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.
by Jay Gribble, vice president, International Programs
It’s especially interesting to have a reproductive health advocate and activist offer keynote comments at a meeting of researchers, mainly economists who have a high standard of evidence. Yet Professor Fred Sai, an extraordinary man whose international experience spans decades, offered his insights into the movement of reproductive health transitions on a global scale and within sub-Saharan Africa. And drawing on a combination of his observations and experiences, Professor Sai made the case to the audience of economic demographers that an understanding of the policy environment is critical to the development of evidence-based policies. Given that one of the key reasons for the creation of the PopPov network is to support an evidence base to better understand the relationship between reproductive health, population growth, and economic development, Professor Sai’s message helped set the tone for the 6th annual PopPov network conference and reinforced the importance of strong evidence that can be explained to policymakers.
One of Sai’s observations was related to the use of family planning in the continent. In Eastern and Southern Africa, about 40 percent of married women use modern family planning; in contrast, use in West Africa is much lower—in Ghana, one of the regional leaders in family planning, fewer than 20 percent of women use modern family planning; in other countries, such as Mali, only about 4 percent of married women use family planning.
Fred Sai speaking at the 6th Annual PopPov Network Conference in Accra, Ghana. Photo: PRB.
In spite of low prevalence, many leaders and advocates argue that family planning is a woman’s right—a point that most people take for granted and about which few would argue. Although the language of human rights is used, Professor Sai made a point that is vital to understanding what having a right really means. “A right is not a right if the citizenry is unaware nor can they be fulfilled without government provision to the people.” Professor Sai makes a keen distinction that separates the language that many policymakers use and the reality of millions of women and couples around the world. If people don’t know about family planning, then how can they be expected to exercise their right to decide on the timing and spacing of having children? Similarly, if governments do not work to make family planning information and services available to the public, than it is complicit in not holding up the rights of their citizen. Without both knowledge of and access to family planning, the rights of millions of women and men cannot be achieved.
So, you’ve spent the past couple of years narrowing down your research question, developing your research model, collecting and analyzing data, conducting field work, and writing. Now your paper, with some major findings that can have a big impact on policy, is about to be published. Now what? How do you reach policymakers with your research? How can you affect change? These are fundamental questions being addressed by the PopPov network’s annual conference. The Honorable Joy Phumaphi, former minister of health of Botswana and vice president at the World Bank, focused her discussion on what to do and what not to do when approaching policymakers to be effective in her commentary on the close of the third day of the conference.
“You have to communicate in the same way they are thinking,” she said. Above all, policymakers, especially in low-income countries, are concerned with economic growth. In her experience, Phumaphi explained, they don’t see population growth as a major concern. In fact, since they want a larger market size to develop their economies, population growth can actually be beneficial. So framing the need for family planning services by connecting it population will not address their concerns. “You need to highlight benefits that address policymakers’ concerns, not your concerns,” said Phumaphi.
She gave a couple of examples from her own career.
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:
This week, a bunch of us from PRB are in Accra, Ghana for the 6th Annual Research Conference on Population, Reproductive Health, and Economic Development as part of the PopPov Research Network. The Population and Poverty Research Network (PopPov) was created in 2005, when the William and Flora Hewlett Foundation formed partnerships with funding agencies and program implementers, bringing together researchers from leading higher education institutions worldwide. PopPov’s goal is to provide clear evidence that investing in reproductive health can provide economic benefits at both the household and country level, and how to reach policymakers and donors with these messages. This week, conference participants will present their ongoing and completed research on population, reproductive health, and economic development; identify gaps in evidence and methods that inhibit the development of sound policies on population and economic development; and discuss examples of the influence of research on policies and how to communicate research findings to policymakers.
We’re honored to be co-hosting the conference with the University of Ghana. Fred Sai, Former Presidential Advisor on Reproductive Health and HIV/AIDS, will give the keynote address tomorrow. I’m excited to hear his perspective on the progress and challenges since the International Conference on Population and Development (the “Cairo conference”) in 1994. (Dr. Sai was the chair of the conference’s Main Committee.) Since then, the focus of global family planning efforts has shifted to women’s rights and empowerment, for women to be able to decide the family size they desire and have control over their fertility. Donor funding and programming for family planning is increasing, but the links to economic development is not as clear. And with many other public health and development issues competing for donor and policy attention, strong evidence is needed. I expect Dr. Sai, and the conference in general, to discuss many of these issues.
Throughout the week, I’ll be blogging from Accra and interviewing researchers on various population and economic issues and their implications for public policy. Stay tuned for more posts from Accra and quite a few videos on the PRB site over the coming weeks. Want to learn more about the conference? Visit the PopPov website for the agenda, conference paper abstracts, and more.
