Family planning targets in relation to fertility reduction and reproductive health care in ECA member states

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Family Planning Targets in Relation

to Fertility Reduction and Reproductive Health Care in ECA Member States

United Nations

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ECA/I'OPtrP/9413(b)/4

Famlly Planning Targets in Relation

to Fertility Reduction and Reproductive Health Care in ECA Member States

•

United Nations Economic Commission

for Africa

Addis Ababa

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. . . . . . . . . . . . . .

Children of Adolescents . .

27 30 34 C. Health of Women Aged 20 - 34 Years and 35 Years and

Over, and Their Children • • . • . . . . . ... . 38 D. Sexually Transmitted Diseases Including HIV/AIDS 41 E. Cultural Factors Affecting Reproductive Health . 44

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J:V. PACTORS TO COMPLEMENT PAMJ:LY PLANNJ:NG ACTJ:VJ:TJ:ES TO

REDUCE PERTJ:LJ:TY AND TO J:MPROVE REPRODUCTJ:VE HEALTH 46 A. General Improvement in Socio-economic Conditions 46 B. Government Commitment to Reduce Fertility and to

Improve Reproductive Health • • • • • . • • . • 49 C. Education OI the Girl Child and Improved status of

Women .. .. .. .. .. .. .. .. .. .. .. .. 52

D. Poverty Alleviation . . • . . • . . . 54 E. Support of Do~or Organizations and Governments,

Agencies, Non-Governmental Organizations and the Private Sector to Family Planning and Reproductive

Health Care Programmes 56

V. SUMMARY AND RECOMMENDATIONS A. Summary • . . .

B. Recommendations

57 57 59 B. (i)

B. (ii) B.(iii)

ANNEXE - TABLES

Family Planning and Fertility Reduction Targets .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..

Family Planning and Reproductive Health Care .. .. .. .... ... .. '.. .. .. .. ..

Factors to Complement Family Planning

Activities to Reduce Fertility and to Improve Reproductive Health

59 62

64 66

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PREFACE

since the 1970s, socio-economic conditions in African countries have continued to deteriorate. In the preamble to the Dakar/Ngor Declaration, African Governments asserted that it was their prime responsibility to improve the quality of life of the African peoples and to redress their economic and social situation. They expressed concern about the persistent high population growth rate and associated high fertility levels, high infant, child and maternal mortality levels, high morbidity and the incidence of HIV/AIDS, inadequate policies for the improvement of the legal status of women in the family and their integration into the development process, ineffective programme~ for children and young people, problems of refugees and displaced persons.

Furthermore, African Governments recognized the need for an increased role of the publib and private sectors as well as non- governmental organizations in po,pulation and integrated development programmes. They recognized population matters as integral part of the socio-economic devel~pment process as had been stressed ~n

the Kilimanjaro Programme of Action (KPA) for African Population and . Self-Reliant Development in 1984. Consequently African countries indicated that population matters should be accorded high priority in allocation of financial resources.

Both the KPA and the Dakar/Ngor Declaration have g~ven great importance to family planning programmes as a means of improving the health of mothers and children as well as reducing fertility and population growth rat~s. The Dakar/Ngor Declaration came up with bold and ambitious demographic targets for Africa to: reduce population growth rates, infant, child and maternal mortality rates; and to increase life expectancy at birth and to increase contraceptive prevalence levels. It is essential that African countries take concrete measures to implement the recommendations of the KPA and the Dakar/Ngor Declaration.

This study focuses on family planning programmes targeting in the context of reducing fertility and improving reproductive health care. It was undertaken as part of the continued efforts of the ECA secretariat to carry out studies on family planning and population in the context of socio-economic devel.opment given member States increased interest in population and family planning programmes .. This study should be of interest to those involved in population and family planning programmes, programmes to reduce fertility, programmes to address problems of adolescents associated with early marriages and childbearing, e.g. unwanted pregnancies, maternal deaths and unsafe abortions. It is important to note that the issUes addressed in this study were discussed at the September 1994 united Nations International Conference on Population and Development held in Cairo, Egypt.

Among the studies and publications on family planning in Africa produced by the secretariat since the adoption of the KPA

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include the following: The Demographic, Health, Economic and Social Impact of Family Planning in Sele~ted African Countries, ECA/PD/1985/9, March, 1985 which was later revised and-published as

Some Aspects of Family Planning Programmes and Fertility in Selected member states, E/ECA/SER/A/7; Report on Integrated Maternal and CQild Health and Family Planning Programmes in Africa, 1987; social, Cultural and Legislative Factors Affecting Family Formation and Fertility in Selected African Countries, 1988; The Impact of Maternal and Child Health and Family Planning {MCH/FP}

Programmes on Fertility, Infant and Childhood Mortality and

Maternal Health, 1989; statistical Compendium on Contraceptive Prevalence and Practice in African Countries, 1990; Guidelines on Improving Delivery and Evaluation of Population and Family

Planning programmes in African Countries, 1991; Strategies to Improve Contraceptive Use to Influence Demographic Trends in African Countries, 1992; AlternativeE! to Traditional Approaches in the Formulation and Implementation of Family Planning Programmes in African Countries, 1993; and Comparative Study on Family Planning and Birth spacing Programmes in ECA member States, 1993.

