Meeting Objectives Present data on the status and trends of FP needs and

programs in sub-Saharan Africa.

Identify effective strategies to demonstrate the importance of strong FP programs within the context of health and development priorities in SSA.

Identify next steps to effectively mobilize existing resources to strengthen FP programs to address current health and development priorities in SSA.

Status and Trends of Family Planning in Sub-Saharan Africa

USAID Africa Bureau and

Global Bureau for Health

October 30, 2002

FP in Sub-Saharan Africa Task Force

Khadijat Mojidi Nomi Fuchs

Daniel KabiraKatharine KreisDaniel Halperin

Jyoti Schlesinger

Kendra PhillipsAdrienne CoxDana Vogel*

Population of Sub-Saharan Africa by Age and Sex: 2000 and 2005

Source: U.S. Bureau of Census.

MaleMale FemaleFemale

Age group 10 – 19 represents 24% of the total population

Fertility Decline in Selected World Regions, Early 1960s to 2002

6.7

5.8

6.7

6.0

2.7

2.5

2.5

1.6

5.4

3.0

2.74.6

0 1 2 3 4 5 6 7 8

Latin America

Asia

Sub-Saharan Africa

Developingcountries

Developedcountries

WorldEarly 1960s

2002

Children per woman*

* The average total number of children a woman will have given current birth rates.Source: US Bureau of the Census, International Data Base, September 23, 2002.

African Contraceptive Prevalence Rate Compared to Other Regions

Source: Population Reference Bureau, 2002.

Rate of Modern Contraceptive Prevalence among Married Women

13

43

5962

0

10

20

30

40

50

60

70

Sub-Saharan

Africa

North Africa Asia (exc luding

China)

Latin America

Wo

me

n u

sin

g c

on

tra

ce

pti

on

(%

)

Family Planning Data

Population/Family Planning Programs in Africa – 25 Programs

Ongoing Programs West Africa RegionalBenin ProgramDR Congo Burkina FasoEritrea CameroonEthiopia Cote d’IvoireGhana TogoGuineaKenyaLiberiaMadagascarMalawiMaliMozambiqueNigeriaREDSO/ESARwanda SenegalSouth AfricaTanzaniaUgandaZambiaZimbabwe

Strategic Objective in Population and Family Planning

Trends in Contraceptive Prevalence Rates: Select Countries

* Percent of married women ages 15 to 49 using modern contraception.Source: Demographic and Health Surveys 1978-2001.

Wo

me

n u

sin

g c

on

tra

ce

pti

on

(%

)*

Representative Contraceptive Prevalence Rates* (population in millions)

Source: Demographic and Health Surveys, most recent available data. No recent data available for Angola, DR Congo, Lesotho, and Swaziland. Total population, mid-2002. 2002 World Population Data Sheet, PRB, 2002.

* Married women, Modern Methods

Contraceptive Prevalence and Adult HIV Prevalence

Source: Report on the global HIV/AIDS epidemic. UNAIDS, July 2002; DHS; UN. Hill K, et al. Estimates of maternal mortality for 1995, Bulletin of the World Health Organization 79(3), WHO 2001: 182-193.

5% - 9.9%

10% - 19.9%

1% - 4.9%

Over 20%

Modern Contraceptive Prevalence,

Married Women 15-49

Adult HIV Prevalence

2002

3% - 9.9%

10% - 14.9%

1% - 2.9%

Over 15%

0% - 0.9%

3.5

4

4.5

5

5.5

6

6.5

7

7.5

8

1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Mali Ghana Kenya Madagascar SenegalTanzania Uganda Zambia Zimbabwe CameroonTogo Nigeria Ethiopia Malawi

Comparison of Total Fertility Rates for Selected African Countries: 1986-2000

Source: DHS for years indicated.

To

tal

Fe

rtil

ity

Ra

te (

ch

ild

ren

/wo

ma

n)

Use and Total Unmet Need* Women 15-49

0

10

20

30

40

50

60

Chad

1996

/97*

*

Niger 1

998

Nigeria

199

9

Benin

199

6

Camer

oon

1998

Ghana

199

8

Mal

i 199

6

Guine

a 19

99

Zambia

199

6

Burkin

a Fa

so 1

998/

99

Cote

d'Ivo

ire 1

998/

99

Togo

1998

Seneg

al 1

997

Liber

ia 19

86

Ethiop

ia 2

000*

*

Zimba

bwe

1999

Ugand

a 20

00/0

1

Kenya

199

8**

Mal

awi 2

000*

*

Use Total Unmet Need

Source: Demographic and Health Surveys.

