by Kate Gilles, policy analyst, International Programs
“Family planning is a family business…and both men and women should be involved.” This was one of the key points in the Malawian Vice President’s official opening remarks at Malawi’s first National Leader’s Conference on Family Planning, Population, and Development. Other speakers and presenters returned to the issue of male involvement again and again throughout the day, highlighting one of the main and most persistent barriers to contraceptive use in Malawi.
The objective of this conference is to reposition family planning as a sustainable development issue, not just a health issue. Repositioning efforts are frequently targeted to national leaders and policies, but there is a complementary shift that can and must happen at the family level. Just as national decisionmakers from all sectors must be encouraged to see the relevance of family planning to their own work, so must men (who are often the decisionmakers at the family level) be encouraged to see the benefits of family planning for all members of their family. And just as family planning must be reframed as more than a health issue, it must also be reframed as more than a women’s issue.
According to data presented at one of the afternoon sessions, husband’s opposition is one of the top two reasons that women do not use contraception. Depo-Provera is one of the most popular methods in this country, in part because it can be used clandestinely. Clearly, reaching out to men to increase their support for family planning is critical for women’s ability to use contraception. And indeed, research has shown that couples are more likely to use family planning when the male partner is involved in family planning and childrearing.
So how do we achieve the goal of increasing male involvement in family planning? In her opening remarks, the Deputy Minister of Health, Halima Daud, MP, gave a special welcome to the chiefs and traditional leaders in attendance, noting that they are the “gatekeepers of culture” and have great influence at the community level. Vocal support from this group – local chiefs and leaders – will be key for reaching men at the individual and community level, where decisions about family planning are made, and in rural areas, where TFR is highest and contraceptive use lowest.
by Jay Gribble, vice president, International Programs
As the National Leaders Conference on Family Planning, Population, and Development opens with all protocols observed, it’s quite inspiring to hear the comments of leaders who have made opening remarks. Lilly Banda of USAID/Malawi’s Health team spoke of the importance of addressing unmet need for family planning—making modern family planning information and services available to women who want to avoid pregnancy—as a key strategy to achieving Malawi’s development goals, including the Millennium Development Goals (MDGs). The high level of unmet need undermines achieving the MDGs. At the same time, slowing Malawi’s population growth and achieving sustainable levels of fertility will contribute to a higher quality of life for the people of Malawi. As such, family planning is an indispensable development issue, contributing to health and the economic development of Malawi. There is a role for all stakeholders in the process, for together—the public and private sectors, traditional and public officials, government and civil society—all have a vital role to play.
As USAID Mission Director Doug Arbuckle pointed out, this is the first-ever conference in Malawi for population and development, signaling that the Government of Malawi is identifying these issues as a priority for the development and well-being of the nation. Population growth remains a tremendous development challenge: In the 2008 census, Malawi’s population was 13 million; it is currently close to 15 million. With such rapid population growth, addressing the issue is not just a matter of good development policy, it is a matter of life and death. So critical is the importance of addressing Malawi’s population growth, that the challenge of population growth can doom all other development policies.
It’s been 40 years since the 1972 U.S. Commission on Population Growth and the American Future submitted its final report to Congress and President Nixon. Chaired by John D. Rockefeller III, and known as the Rockefeller Commission, the final report concluded that further U.S. population growth offered “no substantial benefits” and argued that “gradual stabilization through voluntary means … would contribute significantly to the nation’s ability to solve its problems.” But Nixon, who originally called for the report, rejected it bowing to election-year political pressure.
“In retrospect, the report stands up well; the conclusions remain strong and the research solid,” said Charles Westoff, a Princeton University sociologist and the commission’s staff director. He acknowledged that the commission “totally failed” to anticipate the volume of immigration or to foresee the increase in out-of-wedlock child bearing. The report included more than 50 recommendations, some of which now appear naïve, such as calling for the establishment of a “National Institute on Population,” he noted.
The report’s carefully worded recommendations on legalizing abortion nonetheless led to its rejection, he said. Yet, the report’s emphasis on eliminating unwanted pregnancies and “enabling women to have the number of children they wanted” formed the basis for the consensuses that emerged from United Nations world population conferences beginning in Bucharest, Hungary, in 1974, according to Westoff.
Today’s debate on abortion and access to contraception “is not too far away from 40 years ago,” said Christine Bachrach, a researcher now affiliated with both the University of Maryland and Duke University. She pointed out that many of the report’s goals regarding raising women’s status and improving reproductive health have been achieved. Specifically, total fertility rates are now below replacement level, unintended births have declined, and women’s educational levels and labor force participation rates have both increased.
In Bachrach’s view, the commission underestimated the power of religion: Out of 100 papers, not one was on religion and she found only nine mentions of the word ‘religion’ in passing. Also, although contraceptive research led to the introduction of new methods, they have “barely made a dent in contraceptive practice,” she reported. Among the issues to address over the next 40 years is family investment in children and child well-being in the wake of nonmarital births, multi-partner fertility, unstable cohabiting relationships, and declining marriage, she said.
The commission’s report “did not have a lot to say about population aging,” noted John Haaga of the National Institute on Aging. This may be because old-age entitlements were proportionately less expensive in the 1970s and the rise in public-sector health care spending was not foreseeable, he suggested.
by Jay Gribble, vice president, International Programs
Sitting in the conference hall of the Crossroads Hotel in Lilongwe, Malawi’s capital, as the National Leaders Conference on Family Planning, Population, and Development is about to open, I can feel a sense of optimism along with a sense of challenge at the same time. It’s a great feeling to return to Malawi after several months and see people again—knowing how hard many have worked to make this conference a reality. There is a sense of hope as President Joyce Banda has assumed leadership of the nation that issues of reproductive health and development will be prioritized in the administration. Yet there is also challenge. Yesterday, the Malawi currency was devalued by almost 50 percent, gasoline continues to be difficult to find, and there are other indications that the situation is slow to improve.
