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Reproductive Science: Expanding Choice, Empowering Women, Securing the Future Laneta Dorflinger, PhD Lafayette College October 20, 2011.

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Presentation on theme: "Reproductive Science: Expanding Choice, Empowering Women, Securing the Future Laneta Dorflinger, PhD Lafayette College October 20, 2011."— Presentation transcript:

1 Reproductive Science: Expanding Choice, Empowering Women, Securing the Future Laneta Dorflinger, PhD Lafayette College October 20, 2011

2 Expanding access to contraception The Need is Urgent…The Time is Right World Population to reach 10 billion by 2100 if Fertility in all Countries Converges to Replacement Level U NITED N ATIONS, 3M AY, 2011 – The current world population of close to 7 billion is projected to reach 10.1 billion in the next ninety years, reaching 9.3 billion by the middle of this century, according to the medium variant of the 2010 Revision of World Population Prospects

3 Of the nearly 7 billion people in the world today 1.4 billion (20%) are living on less than US$1.25 a day 48% live on less that $2 per day 2.6 billion (37%) have no access to toilets, latrines or other forms of improved sanitation Over 33 million are living with HIV Average per capita health care expenditures in sub-Saharan Africa < $100 Source: Millennium Development Goals and PBR 2011 Population Datasheet

4 Ensuring access - Expanding choice

5 Presentation Outline Overview of global fertility and contraceptive use Maternal mortality and morbidity –Role of family planning in reducing maternal death The contribution of family planning to achieving the Millennium Development Goals (MDGs) Current contraceptive technology Need for new technologies Areas of research that could fill greatest gaps Economic realities of expanding access and choice

6 Presentation Outline Overview of global fertility and contraceptive use Maternal mortality and morbidity –Role of family planning in reducing fertility and maternal death The contribution of family planning to achieving the Millennium Development Goals (MDGs) Current contraceptive technology Need for new technologies Areas of research that could fill greatest gaps Economic realities of expanding access and choice

7 Total Fertility Rate (TFR) Source: PRB 2010 World Population Data Sheet Modern Contraceptive Prevalence (CPR) Highest fertility rates and lowest modern contraceptive prevalence rates are found in Africa and South/Western Asia. Highest numbers of women needing family planning services are in South/Western Asia. Total fertility rates and modern contraceptive method prevalence

8 Contraceptive use and method by region Percentage of married women RegionAny Method Any Modern Method* Total Fertility Rate World North America LAC East Asia South Asia Sub-Saharan Africa * Modern methods include male/female sterilization, pills, IUD, injectable, implants, condoms, female barriers, EC

9 Contraceptive Use and Unmet Need in Africa Courtesy of Scott Radloff, USAID, 2011

10 Unmet need of 215 million in developing countries translates to: 53 million unintended pregnancies, leading to: 24 million abortions 150,000 pregnancy-related deaths [1/2 in Africa] 640,000 newborn deaths 600,000 orphans Source: Guttmacher Policy Review, Summer 2008, Vol 11, Number 3

11 Presentation Outline Overview of global fertility and contraceptive use Maternal mortality and morbidity –Role of family planning in reducing fertility and maternal death The contribution of family planning to achieving the Millennium Development Goals (MDGs) Current contraceptive technology Need for new technologies Areas of research that could fill greatest gaps Economic realities of expanding access and choice

12 Measuring maternal mortality Total number of deaths –While pregnant or within 42 days of termination, due to complications of pregnancy or childbirth Maternal mortality ratio –Number of maternal deaths during a given time per 100,000 live births –Indicator of the quality of the health care system Maternal mortality rate –Number of maternal deaths during a given time per 100,000 WRA –Influenced by prevalence of pregnancy and risk of dying from a pregnancy Lifetime risk of death –Probability that at 15 year old will die in her lifetime of maternal causes –Influenced by number of pregnancies, spacing of pregnancies, and the quality of the health care system

13 Figure 3 Source: Hogan et al. The Lancet 2010; 375: Maternal mortality ratio for 181 countries, 2008

14 Lifetime risk of maternal death RegionLifetime risk of maternal death (1 in X) World Total140 Developed4,300 Developing120 South Asia110 Sub-Saharan Africa31 Middle East/N Africa190 Source: Trends in Maternal Mortality WHO, UNICEF, UNFPA and The World Bank.

