Showing posts from category family planning.
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Accessing Maternal Health Care Services in Urban Slums: What Do We Know?
›“Addressing the needs of urban areas is critical for achievement of maternal health goals,” said John Townsend, vice president of the Reproductive Health Program at the Population Council. “Just because there is a greater density of health services does not mean that there is greater access.”
Townsend moderated a discussion on the challenges to improving access to quality maternal health care in urban slums as part of the 2011 Maternal Health Dialogue Series with speakers Anthony Kolb, urban health advisor at USAID; Catherine Kyobutungi, director of health systems and challenges at the African Population Health Research Center; and Luc de Bernis, senior advisor on maternal health at the United Nations Population Fund (UNFPA). [Video Below]
Mapping Urban Poverty
“Poverty is becoming more of an urban phenomenon every day,” said Kolb. With over 75 percent of the poor in Central Asia and almost half of the poor in Africa and Asia residing in cities and towns by 2020, “urban populations are very important to improving maternal health,” he added.
Collecting accurate data in informal settings such as slums can be very challenging, and there is often a “systematic undercounting of the urban poor,” said Kolb. Data often fails to capture wealth inequality in urban settings, and there is often a lack of attention to the significant variability of conditions between slums.
Kolb also warned about the risk of generalization: “Slums and poverty are not the same.” In practice, there is not a standardized definition of what constitutes a slum across countries, he said. “It is important to look at different countries and cities individually and understand how inequality is different between them.” Slum mapping can help to scope out challenges, allocate resources appropriately, and identify vulnerability patterns that can inform intervention design and approach, he said.
Maternal Health in Nairobi Slums
Addressing the maternal health needs of the nearly 60 percent of urban residents who live in slums or slum-like conditions will be a critical step to improving maternal health indicators of a rapidly urbanizing Kenya, said Kyobtungi.
Only 7.5 percent of women in Kenyan slums had their first antenatal care visit during their first trimester of pregnancy and only 54 percent had more than three antenatal care visits in all – rates significantly lower than those among urban women in non-slum settings.
“In some respects, [the urban poor] are doing better than rural communities, but in other ways they are behind,” said Kyobtungi. But, she said, there are many unique opportunities to improve maternal health in slums: “With these very high densities, you do have advantages; with very small investments, you can reach many more people”
Output-based voucher schemes – in which women pay a small fee for a voucher that entitles them to free, high-quality antenatal care, delivery services, and family planning – have been implemented to help poor, urban women access otherwise expensive services. But poor attitudes towards health care workers, transportation barriers, and high rates of crime still prevent some women from taking advantage of these vouchers, said Kyobtungi.
The majority of maternal health services in slums are provided by the private facilities, though size and quality vary widely. “There is a very high use of skilled attendants at delivery, but the definition of skilled is questionable,” said Kyobtungi
“Without supporting the private sector,” Kyobutungi said, “we cannot address the maternal health challenges within these informal settlements.” Combined with an improved supervision and regulation system, providing private maternal health facilities with training, equipment, and infrastructure could help to improve the quality of services in urban slums, she concluded.
Reducing Health Inequalities
“While we have evidence that health services, on average, may be better in urban areas than in rural areas, this often masks wide disparity within the population,” said de Bernis. “Reducing health inequities between and within countries is a matter of social justice.”
When it comes to family planning, total fertility rates are lower in cities, but “the unmet need…is still extremely important in urban areas,” explained de Bernis. Many poor women in cities, especially those who live in marginalized slum populations, do not have access to quality reproductive health services – a critical element to reducing maternal morbidity and mortality rates.
Economic growth alone, while important to help improve the health status of the poor in urban settings, will not solve these problems, said de Bernis. To reduce health disparities within countries, de Bernis advocated for “appropriate social policies to ensure reasonable fairness in the way benefits are distributed,” including incorporating health in urban planning and development, strengthening the role of primary health care in cities, and putting health equity higher on the agenda of local and national governments.
Event Resources:Source: African Population Research Center, United Nations Population Fund.
