Secretary of State Hillary Clinton hosted the first-ever event at the State Department to commemorate Zero Tolerance to Female Genital Mutilation/Cutting (FGM/C) Day on Feb. 16. Guest speakers and a panel of experts included Congressman Joseph Crowley (who has co-sponsored the “Girls Protection Act of 2011” that would make it a crime to transport girls overseas for FGM/C), and representatives from NGOs, Islamic organizations, and the UN who have worked on ending FGM/C.

State Department photo by Michael Gross.

At the Fourth World Conference on Women in Beijing in 1995, Clinton, then-U.S. First Lady, proclaimed that FGM/C is a violation of human rights. Human rights are women’s rights, and that women’s rights are human rights, she said. Since then, there has been significant global progress in the movement to stop this harmful practice that has affected between 100 million to 140 million girls worldwide, with negative physical and mental health effects. Much more attention is being paid to the harmful effects and the magnitude of the practice, from the international level down to small villages. To date, 18 African countries have outlawed the practice of FGM/C.

Clinton recalled visiting a village in Senegal in 1997 and seeing how progress can be made firsthand. The village elders had been thinking of the detrimental health and quality of life effects of FGM/C on their daughters and they decided the practice had to end, despite generations of tradition. Tostan worked with the community to put the emphasis of this social change on democracy and ensuring participation. Imams explicitly argued that there was no religious basis for FGM/C. The key, according to Clinton, was that there was no finger pointing; no one came from the outside to enforce a change of tradition. PRB’s Women’s Edition journalists learned the same lessons in their field visit to two villages in Senegal where  Tostan has worked to further education and knowledge about democracy and human rights. This visit, during the recent International Conference on Family Planning, highlighted the gains that have been made in the empowerment of girls, the end of harmful traditional practices, and economic advances throughout the villages (see the slideshow below).

“Let’s be clear,” Clinton said. “This is a deeply entrenched practice. We need to be unrelenting and understand what works.” She said that it is important to approach the work to end FGM/C with humility. Honest and direct conversation with those with first-hand experience with this issue makes all the difference. To those who would argue that local customs should be respected, Clinton argued that many cultural practices that used to be common are now seen as inexcusable. “[FGM/C] is plain and simple a human rights violation.”

But what approaches work best? In the panel discussion, it became clear from four key points:

• Engagement: In Senegalese villages that have ended FGM/C, the change came from the community itself, not from the outside. Working with religious leaders such as Imams has been instrumental in making people understand the harmful nature of the practice since they are trusted within the community.
• Dialogue: Changing tradition and social norms requires dialogue with parents, children, and community and religious leaders.
• A nonaccusatory and nonconfrontational tone. According to panelist Molly Melching, executive director of Tostan , certain phrases and words close dialogue and others open the path to dialogue. The approach and humility taken when working with communities makes all the difference, she said.
• A willingness to look from others’ perspective. In her closing remarks, UNICEF deputy director Geeta Rao Gupta said that we need to look from other perspectives in order to bring about change. For example, 20 years ago, there was little acknowledgement of FGM/C as a human rights violation; now, it is common knowledge.

When one of the panelists described  the progress being made in Iraq to abandon FGM/C in six villages, we were reminded that this isn’t just an African issue (nor is it just a Muslim issue). To learn more about the scale of FGM/C worldwide, in Africa and other regions, check out PRB’s Data Sheet on FGM/C.

Natural decrease improves in Russia. Russia continued its recovery in 2011 from its dramatic natural decrease (births minus deaths) of past years, but not from a rising birth rate. Natural decrease in 2011, just reported by the national statistics office GOSKOMSTAT, fell further to -131,208 in 2011 from -241,340 in 2010. It had reached  an eye-popping low point of -958,532 in 2000. But births in 2011 were basically the same as in 2010, 1,793,828 vs. 1,789,623. It was the decline in deaths from 2,030,963 in 2010 to 1,925,036 in 2011 that resulted in a rosier natural decrease. Interesting development.

