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

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 UNITED NATIONS, 3MAY, 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 On May 3 of this year, the UN released the latest revision to their regularly updated World Population Prospects. The new projections are a wake-up call for many governments around the world regarding the need to fulfill the demand for contraception. I should point out that this projection is what is termed the MIDDLE VARIANT projection, and is based on their medium projection of fertility (the average number of births a woman will have in her lifetime). However, if the average fertility globally is a modest 0.5 birth higher, then the population could reach 10.6 billion by 2050, and 15.8 by 2100. This is more than a doubling of the number of people today and is just a staggering thought. Throughout the 2000s, there were two reports predicting a peak in the low 9 billions, followed by a decline. However, the fertility declines that had been expected didn’t materialize as rapidly as projected. Growth in Africa remains so high that the population there could more than triple in this century, rising from today’s one billion to 3.6 billion, according to the report— a sobering forecast for a continent already struggling to provide food and water for its people, along with many other challenges, not the least of which is stability.

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 Setting the stage, I want to remind you that: Bullets ------ In countries such as Madagascar, Malawi, Rwanda = 90% live on less than $2. In India, about ¾ live on less than $2 per day. While the US spent $2.6 trillion on health care in 2010, or about $8,700 per capita, the ave per capita in SSA was under $100. Sub-Saharan Africa figures cover the provision of health services (preventive and curative), family planning activities, nutrition activities, and emergency aid designated for health Today, I hope to convince you that ensuring access to contraception, and expanding choice of affordable, highly effective, and easy to use family planning methods, is truly critical to the ultimate condition of the World. Source: Millennium Development Goals and PBR 2011 Population Datasheet

Ensuring access - Expanding choice I’ve spent my career working to help improve women’s health, and in particular to expand access to family planning in the developing world. In developing countries, millions of women and couples want to prevent pregnancy but don’t have access to modern contraception. This impacts their health, their educational opportunities, their ability to provide for their families, and indeed the overall health of their families.  And as I will review, it impacts many other “things” that we should all be concerned about including the environment and the ability to feed populations, and global stability generally. Despite an economic crisis in this country, spending on global reproductive health is not only the right thing to do, it is critical to our national interest. We all have an important part to play.

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

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

Total Fertility Rate (TFR) Total fertility rates and modern contraceptive method prevalence Total Fertility Rate (TFR) Modern Contraceptive Prevalence (CPR) Total fertility rate is: the average number of children that would be born to a woman over her lifetime if (1) she were to experience the exact current age-specific fertility rates thru her lifetime, and (2) she were to survive from 15 through her reproductive life. Replacement rates: roughly 2.1 births (affected by mortality); however, globally, the TFR at replacement is 2.33 children per woman (2003 estimate). At this rate, the global population growth would trend towards zero. Modern contraceptive prevalence rate is: Percentage of women between 15-49 who are practicing contraception (or whose partners are using contraception). 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. Source: PRB 2010 World Population Data Sheet

Contraceptive use and method by region Percentage of married women Any Method Any Modern Method* Total Fertility Rate World 62.7 56.1 2.5 North America 78.1 72.9 1.9 LAC 67.0 2.2 East Asia 82.8 81.3 1.5 South Asia 53.9 45.8 2.7 Sub-Saharan Africa 28.6 15.7 5.2 This table is adapted from the World Contraceptive Use Poster which is put out every one to two years by the United Nations Population Fund and the 2011 World Population Factsheet from PRB. The distribution of contraception use clearly varies. PURPOSE OF SHOWING NUMBERS WILL BE CLEAR ON NEXT SLIDE: To achieve replacement level fertility, modern CPR needs to be in the range of 70%. As you can see on the first line – world wide 63 percent of married women report using any method of contraception – this percentage includes traditional methods, withdrawal, abstinence and fertility awareness methods, or natural family planning. * Modern methods include male/female sterilization, pills, IUD, injectable, implants, condoms, female barriers, EC

Contraceptive Use and Unmet Need in Africa Most unintended pregnancies result from not using a modern contraceptive. •148 million women in Sub-Saharan Africa and South Asia want to avoid pregnancy but use no method or a traditional one. •Unmet need for modern methods varies by women’s personal characteristics, life stages and living situations. Remind them of the population growth projections Courtesy of Scott Radloff, USAID, 2011

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

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

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 A woman’s lifetime risk of maternal death is a function of many factors including the number of children, the spacing of these births and the conditions related to giving birth.