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EXECUTJ:VE SUMMARY . ,"" "t!

lJt: _., - ^>

African countries have expressed great concern on the effects of high fertility, population growth and mortality rates on socio- economic development and well-being ..of their people. These concerns are reflected in such documents as the Kilimanjaro Programme of Action and the DakarjNgor Declaration on Population, Family and Sustainable Development. African countries have called for the need to reduce the high rates of : fertility; infant, child and maternal mortality. The DakarjNgor Declaration has, in fact, recommended ambitious demographic targets to be attained for the African region for the years 2000 and 2010.

Early marriage and child bearing, in the absence of access to contraceptives, is associated with high fertility, high maternal mortality and morbidity risks to adolescents, adult women and the children as well. Thus, high fertility has grave impact on reproductive health of the population, especially on women and children. In most African countries, adolescents are denied access to family planning information and services. The' majority of women, especially in rural areas in Africa lack information and services on family planning. Pregnant adolescents and adolescent mothers also face difficulties in having access to medical health' f?ervices.

Family planning programmes have demonstrated to contribute significantly to reduction of fertility and to improvements in reproductive health care of both mothers and children. These programmes should provide adequate information and services to adolescents and adult women. Adolescents should be encouraged not to have children until they.are about 20 years. Adult women, both married and single should space pregnancies and births at least 2 years. For those women who indicate they want no more children after they have attained the desired family size, family planning methods to limit children should be available to such women.

However, family planning services ..should also help infertile and sub-fecund women to realize their desire to have children. It is essential that family planning programmes are implemented without coercion even where deliberate demographic goals have been adopted.

Family planning programmes should be implemented in the context of overall socio-economic development goals.

Family planning programmes to reduce fertility need to set specific targets on contraceptive use and fertility indicators to be achieved at any given future dates. The targets should be realistic and not too ambitious. There should be a mechanism for monitoring and evaluation of the programmes to measure progress being attained. Lessons from evaluation should be used to modify targets if need be as well as to change strategy for implementation of the programmes. various population groups will need to be targeted regarding family planning programmes to reduce fertility.

These should include: the general population; adolescents; women

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aged 20-34 years; women aged 35 years and over; men; rural and urban population; special groups like refugees and displaced populations as well as those in squatter areas; members in the commurtity and household who influence decision making on family size; and health personnel.

Regarding family planning and reproductive health care, it is important to consider these as individual rights as reflected in several international conventions, and declaration~ to which most governments are signatories. The health of adolescents, adult women and children should be of paramount importance. In this context, provision of family planning would prevent the unwanted pregnancies to adolescents and adult women. It would also reduce the incidence of unsafe abortion. Family planning and reproductive health care Should also address such issues as sexually transmitted diseases and HIV/AIDS as well as cultural factors affecting reproductive he~lth. In implementing family planning and reproductive health programmes, emphasis should be on providing quality services.

General improvements in socio-economic conditions would facilitate and enhance the impact of family planning to reduce fertility and to improve reproductive health. Poverty alleviation should be seen as overall efforts of improving socio-economic conditions. These should focus on providing basic needs such as employment, food, potable water, sanitation, health, education, shelter etc. There should be special attention to improve the education of the girl child and status of women. Women with adequate education and improved status are positively correlated with lower fertility and improved health for themselves and that for their chi,ldren and families. There is need to involve actively women and the population to participate in planning and implementation of all programmes affecting their lives.

If African Governments are committed to reduce fertility and·

improve reproductive health care, they should ensure that their population and development policies are consistent in all sectors.

All laws that hinder provision of information and services on family planning to adolescents as well as adult women should be reviewed and amended accordingly. Similarly laws discriminating against women e.g. the inheritance laws, should all be amended in favour of girls and women. Where laws have already been enacted to improve the status of women, concrete action programmes 'in support of these laws should be implemented.

In view of Africa's socio-economic crisis, there is need for African countries to be assisted in their attempts to improve their economies and well-being of their people. Thus donor governments, agencies, organizations, non-governmental organizations and the private sector should assist African countries. In providing assistance, these organizations should be sensitive to the development needs and social aspirations of' the people. There

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should be mutuai trust on both sides. African countries _shoul~

provide an enabling environment to ensure that support provided by various organization has the expected impact.

The Programme of Action agreed at the united Nations 1994 International Conference on Population and Development ( ICPD ) strengthens the findings and recommendations of this study.

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I. INTRODUCTION

It will be recalled that the 1974 World Population Plan of Action (WPPA) suggested that for those countries which considered their birth rates detrimental to their national purposes, to set quantitative goals and to implement the necessary relevant policies. The Mexico, city Declaration on Population and Development states: "Unwanted high fertility adversely affects the health and welfare of individuals and families, especially among the poor, and seriously impedes social and economic progress in many countries. Women and children are the main victims of unregUlated fertility. Too many, too close, too early and too late pregnancies are a major cause of maternal, infant and childhood mortality and morbidity.":!./ In order to alleviate'some of these problems, the Kilimanjaro Programme of Action (KPA) for ,African population and Self-Reliant Development urged African countries to incorporate family planning services into the maternal and child health services.~/ The same KPA recommended to African Governments to consider population as a central component in formulating and implementing policies and programmes for accelerated socio-economic development. The 1984 International Conference on Population and Development had urged governments that had adopted or intended to adopt fertility policies to set their own quantitative targets. similarly, countries implementing family planning programmes were urged to establish programme targets at the operational level but without coercion'in implementing the set targets.:J../

The Dakar /Ngor Declaration on Population, Family and Sustainable Development adopted at the ,Third African Population Conference has reaffirmed the importance of fertility reduction and improving reproductive health care. It has recommended to African Governments to "create a conducive socio-economic climate and sustained political will for the pursuit of such effective fertility policies as make for: setting fertility and family planning targets for all people of reproductive age and take measures to reduce infertility where needed".J../ The Dakar/Ngor Declaration has set population growth rate targets for the African region to be reduced from 3.0% 'in 1992 to 2.5% and 2.0% by the years 2000 and 2010 respectively. This will have to be brought

:!./ united Nations, Report of the International Conference on population, 1984, p.3.