Photo Credit: “Work Bound,” courtesy of flickr user Meanest Indian (Meena Kadri). -
Watch: Jennifer Dabbs Sciubba on Population and National Security
›April 28, 2011 // By Schuyler Null“Long-term trends really are what shape the environment in the future,” said Jennifer Dabbs Sciubba in this interview with ECSP. “As we’ve seen recently with…revolution in North Africa, it’s the long-term trends that act together for these things to happen – I like to say demography is not usually the spark for a conflict but it’s the fodder.”
Sciubba is the Mellon Environmental Fellow in the Department of International Studies at Rhodes College. In her new book, The Future Faces of War: Population and National Security, she discusses the importance of demographic trends in relation to security and stability, including age structure, migration, youth bulges, population growth, and urbanization.
One of the most important things to emerge from the book, said Sciubba, is that countries that are growing at very high rates that are overwhelming the capacities of the state (like many in sub-Saharan Africa) really will benefit from family planning efforts that target unmet need.
Afghanistan, for example, “has an extremely young age structure,” Sciubba pointed out. “So if you’re trying to move into a post-conflict reconstruction atmosphere…you absolutely have to take into account population and the fact that it will continue to grow.”
“Even if there are major moves now in terms of reducing fertility, they have decades ahead of this challenge of youth entering the job market,” Sciubba said. “Thousands and thousands more jobs will need to be created every year, so if you have a dollar to spend, that’s a really good place to do it.”
For more on Jennifer Dabbs Sciubba and The Future Faces of War, see her book launch at the Wilson Center with Deputy Under Secretary Kathleen Hicks of the Department of Defense (video) and some of her previous posts on The New Security Beat. -
Rukia Seif, PHE Champion
Making Life Easier in Rural Tanzania
›This PHE Champion profile was produced by the BALANCED Project.
Rukia Seif is a population, health, environment (PHE) peer educator who promotes simple economic, environmental, and health behaviors that make sense. In many ways, the Mkalamo village where Rukia lives is a typical rural Tanzanian agricultural village. In another important way it is very different. Mkalamo abuts the biodiversity rich Saadani National Park – the only wildlife park in Tanzania that borders the sea. Ironically, this park does not make life easier for people living in Mkalamo but more difficult. In the park, there is a ban on the cutting of wood, making it difficult to find enough to fuel villagers’ cooking stoves. Also, increasing numbers of the park’s wild animals often destroy the villagers’ precious crops.
As a PHE peer educator, Rukia talks with her fellow community members about simple things they can do to improve their lives. Her messages are clear:- By planning their families, women can ensure their own and their children’s health and can decide the optimal number of children that they can provide for.
- By using fuel efficient stoves, women can spend less time collecting fire wood, freeing up time for other chores or livelihood activities and reducing the amount of needed fuel, thus helping sustain the forests for future generations.
- By joining community-led savings and credit associations, women and men gain access to capital, allowing them to scale-up current livelihoods or diversify to new sources of income.
Rukia sets a good example of how doing these simple things can improve a family’s life and protect the environment. At age 36, she is a mother of three girls, ages 14, 12, and one and a half. Rukia and her husband, Seif Ramadhani, are taking measures to plan their family. Rukia used pills before they decided to have their last daughter. Now they are using condoms as a back-up while Rukia is breastfeeding the baby. Through her work, Rukia meets and talks to many people every day. She discusses family planning and if someone is interested, she refers them to community-based distributors and the dispensary for family planning services.
“I talk to my peers about planning their families so we have enough natural resources to meet the needs of the villagers who depend on these resources,” she said. “Also, when you plan your family, you will get more time to perform other activities.”
An active member of the savings and credit association, where she also acts as the accountant, Rukia is living proof of this last statement. Through savings and loans, Rukia has diversified her income by buying a sewing machine and a fuel-efficient oven. Today, she generates income from cow and poultry husbandry, tailoring, bread-making, selling soft drinks, and constructing fuel-efficient stoves. With this increased income, Rukia and her husband have been able to put an iron sheet roof on their house and send their first-born daughter to secondary school – a great achievement in a country where only five percent of women stay in school beyond the primary level.