Maternal mortality ratio for 181 countries, 2008 Figure 3 Mention ranking of the US in most recent Save the Children report Remember, MMR is the number of maternal deaths during a given time per 100,000 live births With the exception of South Africa, across SSA, the MMR is over 300. Source: Hogan et al. The Lancet 2010; 375:1609-1623

Lifetime risk of maternal death Region Lifetime risk of maternal death (1 in X) World Total 140 Developed 4,300 Developing 120 South Asia 110 Sub-Saharan Africa 31 Middle East/N Africa 190 Source: Trends in Maternal Mortality 1990-2008. WHO, UNICEF, UNFPA and The World Bank.

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 Ross and Blanc estimate that about 50% of the reduction of MMR between has been due to contraception. Source: Hogan et al. The Lancet 2010; 375:1609-1623

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

Annual global maternal mortality 939 Boeing 777’s fully loaded with women aged 15-45 or…. More than two planes per day Slide courtesy of Dr. David Grimes

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

Primary health center and “Zambulance” Suburban area of Lusaka, Zambia Life is different for women in most of the developing world than it is for most women in the US. This primary health center is in a suburban area of the nation’s capital. The Zambulance is used to bring high-risk women in labor into the health post for delivery. Courtesy of Dr. Cindy Geary, FHI 360

Family Planning Reduces Maternal Mortality COUNTRY Contraceptive Prevalence* Lifetime probability of maternal death (1/X) US 73% 2,100 India 49% 140 Malawi 38% 36 Nigeria 9% 23 The number of maternal deaths is influenced by the probability of becoming pregnant and the risk of death while pregnant Probability of becoming pregnant is influenced by a number of factors, importantly effective use of contraception * Percent of married women ages 15-49 using modern method Source: PRB World Population Datasheet, 2011 and Save the Children State of the World’s Mothers, 2011 CSIS Renewing US Global Leadership in RH, 2/5/09 FP MDGs Overview, March 10 20

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 Many pregnancies end in abortion…In developing countries, about 15% of maternal deaths are related to unsafe abortion. This is one of the hugely controversial areas in my field – the issue of abortion and the linking of family planning methods to abortion. Grimes. Lancet 2006;368:1908

Increased use of modern contraceptive methods reduces rates of abortion The frequent conservative concern that increased access to contraceptive technology will increase abortions is unfounded and counter to the evidence. Slide courtesy of Scott Radloff, USAID, 2011

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

Millennium Development Goals Goals to end poverty and inequality Targets for global development Commitments by 189 countries Priorities for funding Opportunities for multinational organizations The eight Millennium Development Goals (MDGs) – which range from halving extreme poverty to halting the spread of HIV/AIDS and providing universal primary education, all by the target date of 2015 – form a blueprint agreed to by all the world’s countries and all the world’s leading development institutions. They have galvanized unprecedented efforts to meet the needs of the world’s poorest.

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 For example: Halve the % who live on less than $1 per day Reduce by 2/3 the under-five mortality rate FP MDGs Overview, March 10

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

Teenage Pregnancy and Motherhood (Percent with children or currently pregnant) Country Age 16 17 18 19 Kenya 2008 9.4 16.5 26.2 36.2 Malawi 2010 12.6 21.7 43.4 63.5 Uganda 2006 8.5 25.5 41.0 58.6 Nigeria 2008 13.0 24.2 35.7 38.4 India 2005/06 6.4 12.5 24.0 Bangladesh 2007 18.6 33.4 42.5 58.5 More than half the adolescents in many countries in sub-Saharan Africa have a child. Teenage childbearing interrupts education, as well as long-term social and economic mobility. These young mothers are denied the opportunity to pursue basic and advanced educational goals. Children born to very young mothers are normally predisposed to higher risks of illness and death. Adolescent mothers are more likely to have complications during pregnancy. Women with less education are more likely to have children at a young age. Source: Demographic and Health Surveys (DHS), Macro

