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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 l.jpg

A Visible Agenda for Family Planning

AMY O. TSUI

GATES INSTITUTE

JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH

MAY 6, 2009


Outline l.jpg
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


Dilemma of past success insiders view on the future of the international family planning movement l.jpg
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


The changing visibility of family planning l.jpg
The Changing Visibility of Family Planning the International Family Planning Movement

  • 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.”


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Factors in the Loss of Visibility the International Family Planning Movement

  • Loss of a sense of urgency

  • Competing health and development priorities

  • Rising political conservatism

  • Lack of leadership


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Possible Responses Cited the International Family Planning Movement

  • Form synergistic alliances

  • Reposition the message

  • Improve contraceptive service delivery

  • Develop new leadership to encourage developing countries to take responsibility


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Christian Science Monitor, January 26, 2009 the International Family Planning Movement


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The Future of the Family Planning Movement? the International 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.”


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Lancet 2006, 368: 1810-27 the International Family Planning Movement



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World Bank Projection Series 1983, 1988, 1990 Research at the World Bank

  • 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


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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


Equity in contraceptive prevalence over time bangladesh 1997 2004 and kenya 1993 2003 l.jpg
Equity in Contraceptive Prevalence over Time: Census Bureau, World Bank and United NationsBangladesh 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


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General Census Bureau, World Bank and United Nations

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


Who models for estimating of female deaths that are maternal and maternal mortality ratios l.jpg
WHO Models for Estimating % of Female Deaths Census Bureau, World Bank and United NationsThat Are Maternal and Maternal Mortality Ratios


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A New Approach for Estimating Abortion Rates Census Bureau, World Bank and United Nations

  • 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


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With This Set of Non-Simultaneous Equations Census Bureau, World Bank and United Nations

  • 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)


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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


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30 Years of Population and Increased Total and Modern Contraceptive PrevalenceDevelopment 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


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The Fertility Transition and Income Levels Increased Total and Modern Contraceptive Prevalence

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


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Educated Women Marry Later in All Regions Increased Total and Modern Contraceptive Prevalence(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.


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Pakistanis More Educated but Women Lag Behind Increased Total and Modern Contraceptive Prevalence

Population Age Education Pyramid (10+)

1991 2006

Sources: PDHS 1991 & PDHS 2007, NIPS


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Working memories of children raised in poverty have smaller capacities than those of middle-class children

Stress affects neural development


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Ghana’s Fertility Transition and capacities than those of middle-class childrenFP 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


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Ghana’s Improved MCH Indicators: 1988-2008 capacities than those of middle-class children

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


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Countries with Unlaunched or capacities than those of middle-class childrenStalled Fertility Transitions

Zambia 1992-2002

Francophone African countries

Kenya 1975-2003

Egypt, Tanzania, Bangladesh


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Unit Costs of Key Development Interventions capacities than those of middle-class children

Source: Achieving the Millenium Development Goals, Futures Group International


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Possible Responses Cited: Ongoing Efforts capacities than those of middle-class children

  • 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


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Possible Responses Cited: Ongoing Efforts-2 capacities than those of middle-class children

  • 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


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November 15-18, 2009 capacities than those of middle-class childrenInternational Family Planning Conference, Ugandawww.fpconference2009.orgThank you