Rukia demonstrated her two fuel-efficient stoves: one is a metal oven that she uses for baking breads and cakes, the other is a simple mud stove that she uses for cooking. The mud stove, which costs less than $2 to build, is getting increasingly popular in the community. It saves fuel wood, prevents fires, produces less smoke (a serious health hazard), and cooks the food faster!
“I can even wear my best clothes and put on some lip shine when I use this stove, because it does not foul up the air,” Rukia explains with a laugh. Seeing the benefits of the fuel efficient stoves, she has inspired ten community-based distributors and five village leaders to join the team of individuals showcasing the fuel efficient technologies.
Rukia is a perfect example of practicing what one preaches. She is improving her own life, helping others learn to do the same, and protecting the very natural resources upon which almost everyone in Mkalamo depends.
This PHE Champion profile was produced by the BALANCED Project. A PDF version can be downloaded from the PHE Toolkit. PHE Champion profiles highlight people working on the ground to improve health and conservation in areas where biodiversity is critically endangered. -
Is Universal Access to Family Planning a Realistic Goal for Sub-Saharan Africa?
›“What do we require to ensure universal access to family planning services that are appropriate, affordable, accessible, and of good quality?” asked Michael Mbizvo, director of the Department of Reproductive Health and Research at the World Health Organization at the Wilson Center last month. [Video Below]
To talk about this difficult question and present research and programmatic evidence for sub-Saharan Africa, Mbizvo was joined by panelists Fred Makumbi, senior lecturer and head of the Department of Epidemiology and Biostatistics at Makerere University, Uganda; Oladosu Ojengbede, director of the Center for Population and Reproductive Health, University of Ibadan, Nigeria; and Frank Taulo, director of the Center for Reproductive Health and senior lecturer of obstetrics and gynecology at the University of Malawi.
Integrating Family Planning and HIV Services
Makumbi shared a number of findings on fertility preferences, behaviors, and contraceptive uptake in the context of HIV infection and care in Uganda. “Integrating family planning services into HIV services could help address the family planning needs of both HIV infected and uninfected,” he said.
According to new research conducted as part of the Rakai Community Cohort Study, despite significant gains in family planning use over time, there is still a high unmet need for contraception, irrespective of HIV status, in the Rakai district of central Uganda, said Makumbi. Male partner’s fertility desires were found to play an important role in pregnancy rates, and compared with previous studies conducted in the Rakai district, researchers saw an increase in pregnancy incidence and prevalence among HIV positive women, especially those on anti-retroviral therapy. HIV care that included voluntary counseling and testing was associated with significant increases in the use of family planning, and in particular, the use of condoms.
To effectively promote universal family planning in sub-Saharan Africa, “there is a need to strengthen family planning services in HIV care programs, with promotion of modern contraceptive methods, and with particular attention to women on anti-retroviral therapy,” said Makumbi. “Strategies to address desire for high fertility need to be developed, especially with regard to male involvement,” he added.
Multi-Pronged Approach to Universal Family Planning
“Family planning success in sub-Saharan Africa is a must for the region’s sustainable development,” said Ojengbede. “Poor commitment to women’s health in sub-Saharan Africa” has not only resulted in high fertility rates and poor maternal health indices but has also negatively impacted economic and human development in the region, said Ojenbede.
To increase access to and use of family planning, Ojengbede stressed the need to generate and sustain government commitment, promote legislation to support women’s autonomy, and implement policies to improve access to quality reproductive health services.
At the community level, Ojengbede said, the public health community must work to integrate family planning services into all reproductive health programs, including prevention of mother to child transmission; accelerate female empowerment programs; actively engage males in family planning access and uptake; and address social and cultural barriers that prevent widespread adoption of family planning.
“Traditional rulers can occupy a critical position to enact positive change in their communities and at the national level,” said Ojengbede. In Nigeria, for example, providing education about the health and economic benefits of family planning has helped traditional leaders embrace family planning and develop their own strategies to promote birth spacing in their communities.
“Universal family planning access must be achieved through a multi-pronged approach that should be colored with socio-cultural sensitivity, solid evidence, and sustainability,” concluded Ojengbede.
Eliminating Unmet Need: “Yes, We Can”
“It is time to prioritize issues that are affecting women and family planning is a very critical area,” said Taulo.
