The Summit on Family Planning drew policy makers, donors and health professionals to London on 11 July to discuss how to provide access to contraceptives to more of the world's poorest women who want them. The goal going forward is to enable an additional 120 million women in poor countries to use modern family methods. Organizers say this will save the lives of 200,000 women who will otherwise die from pregnancy or childbirth; prevent 110 million unwanted pregnancies; result in 50 million fewer abortions; and save the lives of three million babies. Dr. Gary L. Darmstadt, a pediatrician with broad experience in research, teaching and development strategies, leads the mother and child health and nutrition teams at the Bill & Melinda Gates Foundation, which co-hosted the summit with the United Kingdom's Department for International Development. He spoke with AllAfrica before the Summit began.
Do you see maternal mortality, child survival and newborn survival as related issues?
They are very much interrelated issues. Where mothers don't survive, the survival and the health and well-being of the children is markedly adversely affected. And the health of the newborn and the young child are fundamentally linked to the health of the mother. For example, the nutrition of the mother is so important in setting the stage for child health.
There is a 'thousand day window' - from pregnancy to age two - where you have the opportunity to intervene with maternal nutrition and early child nutrition to improve the survival and the neuro-development of the child. Beyond that window, there is irreversible damage: you have reduced IQ and increased risk for illnesses, such as diabetes and cardiovascular disease, in adulthood. The link is strong between maternal health and very early care and setting the stage for your development and well-being and productivity throughout your entire lifetime.
Why has family planning become a focus of maternal and child health programs?
Family planning is one of the key links that has been neglected.
There is decreased funding. There is decreased political commitment, compared to the 1970s and early 1980s. We need a revitalization of funding, of improved policy and improved programs that focus on giving women, girls and men the opportunity to plan their families.
We set a goal at the family planning summit to provide contraceptive access to120 million women who currently do not want to become pregnant but are not using contraceptives. The best data available indicates that if we can achieve that goal - and this data gives you some sense of that interrelatedness between maternal and child mortality and health - there would be 200,000 fewer maternal deaths between now and 2020, about the million child deaths would be prevented, and 50 million fewer abortions were occur - just astounding figures.
And by giving women the ability to plan their families, they are better able to also plan their finances and to invest in the children that they have - to provide them with a better education, to improve their health and improve their productivity potential as an adult.
We have seen in Thailand and South Korea, for example, where you have improved health and family planning coming together, you can transform the economic situation for entire nations and bring people out of poverty.
What are the major impediments to achieving that in Africa?
I think in a very general sense it boils down to a couple of things: improved collaboration and improved information.
We need improved collaboration among all the partners. We need governments – and, really, all of us - to commit to improved policies and to allocate resources toward family planning. One thing that has been astounding to us as we've been doing our analysis for the summit is that neither donors nor countries can indicate how much money is going towards family planning. It's all kind of rolled up at levels that don't really give you a transparent look into what is being spent on this issue. That needs to be improved. We all need to be accountable for the investments that we are making and for the smart use of that money.
Another area in which we can better collaborate is around procurement of contraceptives and making them available to women who are wanting them. Currently the field is very fractured. You've got each country negotiating their own deals, each procurer negotiating their own deals, each manufacturer doing the same thing. There is no global forecast of the need. Therefore we don't have the ability to shape the market and to improve market dynamics.
Information is the other key factor. With better collaboration and better information, we could do a lot to drive down prices.
When you get down to country level, we need to improve our understanding of what women really want and make sure that basket of contraceptives is available to them, so that they can decide what best meets their need. We need to look carefully at the breakdowns that occur – for example, from the national level down to the delivery points in clinics and with frontline workers who are actually providing contraceptives to women. Currently we are pretty lacking in that kind of data at country level.
We have taken a look at those issues in a handful of countries, and it does come down to needing to build from the ground up - for example, hiring a person who goes around and makes sure that clinics don't just wait for the central level to send it down to them. Rather, they actively work to identify what women want and pull it down from the central level to the clinics and make it available.
We have an experiment going in Senegal. Previously, for example, an injectable contraceptive (the most popular method) was stocked out forty percent of the time, and implants were stocked out 80 percent of the time. We have turned that into zero days of stock out! Women are pouring into these clinics, asking for these methods. Now that they know that the stock is actually there, we are seeing the demand for them really sky rocket.
So these are the kinds of things that we need to transform the field.
That calls to mind a meeting on malaria a few years ago at the Karolinska Institute in Stockholm. Those issues you mention - the lack of data, the fractured forecasting of need and procurement processes - were major challenges at that point for manufacturers and distributors of bed nets. I realize that distributive mechanisms for contraception, including availability of trained clinicians, are more complicated. But addressing those problems transformed the malaria-prevention field and saved a lot of children's lives in a short period of time. Are you optimistic that similar advances in contraceptive availability can be made quickly?
Yes, we really are. You make an important point - that there are a lot lessons to be learned from other fields, and we're actively seeking those lessons.
For example, we are applying a lot of lessons from our experience with market shaping for vaccines to the contraceptive field - trying to use similar mechanisms to drive down prices, make contraceptives more acceptable, and put them in the hands of women who want them. So, yeah, we're highly optimistic that we can make a huge difference in this field through those kinds of mechanisms.
New studies from the Guttmacher Institute, the UN Population Fund and Save the Children, among others, show Africa lagging behind on maternal and infant deaths, despite pockets of progress. How do you tell the true, tragic stories of Africa, while arguing that even though it hasn't kept pace with the rest of the world, Africa can make great strides with a few targeted interventions?
Well, we have some great recent examples of progress in Africa with family planning. Rwanda and Ethiopia immediately come to mind as countries that have transformed their systems and shown phenomenal progress over the last five years in the contraceptive prevalence rate. That is essentially the proportion of married, reproductive-aged women who are using modern contraceptives. We have seen doublings - and more - in these countries. So we know it can be done.
And in Senegal, the example I just cited, a couple of districts have seen phenomenal increases in the uptake of contraceptives, just by making them available and giving women what they want. The government is now saying, "We are ready to scale this up. We want to take this nationwide, and we want your help." And we are embarking on the process with them.
The Family Planning Summit is targeted towards the low-income countries of the world, particularly the poorest countries - but countries who step up and say, "We have a plan; we want to make this happen; we want your help; and we want to collaborate." Those are the opportunities we are looking for: to bring these mechanisms to countries and to hold each other accountable, to ask countries to step up their financial and political commitment – and, likewise, getting donors collaborating to support countries' needs. So we are very optimistic that approaches based on countries' plans and countries' goals will really make a difference.
How will you deal with public controversy around contraceptives?
The Summit is all about giving poor women, in the poorest countries in the world, the opportunity to plan their families. Everywhere we go, we hear stories from women saying, "I have got eight children, and I have just learned for the first time that I actually could plan for my family going forward. I wish I had known this five or ten years ago." This is what women want. Everybody wants to save the lives of mothers and their children. There really is no controversy about that.
How will you define Summit success?
Everybody has a role to play: governments, donors, the private sector - and civil society. Organizations play a very important role on the ground in helping to ensure that programs are effective, that there is no coercion involved, that this is entirely voluntary.
We really feel that this is the moment -- a once-in-a-lifetime opportunity to transform the ability of women around the world to plan their families. As we have discussed, the benefits of this are overwhelming in terms of the lives saved, the improvements in health, and the economic benefits. We could not be more excited about what is coming up.
The Bill & Melinda Gates Foundation supports the AllAfrica Foundation's development reporting project.