Family planning in South-East Asia: factsheets

B an gl ad es h an d Fa m ily P la nn in g: A n ov er vi ew 1 Bangladesh and Family Planning: An overview Background The 2011 census pegs the population of Bangladesh at 150.6 million, refl ecting an increase of more than 20 percent over the 2001 census population levels. This decadal growth rate is higher than the 17 percent growth in population seen from 1991 to 2001. With an area of just 147,570 sq. kms., this population load translates into an average population density of 1015 persons per sq.km which is one of the highest in the world. In face of the relatively poor economic status of the country, the large population size puts an excessive strain on the countries resources and is a major impediment to its economic development. Situation Analysis The rapid growth in Bangladesh’s population can largely be attributed to the age distribution of its people. As can be seen from the population pyramid (Figure 1), 56% of the women in Bangladesh are in the reproductive age group of 15–49 years. Another 31% of the population is below the age of 15 years and will soon be entering the reproductive life span and contributing to the increasing numbers. Total fertility rate Owing to intense efforts in the country to control the population growth, the total fertility rate (TFR) has been steadily reducing over the past almost four decades. From extremely high levels of 6.3 in 1975, to 3.3 in the year 2000, the TFR now stands at 2.3 according to the Bangladesh Demographic and Health Survey 2011, which is still some distance away from replacement fertility levels. According to a an analysis done by the Population Reference Bureau in 2003, even if Bangladesh reached replacement level fertility by 2010, population stabilization would take another 15 years, the growth being fuelled by the large proportion of youth in the country. Figure 1: Population pyramid, 2010 A ge ( in y ea rs ) Per cent FemaleMale 5 0 5 105 100 90 80 70 60 50 40 30 20 10 0 Source: UN Population Projections 2010 2B an gl ad es h an d Fa m ily P la nn in g: A n ov er vi ew Contraceptive prevalence rate (CPR) A large proportion of this reduction in TFR can be attributed to the growing availability and use of contraceptives by Bangladeshi couples. According to the Bangladesh Demographic & Health Survey 2011, contraceptive use among currently married women has been increasing steadily from 1993–94, when it was 44.6% (not shown in graph) to 53.8% in the year 1999–2000, and reached 58.1% in 2004. Then with a slight dip in contraceptive use at 55.8% as per DHS 2007, it now pegs at 61.2% as per latest DHS 2011. There exists an urban-rural divide in the use of contraception with 52% of the urban women using a modern method of contraception compared to only 46% of the rural women. However, more alarmingly, these averages mask the geographic (inter-division) differentials in contraceptive use. For example, Sylhet division of Bangladesh has the lowest modern method CPR of only 25%, while it is more than double in Rajshahi division, where modern method CPR is 57%. The DHS found no signifi cant difference in contraceptive use between married women belonging to different wealth quintiles, thus showing that poverty is not a factor that restricts access of women and couples to contraceptive products and services. As the TFR continues to show a steady decline despite the fl uctuations in CPR, it can be inferred that increase in contraceptive use is not the sole factor responsible for decrease in fertility levels. One of the other reasons that may be contributing to this reduction is the improvement in access to maternal health services, including safe abortion services (including menstrual regulation), which has helped reduce the number of unplanned and unwanted births. It must be noted that the Bangladesh government does not promote abortion as a family planning method, but provides facilities for the same as an integral part of maternal health services, and in concordance with the international treaties on women’s rights. Contraceptive method mix Of the 56% of married women who are using a contraceptive method, 8% are using traditional methods such as withdrawal and periodic abstinence, and only 48% are using a modern method of contraception. The pill continues to be the most preferred method with 29% of the married women relying on the same to prevent conception. Another hormonal method, injectables, comes a distant second in the list with 7% of the women using the same. Five percent of the women in the survey had relied on tubal ligation as the method of choice. Condoms were the only male centric method that found any substantive proportion of acceptors (5%). Modern contraceptive use by division Pe r ce nt o f c ur re nt ly m ar ri ed w om en us in g m od er n co nt ra ce pt iv es Barisal 38 .1 41 .6 45 .8 43 4 7. 1 23 .6 31 .1 16 .2 25 .2 22 .1 24 .7 35 .2 36 .9 4 2. 7 42 .5 4 8. 8 47 .5 51 .1 43 .2 51 .7 51 .3 51 .1 53 5 6. 1 46 .5 5 1. 9 51 .9 5 8. 4 57 .1 58 .3 35 .5 37 .7 38 .2 4 4. 