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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