There are still many challenges to overcome before Malawi can achieve universal family planning access, including poverty, misconceptions and myths about family planning, lack of availability of reproductive health supplies, poor infrastructure, shortage of trained professionals, and religious and cultural barriers.
“Commodities are also very much dependent on the donor,” said Taulo, pointing to the challenges of insufficient funding and political will. “Failure to connect family planning to economic development and political stability is one of the main areas that we are struggling with,” he added.
“We have lots of challenges, but also many achievements,” said Taulo. Malawi has made important strides in expanding access to family planning by implementing community-based strategies and youth-friendly programs, developing public-private partnerships, engaging policymakers and traditional leaders, and encouraging media coverage of family planning issues.
“Education is another family planning product,” said Taulo. Moving forward, a “deliberate focus on girl child education” and promotion of women’s welfare can have a major impact on fertility reduction, he said.
“We can eliminate unmet need for family planning in Malawi, if we put our heads together, our thoughts together, and our energy together,” concluded Taulo.
Source: World Health Organization.
Image Credit: “Women’s Health Clinic” courtesy of flickr user advencap. -
Madagascar, Past and Future: Lessons From Population, Health, and Environment Programs
›In Madagascar, “today’s challenges are even greater than those faced 25 years ago,” said Lisa Gaylord, director of program development at the Wildlife Conservation Society. At an event at the Woodrow Wilson Center on March 28, Gaylord and her co-panelists, Matthew Erdman, the program coordinator for the Population-Health-Environment Program at Blue Ventures Conservation, and Kristen Patterson, a senior program officer at The Nature Conservancy, discussed the challenges and outcomes of past and future integrated population, health, and environment (PHE) programs in Madagascar. [Video Below]
Nature, Health, Wealth, and Power
Gaylord, who has worked in Madagascar for nearly 30 years, gave a brief history of USAID’s activities on the unique island, which she called a “mini-continent.” She used the “nature, health, wealth, and power” framework to review the organization’s environment, health, and livelihoods programs in Madagascar and their results. Governance, she said, is the centerpiece of this framework, but this piece “maybe didn’t have an adequate foundation” in Madagascar to see the programs through the political crisis.
Though its programs started at the community level, Gaylord said USAID’s objective was to scale up to larger levels. “You can’t always work on that level and have an impact,” she said, and there was “tremendous hope” in 2002 for such scaling up when Madagascar elected a new president, Marc Ravalomanana.
Unfortunately, changes in funding, a lack of economic infrastructure, and poor governance forced development programs to scale down. After President Ravalomanana was overthrown in a military coup in 2009, the situation got worse – the United States and other donors pulled most funding, and only humanitarian programs were allowed to continue.
“What worries me is that I think we have gone back” to working on a village level, Gaylord said. “We want to go up in scale, and I think that we felt that we could in Madagascar, but that’s where you have the political complexities that didn’t allow us to continue in that direction.”
Going forward, Gaylord said that it is important to maintain a field-level foundation, take the time to build good governance, and maintain a balance in the funding levels so that no one area, such as health, dominates development activities.
Living With the Sea
Based in southwestern Madagascar, the Blue Ventures program began as an ecotourism outfit, said Erdman, but has since grown to incorporate marine conservation, family planning, and alternative livelihoods. One of its major accomplishments was the establishment of the largest locally managed marine protection area in the Indian Ocean, called Velondriake, which in Malagasy means “to live with the sea.” This marine area covers 80 kilometers of coastline, incorporates 25 villages, and includes more than 10,000 people. The marine reserves for fish, turtles, and octopus, as well as a permanent mangrove reserve, protect stocks from overfishing.
One of the biggest challenges facing the region is its rapidly growing population, which threatens the residents’ health and their food security, as well as the natural resources on which they depend. More than half the population is under the age of 15 and the infant and maternal mortality rates are very high, Erdman explained. Blue Ventures, therefore, set up a family planning program called Safidy, which means “choice” in Malagasy.
“If you have good health, and family size is based on quality, families can be smaller and [there will be] less demand for natural resources, leading to a healthier environment,” said Erdman.
