People the world over come here every day looking for family planning information. Knowing that, I have decided to create a compendium post of sorts about everything I have learned and seen about family planning in my travels to and reporting from sub-Saharan Africa over the past few years.
I first learned about the critical importance of family planning when I covered the London Family Planning Summit a few years ago. Melinda Gates, along with key partners, called on governments and civil society to lay out a strategic plan to provide family planning services and contraceptives to 120 million underserved women in low-and middle-income countries. Currently there are 222 million women around the world who would like to space or delay their pregnancies.
Read the current Family Planning 2020 Progress Report with full commitments since the 2012 Summit. Undoubtedly there is a long way to go to reach the unmet need for modern contraceptives, but the initial commitments have been promising. $1.3 billion USD in funding for family planning was delivered in 2013 enabling 8.4 more women and girls to have access to modern contraceptives.
At the London Summit, I will remember the commitments read by country representatives. Dr. Tedros Adhanom Ghebreyeseus, former Minister of Health of Ethiopia, stood out. He said, “Inaction is no longer an option. It’s not what we promise today, but what we do when we get back home.”
Below are photos of family planning services and programs as well as modern contraceptives from Addis Ababa, Lusaka, Johannesburg and Dar es Salaam.
In sub-Saharan Africa, 49 million women use traditional methods of family of no family planning methods at all. In Ethiopia, 39.1 percent of women use modern contraceptives up from 15 percent in 2005. The current low rate of contraceptive use in Ethiopia is a result of a combination of factors: cultural biases as well as a lack of trained health workers that can reach every woman in the country. Ethiopia is Africa’s second-most populated country behind Nigeria with 90 million people and only has a few hundred OBGYNs. There is currently only one obstetrician for 1.8 million women in Ethiopia.
That said, Ethiopia’s federal government has done an exceptional job training health workers since its Health Extension Workers program officially launched in 2003. Now 34,000 women strong, Ethiopians are afforded access to skilled health workers in their villages and cities, but there is still an unmet need for reproductive health and family planning services from health professionals.
The University of Michigan was recently gifted an anonymous $25 million dollar grant to train Ethiopian doctors in reproductive health services. University of Michigan’s new Center for International Reproductive Health Training will train incoming doctors, nurses and midwives in comprehensive family planning services at seven medical schools across Ethiopia. The first phase of the grant will be used to build upon the work the University of Michigan is already doing at St. Paul Hospital Millennium Medical College in Addis Ababa.
“Every day, women across the globe are dying and suffering from poor health outcomes because they don’t have access to high quality, comprehensive reproductive health care,” says Senait Fisseha, M.D., J.D., the center’s director in a statement. Fisseha, who was born in Ethiopia, is a reproductive endocrinology and infertility specialist at the U-M Health System.
“We are overwhelmingly grateful for this extraordinary grant that allows us to build on our strong foundation of global reproductive health programs and continue to pursue a longtime dream to provide all women a full scope of high quality reproductive health care when and where they need it.”
With a maternal mortality ratio of 420 per 100,000 live births in Ethiopia, family planning services are essential to keep more mothers alive, especially teenage mothers who are not prepared physically to bear children. The average Ethiopian woman has 5.5 childrenaccording to the most recent demographic data.
“Our center will help empower women to make their own decisions about their own reproductive health, thereby choosing whether and when to start a family,” Dr. Fisseha continued. “Our ultimate goal is to help train future generations of capable and competent health care providers in many parts of Africa and South Asia who can deliver comprehensive reproductive health services, and also be advocates for the safest and best health care possible at every stage of a woman’s life.”
Virgila is more charismatic and animated than most actors I know.
She’s a PSI-trained health worker on the outskirts of Port Au Prince, Haiti. And she’s passionate about her work. She goes door-to-door educating women about the benefits of reversible contraception like the IUD.
Giving birth is dangerous business for Haiti’s poor, who suffer the highest maternal mortality rate in the western hemisphere. To save the lives of mothers, we must ensure that we prevent unintended pregnancies from occurring.
