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A Visible Agenda for Family Planning

A Visible Agenda for Family Planning. AMY O. TSUI GATES INSTITUTE JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH MAY 6, 2009. Outline. Reasons for the near complete invisibility of family planning achieved since mid-1990s Is reversal possible?

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A Visible Agenda for Family Planning

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  1. A Visible Agenda for Family Planning AMY O. TSUI GATES INSTITUTE JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH MAY 6, 2009

  2. Outline • Reasons for the near complete invisibility of family planning achieved since mid-1990s • Is reversal possible? • Internal research at the World Bank on population and development, fertility and family planning • Heeded? • Family planning as a driver for reducing maternal and infant deaths, abortions and unwanted fertility • Response levels

  3. Dilemma of Past Success: Insiders’ View on the Future of the International Family Planning Movement • What is the perception of population insiders on the trend in international visibility and support for the family planning movement? • What are the main reasons for this trend? • What are the potential responses? SFP 36(4):263-276, 2005

  4. The Changing Visibility of Family Planning • Consensus in 2004 that family planning has lost visibility on the international development agenda • Most view this as unfortunate and likely to continue • For some, family planning became stigmatized “…When you hesitate to say the words ‘family planning’, something is happening. When you say ‘reproductive health’ and have to be careful, something is happening.” “Family planning has become stigmatized. Big chunks of the global power structure think it’s morally suspect.”

  5. Factors in the Loss of Visibility • Loss of a sense of urgency • Competing health and development priorities • Rising political conservatism • Lack of leadership

  6. Possible Responses Cited • Form synergistic alliances • Reposition the message • Improve contraceptive service delivery • Develop new leadership to encourage developing countries to take responsibility

  7. Christian Science Monitor, January 26, 2009

  8. The Future of the Family Planning Movement? • Possible sequel models • Overlap • Cooptation by another social movement with overlapping objectives • Revival • Movement re-energized by concern over prolonged stalls in fertility declines and stagnation in contraceptive prevalence levels • Driven by emerging international NGO networks • “The great fear is that just as we are poised to declare victory, we may be losing focus and commitment could suffer a major setback.”

  9. Lancet 2006, 368: 1810-27

  10. Population and Development, Fertility and Family Planning Research at the World Bank

  11. World Bank Projection Series 1983, 1988, 1990 • World Bank projection • of future fertility, unlike • those of UN, based on • crossnational analysis • of fertility determinants. • Onset of transition • timed to life expectancy • reaching 50 years Source: NAS, Beyond Six Billion

  12. 1977 Projected Population (000s) of the World in 2000: US Census Bureau, World Bank and United Nations World Bank 1977 projections by KC Zachariah, MT Vu, E Bos

  13. Equity in Contraceptive Prevalence over Time:Bangladesh 1997-2004 and Kenya 1993-2003 Source: Gwatkin et al., 2007 Concentration Index Change: BG -0.03 to -0.06; KY -0.18 to-0.21

  14. General Fertility = 222.28 – 3.05 (CPR mw ) + 0.012 (CPR mw)2 Rate Total Fertility = 7.20 – 0.10 (CPR mw) + 0.00041 (CPR mw)2 Rate

  15. WHO Models for Estimating % of Female Deaths That Are Maternal and Maternal Mortality Ratios

  16. A New Approach for Estimating Abortion Rates • Charles Westoff, DHS Analytical Studies 13, 2008 • Total Abortion Rate (TAR) = 4.09 – 0.037 (Modern CPR) – 0.386 (Total Fertility Rate) N = 67 R=0.88

  17. With This Set of Non-Simultaneous Equations • Can estimate GFR with change in CPR • Can estimate change in number of maternal deaths with CPR-induced change in GFR • Can estimate change in Total Abortion Rate with change in modern CPR and TFR • 7 country examples assume 1.5% point change per annum between 2009 and 2015 (MDG achievement year)

  18. Averted Maternal Deaths and Reduced Total Abortion Rate with Increased Total and Modern Contraceptive Prevalence TAR=Average number of abortions per woman 15-49 if exposed to current age-specific abortion rates throughout reproductive lifetime. CPR change assumes +1.5% points per year for 6 years to 2015

  19. 30 Years of Population and Development Paradigms (Global Belief Systems) • Mid 1970s • Family planning  Fertility  Population growth  Economic development • Mid 1980s • Population growth as a neutral factor • Mid 1990s • Women and reproductive health • Mid 1990s Millenium Development Goals • Poverty reduction and equity

  20. The Fertility Transition and Income Levels Low Income Middle Income High Income Environmental Control Lactational Control Individual Control Societal Control Actual Fertility Source: W. Robinson, , Economic Development and Population Control, 1983

  21. Educated Women Marry Later in All Regions (Percentage Women Ages 20-24 Never Married by Age 18, by Years of Schooling and Region) Source: National Research Council and Institute of Medicine (2005). Growing Up Global: The Changing Transitions to Adulthood in Developing Countries. Panel on Transitions to Adulthood in Developing Countries.

  22. Pakistanis More Educated but Women Lag Behind Population Age Education Pyramid (10+) 1991 2006 Sources: PDHS 1991 & PDHS 2007, NIPS

  23. Working memories of children raised in poverty have smaller capacities than those of middle-class children Stress affects neural development

  24. Ghana’s Fertility Transition and FP Reversal: 1988-2008 TFR declined from 6.4 to 4.0 Contraceptive prevalence rose from 13 to 25% between 1998-2003 and then “dropped” to 24% in 2008 Modern CPR dropped from 19 to 17% between 2003 and 2008 Marginal use of LTMs Suggests increased use of induced abortion

  25. Ghana’s Improved MCH Indicators: 1988-2008 U5MR declined from 155 in 1988 to 80 in 2008 IMR declined from 77 to 50 over same period Improvements observed in antenatal care by trained professional, receipt of 1+ maternal tetanus toxoid injection and medically assisted delivery

  26. Countries with Unlaunched or Stalled Fertility Transitions Zambia 1992-2002 Francophone African countries Kenya 1975-2003 Egypt, Tanzania, Bangladesh

  27. Unit Costs of Key Development Interventions Source: Achieving the Millenium Development Goals, Futures Group International

  28. Possible Responses Cited: Ongoing Efforts • Form synergistic alliances • No FP equivalent to GFATM, IAVI, GAVI • Making The Case • Reposition the message • FP as an essential investment toward achieving the MDGs • Improve contraceptive service delivery • Contraceptive security coalition • Information and counseling, counseling, counseling

  29. Possible Responses Cited: Ongoing Efforts-2 • Develop new leadership to encourage developing countries to take responsibility • In “owning” family planning • For budgeting and acquiring contraceptive supplies • To raise visibility and priority of FP as a pre-conceptional health intervention that improves child and maternal health and economic and gender equity

  30. November 15-18, 2009 International Family Planning Conference, Ugandawww.fpconference2009.orgThank you

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