*All women 15-49, modern methods.**Currently married women 15-49, modern methods.

Unmet Need for Contraception Among Adolescent Women Ages 15-19, by Marital Status

Source: DHS, 1994-1998. Data re-produced from PRB, 2001.

28

7

50

43

27

50

22

40

30

46

24

43

32

20

50

25

47

25

48

20

0

5

10

15

20

25

30

35

40

45

50

Cote d'Iv

oire

Ghana

Keny

a

Madag

asca

rMali

Mozam

bique

Sene

gal

Tanz

ania

Ugand

a

Zambia

Zimba

bwe

Married Unmarried, sexually active

Wo

me

n i

n n

ee

d o

f c

on

tra

ce

pti

on

(%)

* Senegal and Zimbabwe have data only regarding married women using modern methods.

FP Summary Africa’s high fertility will ensure continued rapid growth

throughout most of the region and will surpass 1 billion in 25 years.

Twenty-one of the 25 countries that USAID supports has CPRs of less than 20%--with most under 10%.

High unmet need for family planning among all of reproductive age, especially adolescents who are risk for both pregnancy and HIV.

Data suggests need to revisit USAID programming in responding to country FP and HIV needs.

Maternal and Child Health Data

Western Africa1,040

Eastern Africa1,340

North Africa460

Central Africa 1,020

Southern Africa360

*Maternal deaths per 100,000 live births

Maternal Mortality Ratio*

Source: Kenneth Hill, Carla Abou Zahr, & Tessa Wardlaw: Estimates of maternal mortality for 1995. Bulletin of the World Health Organization, vol.79, no.3, 182-193.

Sub-Saharan Africa 1,100

South Asia 430

East Asia/Pac. 140

LAC 190

DevelopingCountries 440

Maternal Mortality andAdult HIV Prevalence

600 - 1,199

1,200 – 1,799

Less than 600

Over 1,800

Maternal Mortality Ratio(Maternal Deaths

Per 100,000 Live Births)

Source: Report on the global HIV/AIDS epidemic. UNAIDS, July 2002; DHS; UN. Hill K, et al. Estimates of maternal mortality for 1995, Bulletin of the World Health Organization 79(3), WHO 2001: 182-193.

Adult HIV Prevalence

2002

3% - 9.9%

10% - 14.9%

1% - 2.9%

Over 15%

0% - 0.9%

CPR and Maternal Mortality Ratio by Country

55.1

50.4

32

26.1

18.2 16.914.4

8.6 8.2 7.3 6.3 5.7

13.4

1059

867

586

11291198 1188

1841

630576

609

341

1339

1056

0

10

20

30

40

50

60

SouthAfrica1998

Zimbabwe1999

Kenya1999

Malawi2000

Uganda2000/01

Tanzania1999

Zambia1996

Ghana1998

Nigeria1999

Senegal1999

Coted'Ivoire1999

Ethiopia2000

Mali 2001

0

200

400

600

800

1000

1200

1400

1600

1800

2000CPR Maternal Mortality per 100,000 births

Source: Demographic and Health Surveys for CPR. Hill K, et al. Estimates of maternal mortality for 1995, Bulletin of the World Health Organization 79(3), WHO 2001: 182-193.

Pe

rce

nta

ge

of

wo

me

n u

sin

g m

od

ern

me

tho

ds

De

ath

pe

r 1

00

,00

0 b

irth

s

Maternal Mortality Summary

Maternal mortality rates in SSA are unacceptably high, ranging from 341 (South Africa) to 1841 (Ethiopia) per 100,000 women, nearly two to three times that of the rest of the developing world.

Most maternal deaths are due to: Closely-spaced births Complications during delivery and unsafe abortions Inadequate obstetrical care

Family planning could reduce maternal mortality by 20% or more.