Virgila says, “I reach women wherever they are. I go door-to-door. I go to hospitals. I go to mother’s associations. I go to community meetings.”
She waves her arms, “There is so much need. It’s never ok to stop working. I want women to be able to have the number of children they want.”
Roslyne, a woman who arrived at the clinic today to get an IUD says, “Ms. Virgila knocked on my door one day. That’s why I’m here.” Roslyne — who ekes out a living for her family by selling spinach she grows — has five children, ages 13, ten, six, two and one. She didn’t know about the IUD before Virgila told her about it.
The work Virgila does changes people’s lives — plain and simple. Please join me and support the effective work of community health workers. For a short time, your donation will go twice as far through this generous challenge match.
P.S. Peter Singer says, “I recommend PSI because they focus on interventions with proven impact that help children survive the most serious health challenges they face — like a lack of family planning, HIV and AIDS.” Donate now.
Ashley Judd is a celebrated American actress and humanitarian. She became an ambassador for PSI in 2002 and served as a board member from 2004 to 2013.
In Tanzania, orange has increasingly become the recognized color of family planning and reproductive health services. Population Services International’s orange Familia brand is quite common in most regions of this coastal country of 49 million. PSI, a global non-profit organization dedicated to improving the health of people in the developing world, has consistently and effectively branded everything in its nationwide Familia social franchise network since it began in 2009 with unforgettable orange and its semi-cursive Familia logo that bears a heart at the beginning of its name. All aspects of the Familia social franchise network from its clinics’ signage to the clothing of its health workers to its condom brand that claims in part 80% of Tanzania’s condom market and its health education booklets, all get PSI’s extensive branding treatment. The result: PSI Tanzania was able to serve 119,000 clients in 2013 through Familia via word of mouth and effective marketing.
Familia is PSI’s social franchise network of over 260 private sector clinics across 23 regions that primarily provides family planning, cervical cancer and maternal health services as well as health services for children under the age of five in urban and peri-urban community settings in Tanzania. Tanzania’s most remote areas are serviced by PSI outreach teams.
Over the years I have had the distinct privilege of meeting health workers around the world from Ethiopia and Kenya to Tanzania and South Africa to India and Brazil. Health workers, particularly in low- and middle-income countries, are the unequivocal backbone of health systems that can oftentimes be severely taxed due to the overwhelming number of people who rely on them for care to the disarray of health systems’ frameworks coupled with a dismal lack of financial allocations to national health care.
Frontline health workers I have met throughout the years. Left to right: Angawadi workers in Delhi, a family planning health worker in Johannesburg, a member of the Health Development Army in Hawassa, Ethiopia, hospital administrators in Lusaka, Zambia, and nurses in Morogoro, Tanzania.
While her husband holds their youngest child, Twesigye Christente waits to receive a long-acting contraceptive at the Kinaaba Health Center II. Photo: UNFPA/Omar Gharzeddine
This week Uganda held its first national family planning conference in Kampala. This is particularly significant because family planning has not always been pressing on the agenda of Uganda’s longtime president, Yoweri Museveni. In fact, under Museveni’s 30 year leadership, Uganda’s population more than doubled from 1986 until 2012. Museveni has traditionally advocated for a large population that he believed could boost economic growth for Uganda. But during this week’s family planning conference Museveni changed his stance on women’s right to space their pregnancies saying, “Although I advocate for a big population, I have realised that a poor quality population cannot transform the country.”
Family planning has gained worldwide traction since the London Family Planning Summit held in July 2012. At the summit, Uganda committed to decreasing its unmet need for family planning services by 40 percent and increasing its budget for family planning by 30 percent from $3.3 million USD to $5 million USD. By 2022, Uganda wants its unmet need for family planning services to reach 10 percent. Right now Uganda’s unmet need for family planning services hovers around34 percent.
Uganda has extensive work to do in order to reach its summit commitments, but this week’s national family planning conference signals to the world that it government leaders have amassed enough political will to put family planning on its national agenda and to be held accountable for its public goals.