~/ United Nations Economic Commission for Africa, Kilimanjaro Programme of Action for African Population and Self-Reliant pevelopment, 1984.

:J../ United Nations, Op cit, 1984.

J../ United Nations Economic Commission for Africa, Dakar/Ngor Declaration on Population, Family and Sustainable Development,

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about mainly through fertility reduction. Family planning is one of the means to contribute to family reduction. Accordingly the Dakar/Ngor declaration has included for the Africa region as a whole to attain contraceptive prevalence of 20% and 40% by the years 2000 and 2010 respectively.

Family planning and fertility reduction in the context of reproductive health care have been given significant attention in the various other conferences including: the Conference on Reproductive Health Management in Sub-Saharan Africa held in 1984;

the All-African Parliamentary Conference on Population and Development, held in 1986;- the International Conference on Better Health for Women and Children through FamiJ.y Planning, held in 1987; the International Conference on Safe Motherhood, in 1987; the International Forum on Population in the Twenty-First century, held in Amsterdam in 1989, which adopted the Amsterdam Declaration on "A Better Life for Future Generations"; the 21" Conference of Regional Health Ministers of East, Central and Southern Africa countries in 1993; the Conference on Reproductive and Family Health in Africa organized by the Union for African population studies in Cote D'Ivoire in 1993; the Medical Women's International Association Conference on the Health of Women and Safe Motherhood: Africa and the Near East, held in Kenya in 1993; and several meetings or conferences on country level in most African countries.

The Programme of Action of the International Conference on PopUlation and Development in 1994 stressed the need for countries that have not completed their demographic transition to take effective steps to do so. In this regard, countries were called upon to recognize the interrelationship between fertility and mortality levels and aim at reducing high levels of infant, child and maternal mortality so as to lessen the need for high fertility and reduce the occurrence of high-risk births.

Family planning targets in relation to fertility reduction and reproductive health care is relevant and useful where deliberate policies and programmes have been adopted to moderate demographic trends and to improve the health of mothers and children. Progress in implementation of such policies and programmes would be measured through evaluations in attainment of the set targets. It should be emphasized that many factors contribute to influence changes in fertility and health status of the population. Family planning is just one of the many factors. In general, economic, socio-cultural as well as institutional factcrs all affect fertility changes and the health situation the population.

The current study was prepared as one of the approved studies :nder non-recurrent pUblications of the ECA Population Division under sub-programme 3 on Poverty alleviation through sustainable development for the biennium 1994/95. In the context of the Daka.l':/Wq:>r Declaration, the study's objective is to facilitate how

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family planning and fertility targets could contribute to fertility reduction as well as improve reproductive he~lth care; and in the long te~m contribute to poverty alleviation.

The study is in five parts including the introduction in Part 1. Part II focuses on family planning and fertility reduction' targets. Part III discusses family planning and reproductive health care. Other factors which complement family planning activities to reduce fertility and improve reproductive health care are discussed in Part IV. Part V presents summary and recommendations.

II. FAMILY PLANNING AND FERTILITY REDUCTION TARGETS

For over decades, fertility has remained very high in Africa while in the other.developing regions fertility has been declining.

In these other regions, family planning programmes started much earlier and have had a considerable impact in reducing fertility.

Current total fertility for developing countries is about 3.6 while for Africa it is 6. Data in Table 3 shows that in many countries in Africa total fertility is above 6. In view of the demographic targets in the Dakar/Ngor Declaration to reduce population growth rate, fertility reduction should be addressed as i t is a major component affecting population growth rate. The 1994 ICPD has noted that family planning has contributed half of the decline in average fertility rates in developing countries from between 6 to 7 children per women in the 1960s to the present rates of about 3 to 4 children. Thus fertility targets in the context of family planning and over all socio-economic development should play an important role towards reducing fertility as well as population growth rates.

In family planning and fertility reduction targets, i t is important to view targets in two ways. Firstly, targets may refer to specific family planning programme outputs in terms of activities to be achieved and the expected impact of these activities to contribute to reduction of fertility. Secondly, targets may refer to population groups to be addressed. Both of these are discussed below in sections A and B respectively.

A. Specific Targets

Family planning programme activities as targets could include:

number of family planning outlets as centres to be established;

number of personnel to be trained to provide family planning services. These can be established by an individual family planning programme organization or may be an objective of a national population and family planning programme. This study, however, is mainly interested at family planning targets expressed

in the form of contraceptive prevalence and fertility reduction.

Fertility reduction targets may sometimes be adopted indirectly

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through targets to red~ce population growth rates, this aspect is not examined here as in most cases both fertility and population growth rates are generally reflected in population family planning policies and programmes.

A.(i) contraceptive Prevalence Targets

An increasing number of African countries are adopting, specific contraceptive targets to be achieved between two or more periods in time. Contraceptive prevalence is generally expressed as a percentage of women of reproductive age or a percentage of married women using contraceptives. Some examples of these targets from selected national population policies or as reflected in national development plans are given below..

