in Mozambique.
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In the survey, 11.6 percent of currently married women or in union women said that they were using some form of family planning, with 11.1 percent using a modern method. Injection topped the list of modern methods at 5.1 percent, followed by 4.5 percent using the contraceptive pill, and 1.1 percent the male condom. Contraceptive use by method was very similar to that in the 2003 DHS, which was 16.5 percent for all methods and 11.7 percent for modern methods . These are methods commonly used for spacing births, not limiting their number, something frequently observed in sub-Saharan Africa.
The decline in infant and child mortality, as reported in surveys, has been rather dramatic. The infant mortality rate (IMR) in the five years before the 2011 DHS was 64 infant deaths below age 1 per 1,000 live births, down from 79 in the five to nine years before the survey and 106 in the 10 to 14 years before the survey. In the 2008 MICS, the IMR for the five years before the survey was 95, suggesting that it could possibly be higher than the 2011 DHS indicates. But decline in the IMR seems quite evident. The decline in the child death rate, ages 1 to 4, was slightly slower than for infant mortality, to 35 deaths per 1,000 five years before the survey from 46 five to nine years before the survey and 59 10 to 14 years before.
by Rachel Winnik Yavinsky, policy associate, International Programs
Bwindi district is located in the southwest corner of Uganda, about a 12-hour drive from Kampala. The district is the site of Bwindi Impenetrable National Park, a UNESCO World Heritage Site that is home to around 300 of the world’s estimated 740 remaining mountain gorillas. Bwindi’s other residents, the humans who surround the park, face many challenges, including lack of sustainable livelihoods, poor sanitation infrastructure, high fertility rates, and human, wildlife, and livestock conflict. Many of these difficulties are being addressed by a local PRB partner, Conservation Through Public Health (CTPH). CTPH was originally founded to monitor disease among the gorilla population, and prevent these rare and special animals from acquiring illnesses from the local humans and livestock. Today, CTPH manages a comprehensive and integrated population, health, and environment (PHE) program that seeks to improve the health of humans, livestock, and wildlife, and promotes health and conservation education and cooperation in the communities. PRB has been supporting CTPH for three years to steer the Uganda PHE working group and promote the PHE approach in the region.
Photo: Rachel Winnik Yavinksy/PRB
I recently joined staff from the Uganda Health Communications Alliance and journalists from many of Uganda’s major news outlets on a study tour of CTPH projects. These study tours aim to help journalists better understand PHE connections and thus improve reporting on population and family planning. We visited CTPH’s Gorilla Research Clinic, where they track the health of local wildlife, and met with CTPH partners, the friendly and passionate staff at the clean and well-stocked Bwindi Community Hospital. CTPH also maintains a partnership with the Uganda Wildlife Authority, which shares CTPH’s mission of protecting the health of gorillas and other wildlife.
by Noor Sabah Rakshani, 2011-2012 PRB Policy Communication Fellow and student in Health Care Management and Leadership at the Johns Hopkins Bloomberg School of Public Health.
The last of the permanent cave villages in North America, of the Anasazi Indian tribes, existed about 1000-1300 AD. But in some parts of the world in Africa, Asia, Europe, and the Middle East, people still live in caves. As civilizations have evolved over millennia, we no longer expect humans to be living in caves. The photo below, however, contradicts our expectation of human living conditions in the 21st century. The girl in the photo is receiving oral polio vaccine and lives with her family in a cave in the southwest province of Balochistan, Pakistan. Her family might have been forced out of their settled dwellings due to a number of reasons such as recent floods or ongoing insurgency, which has displaced millions out of their homes, or because of abject poverty.
Photo: Balochistan Vaccination Program Office
I hope this is a temporary settlement for her and other children in similar living conditions, but this also points to a larger neglected issue: the migratory population in Pakistan. This population can be categorized mainly as:
by Amanda Roach, program assistant, International Programs
At the March 7, 2012 event “A New Century: African Women, Health and the Future of Development,” Dr. Daniel Singer, Director for Global Health Research and International Activities at National Institutes of Health remarked, “Public health is like sex. Thinking about it and talking about it is not the same as doing it.” Those in attendance at the Africare-sponsored event shared his sentiment that more work is needed to implement women’s health initiatives in Africa.