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

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

Child Mortality by Birth Interval Relative Risk Child Mortality Add WHO statement from Gates presentation Duration of Preceding Birth Interval (Months) Source: DHS; Rutstein S. (2005)

Family Planning Prevents HIV 4 Phase Approach to Perinatal HIV Prevention Four-phased approach to preventing perinatal HIV transmission 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 1 Phase 2 Phase 3 Phase 4 CSIS Renewing US Global Leadership in RH, 2/5/09 FP MDGs Overview, March 10 31

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 Many programs that provide services to HIV positive individuals, are “overwhelmed” with providing general services and are unable to provide FP. FP/HIV integration research… Sources: Rochat et al., JAMA 2006:295:1376-8; Desgrées-du-Loû et al., Int J STD AIDS 2002;13:462-468; Bangendanye, et al., Presented November 2007. FP MDGs Overview, March 10

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 FP MDGs Overview, March 10 CSIS Renewing US Global Leadership in RH, 2/5/09 33

Family Planning Critical to Achieving MDGs Reduced child mortality Improved maternal health Gender equity Universal primary education Combatting HIV/AIDS Environmental sustainability Sexual and reproductive health Eradication of poverty To conclude, this is a wonderful visual of how reproductive health, particularly family planning, forms the roots and trunk of the tree that are critical to the success of all the Millennium Development Goals to improve lives worldwide. Global partnership for development Courtesy of Jeff Spieler, USAID. Adapted from HRP/RHR/WHO

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

Source: Adapted from WHO 2006 Current contraceptive methods and typical effectiveness More effective How to make your method most effective Less than 1 pregnancy per 100 women in one year Vasectomy Female Sterilization Implant After procedure, little or nothing to do or remember Vasectomy: Use another method for first 3 months IUD 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 LAM Injectables Pills Patch Ring Male Condoms Female Condoms Condoms, diaphragm, sponge, withdrawal: Use correctly every time you have sex . Sponge Diaphragm Withdrawal Some years ago, Markus Steiner – a colleague from FHI 360 – conducted research to better understand how individuals understand the effectiveness of various contraceptive options. The goal of this work was to improve how service providers counsel users with regard to effectiveness. He and others then worked with the World Health Organization to develop this pictorial presentation that has become a centerpiece of counseling materials in many developing country programs. Fertility-Awareness Based Methods Spermicide: Use correctly every time you have sex Fertility-awareness based methods: Abstain or use condoms on fertile days. Spermicide Less effective About 25 pregnancies per 100 women in one year Source: Adapted from WHO 2006

Pregnancy risk and continuation rates for select contraceptive methods at one year Perfect Use Typical Use No method 85 Male condom 2 18 Pill, Patch, Ring 0.3 9 Depo-Provera 0.2 6 Copper-IUD 0.6 0.8 Mirena Implanon 0.05 Female sterilization 0.5 Male sterilization 0.10 0.15 For the quantitative in the audience, this is another way of looking at effectiveness data (that used by FDA) Contraceptive effectiveness is a measure of the success of typical use of a method. It incorporates efficacy – how well a method works when used consistently and correctly – and other factors such as compliance with use. While PERFECT USE is similar for all but the condom, typical use is much higher for the user-dependent methods. PERFECT use failure rates: Low for all methods, even for the condom. TYPICAL USE failure: Quite high for user-dependent methods. Source: Trussell, Contraception 2011; 83:397-404.

Pregnancy risk and continuation rates for select contraceptive methods at one year Perfect Use Typical Use Percent Continuing No method 85 Male condom 2 18 43 Pill, Patch, Ring 0.3 9 67 Depo-Provera 0.2 6 56 Copper-IUD 0.6 0.8 78 Mirena IUS 80 Implanon (implant) 0.05 84 Female sterilization 0.5 100 Male sterilization 0.10 0.15 Another challenge with user-dependent methods relates to continuation rates which also have an overall impact on pregnancies – highlighted in Yellow. Source: Trussell, Contraception 2011; 83:397-404.