Botswana: The 1979-1985 Maternal and Child Health/Family Planning (MCH/FP) targets were to increase contraceptive prevalence from 12% during 1981-1983 to 15% in 1985 among married women.

Egypt: The 1973 population Policy included targets to increase contraceptive use in rural areas to 25% and in urban areas to 35% by 1982. Later national targets were to' increase contraceptive rates among married women from 38% in 1988 to 51% in 1996 and to 60% by the year 200.0.

Ethiopia: The 1993 National Population Policy has included a target to increase contraceptive prevalence rate from 4% in 1993 to 44% by the year 2000.

Ghana: Targets included the attainment of a contraceptive prevalence rate of 10% between 1970 and 1975, 40% in 1990 and 65%

by the year 2000.

Kenya: Targets for the 1990s are to increase contraceptive use among married women from 27% in 1989 to 30% in 1995 and to 40%

by the year 2000.

Nigeria: The 1988 National population Policy included a target of extending coverage of family planning services to 50% of women of child bearing ages by 1995 and to 80% by the year 2000.

Tunisia: The 1982 to 1986 6^ili Development Plan targets were to increase contraceptive use from 27% in 1980 to 40% in 1986 for the country as a whole; from 18% - 36% for rural areas; and from 35% to 45% in urban areas.

A.(ii) Fertility Reduction Targets

Fertility reduction targets may be expressed in many different ways. The common ones relate to total fertility rate and crude birth rates. Total fertility is expressed as the average number of

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children that would be born alive to a woman during her life based on prevailing age-specific fertility rates. Crude birth rate is the number of births per 1000 population in a given year. Some examples from some of the African countries on total fertility and crude birth rate targets are given below.

Egypt: The 1973 Population Policy included a target to 'lower crude birth rate from 33.7 per 1000 in 1973 to 23.6 in 1982. These were later revised - to reduce crude birth rate from 40 per 1000 to 20 per 1000 in 1980 and to 20 per 1000 by the year 2000. Some of the total fertility targets include reduction of total fertility from 4.6 children per woman in 1988 to 3.7 in 1996 and to 3.1 by the year 2001.

Ethiopia: The 1993 National Population Policy is to reduce total fertility rate from 7.7 children per women in 1993 to approximately 4 children by the year 2015.

Ghana: Some of the fertility targets which had been set after the 1969 Population Policy were to reduce total fertility from 7 to 8 in the late 1960s to 5 in 1985 and to 4 by the year 2000.

Kenya: The 1974-1978. five year Health and Family Planning Programme included targets of reducing crude birth rate from 48 per 1000 in 1974 to 43 in 1979. For the 1990s, these were revised - to attain a crude birth rate of 42 per 1000 in 1995 and 35 per 1000 in the year 2000. Total fertility target is to reduce it to 5.2 by the year 2000.

Nigeria: The National Population Policy included a target of total fertility reduction from 6 in 1988 to 4 by the year 2000.

Zambia: The 1989 Population Policy has included a target to reduce total fertility rate from 7.2· children per women in 1989 to 6 by the year 2000 and to 4 by the year 2015.

A. (iii) Observations on Targets·' Setting

It was observed in an earlier pUblication that targets on fertility and contraceptive use are some times unrealistically set or very ambitions . .2./ If we look at the Ethiopian target for example, to increase contraceptive use from 4% in 1993 to 44% by 2000 implies that the prevailing contraceptive level has to be increased by 11 times in 7 years. Given the prevailing socio- economic conditions, the estimates appear too ambitious. Similar observations can be made on the contraceptive targets of Ghana.

The 1988 Ghana Demographic and Health Survey showed a contraceptive fd united Nations Economic Commission for Africa, Guidelines on Improving Delivery and Evaluation of Population and Family Planning Programmes in African Countries, Addis Ababa, December 1991.

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use of 13% among married women.

40% by 1990 and 65% by the year the targets were set.

Thus contraceptive use targets of 2000 were unrealistic at the time Similar observations could be made with regard to fertility targets. In Nigeria, the 1990 fertility rate was 6 and the population policy target to reduce total fertility from over 6 in 1988 to 4 in the year 2000 is rather to unrealistic taking into account that in 1990 contraceptive use was 6%. In fact only 3.5%

of the married. women were using a modern contraceptive method in 1990. In Ghana too, an earlier target of reducing total fertility rate between 7 and 8 in the. late 1960s to 5 in 1985 and to4 by the year 2000 appears to. have been too high considering that the current total fertility is about 6. In Kenya, the target of reducing crude birth rate from 48 per 1000 in 1974 to 43 per 1000 in 1979 was unrealistic. The crude death rate had risen to 52 per 1000 in 1979.

It should be emphasized that in setting targets, these should be based on a detailed analysis of the socio-economic and demographic situation of the country. Particular attention should be made also to reflect on past trends on which to estimate future trends; resource requirement (financial, human and material); the attitudes of the population on contraception and fertility and institutional and organizational structures required to support attainment of given targets. Targets without great government policy commitment, however realistic these targets may be, may not necessarily be attained. Setting of targets within the framework of national policy should not be a monopoly of one organization but should involve as many institutions as possible to ensure that the finally adopted targets reflect a general consensus.