On the eve of the 101st International Women’s Day, Africare, in partnership with the United Nations Foundation and Global Health and Diplomacy, assembled a panel of advocates to discuss the state of women’s health in sub-Saharan Africa. Dr. Singer was joined by an impressive list of women’s health and development supporters including: Kathy Calvin, CEO, United Nations Foundation; U.S. Congresswoman Karen Bass of the House Subcommittee on Africa, Global Health and Human Rights; Ambassador Amina Salum Ali, African Union Ambassador to the U.S.; and Ambassador Mwanaidi S. Maajar, United Republic of Tanzania Ambassador to the U.S. The prevailing theme was how to best move forward the women’s health agenda in Africa.
Current statistics show it is very unlikely that sub-Saharan Africa will reach its target for UN Millennium Development Goal (MDG) 5, which aims to reduce the maternal mortality ratio by three quarters between 1990 and 2015, and achieve universal access to reproductive health by 2015. Though progress has been made in the majority of African nations, many countries in sub-Saharan Africa still report low rates of births attended by skilled professionals as well as high rates of maternal mortality and lifetime chances of women dying from maternal causes. In Ethiopia only 6 percent of births are attended by skilled professionals, only 14 percent in Chad, and 46 percent in sub-Saharan Africa as a whole. In Chad and Somalia, 1,200 out of every 100,000 women die while giving birth, nearly twice the ratio in all of sub-Saharan Africa. Comparatively, while there is a 1 in 3,600 chance a woman will die from maternal causes in the developed world, sub-Saharan women face a ghastly 1 in 31 chance of dying from such causes. (Data from PRB’s 2011 World’s Women and Girls Data Sheet)
A young mother lies with her newborn child. Photo Credit: UNFPA
by Mary Ellen Stanton, CNM, USAID Senior Maternal Health Advisor
When I started midwifery training decades ago in the United States, in the hospital where I worked, I first saw evidence of disrespect and abuse of women in labor. Women were separated from families and visitors from admission to discharge four days later and, in the second and third stages of labor, their legs were secured by stirrups and their wrists put in leather restraints. Soon after, I worked in West Africa in a government maternity and witnessed women being verbally abused — “if you don’t push and your baby is born dead, it will be your fault” – and physically abused by slapping and massive fundal pressure to force delivery. Women were ridiculed for making too much noise in labor — and then were chastised if they were silent and delivered alone.
Fast forward decades later. As I visit maternity services in a number of countries, I don’t need to look far to see and hear evidence of disrespect and abuse of women in childbirth. A convulsing woman in labor on the steps of an urban referral hospital turned away from because she cannot pay. A doctor who derides poor women for not using family planning to control their fertility. A nurse who tells me that postpartum mothers “sneak in” to see their hospitalized newborns at night, while the families seek to find funds to pay the bills in order to get their newborns discharged. Unclothed women laboring and giving birth as visitors walk by. A researcher who tells of a postpartum mother being detained for months because she could not pay her bill. The human rights worker who tells me that refugee women are discriminated against in childbirth and that one refugee was forced to keep her stillborn in her bed with her for 24 hours against her will.
Navrongo, a rural district in northern Ghana that faced high infant and under-5 mortality and where women averaged over 5 children each 20 years ago, was the focus of an innovative and influential public health project from the early 1990s to 2002. Based on the network and infrastructure of an existing vitamin A supplementation program that had started in 1989, the project was ambitious and wide-ranging. It included providing bed nets for malaria prevention, treating and preventing anemia in pregnancy, restructuring the way health services were delivered, combating Female Genital Mutilation, providing family planning services, and more. In a few years, quality health services were available for the first time and the fertility rate and under-5 and infant mortality rates had declined sharply.
Dr. Fred Binka, the former director of the Navrongo Health Research Centre and current professor at the School of Public Health at the University of Ghana joined a panel of Ghanian Ministry of Health officials and researchers at the PopPov conference to discuss the Navrongo project and its wide-ranging effects. Three points struck me from the panel presentation and discussion:
The Cameroon 2011 Demographic and Health Survey – Multiple Indicator Cluster Survey is the fourth DHS in a series that began in 1991. As so often observed in sub-Saharan countries, the birth rate decline has “stalled” at a high level and, in Cameroon’s case, for quite some time. The survey interviewed 15,426 women ages 15 to 49 and 7,191 men ages 15 to 59 from January to August, 2011. The total fertility rate (TFR — the average number of children would bear in her lifetime if the birth rate of a particular year were to remain constant) obtained in the survey was 5.1 for the three-year period preceding the survey. For urban women, the TFR was 4.0 and, for rural women, who were a 46.1 percent of the sample, 6.4. The TFR in the 2010 DHS was actually slightly higher than that obtained in the 2004 survey, when it was 5.0 nationally, and 6.1 for rural women while that of urban women remained unchanged. TFR decline came to an end in Cameroon from 1998 onwards as can easily be seen in the figure below. In the survey, 49.3 percent of women with five living children said they did not wish to have any additional children and 64.9 percent of those with six or more children also said that they wished to cease childbearing. Of those two groups, the percentage who declared themselves to be sterile or who were sterilized was 5.1 percent and 5.9 percent, respectively.
