1. Dr. Paul Nyongesa Senior Lecturer, Dept of Reproductive Health, School of Medicine, College of Health sciences, Moi University, Eldoret, Kenya. Jack Odunga. Research Assistant, Moi University,Eldoret,Kenya. 2. Outline: Contraception use in SSA Introduction: Contraceptive use in SSA Importance of Contraceptive use (MDG 5) Fertility rates in Sub-Saharan Africa Contraceptive prevalence in Africa Unmet Needs in Africa Benefits of Family Planning Determinants of Contraceptive use: Contextual and Proximate Female Education and Contraception use Cultural Barriers to Contraception Family Planning and Religion HIV and Contraception Approaches to increase contraceptive use: Biopsychosocial Model Recommendations: Beyond 2015 3. Introduction Family planning is an important strategy in promoting maternal and child health. It improves health through : spacing of births and avoiding pregnancies at high-risk maternal ages and parities. This is highlighted in MDG 5: a UN Goal with 2 targets and 6 indicators since the ICPD in Cairo, Egypt since 1994. 4. MDG 5:Targets and Indicators Goal 5: Improve maternal health Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Target 5.B: Achieve, by 2015, universal access to reproductive health (Highlighted after the ICPD in Cairo, Egypt in 1994). 6 Indicators: 5.1 Maternal mortality ratio 5.2 Proportion of births attended by skilled health personnel 5.3 Contraceptive prevalence rate(CPR) 5.4 Adolescent birth rate(ABR) 5.5 Antenatal care coverage (at least one visit and at least four visits) 5.6 Unmet need for family planning 5. Universal Access to Reproductive Health Care in sub-Saharan Africa Gaps in access to care still exist and remains a mirage Prenatal care is 73.47% on average Births attended by skilled health attendant is 46.13%, Contraceptive prevalence rate (of women ages 15-49) is 21.83% World Bank Report For Sub-Saharan Africa in 2012 6. Benefits of family Planning (Guttmacher Institute) Preventing pregnancy-related health risks in women Reducing infant mortality Helping to prevent HIV/AIDS Empowering people and enhancing education Reducing adolescent pregnancies Slowing population growth. 7. Family Planning in sub-Saharan Africa(SSA) Region Characterized by a paradox of 1. High fertility rates esp. among adolescents 2. Low contraceptive use across all ages 3. High unmet need for family planning A situation suggestive of both provider-side and user side barriers and constraints that are needed to overcome. 8. Fertility Rates in Africa Fertility rates still high in sub- Saharan Africa(UN Population Division -2012). Sub-Saharan Africa has the highest average fertility rate in the world at 5 compared to 2 for Europe and 2-3 for Asia, Latin America and the Caribbean . Fertility rate have converged or are converging towards 2 by the year 2050 for all regions of the world except for Africa probably due to sub-Saharan. 9. Global Fertility rates 10. HIV/AIDS Epidemic and Fertility The HIV/AIDS epidemic has impacted fertility levels in Sub- Saharan Africa-causing either stagnation or accelerated decline in fertility. The region has the highest prevalence of HIV/AIDS and the largest number of people living with HIV/AIDS in the world. Stagnation in fertility decline over the past 10 years has been related to the increase in HIV prevalence. In Zimbabwe, for example, estimated total fertility was 8.5 percent lower than it would have been in the absence of HIV, and HIV-associated changes in fertility behavior accounted for one-quarter of the drop in fertility since the 1980s (Terceira, Simon, and Gregson 2003) In South Africa, where the prevalence of HIV is among the highest in the region, the spread of HIV is expected to accelerate fertility decline (Moultrie and Timaeus 2003). 11. Fertility Rates in Sub-Saharan Africa 12. Fertility trends in Kenya. The KDHS 2008-9 data indicate: TFR declined during the 1980s and 1990s, changing from a high of 8.1 children per woman in the late 1970s to 6.7 in the late 1980s, and dropping to 4.7 during the last half of the 1990s. However, fertility seemed to rise, marginally, after 1998, reaching a TFR of 4.9 children per woman during the 2000-02 period. The TFR then seems to resume its decline, reaching a low of 4.6 children per woman during the 2006-08 period 13. Trends in Total Fertility Rate, Kenya 1975-2008 14. The Kenya Family Planning Program The Kenyan family planning program was by a started in the 1950s by a group of volunteers started and launched as the 1st in Africa in 1967 that a national family planning program. Under this plan, family planning was integrated into the maternal and child health division of the Ministry of Health. In 1984, the Government ratified a set of population policy guidelines to assist in the implementation of the program. Reflecting the 1994 International Conference on Population and Development (ICPD), these guidelines were further revised in the population policy for sustainable development, issued in 2000 (United-Nations 1994; Jain 1998; CBS et al. 2004). 