That’s a lot of marriages in one day. The day one gets married in India depends upon astrology. Marriages are heavily concentrated during a propitious day or days. But I recently learned that back on Nov. 28, 2011, there were 60,000 marriages in Delhi (The Indian Express, Nov. 27, 2011). I have been there when there were about 18,000, but 60,000 is truly phenomenal. Hindu and Sikh wedding ceremonies take place over a period of days and are lavish affairs requiring a tent venue for the groom to prepare and some type of wedding hall. That’s in addition to white horses, brass bands, and fireworks for the baarat when the groom processes to the wedding venue with his family. Wish I’d been there!

And, yes, a bit more about Taiwan. Taiwan, which recorded the lowest 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) in recent world history, if not in all history, at 0.9 children per woman during 2010, the unlucky year of the Tiger. In 2011, the Rabbit year, births jumped to 196,627 from 166,886 in 2010. While the Rabbit year is not particularly auspicious, it seems some couples waited until the Tiger Year had ended to have a child.  The Dragon year began on January 23, 2012 and is a very auspicious year. That will be followed by the Snake year, which is not particularly auspicious for births. So, are we are likely to see a bit of a “baby boom,” but only for a while? The Taiwanese government is very worried about the population aging consequences of such a low birth rate.

Census news. Canada has reported the early results of its May 10, 2011 census: 33,476,688. Population growth was larger from the 2006 to 2011 censuses in western provinces and territories, such as Yukon (11.7 percent) and Alberta (10.8 percent). Nova Scotia has the slowest growth, an increase of only 0.9 percent in the period. Nationally, the country’s census counts increased by 5.9 percent between the censuses, the highest rate among the G8 countries. According to Statistics Canada, the count was about 1 million less than the population previously estimated for July 1, 2011. Following studies of both undercount and overcount, Statistics Canada suggests the higher precensal estimate continue to be used Canada will then base new population estimates on the results. In 2001, the net undercount was 2.99 percent and, in 2006, it was 2.67 percent. The improvement in 2006 was due to an increase in overcounting which more than offset the increase in undercounting. The 2011 undercount study is scheduled for release in March 2013.

Pop quiz: Where are the fewest mobile phone subscribers per capita in the world? If you answered sub-Saharan Africa and parts of South and Southeast Asia, congratulations. Judging from available data, despite a lot of media coverage on the growth of mobile technology in developing countries, the lowest-income countries have some catching up to do. The global disparity in who owns and uses mobile phones is enormous, ranging with a rate of just one mobile phone subscriber per 100 people in Myanmar to 209 per 100 in the United Arab Emirates.  The map below from PRB’s DataFinder conveys this variation. The darker the shading, the higher the ratio of mobile phone subscribers. Incidentally, it’s interesting to note that the United States, at 87 subscribers per 100 people, is tied with Japan but lags far behind countries such as El Salvador (113), Italy (152), and Estonia (188).

However, there’s another side to the story.

Slate posted the map below (click through for the full interactive version on Slate’s website) based on data from The World Telecommunications/ICT database. The darker the shading, the higher the ratio of mobile phone users to fixed-line subscriptions. Notice anything remarkable between the map above and the map below? They’re essentially inverse versions of each other. The countries with the lowest mobile phone subscribers per capita (as shown in the map above) are also the countries with the highest ratio of mobile-to-fixed line subscribers. For example, Italy with a high mobile phone subscriber rate has a low ratio of 4.2 mobile phone subscribers for each fixed line. Estonia, with an even higher rate of mobile phone subscribers has a lower ratio at  3.4. But in some countries, the ratio tops 200-to-1. For example, in the Democratic Republic of Congo, there are over 280 mobile phone subscribers to each fixed-line connection. This shouldn’t be too surprising as countries with smaller proportions of mobile phone users tend to be poor and lack telecommunications infrastructure. However, it is striking how much the two maps correlate.  It also clearly shows the “leapfrogging” that is happening in the poorest countries and communities as people gain access to digital communications via mobile phones, bypassing the need for land lines for phones and computers to access the internet.