15 Maternal Mortality Worldwide, 2008 Estimated numbers: 342,900 –Down from 526,300 in 1980 More than 60% of all deaths occur in just 6 countries –India –Nigeria –Pakistan –Afghanistan –Ethiopia –DRC Source: Hogan et al. The Lancet 2010; 375:

16 Tenerife, Canary Islands on March 27,1977 Two Boeing 747’s collided on the runway in fog 583 dead World’s worst airline disaster Slide courtesy of Dr. David Grimes

17 Annual global maternal mortality 939 Boeing 777’s fully loaded with women aged or…. More than two planes per day Slide courtesy of Dr. David Grimes

18 Maternal morbidity Disabilities are estimated to be 20 times more frequent than maternal deaths The ratio of “near misses” ranges from 1:5 to 1:118 Source: Lewis. Br Med Bull 2003;67:27

19 Primary health center and “Zambulance” Suburban area of Lusaka, Zambia Courtesy of Dr. Cindy Geary, FHI 360

20 Family Planning Reduces Maternal Mortality COUNTRY Contraceptive Prevalence* Lifetime probability of maternal death (1/X) US73%2,100 India49%140 Malawi38%36 Nigeria9%23 * Percent of married women ages using modern method Source: PRB World Population Datasheet, 2011 and Save the Children State of the World’s Mothers, 2011

21 Unsafe Abortion About 15% of maternal deaths are related to unsafe abortion An estimated 50,000 to 60,000 women die each year from unsafe abortion Almost all of these deaths occur in developing countries Almost all are preventable Grimes. Lancet 2006;368:1908

22 Increased use of modern contraceptive methods reduces rates of abortion Slide courtesy of Scott Radloff, USAID, 2011

23 Presentation Outline Overview of global fertility and contraceptive use Maternal mortality and morbidity –Role of family planning in reducing fertility and maternal death The contribution of family planning to achieving the Millennium Development Goals (MDGs) Current contraceptive technology Need for new technologies Areas of research that could fill greatest gaps Economic realities of expanding access and choice

24 Millennium Development Goals Goals to end poverty and inequality Targets for global development Commitments by 189 countries Priorities for funding Opportunities for multinational organizations

25 Millennium Development Goals – by 2015 End Poverty and Hunger Universal Education Gender Equality Child Health Maternal Health Reduce maternal mortality by three-fourths Achieve universal access to reproductive health Combat HIV/AIDS Environmental Sustainability Global Partnership

26 Family Planning Prolongs Education Pregnancy a major obstacle to universal education for women High levels of pregnancy in youth Fewer than half of African girls complete primary school Population growth puts pressure on limited education infrastructure –Girls suffer disproportionately

27 Teenage Pregnancy and Motherhood (Percent with children or currently pregnant) CountryAge Kenya Malawi Uganda Nigeria India 2005/ Bangladesh Source: Demographic and Health Surveys (DHS), Macro

28 Family planning enhances gender equity and empowers women Women who use FP more likely to be employed than non-users (Indonesia, Zimbabwe, Bolivia) Unplanned pregnancies interrupt work and career plans (Egypt) Long-acting/permanent contraceptive methods associated with greater likelihood of working for pay (Brazil, Indonesia) Girls in larger families were less likely to attend school than girls from households with smaller families (Ghana) Sources: Woman’s Studies Project; UNFPA, 2003

29 Family Planning Saves Infants Maternal death increases risk of newborn infant death Currently, 2.7 million infant deaths are averted globally each year by preventing unintended pregnancies Spacing planned births and limiting unintended births increases child survival Source: Demographic and Health Surveys

30 Child Mortality by Birth Interval Duration of Preceding Birth Interval (Months) Relative Risk Child Mortality Source: DHS; Rutstein S. (2005)

31 Family Planning Prevents HIV Prevention of HIV in women, especially young women Prevention of unintended pregnancies in HIV- infected women Prevention of transmission from an HIV- infected woman to her infant Support for mother and family Phase 1Phase 2Phase 3Phase 4 4 Phase Approach to Perinatal HIV Prevention Four-phased approach to preventing perinatal HIV transmission

32 Unintended pregnancies among women with HIV in Africa 51% of pregnancies are unintended among women with HIV in Cote d’Ivoire 74% of pregnancies are unintended among women in an ART treatment program in Rwanda 84% of pregnancies are unintended among women using PMTCT services in South Africa Sources: Rochat et al., JAMA 2006:295:1376-8; Desgrées-du-Loû et al., Int J STD AIDS 2002;13: ; Bangendanye, et al., Presented November 2007.