5 54 .5 70 60 50 40 30 20 10 0 Chittagong Sylhet Dhaka Khulna Rajshahi 1993/94 1996/97 1999/2000 2004 2007 2011 Contraceptive methods Source: BDHS, 2011 B an gl ad es h an d Fa m ily P la nn in g: A n ov er vi ew 3 Comparing to the DHS 1999–2000 fi gures of contraceptive method mix, there is a reduction of more than 2 percentage points in the proportion of non-users of contraception as well as in the users of traditional methods. Similarly, female sterilization rates also show a decline of 1.7% percentage points. The reduction in all these areas is refl ected in the increase in pill use from 23% in 2000 to 29% in 2007. The rate of injectable use peaked to about 10% in 2004, but has again dropped down to 7% in 2007, which is almost similar to the uptake levels in 2000. Other modern methods of contraception such as IUDs, implants, vasectomy etc. continue to fi nd very few takers. Unmet need for family planning The Bangladesh Demographic Health Survey 2007 reveals that 17% of all married women have an unmet need for family planning. This has increased signifi cantly from 11% in 2004. The reduction in contraceptive use from 58% to 56% in the corresponding time frame, can only partially explain the increase in unmet need, and is probably due a reduction in availability and/or utilization of family planning services. The larger reason would be an increase in the felt need for family planning among married women, which, when coupled with stagnant or reducing service accessibility, led to the rise in unmet need. Of the 17% unmet need, 7% is for spacing and 11% for limiting births. There is a very wide inter- division variation in unmet need. It is highest among those living in Sylhet (26%) and Chittagong (23%) divisions and lowest in Khulna and Rajshahi (12% each). This corresponds very well with the CPR levels in these districts. The overall situation is shown by the relevant indicators in the following table. Table 1: Key indicators Total Population, (in million), 2011 (Census) 150.6 Population Growth Rate, Census 2011 1.37% Population Density, (people per square km), 2011 1021 Urban Population, 2011 39.8% Population <15 years of age (percent), 2010 31.3% Total Fertility Rate (TFR), 2011 2.3 Contraceptive Prevalence Rate (CPR), 2011 61% - Pill 27.2 - Injectable 11.2 - Female sterilization 5.0 - Other modern methods 3.2 - Condom 5.5 - Periodic abstinence 6.9 - Withdrawal 1.9 - Other traditional methods 0.4 Unmet Need, 2011 14% Average (median age) at fi rst marriage, 2011 15.5 Median age at fi rst birth, 2011 18 Crude Birth Rate (CBR) (per 1,000 population), 2011 19.2 Maternal Mortality Ratio (MMR), per 100,000 live births, 2011 209 Infant Mortality Rate, 2011 35 HIV adult prevalence (age 15–49), 2012 <0.1% Source: UN Population Projections 2010; BDHS, 2011 4B an gl ad es h an d Fa m ily P la nn in g: A n ov er vi ew Figure 3: Trend in contraceptive prevalence rates (%), 2005–2011 Source: Bangladesh DHS 2011 Pe rc en ta ge o f cu rr en tl y m ar ri ed w om en ag e 10 -4 9 70 60 50 40 30 20 10 0 South-East Asia regional average 57.5 B FS 1 97 5 C PS 1 98 3 C PS 1 98 5 B FS 1 98 9 C PS 1 99 1 B D H S 19 93 –9 4 B D H S 19 96 –9 7 B D H S 19 99 –2 00 0 B D H S 20 04 B D H S 20 07 B D H S 20 11 5 13.8 18.4 23.2 31.2 36.2 41.5 43.4 47.3 47.5 61.2 Figure 4: Contraceptive method use by married women in bangladesh, 2011 Female Sterilization, 5 Male Sterilization, 1.2 Pill, 27.2 Injectables, 11.2 IUD, 0.7 Implants, 1.1 Periodic abstinence, 6.9 Withdrawal, 1.9 Not currently using, 38.8 Male Condom, 5.5 Source: Bangladesh DHS 2011 Figure 2: Trends in total fertility rates, 1975–2011 Source: Bangladesh DHS 2011 B ir th s pe r w om an 7 6 5 4 3 2 1 0 BFS 1975 BFS 1989 CPS 1991 BDHS 1993–94 BDHS 1996–97 BDHS 1990–00 BDHS 2004 BDHS 2007 BMMS 2010 BDHS 2011 6.3 5.1 4.3 3.4 3.3 3 2.7 2.5 2.3 3.3 B an gl ad es h an d Fa m ily P la nn in g: A n ov er vi ew 5 Figure 5: Trends in modern contraceptive use in bangladesh Sources: Bangladesh DHS 2011 BDHS 1993–94 BDHS 1996–97 BDHS 1999–2000 BDHS 2004 BDHS 2007 BDHS 2011 Pe rc en ta ge o f cu rr en tl y m ar ri ed w om en ag e 10 –4 9 Any Method Any Modern Method Pill IUD Injectables Implants Male Condom Female Sterlization Male Sterlization 70 60 50 40 30 20 10 0 44 .6 49 .2 53 .8 5 8. 1 55 .8 61 .2 36 .2 41 .5 43 .4 4 7. 3 47 .5 52 .1 17 .4 2 0. 8 23 26 .2 28 .5 27 .2 2. 2 1. 8 1. 2 0. 6 0. 9 0. 7 4. 5 6. 2 7. 2 9 .7 7 1 1. 2 0. 1 0. 5 0. 8 0. 7 1. 1 3 3. 9 4. 3 4. 2 4. 5 8 .1 7. 6 6. 7 5. 2 5 5 1. 1 1. 1 0. 5 0. 6 0. 7 1. 2 5. 5 Adolescent fertility Bangladesh is a country where the adolescent fertility rate is relatively high. Most of these teenage pregnancies occur within the confi nes of marriage due to the cultural practice of early marriage. It is about 73 per 1,000 girls aged 15–19 years. In Bangladesh, the legal minimum age of marriage is 18 for girls and 21 for boys. However, despite the law governing the age of marriage, early teenage marriages are common and the average age for a girl at fi rst marriage has reduced from 16 years in 2003 to 15 in 2007. About 11% of girls aged 10–14 and 46% of 15–19 years olds are married (Adolescent Health Fact Sheet, WHO, January 2007). Moreover, during the 2007 survey, 6% of the girls aged 15–19 years were reported to be pregnant with their fi rst child. Figure 6: Teenage pregnancy Pe rc en ta ge o f w om en a ge d 15 -2 9 pr eg na nt w it h th ei r fi rs t ch ild 7 6 5 4 3 2 1 0 1993–94 1996–97 1999–2000 2004 2007 2011 Total Urban Rural 5. 6 4. 6 4 .9 4. 8 6. 1 5. 8 4. 2 4 .5 3. 6 4. 3 6. 2 4. 9 5. 7 4. 5 5. 2 5 6 6. 