15. HIV/AIDS IN KENYA(KAIS 2014) Among persons aged 15-64 years, 5.6% were living with HIV infection in 2012, presenting a statistically significant decline from 2007, when HIV prevalence was estimated to be 7.1%. There was wide regional variation in HIV prevalence among adults and adolescents aged 15-64 years, ranging from 15.1% in Nyanza region to 2.1% in Eastern North region. HIV prevalence was significantly higher among widowed men (19.2%) and women (20.3%) than men (1.4%) and women (3.5%) who had never married or cohabited. HIV prevalence was higher among women (6.9%) than among men (4.4%). In particular, young women aged 20-24 years were over three times more likely to be infected (4.6%) than young men of the same age group (1.3%). HIV prevalence among uncircumcised men aged 15-64 years (16.9%) was at least five times greater than circumcised men (3.1%). 16. Contraceptive use in SSA The modern contraceptive prevalence rate vary widely across the region(World Bank-2011). Among women of reproductive age, CPRs for modern methods ranged from 1.2 percent in Somalia to 60.3 percent in South Africa. Geographic variations in family planning use were apparent, with countries in Southern Africa reporting the highest levels of contraceptive use followed by countries in East Africa. With a few exceptions, West and Central African countries report very low rates of family planning use. Some of the lowest contraceptive prevalence rates in the world exist in these two sub regions of Africa of West and Central Africa. 17. Somalia Chad Guinea Angola Niger Eritrea Congo, Dem. Rep. of Benin Sierra Leone Guinea-Bissau Mali Cte dIvoire Mauritania Burundi Central African Republic Nigeria Senegal Liberia Togo Gabon Mozambique Cameroon Congo, Rep. Gambia, The Burkina Faso Ethiopia Ghana Madagascar Djibouti Uganda Comoros Rwanda Zambia So Tom and Princpe Kenya Lesotho Malawi Mauritius Botswana Swaziland Namibia Zimbabwe Modern Contraceptive Prevalence Rates in Sub-Saharan Africa, by Country Source: United Nations Population Division 2009. East Africa Central Africa West Africa Southern Africa 18. Changes in contraceptive method use in SSA The use of traditional methods tends to be higher in settings where acceptance of family planning is low and use of family planning programs is weak. The use of modern methods has increased most markedly in countries that had the greatest increases in CPR (Madagascar, Malawi, Namibia, Zambia, and Zimbabwe). Use of traditional methods in these countries has either remained stagnant or has decreased. Ghana, Kenya, Tanzania, and Uganda showed increases in use of modern methods while maintaining use of traditional methods. In West African countries such as Benin, Burkina Faso, Cameroon, Senegal, and Togo, traditional method use declined and relatively modest gains in modern method use were observed. 19. Unmet need in SSA(too high) Estimated 222 million women in developing countries would like to delay or stop childbearing but are not using any method of contraception(WHO, 2014). In Africa, 53% of women of reproductive age have an unmet need for modern contraception compared to 21% and 22%, in Asia, and Latin America and the Caribbean respectively- regions with relatively high contraceptive prevalence The contraceptive prevalence and fertility in Kenya have leveled off in the recent past( Ojakaa/AMREF 2006). Between 1993 and 1998 total unmet need declined, but then remained constant between 1998 and 2003, at about 25%. 20. Contextual & Proximate Determinants Kingsley Davis and Judith Blake(Mid 1950s) worked out relationships amongst contextual(indirect) and proximate(direct) determinants of fertility as follows: Indirect determinants Direct determinants -Socioeconomic -Intermediate fertility -cultural, Variables -environmental variables Fertility 21. Proximate Determinants of Fertility By John Bongaarts(1978) analysed and indicated that variations in four factors-marriage, contraception, lactation, and induced abortion-are the primary proximate causes of fertility differences among populations. 