Image credit: Slate.com

On a related note, another recent article argues that mobile phone technology may not be the panacea for poverty that many in the development community and in the media have been trumpeting about the past few years.  Yes, more people are able to access banking services, sell their goods to wider markets, and engage with the outside world in ways that weren’t possible before. But, as is so often is the case with development, the poorest of the poor are left out. By examining the case of M-PESA, Kenya’s rapidly expanding mobile-phone-based money transfer system, the article argues that the problem is two-fold: Telecommunications companies don’t build infrastructure in the poorest communities (since they have no incentive to do so) and the service has a prohibitively high transaction fee for the poorest populations. About 60 percent of the poorest quartile doesn’t use the service. This also gets to the question of relying on the private sector for infrastructure needs as opposed to a government taking the lead. When we look at data on growing mobile phone usage, we have to remember the disparities both between and within countries and dig deeper to find out who are gaining access to mobile phones and who are still left out.

In Guinea, a woman receives training in problem-solving skills as part of USAID-supported efforts to encourage communities to abandon female genital mutilation. Photo Credit: Elizabeth Fakan, USAID

by Sandra Jordan, Communication and Outreach Advisor, USAID Bureau for Global Health

Today is the International Day of Zero Tolerance for Female Genital Mutilation and Cutting (FGM/C). Worldwide, 100 to 145 million women have been subjected to this practice, which can range from nicking the skin to a total removal of the external female genitalia. Every day, 6,000 girls are at risk.

Zero Tolerance Day is an opportunity to raise awareness about the harmful effects of FGM/C and unite communities around the world in calling for an end to the practice. FGM/C is practiced across cultures and religions—though notably, major religious doctrines do not mandate the practice. It is most common in Africa, the Middle East, and some countries in Asia. However, it also can be found in the United States, Europe, and other places where migrants bring their cultural traditions with them. Parents and communities practice FGM/C based on cultural beliefs about health, hygiene, and women’s sexuality. In many cases, it is considered a traditional rite of passage.

However, research has consistently shown that all forms of the practice harm women’s health. It causes serious pain, trauma, and frequently severe physical complications such as bleeding, infections, or even death. In the long term, it can also lead to recurrent infections, infertility, and difficult or dangerous childbirth that threatens the lives of both mother and infant.

Read the rest of this post at USAID’s IMPACT blog.

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.

Read the rest of this post at USAID’s IMPACT blog.

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.

Professor Sai, in linking reproductive health and economic development, also highlighted the need to be attentive to the needs of youth. Child marriage, access to education, and child labor all impede national development because they inhibit young people from achieving their potential. Data suggest that fewer girls are forced into early marriage than before and that more girls are going to school and moving into secondary education. While there is some positive movement in improving opportunities for young people, there is also the critical link to job creation so that the better-educated youth have actually take advantage of their skills. To achieve the demographic dividend, it is not sufficient just to change a country’s age structure through reducing fertility. There are other conditions to be fulfilled—those conditions that are the focus of the PopPov network’s research.

As a global leader in reproductive health, Professor Sai has contributed to positive changes of the past 40 years. His insights set the stage for the annual PopPov research meeting, talking about the policies that are needed and the importance of useful, relevant evidence that can be used to increase political support for family planning and reproductive health among African leaders.

by Eric Zuehlke, web communications manager

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.

When she was a principal auditor in Botswana, there was plenty of evidence that showed bringing reproductive health services to women will assist them in limiting family size, space their pregnancies, delay their first pregnancy, etc. So how did she and her colleagues communicate to policymakers, community leaders, and women to effectively expand reproductive health services? They didn’t focus on the benefits in terms of smaller family size. The focus was on the economic benefits. “We said when you bring these services closer to women, women will have more time to work on their farms, to looks after their children, reduce absenteeism in school, and increase household income. That sold the policy. Village chiefs were happy that women will now have more time to plow fields.”

Phumaphi further explained that in Botswana the benefits of family planning were communicated to policymakers by saying we a developing country, we need a skilled workforce, we need to educate every single Botswanan to develop as a country. “That’s how women became educated. It wasn’t an argument that we want to control our population and educate women so that they have less children. The argument was bringing women in as equal partners in national economic development. This led naturally to fewer children.”