1 Contraceptive methods 6B an gl ad es h an d Fa m ily P la nn in g: A n ov er vi ew Figure 7: Modern contraceptive use by age, 2011 Source: Bangladesh DHS 2011 Over one-fi fth of births to adolescents are unplanned. In all the age groups, adolescents have the highest unmet need for family planning. While awareness about family planning methods is high among Bangladeshi couples (99%) irrespective of their age, the use of contraceptives by adolescents aged 15–19 years is much lower than by older married women. According to the 2007 DHS, while about 56% of married women aged 25–34 years were using a modern method of contraception, only two thirds of that percentage, i.e. about 38% of married teenage girls were using a family planning method. Though relatively low, current usage levels refl ect a gradual improvement over the situation in 1992–93 when only 25% of the married adolescent girls (15–19 years) were using a contraceptive to prevent pregnancy. Given the age, the contraceptive method mix used by adolescents refl ects a reliance on reversible methods. In line with the overall pattern in Bangladesh, pills and injectables are the most preferred methods of contraception. Use of condoms is relatively low. Pe rc en ta ge o f cu rr en tl y m ar ri ed w om en a ge 1 0– 49 70 60 50 40 30 20 10 0 15–19 42.4 53.4 50 61 56.9 46 30.4 20–24 25–29 30–34 35–39 40–44 45–49 Figure 8: Adolescent fertility rate (per 1,000 girls aged 15–19 years) Sources: Bangladesh DHS 2011 Adolescent Fertility Rate 60 50 40 30 20 10 0 Pe rc en ta ge o f w om en a ge 1 5– 19 w ho ha ve b eg un c hi ld be ar in g 33 35.6 34.7 32.7 32.7 30.2 1993–1994 1996–1997 1999–2000 2004 2007 2011 South-East Asia regional average 54 B an gl ad es h an d Fa m ily P la nn in g: A n ov er vi ew 7 Access to family planning information and services In the 2007 DHS, 38% of women and 59% of men acknowledged that they had read, seen or heard family planning messages through mass media. Television was the most common source of family planning messages for both men and women. Men also named mid-level media such as posters, bill- boards, and leafl ets etc. as vehicles for family planning related information. About 75% of the married women reported that a satellite clinic had been arranged in their community in the three months preceding the survey. One in fi ve women in the reproductive age group also mentioned visits to their home by a peripheral health worker in the past six months. Given the preference for reversible family methods especially pills and injectables, such outreach sessions coupled with home visits serve as the platform for counseling to ensure continuation of method use and replenishment of contraceptive supplies with the clients. Various multilateral agencies such as UNFPA, UNDP, and UNICEF, along with NGOs such as FPAB, BCCP, SMC, NDSP, PSTC, BRAC, Engender Health, Marie Stopes Clinic Society as working with the government of Bangladesh for expanding communication outreach of family messages as well as increasing access to needed services. Current Family Planning Eff orts The Bangladesh government is now running a comprehensive health programme called the Health Population and Nutrition Sector Development Program (HPNSDP) which aims to not only reduce the population growth rate but also reduce morbidity and mortality levels in the country along with and improvement in the nutritional status of the population, especially the women and children. HPNSDP, which began in July 2011 and is planned for fi ve years till June 2016, is the third sector- wide program in Bangladesh, following in the wake of HPSP (1998–2003 and HNPSP (2003–2011). HPNSDP strategises strengthening of FP services to reach replacement fertility levels. A new operational plan has been drawn up for delivery of maternal, neonatal, child and adolescent health services. The program will make special efforts to reach out to disadvantaged communities and hard to reach areas with the needed services. Areas with high unmet need will receive additional inputs through area based targeted interventions. While continuing with the community-based distribution of contraceptive supplies, HPNSDP will attempt to expand the current method mix, and reach out to a greater number of eligible couples, the program plans to lay special emphasis on provision of long acting permanent methods of contraception such as sterilization. Counseling of eligible couples, especially adolescents for using family planning methods will be an important intervention area of the program. The Bangladesh Family Planning Program has made remarkable progress over the last thirty years due to continuous political commitment, innovative program approach, government and non- government collaboration, strong IEC program, method-mix cafeteria approach and commitment of the fi eld-level functionaries. Challenges and Opportunities 1. Continuing population expansion: The population growth of the country is fuelled by a) large base population, b) population momentum due to a large proportion of youths, and c) a stagnating CPR. While not much can be done about the fi rst two factors, a stagnating CPR is a cause for concern. Despite the efforts by the government and the development partners, CPR in Bangladesh is not seeing an increase. On the contrary, there has been a 2 percentage point reduction in the same between 2004 and 2007. However, the silver lining in this decline is 8B an gl ad es h an d Fa m ily P la nn in g: A n ov er vi ew References: 1. Monthly Statistical Bulletin, Bangladesh, June-2013; http://203.112.218.66/WebTestApplication/userfi les/Image/SubjectMatterDataIndex/Bulleting-2013.pdf 2. Adolescent Health Fact Sheet. WHO. January 2007 3. Bangladesh Bureau of Statistic 2009. http://www.bbs.gov.bd/Home.aspx 4. Bangladesh Demographic Health Survey 1996-1997 5. Bangladesh Demographic Health Survey 1999-2000 6. Bangladesh Demographic Health Survey 2004 7. Bangladesh Demographic Health Survey 2007 8. Bangladesh Demographic Health Survey 2011; http://dhsprogram.com/publications/publication-FR265-DHS-Final-Reports.cfm 9. Country Profi le Bangladesh, Department Making Pregnancy Safer, WHO. http://www.who.int/making_pregnancy_safer/countries/ban.pdf http://www.who.int/maternal_child_adolescent/countries/ban.pdf 10. Family Planning Fact Sheets Bangladesh. WHO. 2003 11. Ministry of Health and Family Welfare Offi cial Website. http://www.mohfw.gov.bd/index.php?option=com_content&view=article&id=166&Itemid=150&lang=en 12. Realising MDG5b: In Bangladesh for young people. 