33 Family planning protects the environment Rapidly growing population –challenges constrained resources (arable land, clean water) –exacerbates environmental degradation –exacerbates food insecurities Preventing unintended pregnancy is the factor in population growth most amenable to intervention Source: Population Reference Bureau, 2009

34 Sexual and reproductive health Environmental sustainability Global partnership for development Combatting HIV/AIDS Improved maternal health Reduced child mortality Gender equity Universal primary education Eradication of poverty Family Planning Critical to Achieving MDGs Courtesy of Jeff Spieler, USAID. Adapted from HRP/RHR/WHO

35 Presentation Outline Overview of global fertility and contraceptive use Maternal mortality and morbidity –Role of family planning in reducing fertility and maternal death The contribution of family planning to achieving the Millennium Development Goals (MDGs) Current contraceptive technology Need for new technologies Areas of research that could fill greatest gaps Economics realities of expanding access and choice

36 Current contraceptive methods and typical effectiveness More effective Less effective Less than 1 pregnancy per 100 women in one year About 25 pregnancies per 100 women in one year Injections: Get repeat injections on time LAM (for 6 months): Breastfeed often, day and night Pills: Take a pill each day Patch, ring: Keep in place, change on time Condoms, diaphragm, sponge, withdrawal: Use correctly every time you have sex. How to make your method most effective After procedure, little or nothing to do or remember Vasectomy: Use another method for first 3 months Spermicide: Use correctly every time you have sex Fertility-awareness based methods: Abstain or use condoms on fertile days. Injectables Pills LAM Female Condoms Spermicide Female Sterilization Vasectomy Ring Patch Male Condoms Implant Sponge Diaphragm Fertility-Awareness Based Methods Source: Adapted from WHO 2006 Withdrawal IUD

37 MethodPerfect UseTypical Use No method85 Male condom218 Pill, Patch, Ring0.39 Depo-Provera0.26 Copper-IUD Mirena0.2 Implanon0.05 Female sterilization0.5 Male sterilization Source: Trussell, Contraception 2011; 83: Pregnancy risk and continuation rates for select contraceptive methods at one year

38 MethodPerfect UseTypical UsePercent Continuing No method85 Male condom21843 Pill, Patch, Ring Depo-Provera Copper-IUD Mirena IUS Implanon (implant) Female sterilization Male sterilization Source: Trussell, Contraception 2011; 83: Pregnancy risk and continuation rates for select contraceptive methods at one year

39 Benefits of Implants vs. Shorter-acting Methods 1.8 million unplanned pregnancies 576,000 abortions 10,000 maternal deaths Hubacher, Mavranezouli, and McGinn, Contraception 2008 The impact would be even more dramatic adding new users Similar impact with a shift to IUDs. If 20% of OC or injectable users in Africa switched to implants -- over next 5 years, it would avert:

40 Presentation Outline Overview of global fertility and contraceptive use Maternal mortality and morbidity –Role of family planning in reducing fertility and maternal death The contribution of family planning to achieving the Millennium Development Goals (MDGs) Current contraceptive technology Need for new technologies Areas of research that could fill greatest gaps Economic realities of expanding access and choice

41 Why do we need more technology? Existing methods do not meet the needs of all Some are difficult to use consistently and correctly ‒ High typical use failure rates ‒ High discontinuation Side effects or fear of side effects Changing needs and desires over reproductive lifespan Missing a spectrum of male methods

42 Target qualities for new contraceptive methods Highly effective in typical use – Forgiving of misuse – User-independent Safe and Acceptable – Minimal side effects or – Have “desirable” side effects (e.g. amenorrhea) – Convenient and easy to use – Use in chronic disease states Provide additional health benefits Very low cost Potential for wide availability – Provided by low level health care providers or be provider independent