Some

targets •.2f ôtherThese could be consulted for additional information.^studies ^have ^dealt ^with ^some âspects ôf A.eiv) strategies Towards Meeting Targets

It is necessary to emphasize that several courses of actions will have to be undertaken by a variety of actors in order to realize or work towards the attainment of targets to increase 2/ United Nations, Review of Recent National Demographic Target setting, New York, 1989; United Nations Economic commission for Africa, "A Review of Assessment of Population Policies in Selected African Countries." (Paper presented at the Third African Population Conference in Dakar, December 1992) 5 October 1992; and United Nations Economic Commission for Africa, "Comparative Study of Family Planning and Birth spacing Programmes in ECA Member States. "(Paper presented at the Eighth Session of the Joint Conference of African Planners, Statisticians and Demographers in March, 1994) 10 December 1993.

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contraceptive use and reduction of fertility. Among the critical areas that need intervention in family planning and fertility reduction should include: political commitment and, strong leadership; changing attitudes; the role of women and men in family planning programmes; the status of wo~en; participation and involvement of communities in programmes; involvement of non..

governmental organizations (NGOs) in programmes; improvements in socio-economic conditions; institutional support to programmes;

information, education and communication (IEC) programmes; deiivery of services; human, material and financial resources; evaluation and monitoring of programmes. These issues have been addressed in some of the earlier studies.21

In many of the policies designed to increase contraceptive use and to reduce fertility in African countries the above issues have been cited to a differing degree in the stated strategies. In Tunisia, various strategies employed overtime included:

regislative reforms which raised the age at marriage for women to 17 years and made abortion available free within the first 3 months; strengthening of infrastructure for the implemeritation of population and family planning programmes; evaluation of programmes; improvement of the status of women through increased education and access to employment; great commitment to financially support population and family planning programmes; greater involvement of the private sector in delivery and implementation of programmes' in the 1990s; integration of family planning programmes into the basic health care service of the Ministry of Health in the 1990s; co-ordination of population and family planning programmes.

The Ethiopian Population Policy mentions the following areas in its strategy: expanding clinical and community based contraceptive distribution by mobilizing public and private resources; raising the minimum age at marriage from 15 to at least 18 years; creation of conditions which facilitate an increased integration of women in the modern sector of the economy; amending laws which adversely affect women's ~ocial, economic and cultural life; establishing teen-age and youth counselling centres in reproductive health; programmes to involve men in family planning;

and IEC programmes. In Ghana, since the late 1980s, the strategies have put stress on IEC programmes and social marketing in distribution of contraceptive supplies. The Egyptian 1980 National strategy for Population and Family Planning Programme stressed the upgrading of family planning services and integrating them into

21 united Nations Economic Commission for Africa: (a) Guidelines on Improving Delivery and Evaluation of Population and Family Planning Programmes in African Countries, December 1991; (b) strategies to Improve Contraceptive Use to Influence Demographic Trends in African countries, December 1992; (c) Alternatives to Traditional Approaches in Formulating and Implementation of Family Planning Programmes in African Countries, November 1993.

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health and social activities; instituting community based socio- economic programmes conducive to family plamling; strengthening IEC programmes. In the case of Kenya, strategies since the late 1980s have put emphasis on provision of family planning at place of work;

decentralization of the implementation of population and family planning programmes to district level; greater involvement of the private sector in delivery of family planning services; IEC activities to change attitude of the population to accept and use contraception.

While strategies at national level may sometimes be well articulated, no actions are taken to translate the strategies to realize the desired· goals and specific targets on increasing contraceptive use and fertility reduction. All actors at various levels, and sectors expected to contribute in taking specific actions towards achievement of given targets on family planning and fertility reductipn should be identified and given specific mandate to implement assignments given them. Strategies need to be reviewed periodical and modified whe"rever possible depending on evaluation of the programmes. Results of evaluations may also call for modifications in the adopted targets. There have been cases in some countries in the past when evaluations were not given much importance and strategies in relation to targets and vice-versa were not reviewed. This resulted in programmes not showing the desired impact.

since there are many actors involved in various programmes and activities towards achieving the same or similar goals, there is need to co-ordinate the various activities and programmes. The institution to be responsible for this is generally included in the policy documents on population and family planning programmes. In some cases a special institution is created e.g. the National Council on Population and Development (NCPD) in Kenya, which was established in 1982. In Tunisia and Zimbabwe, semi-autonomous bodies - the National Office for Family Planning and Population (ONFP) and the Zimbabwe National Family Planning council (ZNFPC) respectively are responsible for co-ordination of programmes. In other cases, the Ministry of Health is given such a responsibility.

B. Population Groups to be Targeted

Family planning programmes with the objective of reducing fertility need to be addressed to the general population. within the general population, specific groups for special attention should be identified and their special needs taken into account.

These specific groups include: adolescents below the age of 20;

women aged 20-35 years; women over 35 years of age; men; population in rural areas; population in urban areas; population such as refugees, displaced persons, and those in squatter areas; members in the community or household who influence decision making on family size; and health personnel. The population groups to be targeted are discussed below.

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•

B.li) The General Population

The principles and objectives of both the KPA ~nd the Dakar/Ngor Declaration are the achievement of population growth rates that are compatible with the desired economic growth and social development goals. One of the specific objective of the KP~

was the improvement in the quality of life in the African region through effective programmes to reduce the high levels of fertility. As is observed from Table 3, fertility levels are around 6 or above in many countries.

The fertility levels in Africa are a reflection of the socio- cultural values favouring high fertility and early marriages.

cultural values do take time to change. Thus there is need to continue to sensitise the entire population from the grassroots up to the top on the interrelationship between high fertility and socio-economic development and the well being of the population.

In many countries, there seem to' be changes especially on government level on the need to reduce fertility levels. This is reflected in the increasing nU~ber of governments adopting population pOlicies which include objectives to reduce fertility and population growth rates. However, on the grass -root there does not seem to be much change on perceptions to reduce fertility levels.