2010. http://www.ippf.org/en/Resources/Reports-reviews/Realising+MDG+5b+in+Bangladesh+for+young+people.htm 13. Reproductive Health at a Glance Bangladesh. World Bank. April 2011. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/ EXTHEALTHNUTRITIONANDPOPULATION/EXTPRH/0,,contentMDK:22897731~menuPK:376861~pagePK:148956~piPK:216618~theSitePK:376855,00. html 14. United Nations, Department of Economic and Social Affairs Population Division, Population Estimates and Projections Section. http://esa.un.org/wpp/unpp/p2k0data.asp 15. UNICEF. http://www.unicef.org/infobycountry/bangladesh_bangladesh_statistics.html 16. World Health Statistic. World Health Organization. 2005, 2006, 2007, 2008, 2009, 2010, 2011. the minimal increase in the modern-method CPR from 47.3% to 48%. This indicates the possibility of converting non-users and/or users of traditional methods to modern methods of contraception. While the government through its new HPNSDP plans to expand the contraceptive mix by specially promoting permanent methods, it should also think of fertility awareness based methods, such as SDM and LAM, which mimic traditional methods and may be more acceptable to users of traditional methods. The other window of opportunity is the increasing levels of unmet need in the country. This refl ects that communication efforts for promoting family planning are working. Thus the government, with help from its non-governmental partners, should continue with its family planning messaging and counseling services and try and match the demand thus generated by ensuring availability of family planning services and supplies. It is hoped that the program’s special efforts to reach out to disadvantaged areas and communities will reduce the regional divide in the availability of services and result in a concomitant and balanced increase in CPR in all the divisions. 2. High adolescent fertility: Bangladesh has a high adolescent fertility rate, one of the highest amongst the SEAR nations. Early initiation of child bearing leads to rapid increases in population by not only lengthening the productive period in the woman’s life, but also by shortening the inter-generational span. As most of the adolescent child bearing occurs within the realm of marriage, it means that the law governing the age at marriage needs a much stricter reinforcement. It is heartening that through HPNSDP the government plans to make special efforts to reach out to adolescents with family planning messages and individual and community level counseling services. Convincing the adolescents to delay the fi rst pregnancy and child birth beyond the adolescent age frame will go a long way in bring TFR down to replacement levels. 3. Family Planning Service provision: The human resources issues such as insuffi cient training for health providers, inappropriate placement and personnel and inadequate supervision and the infrastructure in health sector are the keys challenges that government is facing to improve the health and family planning services. HPNSDP plans to not only increase the number of trained service providers both at the community and facility levels, but also ensure their skill and capacity development through continuing in-service education and training. It also plans to improve coordination between public, private and NGO sectors, and thus hoping to increase coverage levels for various health services, including family planning services. B hu ta n an d Fa m ily P la nn in g: A n ov er vi ew 1 Bhutan and Family Planning: An overview Background Bhutan covers a land area of about 38 394 square kilometres, most of which is hilly terrain. With a population of only 729 4291 in 2011, leading to a population density of 19 people per square kilometre, it is the smallest and least populated country in the South-East Asia Region. In 2005–2010, the average annual population growth rate stood at 1.95% (UN World Population Prospects, 2012). Due to a signifi cant decrease in fertility rates (as discussed below), the shape of the population pyramid of Bhutan has changed. While the 2002 pyramid was bottom-heavy owing to about 40% of the population being under the age of 15 years, this bulge is gradually shifting upwards. As can be seen in Figure 1, an increasing proportion of women (about 60%) are now in the reproductive age group. Situation Analysis Total fertility rate (TFR) Bhutan has made relatively quick progress in reducing the TFR over the past three decades. As shown in Figure 2, while the TFR stood at 2.8 in 2005 (National Statistics Bureau, 2010), it was just above 2.3 in 2011 (World Bank). According to an estimate made in 2010 by the Population Division of the UN Department of Economic and Social Affairs, and given the efforts made in this direction, the rapid decline in TFR will be sustained and will reach replacement fertility levels by around 2020 (Figure 3) (UN Department of Economic and Social Affair, 2010). A ge ( in y ea rs ) Per cent FemaleMale 510 0 5 10 105 100 90 80 70 60 50 40 30 20 10 0 Figure 1: Population pyramid, 2010 Source: UN, World Population Prospects 2012 1The CPR fi gures quoted in Figure 6 are from Population Reference Bureau reports and may not exactly match BLLS 2007 fi gures. 