22. Factors influencing Contraceptive use: Reasons for this include supply-side and demand-side barriers: poor quality of available services; limited choice of methods; limited access to contraception, particularly among young people, poorer segments of populations, or unmarried people; fear or experience of side-effects; cultural or religious opposition; gender-based barriers. Fueled by both a growing population, and a shortage of family planning services. 23. The Contextual Determinants of Contraceptive Use: Behavioural (demand or user-side)factors: Biological(provider or supply-side) factors: Socio- cultural factors 24. Women with more than seven years of education have on average fewer children in Africa than women with no education (Hobcraft 1993) Female Education Impacts on contraception 25. Cultural barriers to Contraceptive use several socioeconomic factors are shown to be associated with high fertility low levels of female education and income per capita rural residence, and high infant and child mortality Other barriers to sustained contraceptive use included medically inaccurate notions about how conception occurs and fears about the effects of contraception on fertility and menstruation, which were not taken seriously by care provider. undermined the effective use of contraception by girls. Many contraceptives are encumbered with potentially unnecessary restrictions on their use. Indeed, fear of side effects, fostered by alarmist labeling, is a leading reason that women do not use contraceptives 26. Family Planning and Religion Christian teachings vary depending upon the denomination. Roman Catholics are forbidden to use medical or physical contraception. Abstinence and the rhythm method are the only officially approved methods of birth spacing. Among Protestants , no specific forms of contraception are forbidden. Islam similarly encourages large families and requires parents to ensure that the basic rights of children are met. Family planning is not forbidden but is more commonly used by traditional adherents for birth spacing. Buddhist religious dogma does not stress procreation; thus, contraception may be used. Chinese religious traditions, such as Confucianism and Taoism, do not prohibit birth control. (Srikanthan & Reid, 2008) 27. Strategies to Contraception in SSA: The BioPsychosocial Approach Intervention programs aimed at increasing contraceptive use may need to involve different approaches: Behavioural (demand or user-side)Approaches: Biological(provider or supply-side) Approaches: Socio- cultural Approaches Including promoting couples discussion of fertility preferences and family planning, improving womens self-efficacy in negotiating sexual activity and increasing their economic independence. 28. Post-primary Education Education will help achieve reproductive behavioural change in face of challenging socio- cultural, gender and economic circumstances(Schultz 1993) 29. Advocate Couple Empowerment The World Bank defines empowerment as the expansion of freedom of choice and action to shape ones life. This definition encompasses two features of womens empowerment: process of change (through which a woman gains power in making decisions) and agency. 30. HIV and Contraception: Dual Contraceptive Use(WHO 2012) A WHO expert group reviewed all the available evidence and agreed that the data were not sufficiently conclusive to change current guidance(WHO Feb 2012). Condom use should be encouraged in HIV-positive women To prevent HIV transmission Prevent STI acquisition As an adjuvant to contraceptives i.e. dual method Condoms alone have a failure rate of 15%-21% at preventing pregnancy In 2012, national HIV prevalence was estimated to be 5.6% among Kenyans aged 15-64 years, signicantly lower than the HIV prevalence estimate in 2007, which was reported at 7.2% 31. Beyond 2015-The Way forward Education Economic Prosperity Universal Access to SRH care Health & survival for women A multi-sectorial approach is imperative to improve womens health in Africa: 1. Girl child /Women Education 2. Access to quality Reproductive Health Care, (Maternal, FP, PMTCT Strategy) 3. Protecting womens rights and Empowerment 32. THANK YOU .