Benefits of Implants vs. Shorter-acting Methods If 20% of OC or injectable users in Africa switched to implants -- over next 5 years, it would avert: 1.8 million unplanned pregnancies 576,000 abortions 10,000 maternal deaths As I just mentioned, long-acting methods, including implants, are more effective in practice than shorter acting methods, including oral contraceptives and injectables, because compliance and continuation rates are higher. As this slide illustrates, widespread use of implants could significantly reduce the numbers of unintended pregnancies, abortions, and maternal deaths in Africa. A similar impact would be seen with IUD use. Source for quote on slide: Hubacher, D, Mavranezouli, I, McGinn, E. Unintended pregnancy in sub-Saharan Africa: Magnitude of the problem and potential role of contraceptive implants to alleviate it. Contraception 2008.78: 73-78. Grimes, D. Forgettable contraception. Contraception. 2009;80(6):497-9. The impact would be even more dramatic adding new users Similar impact with a shift to IUDs. Hubacher, Mavranezouli, and McGinn, Contraception 2008

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

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 Many people say that our greatest challenge is to get out the technologies that we already have. That is indeed partially true, as my previous slide suggests. However, existing methods clearly do not meet the needs of all women or couples. Each of the available methods, in and of themselves, have advantages and disadvantages. Some methods are hard to use consistently and correctly, and that leads to high typical use failure rates. Most existing methods have side effects - These side effects may be acceptable or tolerable to some women and unacceptable for others. Data from many studies, and from DHS surveys, clearly document the fact that 25 to 50%, and even more, of women discontinue use of their chosen contraceptive within the first year. Side effects or fear of side effects is typically most common reason. In addition, there is a dramatic change in the needs and desires of women over their reproductive lives. For example, the needs and optimal choices of young women in their teens or early 20s are very different from the needs of a woman wanting to limit her childbearing in her 30s or 40s.

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 What should be the target qualities of new methods? First, in addressing the shortcomings of some existing methods, a new method would ideally be highly effective in typical use. It goes without saying that a method should be safe and acceptable. Increasingly, there are many women with chronic disease states that make them poor candidates for some methods, e.g. estrogen-containing oral contraceptives. Some attention should be paid to developing new methods that would be safe and broaden choice for these women. Additional health benefits – could advance health causes and also make new methods more appealing to potential users.

Ratio of Health Provider to Population This slide emphasizes the importance of having new methods that are easy to use by lower level health care providers Courtesy of Scott Radloff, USAID, 2011

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)

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 Sino-implant (II) is a new low-cost, highly effective contraceptive implant. Sino-implant (II) is composed of two thin rods, each containing 75 mg of levonorgestrel, the active ingredient. It is similar to Jadelle, in that it provides the same amount of levonorgestrel and has the same mechanism of action. It is currently labeled for four years of use and is distributed with a CE-marked disposable trocar. The CE mark indicates the trocar meets European quality standards of manufacturing. The disposable trocar eliminates the need for autoclaving and facilitates service delivery in resource poor settings. Almost $7.5 million in cost savings to date for over 500K implants.

Population Council Nes/EE vaginal ring Mention that vaginal rings are being evaluated as dual protection technologies. Designed to last one year

Depo-subQ Provera 104 delivery in Uniject For FIGO Faculty Use Only. DO NOT COPY OR DISTRIBUTE. For FIGO Faculty Use Only. DO NOT COPY OR DISTRIBUTE. Depo-subQ Provera 104: New formulation for subQ injection 30% lower dose (104 mg vs. 150 mg) Approved by USFDA (2005) and EMA/UK Uniject: Single dose, prefilled, sterile, non-reusable Easier to use by non-clinical personnel/CHWs Compact; easy to use and store Potential for home- and self-injection Approval by EMA. LDC registration forthcoming 47