As the world learns more about the promise of women to bring peace, prosperity and economic well-being to nations, Rwanda has become a poster child of this promise. Thriving after one of the most brutal genocides in history, today Rwanda is referred to as the heart of the African Renaissance.
In September’s elections Rwandans once again voted in a female majority parliament, directly electing 26 women in addition to the 24 seats reserved for females in the constitution. Rwanda has come to be the world’s leader in women lawmakers holding an unprecedented 64 percent of seats in Rwanda’s parliament, more than any another country in the world. Women also occupy some of the most important government ministries, holding approximately one third of all cabinet positions.
As a result, life is changing fast for women in Rwanda and these investments in women will have a ripple effect that will improve life for their families, communities and the country as a whole. To begin a list of astounding accomplishments, the small African nation has cut poverty by 12% in six years, from 57% of its population to 45%. This is roughly one million Rwandans emerging from poverty, most of them women and children — one of the most stunning drops in the world.
Paul Collier, director of the Center for the Study of African Economies at Oxford University notes that Rwanda can be compared to an East Asian-style “developmental state,” where the government is very serious about growing the economy. “The economy was well managed, with inflation kept low, and the business environment improved.” As a result, over the course of six years Rwanda has moved from around 140th to 60th in the World Bank’s “Doing Business” annual rating.
Some changes in Rwanda are obvious to the eye, such as houses that have tin roofs instead of thatch. A decent roof is one of the first changes people make when they start the ascent out of poverty. Some of the changes are psychological. There is a sense and a hope that things really can improve, and a sense that individual families can do something to better their circumstances.
Josh Ruxin, director of Rwanda Works has lived with his family in Rwanda since 2005. He notes the amazing infrastructure and economic development improvements he has witnessed. “Five years ago, traveling anywhere in the country was bound to be a bumpy ride, if the way was even passable. Today, east-to-west and north-to-south, the road infrastructure is impressive and continues to expand. Five years ago, the country struggled to get tourists in for $375 permits to visit Rwanda’s mountain gorillas. Today, during high season, there are not enough $500 tickets to meet the demand. Five years ago, there were no supermarkets or ATMs, and the cheapest cell phones cost $50. Today there are multiple supermarkets, over a dozen international ATMs, and cell phones that cost $14 are plentiful.”
Ruxin notes that access to formerly inconsistent electricity and running water even for those who could pay for it, is being constantly improved. Hotels and restaurants are popping up everywhere and a service sector is emerging to meet heightened tourism demand. Wireless broadband is being installed across the country and more universities, technical schools, and preschools are opening. The second national language has shifted from French to English.
A Dedicated Focus on Health Outcomes and Family Planning
To accomplish the stunning drop in poverty major investments were made in the rural poor and extensive improvements were made in health programs and outcomes. Collier notes that “most of the achievement is likely due to domestic policies.”
At a summit to review the UN Millennium Development Goals (MDG), Rwanda was commended for its very likely success in meeting and possibly even surpassing the MDG targets for child and maternal mortality by 2015. According to officials at UNFPA, the United Nations Population Fund, which provides contraceptives and other support to rural communities, Rwanda has literally brought its health care system back to life. The government has initiated bold reforms and innovative approaches to make health care accessible and affordable for everyone, with a strong emphasis on reproductive health, including family planning.
Much of the credit for successes goes to the government’s successful health insurance program. Its removal of user fees for family planning services has contributed to significant increases in use of services. There has been a jump from 9% to 26% of contraceptive prevalence among married women aged 15-49, and the skilled birth attendance rate increased from 39% to 52%.
“This a real achievement,” says Asha Mohamud, a reproductive health advisor for UNFPA. “It often takes decades for countries to see this kind of change.”
The Mayange Health Centre is located in the heart of the Bugesera district, just south of the capital city of Kigali. Built in 1999, the clinic serves 25,000 people. Until early 2006, it saw only 5 to 10 patients a day. Nurses were rarely in attendance and pharmaceuticals were not available. Lights had been installed in the facility but there was no electricity to power them. With the new investments in the government’s health insurance program the center has rapidly transformed into a model for the nation.