Under 5 Mortality andAdult HIV Prevalence

Source: UNAIDS/WHO; U.S. Census Bureau

130-149

150-174

Less than 129

Over 175

Under 5 Mortality(Deaths per 1,000

Live Births)

Adult HIV Prevalence

2002

3% - 9.9%

10% - 14.9%

1% - 2.9%

Over 15%

0% - 0.9%

77.1

216.5

119.4

96.1

233.8

318.2

192.4

131.8

147.4

102.1

166.5

107.3 111.5

188.6

273.8

140.2 142.5151.5

0

50

100

150

200

250

300

350

Ethiopia 2000* Ghana '93,'98 Kenya '93,'98 Malawi '93,'00 Niger '92,'98 Nigeria '90,'99 Senegal'92/93,'99

Uganda '95,'00 Zimbabwe'94,'99

De

ath

s p

er

1,0

00

liv

e b

irth

s

Source: Demographic and Health Surveys of indicated years. UNIICEF for regional U5 mortality rates for 2000.

Under-Five Mortality Rates in Selected African Countries: two points in time

Note: Mortality rates given are for the five-year period prior to the survey. * In Ethiopia’s 2000 survey, the previous period is based on recall.

U5M Regional Averages:

SSA 172

South Asia 101

East Asia/Pac. 44

LAC 38

Dev. Countries 90

177.7166

155

142 142

125.2117

106 10498

52

185.9

102

6859

105102.3 99 95 91

66 64.467

59

0

20

40

60

80

100

120

140

160

180

200

Mal

i 19

96

Ethio

pia 2

000*

Mal

awi 2

000*

Burki

na Fas

o 199

9

Guinea

199

9

Togo 1

998

Uganda

2000

/01

Camer

oon 1

998

Ghana

1998

Niger

ia 1

999

Kenya

199

8

Seneg

al 1

997

Dea

ths

per

1,0

00 i

nfa

nts

un

der

ag

e o

ne

Less than two years At least 2 years

Infant Mortality by Birth IntervalOn average, infants born after short birth intervals are twice as likely to die as those born after intervals of two or more years.

Source: Country DHS Reports.* Figures here are only for a 2 year birth interval instead of a 2-3 year interval.

0 50 100 150 200 250 300

GabonGhanaKenya

South AfricaZimbabweSwaziland

NamibiaBotswana

TogoCameroon

LesothoBurundiNigeria

DR CongoUganda

CARCongo (Brazz.)

BeninCote d'Ioire

TanzaniaEthiopiaZambiaMalawi

RwandaBurkina FasoMozambique

Deaths per 1,000 live births

Without AIDS With AIDS

Under Five Mortality with and without AIDS: 2002

Source: Stanecki, K. The AIDS Pandemic in the 21st Century. Draft report XIV International Conference on AIDS, Barcelona, U.S. Bureau of Census, International Database, July 2002.

Infant and Child Mortality Summary

African children are 3-4 times more likely to die than children in other regions.

Infants are twice as likely to survive if the previous birth interval is at least 2 years. Very few children in SSA are spaced at a birth interval of 3 or more years.

Family planning can make a difference.

HIV and CPR Relationship Data

Spread of HIV over time in sub-Saharan Africa, 1984 to 2002

Source: WHO and UNAIDS June 2002.

Estimated percentage of adults(15–49) infected with HIV

20.0% – 36.0%10.0% – 20.0% 5.0% – 10.0% 1.0% – 5.0% 0.0% – 1.0%1994

1984 1989

2002

Adult HIV Prevalence Rates* (Adult population in millions)

Source: Report on the global HIV/AIDS epidemic, UNAIDS 2002. HIV prevalence data for Gabon, Guinea, Liberia, Mauritania, and Niger is from AIDS in Africa: Country by country, UNAIDS 2000.

* Adult HIV prevalence and population (15-49).

HIV and CPR Relationship

Adult HIV/AIDS Prevalence

CP

R (

mo

de

rn m

eth

od

s)

Botswana*KenyaLesotho*Malawi

Burundi*CAR*Cameroon Cote d’Ivoire

Higher (>8%) HIV Lower (<8%) HIV

Higher (>20%)

CPR

Lower(<20%)

CPR

NamibiaSouth AfricaSwaziland*Zimbabwe

MozambiqueRwanda TanzaniaZambia

AngolaBeninBurkina FasoChad*Comoros*CongoDR CongoEritrea

EthiopiaGabon*Gambia*GhanaGuineaGuinea Bissau*LiberiaMadagascar

MaliMauritania*Niger*NigeriaSenegalSierra Leone*Somalia*Sudan*TogoUganda * Denotes countries where USAID does not work.