Lower-cost alternative to Mirena

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 A low-cost, non-surgical option for female sterilization would provide an important opportunity for many women who either fear or can’t get access to surgical sterilization. A new approach such as Essure, is too expensive and difficult to deliver to be applicable to most low-resource settings. Chemical/drugs, such as sclerosing agents, may be low cost alternatives. Male methods: Suppress the production of sperm; Physically disrupt sperm transport; Disrupt sperm maturation; Disable sperm function (Will be covered in more detail in another session at this meeting) Peri-coital method: Many women have infrequent sex and feel they don’t want a method that they have to use continuously. Anecdotal information from repeat ECP users that a method a woman could use at the time of coitus - just before or soon after sex – would be desireable. But it must be highly effective! Immunocontraception has been a somewhat controversial area. Much research was funded in the 80s on this approach. I believe that gaps in knowledge about the immune system were limiting. Advances in immunology that have taken place over the last decade may provide a renewed opportunity for thinking in this area. Many targets (both male and female) are already identified. Most experts and women’s rights advocates believe that a permanent immuno-contraceptive approach would provide too great an opportunity for misuse. However, an approach that would require periodic boosters could be exciting. For my last point, imagine you could say to a woman, you can take a pill that would prevent breast cancer, the only side effect is that you won’t get pregnant. This would be true innovation in contraceptive technology. It is this type of long-term dream/vision that at least some research needs to focus on.

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

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 CSIS Renewing US Global Leadership in RH, 2/5/09 FP MDGs Overview, March 10 51

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

US Funding for HIV and Family Planning $ Billions Appropriated Funding for HIV is essential but this comparison highlights one of the stark realities of international population assistance – that is, the political sensitivity and strong feelings have interfered with common sense with regard to support for FP. www.guardian.co.uk/environment/2011/oct/24/population-hiv-aids-mistake-un Source: CRS (2010) Ted King Lecture, March 2011 53

US Humanitarian and development assistance The irony of these figures is that a recent survey showed that most Americans think that we spend about 25% of our budget on foreign assistance. This shows the truth – about 0.5% on all non-defense foreign assistance. And as I said, within this little sliver is the approximately $500 to $600 million devoted to women’s health! Sources: Office of Management and Budget. historical Table 4.1. outlays by Agency:1962–2016. www.whitehouse.gov/omb/budget/historicals/; InterAction. Federal Budget Table - FY 2011 CR extension. (february 15, 2011) www.interaction.org/document/ interaction-federal-budget-table-2011-cr-extension Save the Children analysis – 2011 Sources: OMB; White House; FY 2011 CR extension

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 If the currently global financial crisis, who knows what will really happen with new funding!

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 October 31, 2011 has been designated “7 Billion Day.” The year before I graduated from Lafayette, the world population reached 4 billion (1974). People were beginning to notice. In October of 1999, just 12 years ago, the population reached 6 billion. So, how much will Americans spend this year, despite the economy, on Halloween? I think we should all celebrate a day that brings joy to kids and chocolates to stomachs, but I would encourage each of you to consider Halloween in a slightly different way this year – because that’s the day that the 7 billionth person will enter this world. Consider being a little more modest and contributing to an organization that helps women and children globally.

Conclusions Expanding choice of the number and spacing of children 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 According to the United Nations, or around October 31st, the world’s 7 billionth person will be born. The year before I graduated from Lafayette, the world population reached 4 billion (1974). People were beginning to notice. In October of 1999, just 12 years ago, the population reached 6 billion. Next week, when many are out trick-or-treating, the world will pass the 7 billion mark…

Some fun web sites to visit www.fhi360.org www.prb.org www.guttmacher.org www.popcouncil.org www.statcompiler.com www.measuredhs.com www.usaid.gov/our_work/global_health/pop/techareas/index.html www.gatesfoundation.org www.nrf.com/modules.php?name=Dashboard&id=54

Thank you!

www.7billionactions.org According to the United Nations, or around October 31st, the world’s 7 billionth person will be born. The year before I graduated from Lafayette, the world population reached 4 billion (1974). People were beginning to notice. In October of 1999, just 12 years ago, the population reached 6 billion. Next week, when many are out trick-or-treating, the world will pass the 7 billion mark…

Drivers of Population Growth Unwanted fertility High desired family size Population momentum Year 9.2 8.3 7.5 6.8 Population size (in billions) 4 5 7 8 9 10 2 3 6 1900 1950 2000 2050 2100 Source: Adapted from Bongaarts (2010) CSIS Renewing US Global Leadership in RH, 2/5/09 FP MDGs Overview, March 10 61

Sequential Age Pyramids for Africa Small changes in fertility can have significant population effects over time Sequential Age Pyramids for Africa in 1960, 1990, & 2010 Male Female Number for each age group in 1,000 Both the total population and youth bulge have grown Source: John May, World Bank * 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.