Growing Health Families Pregnancy Timing and Spacing Lessons from Developing Countries for Your Corner of the World Sara

1. Growing Health Families Pregnancy Timing and Spacing Lessons from Developing Countries for Your Corner of the World Sara Davis, MPH Lisa Firth, MB, MPH The Salvation Army World Service Office

2. The Salvation Army World Service Office Doing The Most Good, Globally SAWSO Based at US NHQ in Alexandria, Virginia, near Washington Founded 1977 Lt. Cols. William and Debra Mockabee National Secretary and Assistant National Secretary Link between US donors - TSA, government & foundations Program, Finance and Development departments, 18 people 3 Technical Advisors Empowerment & Livelihoods Health HIV/AIDS

3. The Salvation Army World Service Office Doing The Most Good, Globally SAWSO Mission To support and strengthen The Salvation Army’s efforts to work hand-in-hand with communities to improve the health, economic, and spiritual conditions of the poor throughout the world

4. The Salvation Army World Service Office Doing The Most Good, Globally SAWSO Vision Create a world where people live in safe and sustainable communities in which differences are respected, basic needs are met, and all enjoy opportunities to learn, work, and worship in freedom

5. The Salvation Army World Service Office Doing The Most Good, Globally SAWSO Purpose Promote the mission of The Salvation Army

6. Your turn…. • International delegates • US delegates • Western • Central • Southern • Eastern • Health professionals • Social workers • Others

7. I hope you’ll mention… [one thing you’d like to learn or discuss during this session]

8. Pregnancy Timing & Spacing Timing: When a pregnancy occurs Spacing: Time between pregnancies or births Both depend on social and biological factors

9. Other Terms Some terms can be emotive or contentious Reproductive health ≠ abortion Birth control Contraception Family planning What can you talk about?

10. What is Family Planning? “Enabling couples to determine the number and timing of pregnancy, including the voluntary use of methods for preventing pregnancy, not including abortion, that are harmonious with their values and religious beliefs.” Christian Connections for International Health

11. Family planning can… • Prevent unintended pregnancies • Prevent induced abortions • Save lives • Promote the health of mothers and children • Allow parents to care for their children well • Increase women’s freedom to contribute to the health and welfare of their families • Henry Mosley, MD, Johns Hopkins Bloomberg School of Public Health

12. Unmet Need 222 million women in the developing world have an unmet need for family planning* Because Their family is complete, or They want to delay pregnancy, but They are not using modern contraception * 2008 Demographic & health surveys

13. Level of Unmet Need • Percentage of women with unmet FP need • 27.1% in Africa (exceeds current use) • 10.1% in Central Asia • 16.4% in South and SE Asia • 15.7% in Latin America/Caribbean

14. News from Burkina Faso “One third of pregnancies in Burkina Faso are unintended and a third of them end in abortion” “Abortion is illegal in most circumstances” IRIN (UN News Service) 24 March 2014

15. Maternal Mortality • = death of a woman that is related to pregnancy • Causes • Haemorrhage • Obstructed labour • Eclampsia • Abortion (miscarriage) • Infection • Other LACK OF FAMILY PLANNING

16. Worldwide Each Year 208 million pregnancies 123 million intended 85 million unintended 31 million miscarriages/ stillbirths 123 million births 31 million unintended births 92 million wanted births 44 million induced abortions

17. Unsafe Induced Abortions WHO estimates that 49% of abortions are unsafe = 21.9 million unsafe abortions/year (97% unsafe in Sub-Saharan Africa) Although abortion rates are decreasing, annual number is increasing with population 47,000 maternal deaths/year from unsafe abortions + 10 x more complications

18. 85 Million Unintended Pregnancies • annually, resulting in • 44 million abortions • 47,000 maternal deaths • Unintended births • 110,000 maternal deaths • From unintended pregnancies • 157,000 maternal deaths • 46% of 342,000 maternal deaths worldwide

19. Addressing Unmet FP Need would avoid an estimated 54 million unintended pregnancies 26 million abortions preventing 104,000 maternal deaths annually - a 30% reduction in maternal deaths

20. Better Access to Family Planning • Abortion rates fall as the percentage of married women using contraception increases • regardless of whether abortion is legal • Charles Westoff, PhD, Princeton • In Bangladesh, as uptake of family planning increased, the birthrate and maternal deaths decreased • Henry Mosley, MD, JHU