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.)
by Jay Gribble, vice president, International Programs
ICFP 2011 has ended and now we are heading on to our next destination, some back home, some to conferences in Ougadougou and Durbin, and others on to places to continue their work. But as I think back on the past few days, I am struck by how complex our field is. I think the conference did a great job not only of drawing out the range of issues that fall within this expanding field of family planning and reproductive health, but also in showcasing some of the most interesting research and programmatic experiences to help us understand how the field is advancing.
One of the conference topics that caught my attention was contraceptive security. In Uganda, I hardly remember a session addressing these issues, but in Dakar, I saw several sessions that focused on innovative financing approaches, the total market approach, social franchising models for family planning, and tracking funding for family planning. The fact that this topic is so visible at ICFP 2011 is encouraging and reflects the great work that groups such as the Reproductive Health Supplies Coalition and others are making on focusing attention on the fact that commodities don’t just magically appear in facilities. Their being there is the result of in-country and international donor policies, forecasting and supply chain processes that work, and funding available to pay for supplies, not to mention the trained personnel who counsel clients and provide services.
Journalists and Ministry of Health officials may not seem to be the most likely partners, but based on the experience of a high-level government official and a long-time journalist in Senegal, there are mutual benefits to working together for the sake of reproductive health. PRB paneled one of the most interesting sessions I’ve attended yet at ICFP yesterday afternoon as Dr. Bocar Mamadou Daff, Director of the Reproductive Health Department in Senegal’s Ministry of Health and El Bachir Sow, news coordinator for Sengal’s newspaper Le Soleil joined a panel of three other local journalists to share their story of how they learned to trust each other and rely on each other’s work. Both shared their story from their personal perspective, explaining what drove them to work with the other in the first place and the obstacles and benefits along the way.
Dr. Bocar Mamadou Daff and El Bachir Sow, third from right and second from right, respectively. Photo: PRB.
It all started, according to Dr. Daff, with a media story years ago by a journalist after a field visit to a family planning clinic. A national-level official angrily asked Daff why the story was published and how the journalist could have received such information. People say a journalist can never be a friend, said Daff, but he realized that he and family planning programs could gain more than lose with journalists on their side. He got to know journalists personally and they were able to build mutual trust. He came to realize they share the same objectives: fostering discussion and making sure people are properly informed. Complex subjects that were taboo, such as youth and family planning, post-abortion care, and rape and incest, were now being discussed openly, thanks to more stories on family planning in the media. Now, colleagues and fellow ministers eagerly share and discuss stories with Daff after they’re published, gathering around newspapers in the office, a far cry from the previous suspicion and mistrust.
El Bachir Sow’s story was of a journalist’s struggle to get Daff to trust him. He listed three components to becoming a successful journalist: trust, commitment, and professionalism. To commit, you need to make persistent efforts to meet with experts and advocates in person. Trust is paramount: “We (journalists) want information, they have information.” In order to get over their suspicion of the story distorting the issue, they must trust you. How does a journalist build trust?
by Jay Gribble, vice president, International Programs
Given the sustained attention to the HIV/AIDS pandemic, one could wonder why it is necessary for family planning to share the stage at ICFP 2011 with the issues of HIV/AIDS. Yet given how family planning, reproductive health, and HIV/AIDS are intrinsically linked, the ICFP 2011 is taking advantage of the opportunity to talk about the need for comprehensive sexual and reproductive health—a topic that is broader than the more focused issue of family planning. And given the recent research finding that use of injectable contraception may increase the risk of HIV infection, the relationship between these two issues has received increased attention. So it is both appropriate and responsible to turn attention to the links between FP and HIV. And as the Honorable Stephen O’Brien observed, the commonalities between efforts to address women’s and men’s FP/RH and HIV needs further reinforce the importance of considering these two issues jointly :
Both require a comprehensive approach that responds to the need for high-quality information, services, and supplies that allow women and men to make informed choices about their sexual and reproductive lives.
There is a need to expand integrated services so that people can address their needs for sexual and reproductive health needs together with those related to HIV/AIDS prevention and treatment.
Programs that respond to the reproductive health and HIV need to be tailored to the needs of vulnerable populations—youth, sex workers, the poor, men, men who have sex with men—among others.
by Kate Gilles, policy analyst, International Programs
These are a few of the sessions offered over the past two days at the International Family Planning Conference in Dakar. Listening to colleagues across the globe describe their work to engage men in family planning and reproductive health makes it clear that over 15 years after the call to action to engage men in family planning was issued at the Cairo conference, male involvement remains a critical strategy. At multiple sessions and panels, participants discussed strategies, benefits, and challenges to engaging men in family planning in positive, constructive ways.
Based on years of research, we know that contraceptive uptake and continuation improve when men are involved. As presenters reiterated throughout Wednesday and Thursday, men who are aware of family planning and have accurate information about contraceptive methods are more likely to support family planning use generally and within their own family. They are also more likely to talk to their wives about family planning, and couples’ communication is an important influence on contraceptive use. Finally, constructive male engagement can improve men’s gender-equitable norms.