The region’s isolation and lack of education and health services are a challenge, said Erdman, but over the past three years, the contraceptive prevalence rate has increased dramatically, as has the number of clinic visits. The program uses a combination of clinics, peer educators, theater presentations, and sporting events, such as soccer tournaments, to spread information about health and family planning.
A Champion Community
“There is a long history of collaborative work in Madagascar,” Patterson said. Focusing on the commune (county) level, she worked in conjunction with USAID, Malagasy NGOs, and government ministries to try to scale up PHE programs in Madagascar’s Fianarantsoa province, which has a target population of 250,000 people.
“We essentially worked at two different levels,” said Patterson. At the regional level, a coordinating body for USAID and local partners called the “Eco-Regional Alliance” met monthly. The “Champion Commune” initiative, which worked at local levels, had three main goals, she explained:
Though working in such remote areas is expensive, and all non-humanitarian U.S. foreign aid has been suspended since the coup, Patterson hopes that development programs will return to Madagascar. Pointing to its vast rural areas, she stressed the importance of integrated efforts: “The very nature of multi-sectoral programs is that they have the highest benefit in the areas that are most remote. These are the areas where people are literally left out in the cold.”- Create a strong overlap with neighboring communes;
- Promote activities that benefited more than one sector (such as reforesting with vitamin-rich papaya trees); and
- Capitalize on the prior experiences of Malagasy NGOs in implementing integrated projects to help build up civil society.
Image credit: “Untitled,” courtesy of flickr user Alex Cameron.
Sources: The New York Times, Velondriake. -
Watch: Elizabeth Leahy Madsen Explains the Demography-Civil Conflict Interface in Less Than Two Minutes
›April 12, 2011 // By Schuyler Null“We know that historically, as well as in the present, countries that have very young age structures – those that have youthful and rapidly growing populations – have been the most vulnerable to outbreaks in civil conflict,” said Elizabeth Leahy Madsen, senior research associate at Population Action International, in an interview with ECSP. “It’s not a simple cause and effect relationship, but we think that demographic trends and pressures can exacerbate underlying conditions.”
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What’s the Link Between Population and Nuclear Energy?
›The popular Big Green Purse blog, written by best-selling author Diane MacEachern, recently asked the Worldwatch Institute’s Robert Engelman, “What’s the Link between Population and Nuclear Energy?” The blog, which encourages women to use the “power of the purse” to improve the environment, wanted to know: “Why aren’t we talking about reducing population as part of our global strategy to minimize dependence on power sources [like nuclear energy] that pollute the environment and threaten people’s health?”
While “reducing population” is not possible, slowing population growth may be, if fertility rates continue to fall. As always, Engelman answered the tough question with thoughtful aplomb, offering three core values as a starting point:One: see the global environmental dilemma not as a problem to be solved but as a predicament to be responded to. We can’t control our future, but we can act with integrity as we aspire to build just societies in an environmentally-sound world. Addressing our numbers can become part of that.
But I’m wondering how the readers of Big Green Purse – which is replete with media-friendly lists like “Top Ten Eco-Tricks” – can translate population and its messy intersection of human rights, health care, and consumption levels into an individual purchasing decision.
Two, embrace human rights as a foundation for our actions. All people – even if too many or consuming too much – have dignity and a right to be here. As it happens, population policies based on the right of all women to choose whether and when to bear a child actually slow the growth of population. …
Three, acknowledge that no one can claim a greater right than anyone else to use energy and natural resources. This is called equity. We cannot object if the poorest people living today and yet to be born succeed in gaining the means to consume as much as Americans do.
As Engelman writes, “The idea that we can easily trim our individual consumption to come into balance with nature – worthy as that effort is – looks increasingly naïve. If people in the developed world slash their per capita greenhouse emissions by half, their effort could be counterbalanced by people in developing countries boosting theirs by just 11 percent.”