2B hu ta n an d Fa m ily P la nn in g: A n ov er vi ew Contraceptive prevalence rate (CPR) The fast-paced decline in TFR can be attributed to the sharp increase in uptake of contraceptives, especially over the past decade or so. While in 2007 only about 36% of couples in the reproductive age group were using a contraceptive method (Bhutan National Statistics Bureau, 2007), the CPR rose to about 66% in 2010 (Bhutan Multiple Indicator Survey, 2010). This rate is high compared with many other countries in the South-East Asia Region. To ta l F er ti lit y R at e 7 6 5 4 3 2 1 0 5.9 3.8 2.6 2.3 1990 2000 2009 2012 Year Figure 2: Trends in TFR Source: World Health Statistics 2011 and 2014. Figure 3: Historical and projected decline of TFR Source: UN Department of Economic and Social Affairs/Population Division, 2010. Year To ta l f er ti lit y (c hi ld re n pe r w om an ) Total fertility 7 6 5 4 3 2 1 Bhutan Southern Asia Asia 1950 2000 2050 2100 B hu ta n an d Fa m ily P la nn in g: A n ov er vi ew 3 Contraceptive method mix As shown in Figure 5, almost all women in Bhutan using contraception rely on a modern method. A negligible 0.2% of these women are using traditional methods. Unlike some other countries in the Region, where there is a greater reliance on sterilization, about 46% of married women in Bhutan are using spacing methods. This could explain the sharp fall in age-specifi c fertility rates, leading to a concomitant decline in the TFR in recent years. The Bhutan Multiple Indicator Survey (BMIS) 2010 reported that about 29% of all married women were using injectable hormonal contraceptives as a family planning method, while another 7.5% were using hormonal contraceptive pills. The injectable remains the most popular method, irrespective of women’s education or economic status. Even among the limiting methods, Bhutan shows an unusual trend, wherein the vasectomy rates at 12.6% far exceed the tubectomy rates at only 7.1%. Male participation and responsibility in family planning decisions is also evident by the moderate use of male condoms, by 5.5% of couples. Figure 4: Trends in CPR, 1994–2010 Source: NHS 2000, BLLS 2007 and BMIS 2010, World Health Statistics, 2014 18.8 30.7 35.4 65.6 66 80 70 60 50 40 30 20 10 0 South-East Asia regional average: 57.5% C on tr ac ep ti ve P re ve la nc e R at e Year 1994 2000 2008 2010 2012 Figure 5: Contraceptive method mix, 2010 Source: BMIS, 2010. Female Sterilization, 7.1% Male Sterilization, 12.6% Intrauterine device, 3.7% Injectable, 28.9% Implant, 0.1% Male condom, 5.5% Any traditional method, 0.2% Pill, 7.5% Not using any method, 34.4% 4B hu ta n an d Fa m ily P la nn in g: A n ov er vi ew From comparison of previous surveys and reports on contraceptive use and fertility trends in Bhutan, it can be seen that the current jump in CPR can almost exclusively be attributed to the rise in acceptance of injectable contraceptives, the utilization rate of which rose from about 6% in 2008 to as high as 29% in 2010 (Figure 6). Oral contraceptive pills and female sterilization also show modest increases. Unmet need for family planning With such a high CPR, about 1 in 10 women in Bhutan has an unmet need for family planning, which is much lower than other countries in the South-East Asia Region. In 2010 (Bhutan Multiple Indicator Survey, 2010), the unmet need for spacing was found to be 4.7%, while the unmet need for limiting was slightly higher at 6.9%. These averages mask a wide age-related variation in unmet need. The unmet need (spacing and limiting combined) for family planning in women aged 15–19 years is much higher at 27.4% compared to only 6.5% in women aged 45–49 years. Thus, while nationally the contraceptive needs of about 85% of women are met, only slightly more than half of adolescents have their family planning requirements satisfi ed. Adolescent fertility Bhutan Multiple Indicator Survey, 2010, found a wide age-related variation in the use of contraception. About 57% of 20–24 year olds were using a contraceptive method, and this increased to 71% among 40–44 year olds. However, only 30% of married women in the age group 15–19 years were using contraception. This relative lack of contraceptive usage is refl ected in high adolescent fertility rates of 59 births per 1000 women in the age group (Bhutan Multiple Indicator Survey, 2010). While 8.5% of girls aged 15–19 years had already given birth to a baby, another 2.5% were pregnant with their fi rst child at the time of the survey. Thus, 11% had begun childbearing. Added to this were another 0.5% women who had had a child before they reached the 15-year age mark. Figure 6: Trends in contraceptive method mix, 2002, 2008 and 2010 Sources: Population Reference Bureau12002, 2008 and BMIS 2010. R at e of c on tr ac ep ti ve m et ho d m ix 70 60 50 40 30 20 10 0 30 .7 65 .6 30 .7 30 .7 28 .9 13 .5 13 .6 12 .6 65 .4 3. 4 3. 4 5. 6 3 .4 3. 4 3. 7 1. 2 1. 2 3. 1 3. 1 5. 8 5. 9 5. 5 7. 1 Any method Any morden method Pill IUD Injection Condom Female sterilization Male sterilization 2002 2008 2010 B hu ta n an d Fa m ily P la nn in g: A n ov er vi ew 5 While the percentage of women with a live birth has remained relatively unchanged over the last 25 years, the latest survey (Bhutan Multiple Indicator Survey, 2010) fi nds a positive correlation between late childbearing and the educational and economic status of a woman. Early childbearing among women aged 20–24 years is about 10 times more common in women with no education (24%) compared to women with secondary education (2.7%). In the South-East Asia Region, as most childbearing occurs within the context of marriage, age at marriage is a very important determinant of sexual debut and childbearing. Slightly more than 15% of girls in the age group 15–19 years were married. There was a