There is need for population education activities to address the general pUblic. It.will be recalled, in this context, that the Istanbul International Congress on Population and Development which was held in Turkey (14-17 April, 1993) adopted a declaration. That declaration emphasized the importance of population education at various levels: at the basic level of education, at the basic level of general secondary, technical and vocational education, at the level of post secondary, university and professional training; and out of school and non-formal education. Appropriate information, education and communication programmes need to be developed and implemented to support family planning programmes. This issue was adequately treated in an earlier study.~/

B.lii) Adolescents Below the Age of 20 Years

According to the World Health organization, adolescents are those between 10 and 19 years old. Sexual activity among adolescents is very common. In addition, early marriages are also common in many African countries. A study conducted'in Eastern Uganda among adolescent mothers indicated that 70% had their first

~/ United Nations Economic Commission for Africa, Alternatives to Traditional Approaches in Formulation and Implementation of Family Planning Programmes in Africa Countries, November, 1993.

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The Botswana 1988 the teenagers 15-19 sexual experience before the age of 14.'i../

Demographic and Health Survey showed that 9% of years had left school due to pregnancy.

It is observed from Table 1 that in Cameroon, almost 16.5% of the adolescent females start child bearing by the age of 15 while in Nigeria a corresponding ,figure is 13%, about 9% in Malawi and almost 10% ~n Niger. By the age of 19, more than 50% of adolescent female ages 15-19 years start child bearing (71% in Niger, 66% in Zambia, 65% in Malawi, 59% in Tanzania, and 57% in Cameroon). The early entry into marriage .among adolescent females is associated with early childbearing as is reflected in Table 2. Adolescent females reporting having a birth before the ~ge of 15 range between 3% and 9% in Uganda, Togo, Nigeria, Niger, Mali, Malawi, Liberia and Cameroon. It is also observed that of the adolescent females 15-19 years 30 to 45% reported having a first birth by the end of age of 19.

The adolescent females generally do not have access to information and contraceptives to regulate their fertility. This is particularly worse with adolescent single females. Among the married adolescent women aged 15-19, the proportions of those who • report using contraceptives are very low in some countries like Nigeria 1%, Niger 2%, Sudan 4%, Tanzania and Togo 5%. (See Table 6). The percentages are above 10 in Botswana, Cameroon, Egypt, Kenya, Morocco, Namibia, Tunisia and Zimbabwe.

It is well known as will be discussed in Part III that many of the births among adolescent females are not wanted. This is reflected in abortions among adolescent females especially those that are not married. Births to adolescents whether single or married should be discouraged as much as possible mostly for health reasons to the adolescent mother as well as her child. Moreover, early marriage and childbearing adversely affect education and employment opportunities for adolescents. Thus the adolescents should be targeted with family planning information, supplies, as well as counselling. If this is done, then fertility among adolescents would be reduced. In some countries popUlation and family planning policies discriminate against adolescents on access to information and contraceptive supplies and yet the policies have the objectives of reducing popUlation growth rates as well as fertility. It .is essential that such policies, which are inconsistent, should be amended and enable adolescents access to family planning information and contraceptives. In some countries action has been taken or has been initiated on this. In Togo, for example, the Ministry of Health and PopUlation has endorsed efforts to teach sexual health in schools and to provide contraceptives to

'i../ IPPF, Open File of June 1993.

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adolescents as well as to remove barriers to access of family planning services for the Togolese youth.lOI

The DRS data between 1986-1989 showed that about 9% of total fertility in Kenya, Senegal, zimbaQwe and Togo was contributed by adolescents aged 15-19. In Botswana; Liberia, Mali and _Zi~babwe, the contribution was as high as 13%. If family planning services were made available to all of the teenagers, a conside~able number of the unwanted births would be prevented. Data in Table 4 shows the following percentages of births or pregnancies that were wanted later or not wanted 5 years before the survey among women below the age of 20: Cameroon 21%; Egypt 27%; Malawi 41%; Morocco and Namibia 34%; Zambia 33%; and Tanzania 23%.

B.(iii) Women Aged 20 -34

Women in the age group 20-34 consists of the largest number of women in the reproductive age group and consequently this is the group with the largest number of pregnancies and births. In most countries in Africa, more than 60% of the total fertility is to women aged 20-34 years. It is thus a very important age group to be targeted for fertility reduction policies. The majority of these women are married and childbearing is given special importance especially in this age group.

In the past, fertility regulation in many African countries was achieved through traditional methods. Social as well as cultural values and norms helped to enforce child spacipg.

Children were spaced between 2 to 3 years and in some cases longer than 3 years. Some of the methods used included prolonged sexual abstinence after giving birth; sexual taboos after giving birth, prolonged breastfeeding, use of rhythm and withdrawal methods, medicinal herbs, abortion etc. Child spacing was practised mainly

for health reasons for the mother and the child. In view of the social changes brought about through modernization and urbanization, some of the effe9tive traditional methods of birth spacing are no more practised as they used to be.

While as in the past child spacing was purely for health reasons, recent trends show that an increasing number of women, married as well as single, also want to limit the number of their children. Among the women 15 to 49 years, 54% indicate they need family planning f·or limiting the number of children in Egypt.

