1. Symposium sur la mortalité maternelle, Dakar 12/10 Luc de Bernis Conseiller Santé maternelle UNFPA Family Planning

2. The Population issue: The World Bank analysis Sub-Saharan Africa faces huge challenges to integrate into the world economy, increase its rate of economic growth, and lift its men and women out of poverty. To achieve these goals, Africa must inter alia improve its governance, build its human capital, improve the health of its citizens, trigger an education revolution, manage the rapid pace of urbanization, increase its agricultural productivity, protect its environment, and adapt to global climate change. The rapid growth of the sub-Saharan population is exacerbating all these challenges, making more difficult the achievement of the Millennium Development Goals (MDGs).

3. The Human rights approach In 1994 in Cairo, at the International Conference on Population and Development 179 countries agreed that: “…Reproductive rights embrace certain human rights that are already recognized... These rights rest on the recognition of the basic rights of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information, and means to do so, and the right to attain the highest standard of sexual and reproductive health... their right to make decisions concerning reproduction free of discrimination, coercion, and violence…” – Para 7.3, ICPD

4. Poverty, Gender, Health, Environment: FP is central for achieving all MDGs MDG1: Eradicate extreme poverty and hunger. Poverty/income, Employment/decent work, hunger MDG 2: Achieve universal primary education MDG 3: Promote gender equality and empower women MDG 7: Environmental sustainability + MDG 4, 5 and 6

5. MDG5: Improve Maternal Health (… to ensure every pregnancy is wanted and every birth is safe!) Two targets: Reduce the Maternal mortality ratio by three quarter, between 1990 and 2015 Achieve, by 2015, universal access to Reproductive health

6. MDG 5B Universal access to Reproductive health Five indicators Adolescent birth rate Antenatal care coverage (at least one visit and at least four visits) Unmet needs for Family planning Contraceptive prevalence rate

7. Strategies for MMR (and MNR) reduction (London consensus – 2010) Family planning (FP) Skilled birth attendance (SBA) Emergency obstetric and neonatal care (EmONC) Community-based interventions: FP, … Health center: FP, ANC, Basic EmONC Referral hospital: FP, Comprehensive EmONC, specialised neonatal care Health system strengthening and Community involvement

8. Avantages médicaux des services de santé sexuelle et reproductive Condom masculin Condom Féminin Contraceptifs Oraux (Pilules) Injectables (+ seringues/aiguilles) Dispositifs intra- utérins (DIU) Implants Spermicides Méthodes des Jours Fixes

9. Why is FP uptake has stalled? 9 Family Planning services Demand Services Policies, Laws, legislation, National priorities, plans and budgets Community empowerment and ownership Empowerment of women and girls and male involvement Information, Perceptions, Beliefs Satisfaction with services Governance, supervision Human resources Supplies and choice of methods HMIS Constellation of services Access, affordability

10. Current situation (SSA) Sub-Saharan Africa (SSA) hosts 25 of the 28 high fertility countries of the world, defined by a total fertility rate (TFR) higher than 5 children per woman. Due to decline of mortality rates (despite HIV epidemic), and high fertility rate, since the 1960s, sub-Saharan Africa’s population has grown at the rate of 2.5 percent per year, implying a doubling time of the population of 28 years. the rate of increase of the contraceptive prevalence rate (CPR) is estimated at only 0.5 percentage point per year (better in Southern Africa, Madagascar, Malawi, Ethiopia, Rwanda).

11. Unmet needs for FP In the least developed countries, 6/10 women who do not want to get pregnant are not using contraception. This unmet need is highest among the disadvantaged individuals who are also most likely to suffer adverse consequences from unprotected sex. When faced with an unintended pregnancy, women with few resources often have an unwanted birth or seek an unsafe abortion, resulting in high rates of maternal mortality and morbidity among this population group. These same women also lack protection from sexually transmitted infections, including HIV.

12. Total Fertility Rate, Contraceptive Prevalence and Unmet Need in Developing Countries and Least Developed Countries

13. Each year, … 42 million women seek an abortion – an estimated 20 millions of those abortions are not safe, resulting in nearly 67,000 deaths annually. modern contraceptives help prevent 2.7 million infant deaths and the loss of 60 million years of healthy life through birth spacing and reducing unwanted pregnancies. FP is instrumental in lowering HIV transmission and mother-to-child transmission of HIV (dual protection)

14. Relation between Maternal Mortality Rate and use of Family Planning services

15. Meeting unmet need for family planning and maternal and newborn health care would save women’s lives. Maternal deaths (in 000s), 2008 550 160 240 410 Current levels of care Expanded maternal and newborn care only Expanded family planning use only Expanded family planning and maternal and newborn care

16. Equity Among underserved groups is the adolescents’ one: new generations begin their sexually active years being often excluded from reproductive health services. They enter adulthood with inadequate information on sexuality and RH and few skills to protect their health and rights. Adolescent friendly services (and not Adolescent health services) SRH education at school

17. Equity Equity (2) FP services too often fail to reach: the poor, those living in remote areas and urban slums, and people with less education indigenous people, individuals with disabilities, people living with HIV, internally displaced people, and migrant workers As a result, socio-economic disparities in SRH indicators are among the largest of any health indicators.

18. Experts meeting on FP and Equity New York, June 2009 Recommendations for research: 5. Support research, both technically and financially, to assess the barriers disadvantaged groups face and measure programme impact on reducing inequities in family planning access and use. 7. Identify priority needs for research, monitoring, and translating research into programmes and policies conducive to reducing inequities in access to reproductive health services at the country level.

19. New Developments Recent analytical work on the East Asia situation has demonstrated that demographic changes, in particular rapid declines in fertility, have brought about a “demographic dividend” caused by more favorable dependency ratios and a relatively larger share of the labor force. Second, the human rights agenda, that includes access to RH and family planning services, has also gained prominence in recent years Source: WB Africa Region. Outline of a strategic plan for Population and Reproductive health. March 2010

20. Some references Reducing unmet need for family planning: Evidence-based strategies and approaches. Outlook 2008; 25(1). Bongaarts J, Sinding SW. A response to critics of family planning programs. International Perspectives on Sexual and Reproductive Health, 2009; 35(1):39-44 James Gribble et Joan Haffey. La Santé reproductive en Afrique Sub-saharienne. 2009 Population Reference Bureau Rapport 2010 sur les OMD. http://www.un.org/fr/millenniumgoals/report2010.shtml How universal is access to reproductive health? http://www.unfpa.org/public/home/publications/pid/6532 http://www.unfpa.org/public/home/publications/pid/6532 State of the World Population 2010. http://www.unfpa.org/swp/http://www.unfpa.org/swp/ Eight lives. Stories of RH. http://www.unfpa.org/public/home/publications/pid/6641http://www.unfpa.org/public/home/publications/pid/6641 Guengant, J.-P. & J.F. May. (2007). Impact of the Proximate Determinants on the Future Course of Fertility in Sub-Saharan Africa. Population Bulletin of the United Nations. Nos. 46/47 2002: 71-95. Birdsall, N., Kelley, A.C., & Sinding, S.W. (Eds). (2001). Population Matters: demographic change, economic growth, and poverty in the developing world. New York, NY: Oxford University Press.