wide urban–rural divide in this indicator, with only 6% of urban girls already married compared to about 21% of girls from rural areas. Current Family Planning Eff orts The family planning programme is guided by the overall goals and objectives set in the national fi ve-year plans, which are geared towards the achievement of Gross National Happiness. Bhutan is currently implementing the Tenth Five Year Plan (2008–2013), which puts major emphasis on the achievement of the MDG and International Conference on Population and Development (ICPD) targets. Some of the objectives are to: • increase CPR from 30.7% to 60%; • reduce population growth rate to from 1.8 to 1.3; • achieve fertility replacement rate; • reduce maternal mortality from 255 to 100 deaths per 100 000 live births; • reduce infant mortality from 40.1 to 20 deaths per 1000 live births; • reduce under-5 mortality from 61.5 to 30 deaths per 1000 live births. The strategies to achieve the stated objectives include improving quality and accessibility to health services; developing adequate and competent human resources; increasing community awareness and empowerment; and, promoting institutional delivery to reduce maternal and newborn mortality. A large proportion of the programme in Bhutan is donor driven. Challenges and Opportunities 1. Reaching out to the unreached: Despite a high CPR at the national level, wide variations exist between different regions, between urban and rural populations, between different wealth quintiles and – most importantly – between age groups. Controlling high adolescent fertility rates will not only help to bring down the overall TFR, but also result in improvement in other maternal and child health-related indices. 2. Weaning off donor support: A sparse population living in diffi cult mountainous terrain makes access to health services and supplies not only practically diffi cult, but also requires increased funds. The improvement of the health sector in Bhutan, including on the family planning front, has been due to a considerable extent to fi nancial and technical support from the donor community. Bhutan needs to allocate more resources to the health programme in order to ensure sustainability of efforts once donor support phases out. 6B hu ta n an d Fa m ily P la nn in g: A n ov er vi ew References: 1. UN, World Population Prospects. 2012 2. Population data sheet 2012. s.l. : Population Reference Bureau 3. The World Bank. http://datatopics.worldbank.org/hnp/. http://worldbank.org. [Online] [Cited: November 06, 2012.] 4. National Statistics Bureau, Government of Bhutan and UNFPA. http://www.nsb.gov.bt/Order/Data-Sheet.pdf. http://www.nsb.gov.bt. [Online] 2010. [Cited: November 30, 2012.] 5. UN Department of Economic and Social Affairs. http://esa.un.org/wpp/country-profi les/pdf/64.pdf. [Online] 2010. [Cited: November 30, 2012.] 6. Bhutan National Statistics Bureau. Bhutan Living and Standard Survey 2007 (BLSS 2007). Thimpu, Bhutan : s.n. 7. Bhutan National Statistics Bureau, UNICEF and UNFPA. Bhutan Multiple Indicator Survey 2010. Thimpu, Bhutan : s.n., May 2011. 8. National Health Survey, 2000 D em oc ra ti c Pe op le ’s R ep ub lic o f K or ea a nd F am ily P la nn in g: A n ov er vi ew 1 Democratic People’s Republic of Korea and Family Planning: An overview Background The Democratic People’s Republic of Korea is formed largely by the Korean peninsula, located in central East Asia. Geographically, it is largely made up of diffi cult mountainous terrain, and less than one fi fth of the land is cultivable. The total population was 24 million in 2010, with an annual population growth rate of 0.4%. As can be seen from the population pyramid (Figure 1), while 23% of the population is less than 15 years of age, another 14% is over the age of 60 years (Democratic People's Republic of Korea Statistic Summary, 2002). Thus, the population structure is in a transitioning phase, as typically seen in countries with concomitant declines in birth and death rates. Situation Analysis The Democratic People’s Republic of Korea has an extensive health system and an adequate number of health workers. However, due to multiple natural disasters, economic downturn and political isolation, many of the health gains the country made up to the 190s have now been reversed (DPR Korea Country Profi le, 2011). A multiple indicator cluster survey (MICS) was conducted in 2009 by the Central Bureau of Statistics with support from UNICEF (DPR Korea Multiple Indicator Survey, 2009). However, this survey did not capture any information on family planning related indicators. Hence, fertility and family planning related data in this fact sheet are based on the 2002 national Reproductive Health Survey, as well as from international agency estimates for the country. Figure 1: Population pyramid, 2010 Source: UN Population Projection 2010. A ge (i n ye ar s) Per cent FemaleMale 5 0 5 105 100 90 80 70 60 50 40 30 20 10 0 2D em oc ra ti c Pe op le ’s R ep ub lic o f K or ea a nd F am ily P la nn in g: A n ov er vi ew Source: Democratic People's Republic of Korea Statistic Summary, 2002; DPR Korea Multiple Indicator Cluster Survey, 2009, DPRK Key Facts, 2010; Human Rights Watch, 2012 Table 1: Key indicators Total population (in millions), 2009 census 24.05 Population growth rate, 2010 0.4% Population density (people per square km), 2002 190 Urban population, 2010 60% Population <15 years of age, 2003 22.9% Total fertility rate, 2012 2.0 Contraceptive prevalence rate, 2008 67.2% – Pill 3.7 – IUD 42.8 – Female sterilization 4.4 – Male sterilization 0.8 – Condom 5.8 – Other modern methods 0.9 – Traditional or