Figures for other countries are: Morocco 40%, Namibia 26%, Zambia 18%, Sudan and Tanzania 17%, Cameroon 15% and Nigeria 12%. (See Table 9). The percentages of women who express need for spacing children range between 20 to 30% in sudan, Cameroon, Morocco, Tanzania, Namibia, Malawi and Zambia. Table 9 also shows that most

10/ International Centre on Adolescent Fertility "Passages" Vol.

XII, October 1993.

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of the demand for family planning for both spacing and limiting of children is not met. The percentage of the demand for family planning met in some of the countries are'as follow~: Niger 19%, Tanzania and Sudan 23%, Namibia 55%, Morocco 69% and Egypt 71%.

The need for spacing or limiting fertility can also be looked at from a different perspective by finding out if a given birth to a woman was wanted at tl)e time or was wanted' later or was not wanted at all: Table 5 shows the percentage distribution of women who had a birth in the last 12 months before the survey by birth planning status. In Botswana, 52% of the women indicated the birth was wanted later while in the other countries the corresponding figures were as follows: Kenya 42%, Togo 33%, Uganda and Ghana 30%, Tunisia, Sudan and Burundi 22%. The percentage of women who reported that the birth was not wanted at all was highest in Liberia, 26%; this was followed by Tunisia, 17%; and Kenya 11%.

Lower percentages between 3 and 7% were reported in Botswana, Burundi, Ghana,~ali, Togo and Uganda.

The strategies to reduce fertility through family planning should, among other things, concentrate on meeting the unmet demand for spacing as well as limiting of births. For those who want to space births, various reversible methods of contraception as well as information on these methods should be made available to such women. Quality of services is a major key for women to continue using contraceptive methods. It is important also to target women who have just given a live birth as such women are likely to want to space the next birth and accept to use contraceptives until the next child is desired. However, for those women who want to limit the number of children after attaining their desired family size, family planning methods like sterilization should be recommended.

However, women should be provided with adequate information that such methods are not reversible.

B.(iv) Women 3S Years of Age and Over

According to DHS data between 1986-1989, 21 to 26% of the total fertility is contributed by women aged 35 to 44 years in Botswana, Burundi, Ghana, Kenya, Liberia, Mali, Morocco, Senegal, Togo, Tunisia, Uganda and Zimbabwe. It is generally. known that births to women 35 years and over. are associated with high risks to child and maternal mortality and morbidity,

As shown in Table A, more than 30% of the married women aged 35 to 39 reported they wanted no more children in Egypt, Malawi, Morocco, Namibia, SUdan, Tanzania, and Zambia. The proportions are generally higher for married women aged 40-44 and highest for the 45-49 age group. Figure 1, shows that about 83% of the married women aged 35 to 49 need no more children in Egypt; in Morocco the corresponding figure is 70%. The figures for other countries are:

Zambia 52%, Sudan 47%, Tanzania 44%, Malawi 42%, Nigeria 34%, Namibia 33%, Niger 26% and Cameroon 24%. It is not clear why there

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is much variation in the proportions of women aged 35 to 39 who reported that they wanted more children.

From the information provided above, it is apparent that fertility reduction policies should give special attention to provide family planning services to women aged 35 years and over who need no more children and for these women, permanent methods of fertility control, such as sterilization, should be made available.

However, for the other women who indicated they need more children, temporary methods of birth spacing should be made 'available.

Table A: Percentage distribution of married women aged 35-49 years in five years age groups who reported that they needed no more children

Women's age group Country Survey Year

35 - 39 40 - 44 45 - 49

-

Cameroon 1991 27 26 20

Egypt 1992 83 85 80

Malawi 1992 37 43 45

Morocco 1992 64 72 73

Namibia 1992 31 29 40

Niger 1992 16 27 35

Nigeria 1990 23 33 46

Sudan 1989/90 36 46 55

Tanzania 1991/92 36 49 46

Zambia 1992 43 52 61

Source: country DHS Reports.

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100

90

80

70

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Figure 1

Percentage of married women aged 35 - 49 who reported they want no more children

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(25)

B. (v) Men

Efforts to increase contraceptive use and reduce fertility rates in African countries should involve both men and women. Men generally make decisions or influe~ce decisions on many issues in African societies and fertility reduction and use of contraception by their wives is no exception. It has. been observed by Ezeh from the Ghana 1988 Demographic and Health survey and from the focus group discussions in 1991 that a man's fertility preference seemed to influence the wife's willingness to use contraceptives. Wives of men who did not want more children were more likely to approve family planning than wives of men who wanted more children.

However, women's contraceptive attitudes did not affect their husbands fertility preference. 11/

Men have been reported in a number of countries to be opposed to use of family planning. For example, in many countries men relate use of condoms to prevention of sexually transmitted diseases outside marriage and not to fertility regulation.

Moreover some men are opposed to family planning because they feel that i t promotes promiscuity. However, in some countries, men are changing their attitudes and want more information on family planning. Men should not only get more information on family planning but should be actively involved in various activities, to the extent possible. Since men cannot be reached through health system regarding family planning, there is need to reach them through other aVenues like places of work or sports, entertainment, TV, radio, cultural shows etc.

Earlier efforts on family planning concentrated on women and left out men. Since the late 1980s African countries have been taking action to involve men in family planning activities. Among the countries with programmes or projects involving men include:

Benin, Ethiopia, Gambia, Kenya, Lesotho, Malawi, Mauritius, Morocco, Nigeria, Sierra Leone, Swaziland, Togo, Zambia and

Zimbabwe. The IPPF and family planning associations in various African countries have been and continue to be instrumental in male programmes and activities in family planning.