Enrollment in the clinics programs has grown quickly, and the number of patients has skyrocketed to more than 150 each day. Those enrolled pay an annual premium equivalent to 2 US dollars and women who keep four appointments during a pregnancy can deliver at no cost. Staff training and infrastructure improvements have significantly enhanced services, and now the lights are turned on permanently.
Other major changes include new equipment and more staff to contribute to safe and hygienic births. The clinic used to only have three trained nurses and most mothers were still giving birth at home. Now it has eighteen nurses available and most of the mothers in the area now give birth at the health center. Life expectancy for the babies has improved as well and mothers are educated to stay for three days after delivery to ensure the health of their newborn.
The initial results of these health investments in Rwanda are impressive. Child mortality has decreased by over 30% since 2005 and maternal mortality declined by 25 % in the years up to 2005. There has been a decline in the fertility rate from 6.1 to 5.5 children per woman, and achievement of immunization rates of 95% were attained by 2008.
The Need for More Progress
These new achievements will have notable effects on the population as a whole as the country grows, but even more progress is needed. The land in Rwanda is already intensively settled, and the hillsides densely cultivated with bananas, coffee and vegetables. With approximately 368 people per square kilometer, Rwanda is one of the most densely populated countries in Africa. And because of its terrain — the country is known as the land of a thousand hills – that means that not all of the land is arable. And with two thirds of its population under the age of 25, dropping fertility rates are good news. The dramatic expansion of family planning that is taking place and the growing desire for smaller families will be a key feature to managing future growth.
There is still much to done, however. For example, women in the rural Muhura area still bear an average of six children or more. Until recently, they had little choice in the matter. According to representatives from UNFPA, the nearest health clinic, like about 60% of the health services in Rwanda, is run by the Catholic Church. The only contraceptive devices offered there are cycle beads, a refinement of the rhythm method. Transportation to these rural health posts is problematic as busses pass through town only a couple of times a week, and there are no private cars. An “ambulance” is traditionally four men carrying someone in a hammock dozens of kilometers or more over hilly rutted roads to the nearest hospital.
But thanks to new investments from the government today women can be referred to new secondary health posts, where family planning counseling and contraceptives are available free of charge. In Muhura for example, the Health Ministry converted an empty building into a secondary health post that offers family planning information and services three days a week. 65 secondary rural health posts have already been established throughout the country, and 21 more centers are planned.
Once the health post opened, women began coming, first in a trickle, then in droves. “Now we see about 50 women a day,” said the nurse who runs the rural post program in Muhura.
Rwandan women have not always been so accepting of family planning. Traditionally, having children has been a source of respect and pride and rumors and misconceptions about contraceptives, and fear of side effects were common. But According to UNFPA officials a massive effort is underway to educate Rwandan communities, both men and women, about the value of smaller families. The government is very conscious of demographic trends, said Cheik Falls, the UNFPA deputy representative in the country. “They know that they have a special country because of the all the hills. If the demographic aspects are not mastered, it will jeopardize development efforts.”
As a result of this growing awareness attitudes are changing and the desire for smaller families is increasing. At a meeting in Muhura hosted by UNFPA, officials noted that when local women were asked, “How many have more than five children?” dozens of women raised their hands.
And when asked “How many are done having children?” almost all of the hands went up. According to DHS data, only 7 % of married women in Rwanda want to have another child soon.
“I want to raise the three children I have properly and pay for their education,” says a 28-year-old mother. “When you have a lot of children you will remain poor.”
Now that contraception has been made more widely available, women who want to stop having babies but whose husbands object are told it is their right to choose. Some even go to these rural health posts in secret for three-monthly injections.
These secondary health posts are attracting clients and interest in modern contraceptive methods, says Daphrose Nyirasafali, a reproductive health and rights officer with UNFPA Rwanda. “The government and its partners are optimistic this strategy will boost the adoption of modern family planning methods, resulting in a more manageable fertility rate and sustainable development.”