Lower HIV and Higher CPR

Higher HIV and Higher CPR105 million people

No SSA countries fall in this category

Lower HIV and Lower CPR466 million people

Higher HIV and Lower CPR118 million people

HIV and CPR Relationship

Higher HIV/Higher CPR105 million

Higher HIV/Lower CPR118 million

Lower HIV/Lower CPR466 million

Lower HIV/Higher CPRNo SSA countries in this category

Ecological Relationship Between Male Circumcision and Heterosexual HIV Transmission

Sources: Halperin D, Bailey R. “Male circumcision and HIV infection: 10 years and counting.” Lancet 1999; 354:1813-5.

Notes: * Countries excluded from table for following reasons: 1) estimated proportion of men circumcised >20%, <80%; 2) similar risk factors for heterosexual HIV not present; 3) insufficient information; 4) very small countries.

** June 1998 UNAIDS/WHO percent estimates. *** If the predominately non-circumcising region of western Kenya, where seroprevalence is approx. 35%, is excluded, national prevalence would be approx. 8%.

<20% Circ. Seroprevalence** >80% Circ. Seroprevalence**

Zimbabwe 25.84 Kenya 11.64***Botswana 25.10 Congo (Braz.) 7.64Namibia 19.94 Cameroon

4.89Zambia 19.07 Nigeria 4.12Swaziland 18.50 Liberia 3.65Malawi 14.92 Sierra Leone 3.1Rwanda 12.75 Ghana 2.38

Benin 2.06

HIV-1 prevalence in African countries with similar risk factors for heterosexual HIV infection.*

World Population Projections by Region or Country

Source: PRB World Population Data Sheet, 2001.

24

13

21

17

9

12

5

25

16

18

17

9

95

26

20

17

17

974

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nt

of

wo

rld

po

pu

lati

on

2001 2025 2050

Year

North America

Europe

LAC

India

China

Africa

Other Asia and Oceania

Even with the world’s worst HIV epidemic, the population growth rate in Africa will continue to increase at the most rapid rate.

Summary of HIV and CPR Relationship:

SSA countries with the worst HIV epidemics tend to have higher CPR, lower MMR, and lower TFR.

While AIDS has exploded in some SSA countries, HIV rates in most of Africa have remained at relatively low levels.

Epidemiological data on the male circumcision-HIV relationship suggests there may be limits to the spread of HIV in most West African and some other SSA countries, where male circumcision is widely practiced.

Most SSA countries (584 million people out of 688 million total) have very high FP needs, with CPR usually less than 20%. Of these, 466 million people live in countries with both very low CPR and HIV prevalence less than 8%.

Funding Data

0

100

200

300

400

500

600

1995 1996 1997 1998 1999 2000 2001

Year

Fu

nd

ing

Am

ou

nt

in m

illio

ns

Agency

Africa Bureau

USAID Population Funding Trends

Source: USAID Agency Funding Data, Global Population Office.

USAID PHN Funding Trends: SSAPopulation: 673 million

0

50,000

100,000

150,000

200,000

1995 1996 1997 1998 1999 2000 2001 2002

Year

Fu

nd

ing

Am

ou

nt

($0

00

s)

Health includes: Child Survival, Infectious Disease, Other Health, and Vulnerable Children (FY00-03)

Population

HIV/AIDS

Health

Source: Africa Bureau OYB.

Repositioning Family Planning

Africa’s population will continue to increase, averaging about 2.5% increase per annum.

While TFR has declined rapidly in other regions, fertility in Sub-Saharan Africa lags far behind - double that of Asia and Latin America.

There are 584 million people living in 35 SSA countries with contraceptive prevalence less than 20% (most less than 10%).

While HIV/AIDS has exploded in parts of southern and East Africa, West Africa (except Cote d’Ivoire and Cameroon) still has HIV prevalence of less than 8% (usually less than 5 or lower).

Approaches for Resuscitating FP in Sub-Saharan Africa

Promoting FP in HIV/AIDS Settings Promoting Child Spacing in Pre-natal

Settings Promoting Post Partum FP Addressing Unmet need, especially

youth Promoting Male involvement in FP

Questions and Answers