21. Better Access to Family Planning • Improving access to family planning could reduce maternal mortality by 60% Lancet, 2013 • Adolescent Pregnancy • in Europe (Denmark & NL) and the US • Same rates of teen sexual activity • 10 x pregnancy rates in the US

22. Child Health • Influenced by pregnancy timing & spacing: • Women too immature for childbearing • Births too closely spaced • Inadequate care of children • High fertility and child death rate linked

23. Child Health • Underlying influences • Early marriage and childbearing • Short birth intervals • <2 years • Many sequential births deplete mother • 3 years is ideal • S Rutstein et al, 2005

24. Child Survival Short birth intervals increase neonatal & infant mortality and child malnutrition 8 million children died before age 5 years in 2005 2 year intervals could have saved 2 million 3 year intervals could have saved 3 million

25. What about my people? (How) does this apply to them? Are they healthy & well nourished? Do they understand how their bodies work? Are they empowered to make decisions? Do they have misconceptions or taboos? Do they have access to health services?

26. TSA, SAWSO & Family Planning • Previously: • Small-scale family planning activities, usually in conjunction with health (MCH, child health, HIV) or microfinance projects • No TSA consensus on what is or how to do family planning • SAWSO received US government funding for a TSA-wide initiative to harmonize understanding of and approach to family planning

27. International FP Workshop • SAWSO held a family planning workshop facilitated by Dr. Douglas Huber in London, England, June 13-15, 2012. • Attended by 19 representatives of Salvation Army • implementing (developing country) territories • development offices • International Headquarters (IHQ)

28. Workshop Results • Participants: • Shared their experiences with and understanding of family planning • Gained state-of-the-art family planning knowledge • Reflected on culture, faith and the theological grounding for family planning • Proposed minimum standards to be included in a discussion paper to guide TSA internationally • Agreed to development of a family planning program manual

29. Zambia Family Planning Pilot

30. Zambia Family Planning Pilot • Three-day workshop for 18 Salvation Army officers (8 men, 10 women) from ten different localities to equip them to: • Take information on family planning to their communities • Offer selected methods • Refer clients to the healthcare professionals for additional FP services Family planning training is part of a pilot program that can be adopted by other Salvation Army countries in the future.

31. Zambia Family Planning Pilot • A family planning expert & SAWSO developed • a training agenda • a trainer’s manual • a participants handbook • to be revised with feedback from the pilot training and users Lesson plans were based on the GoZ’s Ministry of Community Development and Maternal and Child Health (MCDMCH) resources for community workers. They use the WHO flipchart, A Guide to Family Planning for Community Health Workers and Their Clients.

32. Zambia Family Planning Pilot

33. Zambia Family Planning Pilot

34. Zambia Family Planning Pilot Training Practicing a Session for Male Youth

35. Zambia Family Planning Pilot Training The Major Meets the Method

36. Should we discuss methods? (Later in this session)

37. Next Steps for Zambia • Train TSA officers, soldiers and community volunteers to share information on FP and make referrals in accordance to MCDMCH procedures • Train community volunteers as community-based distributors(CBDs) of FP methods, according to MCDMCH standards • Finalize the monitoring system for TSA Zambia to document their FP work and success • Establish the supply chain with MCDMCH for CBDs to distribute condoms and pills (plus injectables, if the GoZapproves them for CBDs)

38. From Zambia’s Training

39. Facilitating Family Planning • To plan for childbearing, couples must: • Talk about sexual matters, desired family size, etc. • Understand and accept their options • Have access to services that are • Nearby, consistent • Affordable • High quality

40. Salvation Army Health Ministry Vision Statement The Salvation Army seeks to be a significant participant in faith-based, integrated, quality primary health care, as close to the family as possible, giving priority to poor and marginalised members of society. WE CAN DO THIS!

41. Your questions for us…

42. Our Questions for You • Is there unmet need for family planning in your corner of the world? • How might you address it? • Is it difficult to talk about family planning? • (Personally or culturally) • What should we (The Salvation Army) be doing related to pregnancy timing, child spacing and family planning?

43. Report Back Thank you! Sara_Davis@USN.SalvationArmy.org Lisa_Firth@USN.SalvationArmy.org

44. Methods References CONTRACEPTIVE EVIDENCE Questions and Answers www.prb.orgPopulation Reference Bureau FAMILY PLANNING: A Global Handbook for Providers www.who.intWorld Health Organisation