Photo Credit: “Trojan Nuclear Power Plant,” courtesy of flickr user tobo. -
Book Launch: ‘The Future Faces of War: Population and National Security,’ by Jennifer Dabbs Sciubba
›“Demographic trends by themselves are neither inherently good nor bad. It’s really a state’s ability to address these issues that can determine the outcome,” said Jennifer Dabbs Sciubba, the Mellon Environmental Fellow with the Department of International Studies at Rhodes College. At a book launch event at the Wilson Center on March 14 for The Future Faces of War: Population and National Security, Sciubba, along with Deputy Under Secretary Kathleen Hicks of the Department of Defense, discussed the national security implications of demography and its important role in understanding and managing conflicts around the world. [Video Below]
Demography as an Indicator, Multiplier, and Resource
Demography can be thought of in three ways, explained Sciubba: as “an indicator of challenge and opportunity; a multiplier of conflict and progress; and a resource for power and prosperity.”
A country’s age structure can pose a challenge, said Sciubba, because countries with a large percentage of their population under the age of 30 “are about two and a half times more likely to experience civil conflict than states with more mature age structures.” Tunisia’s recent revolution, she said, could be understood as a “story about demography.”
The 26-year-old fruit vendor Mohammed Bouazizi, who set himself on fire on December 17 after being hassled by police, was part of one of the largest age cohorts in Tunisia, those aged 25-29. There are some 64 million young men across the Middle East-North Africa region between the ages of 15 and 30, according to UN estimates. “If his death was the spark” for the unrest in the region, Sciubba said, “it’s the underlying demographic trends that were the fodder.”
Yet, Sciubba sees opportunity within this challenge. Citing the work of Richard Cincotta, she said that “states have half a chance – literally 50 percent – of becoming a democracy once their proportion of youth declines to less than 40 percent.” Tunisia has the best chance in the region of becoming a free democracy based on its demography, followed by Libya, where youth aged 15-29 are 43 percent of the adult population.
At the other end of the age structure, some of the world’s most powerful countries, such as Japan, Germany, Italy, France, Russia, and China, are rapidly aging. This aging will “somewhat decrease the ability of these states to project political, economic, and military power” due to a shortage of labor and a smaller pool of funding, said Sciubba.
Countries with transitional age structures, such as India, Brazil, and South Africa, face different security challenges. With a majority of their populations between 15 and 60 years old, there are more people contributing to the economy than are taking away, which could bolster these countries economically and politically (the “demographic dividend”). Global institutions will have to reform and include these countries, she advised, “or else become irrelevant.”
But the defining trend of the 21st century, said Sciubba, is urbanization. While great sources of economic growth, cities are also quite vulnerable to natural disasters and terrorism because of their concentrations of people, wealth, infrastructure, and bureaucracy.
In looking to the future, Sciubba called for continued support for family planning initiatives. “At least 90 percent of future world population growth will take place in less developed countries,” which are least equipped to handle the demands of that growth, she said. In addition, Sciubba recommended that the United States seek out partnerships with countries that have transitional age structures, particularly India, which could be a stabilizing force in a tumultuous region. She also called on the United States to partner with states in the Western Hemisphere and remain open to migration.
Defense and Demography
“Understanding population is critical to our success in being able to prevent conflict, and also managing conflict and crises once we’re involved,” said Hicks, describing the Department of Defense’s (DOD) interest in demography. However, the DOD does not “treat demographics as destiny,” she said, but instead as “one of several key trends, the complex interplay of which may spark or exacerbate future conflicts.”
Recent world events, such as those in the Middle East and North Africa, “have demonstrated how critical our understanding of population is for security practitioners,” said Hicks. Similarly, the recent earthquake and tsunami in Japan dramatically illustrate the vulnerability of large urban areas. Echoing Sciubba’s comments on population aging, she cited “incredible divestments in defense” in Europe, which, she said, “puts us, as a key partner in NATO, at a thinking stage.”
Under Secretary of Defense for Policy Michèle Flournoy is “deeply interested” in demographic issues, said Hicks. She identified other demographic areas of great interest for her office: the youth bulge in Pakistan, urbanization in Afghanistan, the role of highly educated women in Saudi Arabia, the Chinese diaspora in the Americas, Russia’s shrinking population, and various trends in China, including aging, gender imbalance, urbanization, and migration.
Image credit: “Iraq,” courtesy of flickr user The U.S. Army.
Sources: ECSP Report 12, Financial Times, The New York Times, Population Reference Bureau, UN Population Division.
