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 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

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

Ensuring access - Expanding choice

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 rates and modern contraceptive method prevalence Total Fertility Rate (TFR) 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.

Source:

PRB 2010 World Population Data Sheet

Contraceptive use and method by region

Percentage of married women Region Any Method Any Modern Method* Total Fertility Rate World 62.7

56.1

North America 78.1

72.9

LAC 72.9

67.0

East Asia South Asia Sub-Saharan Africa 82.8

53.9

28.6

81.3

45.8

15.7

* Modern methods include male/female sterilization, pills, IUD, injectable, implants, condoms, female barriers, EC

2.5

1.9

2.2

1.5

2.7

5.2

Contraceptive Use and Unmet Need in Africa

50 40 30 20 80 70 60 10 0 C ha d 20 04 N ig er 2 00 G 6 ui ne a 20 05 M al i 2 00 1 Be ni n 20 01 N ig er Bu ia rk 2 in 00 a 3 Fa so 2 00 Se 3 ne ga l 2 R 00 w 5 an da 2 C 00 am 5 er oo n 20 Et 04 hi op ia 2 00 G 5 ha na 2 00 U 3 ga nd M a ad 20 ag 06 as ca r 2 00 Ta nz 4 an M ia 2 oz 00 am 4 bi qu e 20 03 Za m bi a 20 M 02 al aw i 2 00 4 Ke ny a Zi 20 m 03 ba bw e 20 06 Modern CPR Trad CPR Unmet Need 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

Figure 3 Maternal mortality ratio for 181 countries, 2008

Source: Hogan et al. The Lancet 2010; 375:1609-1623

Lifetime risk of maternal death Region World Total Developed Developing South Asia Sub-Saharan Africa Middle East/N Africa Lifetime risk of maternal death (1 in X) 140 4,300 120 110 31 190 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 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

Courtesy of Dr. Cindy Geary, FHI 360

Family Planning Reduces Maternal Mortality COUNTRY US Contraceptive Prevalence* 73% Lifetime probability of maternal death (1/X) 2,100 India Malawi 49% 38% 140 36 Nigeria 9% 23 * 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

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

Increased use of modern contraceptive methods reduces rates of abortion

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

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

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 Kenya 2008 Malawi 2010 Uganda 2006 Nigeria 2008 India 2005/06 Bangladesh 2007 16 9.4

12.6

8.5

13.0

6.4

18.6

Source: Demographic and Health Surveys (DHS), Macro

17 16.5

21.7

25.5

24.2

12.5

33.4

Age 18 26.2

43.4

41.0

35.7

24.0

42.5

19

36.2

63.5

58.6

38.4

35.7

58.5

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

3.5

3 2.5

2 1.5

1 0.5

0 <18 18-23 24-29 30-35 36-41 42-47 48-53 54-59 60+ 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

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;13:462-468; Bangendanye, et al., Presented November 2007.

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

Family Planning Critical to Achieving MDGs

Reduced child mortality Gender equity Improved maternal health Universal primary education Combatting HIV/AIDS Environmental sustainability Eradication of poverty

Sexual and reproductive health

Courtesy of Jeff Spieler, USAID. Adapted from HRP/RHR/WHO Global partnership for development

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

Current contraceptive methods and typical effectiveness More effective

Less than 1 pregnancy per 100 women in one year

Implant Injectables LAM Vasectomy Pills Female Sterilization Patch IUD Ring How to make your method most effective After procedure, little or nothing to do or remember Vasectomy: Use another method for first 3 months 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 Male Condoms Female Condoms Sponge Diaphragm Withdrawal Less effective

About 25 pregnancies per 100 women in one year

Spermicide Fertility-Awareness Based Methods Source: Adapted from WHO 2006 Spermicide: Use correctly every time you have sex Fertility-awareness based methods: Abstain or use condoms on fertile days.

Pregnancy risk and continuation rates for select contraceptive methods at one year Method Perfect Use Typical Use No method Male condom Pill, Patch, Ring Depo-Provera Copper-IUD Mirena Implanon Female sterilization Male sterilization 85 2 0.3

0.2

0.6

0.2

0.05

0.5

0.10

85 18 9 6 0.8

0.2

0.05

0.5

0.15

Source: Trussell, Contraception 2011; 83:397-404.

Pregnancy risk and continuation rates for select contraceptive methods at one year Method Perfect Use Typical Use Percent Continuing No method Male condom Pill, Patch, Ring Depo-Provera Copper-IUD Mirena IUS Implanon (implant) Female sterilization Male sterilization 85 2 0.3

0.2

0.6

0.2

0.05

0.5

0.10

Source: Trussell, Contraception 2011; 83:397-404.

85 18 9 6 0.8

0.2

0.05

0.5

0.15

43 67 56 78 80 84 100 100

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 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

Target qualities for new contraceptive methods

• • • • •

Highly effective in typical use

– Forgiving of misuse – User-independent

Safe and Acceptable

– Minimal side effects or – – – H ave “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

Ratio of Health Provider to Population

1.5

1 0.5

0 3 2.5

2

WHO estimated health personnel threshold: 2.5/1000 Lesotho 2003 Malawi 2008 Rwanda 2005 Uganda 2005 Zimbabwe 2004

doctors nurses and midwives total (doctor, nurse, and midwife) Community Health Workers 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

Population Council Nes/EE vaginal ring

Designed to last one year

Depo-subQ Provera 104 delivery in Uniject Depo-subQ Provera 104:

   New formulation for 30% lower dose subQ injection (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

Lower-cost alternative to Mirena

Oral contraceptives Intrauterine devices

• • •

Highly effective Reduction of menstrual loss Reduction of pelvic inflammatory disease

• • • •

No daily motivation Long-acting Estrogen-free Rapidly reversible Levonorgestrel intrauterine system The levonorgestrel intrauterine system Hormone cylinder Rate-controlling membrane Levonorgestrel intrauterine system Detail Uterine wall Section of system

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

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

Family Planning and MDGs - Cost Savings 120 100 80 60 40 20 0 Total Savings: $111 M Malaria $4 M Maternal Health $37 M Water Sanitation $17 M Immunization $17 M Education $37 M

Source: USAID-Zambia (2008)

Total Costs: $27 M Family Planning $27 M

US Funding for HIV and Family Planning

Source: CRS (2010)

US Humanitarian and development assistance

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

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

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

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/inde x.html

www.gatesfoundation.org

www.nrf.com/modules.php?name=Dashboard&id=54

Thank you!

www.7billionactions.org

Drivers of Population Growth 10 9 8 7 6 5 4 3 2 0 1900 1950 2000 Year 2050 9.2

8.3

7.5

6.8

Unwanted fertility High desired family size Population momentum 2100

Source: Adapted from Bongaarts (2010)

Small changes in fertility can have significant population effects over time

Sequential Age Pyramids for Africa in 1960, 1990, & 2010

Male

-80,000 -70,000 -60,000 -50,000 -40,000 -30,000 -20,000 -10,000 80-84 70-74 60-64 50-54 40-44 30-34 20-24 0 10-14 0-4 0

Number for each age group in 1,000 Female

10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000

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.