natural methods 10.4 Unmet need, 2003 16.7% – For spacing births 6.3 – For limiting births 10.4 Average age at fi rst marriage, 2002 24.8 Average age at fi rst birth NA Crude birth rate (per 1000 population), 2002 15.6 Maternal mortality ratio (per 100 000 live births), 2012 68.1 Infant mortality rate (per 1000 live births), 2012 16.7 HIV adult prevalence, 2001 <0.01% Total fertility rate (TFR) Interagency estimates pegged the TFR of Democratic People’s Republic of Korea at 2.0 in 2010 (DPR Korea Country Profi le, 2011), which – although 0.1% higher than statistical estimates in 2009 (see Figure 2) – is still lower than replacement level fertility. Even back in 1990, the TFR was 2.4, which is considerably lower than the levels in other countries in the South-East Asia Region. D em oc ra ti c Pe op le ’s R ep ub lic o f K or ea a nd F am ily P la nn in g: A n ov er vi ew 3 Contraceptive prevalence rate (CPR) The CPR for married women in Democratic People’s Republic of Korea was estimated to be 67.2% in 2008 (DPRK Key Facts, 2010). This refl ects a 1.6% decline compared to 2002 levels. Disruption in access to health services due to political strife may be one of the causes of this slight decline. The difference could also be due to lack of comparative measurements, as the 2002 levels are based on a nationwide reproductive health survey. The increase in contraceptive uptake is linked to a concomitant reduction in induced abortion rates, which fell from 17.7 abortions per 1000 women in 1997 to 11.1 in 2002. Figure 2: Trends in TFR, 1990–2009 2.4 2 1.9 2 To ta l F er ti lit y R at e 3 2.5 2 1.5 1 0.5 0 1990 2000 2009 2012 Source: World Health Statistics 2011 and 2014 Source: Reproductive Health Survey 2002. Figure 3: Trends in TFR, 1990–2009 C on tr ac ep ti ve p re ve la nc e ra te 70 68 66 64 62 60 58 56 54 52 50 Year 1990–1992 2002 61.9 68.8 South-East Asia regional average: 57.5% Year 4D em oc ra ti c Pe op le ’s R ep ub lic o f K or ea a nd F am ily P la nn in g: A n ov er vi ew Contraceptive method mix The 2002 survey revealed that couples rely on long-tem or permanent methods for their contraceptive needs (Figure 4). The IUD emerged as the method of choice, with almost 43% of married women opting for the same. While sterilization (female and male) was chosen by slightly more than 5% of the couples, another 6% or so opted for condoms. As can be seen from Figure 5, the contraceptive method mix has remained largely unchanged since the 1990s. Figure 4: Contraceptive method mix for married women, 2002 Pill, 3.7% IUD, 42.8% Male sterilization, 0.8% Condom, 5.8% Other modern method, 0.9% Traditional or natural method, 10.4% Not using any method, 31.2% Female sterilization, 4.4% Source: Reproductive Health Survey, 2002. Figure 5: Trends in contraceptive method mix Source: Reproductive Health Survey 2002. Any method Morden method Pill IUD Injection Condom Male sterilization Female sterilization 61 .8 68 .8 53 58 .4 48 .5 42 .8 0 0 5. 8 4. 1 0. 1 3 .7 4. 4 0. 3 0. 8 C on tr ac ep ti ve p re va ln ce r at e 80 70 60 50 40 30 20 10 0 1990–92 2000 Contraceptive methods D em oc ra ti c Pe op le ’s R ep ub lic o f K or ea a nd F am ily P la nn in g: A n ov er vi ew 5 Unmet need for family planning Despite the relatively high CPR, 16.7% of married women have an unmet need for family planning, of which 6.3% is for spacing and 10.4% is for limiting births. Thus, the health programme is able to satisfy about 80% of the felt family planning need in the country. Adolescent fertility About one sixth of the country’s population are adolescents (aged 10–19 years) and one fourth consists of young people (aged 10–24 years) (Adolescent Health fact sheet - DPR Korea, 2007). Unlike other countries in the Region, teenage pregnancies and early childbirth is not an issue in Democratic People’s Republic of Korea. Adolescent fertility is low, at 0.6 births per 1000 girls aged 15–19 years (Democratic People's Republic of Korea Statistics Summary, 2002). The regional average is 54 births per 1000 girls. This is due to a very high mean age at fi rst marriage in the country, of 24.8 years for girls and 27 years for boys. Only 1% of girls get married at an age of less than 19 years. Similarly, the mean age of women at fi rst birth is 25.9 years (Adolescent Health fact sheet - DPR Korea, 2007). This delay in marriage and subsequent fi rst birth are important factors that have led to low fertility levels, despite a relatively high unmet need for family planning. Current Family Planning Eff orts The Government runs its health programme on the socialist principles that are the basis of the adopted Law on Public Health, Family Law, the Law of Educating and Upbringing Children, the Law of Education etc. (Country Health System Profi le - DPR Korea, 2013). The Government has recognized the ability to decide when and how many children to have as a basic human right and, therefore, has ensured a programmatic focus on family planning since the 1970s. Contraceptive services and supplies are available free of cost at hospitals and at clinics. Counselling for family planning and provision of supplies, such as oral pills and condoms, are also offered to women who attend antenatal clinics and as part of post-abortion services. Doctors and midwives are trained in the provision of services, including performance of sterilization surgeries and insertion of IUDs. For geographically hard-to-reach and disaster-affected areas, the health system relies on mobile health units to deliver services, including family planning. To ensure that youth are aware of reproductive health needs and issues and are able to protect themselves against adverse and unwanted outcomes, including reproductive health morbidities, topics related to reproductive health and hygiene are included in the school curriculum. As education is free and compulsory for all children, inclusion of these topics in the education system means that information reaches out to all youth across the country. 