Changing Laws are Changing Perceptions
Clearly, what is happening in Rwanda is little short of revolutionary.
“There used to be a lot of rapes, wife beating, male domination of women, boys sent to school and not girls,” said Nyirasafali. “That has all changed, even in the countryside.” Rape is now acknowledged as a very serious offense and there is a free police hotline and heavy jail sentences for perpetrators. The legislature has also passed bills aimed at ending domestic violence and child abuse, although these issues remain a vexing issue for the country.
Rwandan women now have the right to own land and property and when they marry they may choose to combine their assets with their husband or they can keep them separate. Inheritance laws have been passed to split a man’s property equally between his wife and both female and male children. As a result the divorce rate is increasing.
A legislative committee has combed through the countries legal code and has compiled a list of laws to modify or toss out altogether to put an end to gender discrimination, including one that requires a woman to get her husband’s signature to receive a bank loan.
New social norms are also unfolding. Traditionally in Rwanda men and women operated in separate spheres and played different roles, said Juliana Kantengwa, a member of Rwanda’s senate. “There were no-go areas, like drumming,” she said, that were male only preserves. During opening ceremonies, we now have teams of girls drumming with strength, enthusiasm and skill. “We (now) see fathers encouraging their daughters to do engineering and get out of nursing. (And) we have quite a number in the army and police force.” Women are driving the economy — working on construction sites, in factories and as truck and taxi drivers.
Louise Mushikiwabo, Rwanda’s foreign affairs minister, and one of eight female ministers, said no one should view Rwanda’s women parliamentarians as “window dressing”. “We have a lot of influence,” Mushikiwabo said. “The president is present most of the time in our cabinet meetings. He encourages us to think out of the box and initiate policy. It’s a very open forum. That’s where all the major decisions for the country are made.”
Having a female majority voice can certainly change priorities. “The fact that we are so many has made it possible for men to listen to our views,” said lawmaker Espérance Mwiza. “Now that we’re a majority, we can do even more.”
Rwanda’s progress for women is being admired around the globe. The government convened an international forum on the role of leadership in gender equality and woman’s empowerment, attracting women ministers, MPs and dignitaries from all over Africa and the world, including the UN deputy secretary general from Tanzania, Asha-Rose Migiro. “I salute you for bringing gender and equality to the heart of the political process,” she told the forum in the Rwandan parliament.
So what is next for this African Renaissance? The government has now set its sights on getting the country to middle-income levels. Growth so far has come primarily from improving existing systems and services. Collier says that to reach middle income, “Rwanda needs pioneer investors and aid to support them with public infrastructure; I hope that it gets them. If it does, then, yes, poverty can continue to fall fast.”
Rwanda’s astounding achievements are welcome news on a continent where overall progress towards these goals has barely registered. They demonstrate what is possible when political will and innovative policy meet the promise of women in leadership.
Choosing ten top tweets from day two of the International Conference on Family Planning wasn’t easy. Thousands of experts, researchers, those representing NGOs, and stakeholders are in Addis Ababa, Ethiopia this week at the largest conference on family planning and reproductive health. Below are ten tweets we feel are informative and provide fantastic discussion points about the issues and solutions for family planning access and services.
I have been fortunate to visit health posts and family planning clinics in a handful of countries. One of the things I always ask to see while visiting are family planning kits used for educational purposes for clients. Some of the kits have been fancy, others have been fairly rudimentary, but they all serve the same purpose: educating women about their options to space or prevent pregnancies.
Below are a few photos of family planning kits I have seen in Ethiopia, Zambia and South Africa. You can also check out a Marie Stopes clinic I visited this summer.
And even though this isn’t a family planning kit I loved seeing young teenage girls at the Fountain of Hope community center for street affected kids reminding each other about peer pressure, STIs, and pregnancy.
Today was the first day of the International Conference on Family Planning in Addis Ababa. With thousands of participants at the conference there was a flurry of tweets throughout the day. Here are ten tweets we identified as extremely informative.