For illustrative purposes, male involvement in family planning programmes in Zambia and Zimbabwe are referred to below.

The Planned Parenthood Association of Zambia (PPAZ) has since 1987 been involved in making men to be interested and take an active part in family planning programmes. PPAZ initialled motivational campaigns for industrial employees targeted at men.

11/ A. Chika Ezeh, "The Influence of Spouses Over each other's Contraceptive Attitudes in Ghana" in Studies in Family Planning Vol. 24, Number 3, 1993; See also International Family Planning Perspectives, Vol. 19, Number 4, December 1993.

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The Association encourages companies to include family planning services in the clinics at work places. Tpe Association has also been invited at times by the labour and social security ministry to

give~alks at union meetings. Furthermore, PPAZ has sponsored male counselling along the rail lines from Ndola, Kitwe and Chingola in the northern copper belt to urban areas in the southern region of Zambia. The result of the PPAZ has been the incorporation of family planni~g services in the company clinics by companies along the rail line. PPAZ promotes all forms of family planning including the pill, condoms, vasectomy, female sterilization and

diaphragm. '

In Zimbabwe, a three year national male motivation project was undertaken at the end of the 1980s to (a) increase knowledge and use of family planning methods among the males of reproductive age;

(b) improve men's attitudes towards family planning; and (c) to promote joint family planning decision making between men and women.

DHS data has clearly shown that there is lack of communication between wives and husbands on family planning issues. As is reflected in Table 10, 53 to 81% of couples never discussed family planning issues in cameroon, Ghana, Liberia, Niger, Nigeria, Tanzania, Togo, and Uganda. The couples who discussed family planning once or twice in the year before the survey for the countries in Table 10 range from 12% in Cameroon to 43% in Botswana. Those who reported having discussed the subject three or more times range from 8% in Niger to 48% in Zimbabwe. A study in Kotobe in Addis Ababa in which husbands were involved in home visit family planning interventions showed that modern contraceptive use by married couples improved significantly in 12 months. The rates were twice as high among couples addressed jointly on family planning than women addressed alone. 12/ Thus IEC programmes should target both men and women and encourage them on open discussions on fertility decision making and use of family planning services. Moreover men and women should all be involved in formulation and implementation of family planning programmes.

The 1994 International Conference on Population and Development reiterated the importance of men's involvement in family planning and reproductive health programmes. Among the actions recommended by that Conference include equal participation of women and men in all areas of family and household responsibilities including family planning and child rearing to be promoted and encouraged by all governments.

12/ Popline, Vol. 16, March/April, 1994.

(27)

8

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B.(vi) Population in Rural, Urban and Special Areas

The majority of the population in African countries (about 70%

or more) live in rural areas. The rural areas are characterized by higher total fertility rates than urban areas as can be seen from Table 3. One of the differentials in urban and rural fertility rates is due to the fact that contraceptive prevalence is much higher in urban areas than in rural areas. This is reflected in Table 7. In countries like Cameroon, Ghana, Malawi, Namibia, Swaziland, Tanzania, Togo and Zambia, contraceptive prevalence rates in urban areas are almost twice or more than twice the levels in rural areas. The differentials in rural and urban contraceptive rates are greatest in Liberia, Mali, Niger, Nigeria, Sudan, and Uganda (see also Figure 2). This is a reflection of, among other things, lack of health and family planning services in rural areas.

Urban areas are generally better served with health and family

planning services. .

Programmes aimed at reducing fertility significantly must therefore ensure that the rural population are given greater attention in providing them with family planning information and services as well as provision of social services and development activities which are conducive to fertility reduction. These should include improvements in education, especially that for women, implementation of primary health care programmes in rural areas, improving the status of women in general. The impact of education in increasing contraceptive use is clear from Table 7 and Figure 3. Married women who have completed primary education generally have higher contraceptive prevalence rates than those who did not complete primary education. Similarly, those who had some primary education had higher levels of contraceptive use than those with no education. Those with more than primary education show the highest contraceptive prevalence levels.

Oelivery of family planning services through community based delivery (CBO) is proving to be contributing significantly to increase of contraceptive use in many African countries. An increasing number of African countries inclUding Gambia, Ghana, Kenya, Nigeria, Senegal, Sierra Leone, Sudan, Swaziland, Tanzania, Zambia, and Zimbabwe are using the CBO to raise contraceptive use in rural areas. All African countries should, wherever possible, make use of the CBO system to deliver family planning and health

services in rural areas.

Although the stUdy indicates that special emphasis should be put on rural areas, it does not imply that provision and improvement of family planning services in urban areas should be ignored. There is need to expand and improve services in urban areas. There is a special population group in urban areas which is generally ignored. This is the population in what is called squatter areas. These people are very poor, they have no access to health and family planning services. Government policies should

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ensure that the health and family planning needs of these people are attended too. It is essential, in fact, to ensure that squatter areas do not develop in the first place. Even without squatter areas, there are many poor people in urban areas whose family planning and health needs should be met. Special programmes by governments, and non governmental o~.ganizations need to be initiated where non exist and strengthened where programmes already exist.

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l::l

%

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60

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40

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10

Figure 3

Current Contraceptive Use Among Married Women

by

Education

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Key

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Some Primary

Completed. Primary More than Primary

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Figure 3 (continued)

Current Contraceptive Use Among Married Women

by

Education

Key

Completed Primary More than Primary Some Primary

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o e

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%

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30 40 50

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Family planning targets in relation to fertility reduction and reproductive health care in ECA member states