Our colleagues have worked hard to make this meeting an opportunity to share information and evidence about advances in the health of Malawi. The conference will galvanize support for family planning and development. And it’s needed, because even though use of modern contraception is high, 42 percent of married women report using modern methods, fertility remains high. During her life, the average Malawian woman has almost 6 children. This situation poses a quandary that will be discussed: Though the use of effective contraception is high, fertility also remains stubbornly high. We will hear from a colleague at Kenya’s National Council on Population and Development (NCPD) on how they have disseminated evidence-based messages to national and subnational audiences to get family planning and population growth on the policy agenda. Tomorrow, I’ll be presenting on Malawi’s chances of reaping a demographic dividend—but only if the country first focuses its attention on the health and education of the poor, and subsequently enacts policies that can stimulate job creation and needed economic reforms.
So it’s an exciting time. Malawi is confronting the challenge of population growth and looking at how it is critical to advancing economic development. Over the next few days, I’ll be providing periodic updates of what comes from the conference.
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 Shai Venkatraman, reporter, NDTV India and PRB Women’s Edition journalist
This post was originally published on Shai Venkatraman’s blog,beyondtheheadlines.
Elizabeth’s five children are waiting for lunch. All she has is a handful of rice, some watery dal and vegetables – clearly not enough. She despairs. Enter Neelam, a social worker. She sympathizes but points out that Elizabeth should have spaced her babies and practiced birth control.
Watching them intently are 50-odd women, tightly packed together inside a tiny shanty in a colony in Dharavi, in Mumbai, Asia’s largest slum. Elizabeth’s story is a familiar one. And the community play gives them an entry point into issues they would otherwise never talk about openly.
The performances are basic, the actors untrained, but the message is a powerful one – Women can and should plan their babies. It’s a message that decades of government campaigns have failed to deliver effectively, because they have focused on permanent methods like sterilization. This leaves out women who want to delay babies.
A lack that the Society for Nutrition, Education and Health Action is trying to address in a first-of-its-kind, joint initiative with the Family Planning Association of India and the Mumbai municipality. “We are looking at reducing unplanned pregnancies. Our objective is to get to young women, introduce correct information, remove misconceptions, tell them about temporary spacing methods and give them autonomy over their fertility,” says Garima Deveshwar Bahl, Program Director, SNEHA.
Interview with Garima Deveshwar Bahl, Program Director, SNEHA
And it is showing results here at Rajiv Gandhi Nagar colony, home to first generation migrants from the states of Uttar Pradesh, Jharkhand, and Bihar. A community of 3500 households, with poor access to basic amenities like water, sanitation, and health services. Most families here have 3 to 5 children. Women want to space their children or limit family size but don’t know how to.
One area that has seen tremendous growth is Nairobi’s largest slum, Kibera. While experts have given estimates ranging from 270,000 to 2 million residents, Kibera is a large area of informal settlements plagued by challenges such as the lack of electricity, job opportunities, and high levels of violence.
While it may be easier to focus on what is lacking in Kibera, there are also many services being provided in the community including affordable and quality reproductive health care by organizations such as Marie Stopes Kenya.
Marie Stopes Kenya was established in Kenya in 1985 as a locally registered nongovernmental organization. It is Kenya’s largest and most specialized sexual reproductive health and family planning organization and is known for providing a wide range of high-quality, affordable, and client-centered services to men, women, and youth throughout Kenya. In 1997, Marie Stopes Kenya opened its first clinic in Kibera and began offering reproductive health services at an affordable rate for residents.
During a visit to the clinic, I had the honor of interviewing the Kibera Clinic Manager, Pamela Warinda. Pamela is a nurse and midwife by training and has been working with Marie Stopes since 1995. She began managing the clinic in Kibera in September, 2010.
by Mia Foreman, policy analyst, International Programs
Kibera, located 5 km from the city center of Nairobi, has been called Africa’s second-largest slum with estimates of around 200,000 to 270,000 residents. Kibera has many challenges, including lack of employment, electricity, proper sanitation, and housing, and high rates of drug use and violence — especially rape. The lack of employment and education are among the biggest contributing factors to the cycle of poverty with many young people surviving through illegal activities, such as prostitution or drug dealing.
Although there are many hardships, every day local citizens are making a difference in this community. I was fortunate enough to spend time with two young ladies, ages 20 and 22, who are doing just that as members of the community-based organization Kibera Hamlet.
Kibera Hamlet was founded in 2004 by youth in Kibera and currently serves more than 150 adolescents and children from the area, 65 percent of whom are orphans and 10 percent of whom are HIV positive. The organization is involved in many activities including The Girls Empowerment Project. The overall goal of the project is to empower young girls to change their lives and decide for themselves what they want their future to look like.
The Girls Empowerment Project was created to bring together young girls to discuss the daily challenges of living in Kibera, such as early marriage, unsafe abortion, pregnancy, and female genital mutilation. The average situation for a girl growing up in Kibera is quite dire. If she is still single at a young age, chances are her family will send her out to look for money to help with the cost of living. Most of the time, this means prostitution. A girl will sleep with a man for 50 Kenya shillings (KSH), less than one U.S. dollar. This is not enough to put food on the table so she will need to sleep with four to five men a day to make enough money to bring back to her family. If she asks the man to use a condom, the price goes down so most girls don’t use condoms.
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.
