Start Too Soon, Stop Too Late:

The importance of addressing the reproductive intentions of women who want to delay a first birth or limit further births

Roy Jacobstein, MD, MPH E ngenderHealth International Conference on Family Planning, Addis Ababa, Ethiopia November 15, 2013

Global megatrends are driving increased demand for delaying first births and limiting further births

“Youth bulge”: 26% of world’s 7 billion people are aged 10-24 Later age of marriage Small family norms mean ideal # of children : Bangladesh 2.2 (2011); Ethiopia age 45-49, 5.7; age 15-19: 3.3 Worldwide, small family norms driven by: – – – – – – Urbanization (~5% in Sub-Saharan Africa, highest rate of increase in world) Improved child survival Increased women’s education / many more women entering formal workforce High cost of education Rising cost of living Spread of global communication

ALL LEAD TO MORE DELAYERS AND MORE LIMITERS

“Youth bulge” in sub-Saharan Africa: increasing along with age of marriage and small family norm Sequential Age Pyramids for Sub-Saharan Africa in 1960, 1990, & 2010 Male

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 (millions) Source:

World Bank

Female

Demand and unmet need for FP is very high in young unmarried women, most of whom are delayers West and Central Africa

+ = Total demand Unmet need Current use

15-19 20-24 East and Southern Africa 15-19 20-24 Latin America and Caribbean 15-19 20-24

0 10 20 30 40 50 60

Source:

Adapted from presentation by K. MacQuarrie, K., Measure DHS, Futures Institute, given at Wilson Center, 9/17/13 70 80 90 100

Access and use of long-acting reversible contraceptive methods (LARCs) by delayers and spacers is low 70% 60% 50% 40% 30% 20% 10% 0% Height of bar = Total demand for FP to delay or space Unmet need to delay or space (no method use)) Traditional method use to delay or space Long-acting reversible method (IUD or implant) Other modern method use (resupply method) Source:

Most recent DHS; data for delayers and spacers, among all women. Secondary analysis by EngenderHealth & Futures Institute (The Respond Project, 2012.

Why has access and use of LARCs been so low?

Sociocultural norms regarding young women: ‒ Young married women “shouldn’t”

use

FP, i.e., “shouldn’t” delay ‒ Young unmarried women “shouldn’t”

need

FP Provider factors ‒ Bias against providing FP services to young and unmarried ‒ Bias against LARCs - received “wisdom” about IUDs, all false : > > >

“IUDs are not for nulliparous women” “IUD use will negatively affect future fertility” “IUD use causes STDs and/or worsens HIV”

Health system factors ‒ High cost of implants ‒ FP programs not oriented to serving adolescents and unmarried women

LARCs could help meet the high unmet need for FP among women who want to delay

 FP demand in young and unmarried women is high, but access is constrained in low-resource countries and unmet need is high:  50-80% demand for FP among married women age 15-24; 20-40% unmet need  ~ 90% of unmarried women 15-24 do not want to become pregnant, but their unmet need for FP is even higher: 50% in some sub-Saharan African countries  Almost all young and nulliparous women are eligible to use LARCs  LARCs are highly effective, convenient, and user-independent  Low access, high unmet need for FP, and provider factors are also a problem in the U.S., for many of the same reasons: “The American College of Obstetricians and Gynecologists recommends that its [provider] members encourage adolescents age 15-19 to consider implants and IUDs as the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.” -

-

ACOG Committee Opinion #539,

Obstet. Gynecol., 2012; 120(4):983-988

Implants use is on the rise in country FP programs 2004 2010 2006 2012/13 2005/06 2010/11 2006 2011 2003 2010 2005 2011 2005 2010

All data are from the

Demographic and Health Surveys

(DHS), for women ages 15-49 currently married or in union. Total modern CPR is 9.9% in Mali (2012-13) and 15% in Burkina Faso (2010).

And being chosen at even higher rates by young, unmarried, educated, and urban women Country & Category Rwanda, secondary & higher educ. Implants Use (CPR) 8.9% Rwanda, sexually-active unmarried women, age 20-24 7.9% Rwanda, married women Ethiopia, sexually-active unmarried women, age 15-19 Ethiopia, married women Burkina Faso, Ouagadougou Burkina Faso, married women (Total Modern CPR in Burkina Faso: 15%) 6.3% 6.7% 3.4% 6.3% 3.4% Mali, Bamako Mali, married women (Total Modern CPR in Mali: 9.9%) 6.1% 2.5% Data source:

Most recent respective DHS survey.

Country

Dominican Republic (2007) Bangladesh (2007) Indonesia (2007) South Africa (2003) Kenya (2008/09) Rwanda (2010) Malawi (2010) Ethiopia (2011) Senegal (2010/11) Nigeria (2008)

Turning our attention to limiters : Demand to limit exceeds demand to space in most of the Global South Total demand for FP (%) 84% 73% 71% 74% 71% 72% 72% 54% 43% 35% Demand to space (%) 23% 22% 30% 19% 30% 34% 35% 33% 31% 24% Demand to limit (%) 61% 51% 41% 55% 41% 39% 38% 21% 12% 11% Source:

Most recent DHS survey; data for women

currently married

or in union

Country Worldwide United Kingdom Brazil United States Canada South Africa India Malawi Nigeria Congo Dem. Rep.

Reflecting high demand to limit, permanent method use is high worldwide, and in many countries Modern Method CPR 56% 81% 77% 73% 72% 60% 49% 42% 10% 6% Female Sterilization Use (CPR) 18.9%:

highest of all modern methods:

223 million 8% 29% 24% 11% 14% 37% 9.7% 0.4% 0.8% Vasectomy Use (CPR) 2.4% (28 million) 21% 5% 13% 22% 1% 1% 0.1% 0% 0% Data sources:

Most recent national DHS surveys available as of 10-2-13; UNDESA,

World Contraceptive Use

, 2011. Data for currently married women.

Use of any LARC or PM among women using contraception to limit is very low in Sub-Saharan Africa Method Mix Among Women Using Contraception to Limit Births

Van Lith LM, Yahner M, Bakamjian L. Women’s growing desire to limit births in sub Saharan Africa: meeting the challenge.

Glob Health Sci Pract

. 2013;1(1):97-107.

Many barriers to access and choice -- for both delayers and limiters Barriers to effective family planning services Physical Cost Medical Location Knowledge Inappropriate eligibility criteria Process Gender Regulatory Health System Socio-cultural norms Legal Lack of method choice Provider factors Outcomes when barriers are overcome: ↑ ↑ ↑ ↑ Access to services Quality of services ↑ ↑ Contraceptive choice and use ↓ ↓ Unintended pregnancy

So, what do we need to to do to better meet the needs of women who want to delay a first birth or limit?

Political will / policy: “walk the talk”: “… We call upon other African leaders to increase funding for family planning commodities and related services from national budgets.”

—Pierre Damien Habumuremyi — Meles Zenawi

Prime Minister, Government of Rwanda Prime Minister, Government of Ethiopia www.thelancet.com

July 10, 2012 Programs : address reproductive intentions across clients’ life cycle Need youth-focused/youth-friendly demand creation & service provision Expand access to LARCs & PMs – if not, no “contraceptive security” Consider using dedicated providers and mobile services

www.respond-project.org

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