43 Ratio of Health Provider to Population Courtesy of Scott Radloff, USAID, 2011

44 Improving upon existing methods Less expensive (“generic” or “alternative”) – Implant systems –Levonorgestrel IUS Easier to use in a compliant way – Vaginal rings Easier to deliver in service settings –Preloaded injectable systems (e.g. Depo SC in Uniject) –Biodegradable implants Multipurpose technologies (Dual protection)

45 Sino-implant (II)/Zarin Two thin, flexible silicone rods, each containing 75 mg levonorgestrel The same amount of active ingredient and mechanism of action as Jadelle Currently labeled for four years of use Available with disposable trocar About $8 compared with $20-$24 for Jadelle

46 Population Council Nes/EE vaginal ring Designed to last one year

47 Depo-subQ Provera 104 delivery in Uniject Depo-subQ Provera 104: tNew formulation for subQ injection t30% lower dose (104 mg vs. 150 mg) tApproved by USFDA (2005) and EMA/UK Uniject: t Single dose, prefilled, sterile, non-reusable t Easier to use by non-clinical personnel/CHWs tCompact; easy to use and store tPotential for home- and self-injection tApproval by EMA. LDC registration forthcoming

48 Lower-cost alternative to Mirena

49 New methods that could be game changers Non-surgical methods of male and female sterilization Reversible male methods Dual protection methods (multipurpose technologies) Highly-effective peri-coital or post-coital method Immunocontraception (women and men) Methods with non-contraceptive health benefits

50 Presentation Outline Overview of global fertility and contraceptive use Maternal mortality and morbidity –Role of family planning in reducing fertility and maternal death The contribution of family planning to achieving the Millennium Development Goals (MDGs) Current contraceptive technology Need for new technologies Areas of research that could fill greatest gaps Economic realities of expanding access and choice

51 Family Planning Saves Dollars Preventing unintended pregnancies is less expensive than treating maternal/ infant complications of pregnancy Longer acting contraceptive methods are the most cost-effective Every $1 spent on family planning can avert $2 to $9 in health costs In Zambia, for every $1 invested in FP, $4 are saved in other development areas

52 Family Planning and MDGs - Cost Savings Source: USAID-Zambia (2008) Education $37 M Immunization $17 M Water Sanitation $17 M Maternal Health $37 M Malaria $4 M Total Savings: $111 M Family Planning $27 M Total Costs: $27 M

53 US Funding for HIV and Family Planning $ Billions Appropriated Source: CRS (2010)

54 Save the Children analysis – 2011 Sources: OMB; White House; FY 2011 CR extension US Humanitarian and development assistance

55 New commitments World Bank 5-year plan for 58 countries UN Secretary General’s Global Strategy for Women’s and Children’s Health International Alliance for Reproduction, Maternal and Newborn Health –US, UK, Australia, BMGF –Pledge of $40 billion ($27 billion new) –Reduce unmet need by 100 million –Expand skilled birth attendants –Expand post-natal care

56 Putting costs in perspective Americans spent approximately $6 billion in 2010 on Halloween costumes/candy/decorations (National Retail Foundation, 2011) Estimated $3.5 billion needed to fulfill global unmet need and prevent: –53 million unintended pregnancies –640,000 newborn deaths –150,000 pregnancy-related deaths –$5.1 million expenditures on health-related services

57 Conclusions Ensuring access to family planning is a critical component to the solution of many of the world’s complex issues –Expanding choice of the number and spacing of children –Improving the health of women –Improving the health of children –Addressing multiple challenges of societies Education, employment, environment, national and global security –Empowering women –Securing the future

58 Some fun web sites to visit x.html x.html

59 Thank you!

60

61 Drivers of Population Growth Source: Adapted from Bongaarts (2010) 0 Unwanted fertility High desired family size Population momentum Year Population size (in billions)

62 Male Female Number for each age group in 1,000 Source: John May, World Bank Sequential Age Pyramids for Africa in 1960, 1990, & 2010 * Population growth rates: 2.5% translates to a 28 year doubling time and rapidly expanding demands on food, water, schools, health services, energy, infrastructure, and land. * Dependency Ratio: 78 children per 100 workers, compared to 42 in LAC, 39 in Asia, 25 in MDCs. * Momentum: young age structure ensures continued population growth for generations. Small changes in fertility can have significant population effects over time


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