In the survey, 23.4 percent of currently married women said that they were using some form of family planning, with 14.4 percent using a modern method. Use of the male condom accounted for more than half of modern use at 7.6 percent, followed by 3 percent using injectables, and 1.9 percent using the contraceptive pill. Reported contraceptive use was similar to that in the 2004 DHS, which was 26 percent for all methods and 12.5 percent for modern methods. (In the 2007 MICS, contraceptive use was reported as 39.7 percent for all methods and 17.6 for modern methods. TFR data were not collected.)
The 2010-2011 Demographic and Health Survey (DHS) interviewed 15,688 women and 4,929 men ages 15 to 49. The total fertility rate (TFR — the average number of children would bear in her lifetime if the birth rate of a particular year were to remain constant) obtained in the survey was 5.0 for the three-year period preceding the survey. For urban women, the TFR was 3.9 and for rural women, who were 51 percent of the sample, 6.0. There has been slow annual decline in survey TFRs in the country of about 0.7 children per woman since 1986 when it was 6.6, although the pace of decline has slowed recently. The TFR obtained in Senegal’s 2008-2009 Malaria Indicator Survey was 4.9, suggesting a potential stall in TFR decline. When asked about their future childbearing desires, 35.7 percent of married women with five living children said that they wanted no more and, among women with six or more living children, 63.8 percent said that they wanted no more. The desire to cease childbearing only comes after one has quite a large family.
*Malaria Indicator Survey
Note: TFRs are for the three years before the surveys except 1999, which is five years.
The Malawi 2010 Demographic and Health Survey (DHS) is the latest in a regular series of DHS surveys that began in 1992. The survey interviewed 23,020 women ages 15 to 49 and 7,175 men ages 15 to 54 from June to November 2010. The total fertility rate (TFR — the average number of children would bear in her lifetime if the birth rate of a particular year were to remain constant) obtained in the survey was 5.7 for the three-year period preceding the survey. For urban women, the TFR was 4.0 and, for rural women, who were a 81.3 percent of the sample, 6.1. This is a fairly typical difference between urban and rural fertility found in surveys. TFR decline has been quite consistent, although slow. The fastest annual decline in survey TFRs was between the 2000 and 2004 surveys at -0.8 while annual decline from 2004 to 2010 was a bit less. If the -0.05 annual change currently observed in the TFR continued, it would take Malawi over 70 years to reach the two-child family. Regarding possible future fertility trends, 51.4 percent of women with four living children said that they not wish to have any more as did 61.9 percent of those with six or more living children.
In the survey, 46.1 percent of currently married women said that they were using some form of family planning, 42.2 percent a modern method. As in much of sub-Saharan Africa, injectables were by far the most frequently used method, used by 25.8 percent of the women. This method was followed by the pill (2.5 percent) and the male condom (2.4). The use of injectables showed the largest increase, from 18 percent in the 2004 DHS.
Note: TFRs are for the three years before the surveys.
Source: National Statistical Office Zomba, Malawi, Malawi Demographic and Health Survey 2010 (Calverton, MD: ICF Macro, 2011).
The decline in infant and child mortality has been somewhat slower than in other African countries. The infant mortality rate in the five years before the 2010 DHS was 66 infant deaths below age 1 per 1,000 live births, down from 81 in the five to nine years before the survey and 92 in the 10 to 14 years before the survey. The decrease in the child death rate, ages 1-4, was more substantial, having declined to 50 deaths per 1,000 five years before the survey, from 79 five to nine years before the survey, and 97 10 to 14 years before it.
by Eric Zuehlke, web communications manager
Note: TFRs are for the three years before the surveys.