“Communication is important. The concerns we have in Africa are concerns that can be addressed through the research we are doing,” Phumpari said. How to bring policymakers on board requires a specific communication strategy. The research agenda doesn’t need to change in order to be effective. The evidence is there. And the end results of communicating research in terms of policy change can be the same. It’s a matter of seeing through policymakers’ eyes and perspective and gauging which benefits will resonate most to them, politically and economically. To those of us working in public health and international development, the health or wellbeing benefits may be evidence enough to invest in family planning and reproductive health; to policymakers working with political and resource constraints, this may not be enough.

by Eric Zuehlke, web communications manager

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:

One of the most interesting aspects to the program was how much success differed depending on whether the community had only nurses, only volunteers, or a combination of both. It turns out that communities that used both volunteers and nurses had much higher rates of contraceptive use and fertility decline and better health outcomes than communities that relied on only nurses or volunteers. According to Binka, volunteers were mostly male and were able to communicate with husbands about family planning. Male involvement was crucial in increasing contraceptive use and increasing family planning use. Nurses, on the other hand, were instrumental in lowering mortality rates, as people began to seek out nurses and rely on them for professional health care.

Another unique aspect to the project was that health centers were built after services were already being delivered and behaviors had changed, not before. The physical building was seen as a “reward” as opposed to a prerequisite to health change. The focus remained on the community, its needs, and use of services as opposed to buildings.

The involvement of the community at all levels was instrumental to its success. From the beginning of the project, dialogue with the community was used not only to get buy-in from residents but also to learn from the community about everything from their health needs to how they constructed buildings to plan for their involvement in building future health centers. There’s been a mixture of success and challenges in scaling-up and replicating the model in other places, but as James Phillips of Columbia University said in response to a question regarding why the Matlab model in Bangladesh didn’t work in Ghana, the problem was that “there are very few Bangladeshis in Ghana.” In other words, local context means everything. Top-down models can’t simply be copied.

by Eric Zuehlke, web communications manager

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.)

The decline in infant and child mortality has been somewhat slower than observed in other sub-Saharan African surveys. The infant mortality rate in the five years before the 2011 DHS was 62 infant deaths below age 1 per 1,000 live births, down from 77 in the five to nine years before the survey and 80 in the 10 to 14 years before the survey, although the pace of decline has picked up. The decline in the child death rate, ages 1 to 4, was slower than for infant mortality, to 63 deaths per 1,000 five years before the survey from 64 five to nine years before the survey and 72 10 to 14 years before. The child death rate is somewhat unusual in that is quite close to the infant death rate, as was also observed in the Burkina Faso and Burundi surveys. More typically, it would be lower than the infant death rate.

Of children under age 5, 57.7 percent were stunted (height-for age) and 27.7 percent severely stunted (included in the 57.7 percent), quite high values for this measure; 28.8 percent were underweight (weight-for-age). Many mothers did follow the WHO recommendation of supplementing breastfeeding with solid/mushy food at the child’s six months of age. At 6 to 8 months of age, only 8.1 percent continued to breastfeed exclusively with 69.7 percent supplementing with solid food. By 9 to 11 months, 94 percent had supplemented. The proportion of young children receiving all required vaccinations was found to be quite high. Among children ages 12 to 23 months, 83 percent had received all child vaccinations although only 61.9 percent were able to produce a vaccination card. Proportions fully vaccinated were nearly equal across urban and rural areas.

Levels of prenatal care and delivery assistance from a skilled provider (doctor, nurse, midwife, or other health personnel) were quite good. Of births in the five years before the survey, 98.9 percent of women had prenatal care from a skilled provider. In addition, 60.3 percent had a skilled attendant at delivery and 59.5 percent of births were in some type of health facility. There were urban-rural differences among these measures. During delivery, 87.9 percent of urban women had a skilled attendant at birth and 86.3 percent of births were in a health facility. Comparable figures for rural women were 57.8 percent and 57.0 percent, respectively. Nonetheless, these are high proportions. Protection from neonatal tetanus was also quite high at 77.6 percent, more than double that in 1987.

All in all, the prospect for fertility decline seems rather doubtful, at least given the TFR trend of the past 24 years. Still, the trend in increasing contraceptive use, even if often interrupted, and very notable improvements in child health may signal a change in overall reproductive health trends in the future.