6D em oc ra ti c Pe op le ’s R ep ub lic o f K or ea a nd F am ily P la nn in g: A n ov er vi ew Challenges and Opportunities Long-standing geographical and political isolation of the country, coupled with large-scale famines, have led to a shifting of national Government priorities and reversal of some health gains. The Government needs to ensure adequate funding of the health system, including the provision of regular supplies. The high level of awareness among the population regarding reproductive health issues and self-care, including family planning, reduces the burden on the Government as minimal effort is required on the demand side. The assistance of various international nongovernmental organizations as well as UN bodies working in the country may be sought to once again streamline health service delivery systems, including those for family planning. References: 1. World Health Organisation. Democratic People's Republic of Korea Statistics Summary (2002 - Present). World Health Organisation. [Online] 2013. [Cited: March 11, 2013.] http://apps.who.int/gho/data/view.country.7400. 2. DPR Korea Country Profi le. [Online] April 2011. [Cited: March 06, 2013.] http://www.dprk.searo.who.int/LinkFiles/Health_Information_Country-Profi le.pdf. 3. Central Bureau of Statistics & UNICEF. DPR Korea Mutiple Indicator Cluster Survey 2009 - Final Report. Pyongyang, DPR Korea : Central Bureau of Statistics, December 2010. Survey Report. 4. World Health Organisation. DPRK Key Facts - 2010. World Health Organisation - Democratic People's Republic of Korea. [Online] 2010. [Cited: March 11, 2013.] http://www.dprk.searo.who.int/LinkFiles/Home_DPRK_fs.pdf. 5. Adolescent Health fact sheet - DPR Korea. World Health Organisation. [Online]. January 2007. [Cited: March 06, 2013.] http://aidsdatahub.org/dmdocuments/Fact_ Sheets_Korea_AHD_07.pdf. 6 Country Health System Profi le - DPR Korea. World Health Organisation - Regional Offi ce for South-East Asia. [Online] World Health Organisation. [Cited: March 12, 2013.] http://209.61.208.233/en/Section313/Section1518_6796.htm. 7. Human Rights Watch. North Korea. January 2012. 8. World Health Statistics, 2014 In di a an d Fa m ily P la nn in g: A n ov er vi ew 1 Background India has experienced remarkable growth over the past two decades and is ranked third globally in terms of purchasing power parity (after the United States of America and the People’s Republic of China) (National Family Health Survey - 3, 2005–06). It is home to 17% of the world’s population – a population of diverse cultures, languages and religions. India has also made progress on most of the MDGs and has invested resources generated from growth into programmes to deliver services to the poor (Reproductive Health at a Glance, World Bank, June 2010). The relevance and importance of family planning in India has to be understood in the context of the burgeoning population, and the persistence of relatively poor social indicators in spite of a booming economy. India, the second most populous country in the world, is projected to exceed 2 billion people by the turn of the twenty-fi rst century. According to the Census of India 2011, the population was nearly 1.210 million, of which 31% are below the age of 15 years and 53% of women are in the reproductive age group (15–49 years). Situation Analysis India was the fi rst country in the world to launch a family planning programme, in 1952, with the objective of “reducing birth rate to the extent necessary to stabilise the population at a level consistent with requirement of national economy”. Gradually, the focus of the programme moved away from population control to population stabilization, and then was integrated with the maternal and child health programme, as family planning became viewed as an important tool to reduce maternal and child mortality. India and Family Planning: An overview Figure 1: Population age pyramid, 2011 Source:Census of India 2011 Male Female 100+ Population (in millions) Population (in millions) 95 – 99 90 – 94 85 – 89 80 – 84 75 – 79 70 – 74 65 – 69 60 – 64 55 – 59 50 – 54 45 – 49 40 – 44 35 – 39 30 – 34 25 – 29 20 – 24 15 – 19 10 – 14 5 – 9 0 – 4 65 52 39 26 13 0 0 13 26 39 52 65 A ge (i n ye ar s) 2In di a an d Fa m ily P la nn in g: A n ov er vi ew Data for India, especially regarding contraceptive use, are a little out of date as no nationally representative surveys have been undertaken following the third round of the National Family Health Survey (NFHS) – India’s DHS – in 2005–2006. Table 1. Key indicators Total population (in million), 2011 1.21 Annual population growth rate, 2011 1.25% Population density (people per square km), 2011 382 Urban population, 2011 31.1% Population below 15 years of age, 2011 30.8% Total fertility rate, 2012 2.4 Contraceptive prevalence rate, 2005–2006 56.3% – Pill 3.1 – IUD 1.7 – Female sterilization 37.3 – Male sterilization 1.0 – Condom 5.2 – Injectable 0.1 – Any modern method 48.5 – Any traditional method 7.8 – Not currently using 43.7 Unmet need for family planning, 2005–2006 12.8% – Unmet need for spacing 6.2 – Unmet need for limiting 6.6 Median age at fi rst marriage for girls (in years), 2005–2006 17.2 Median age at fi rst birth (in years), 2005–2006 20 Crude birth rate (per 1000 population), 2012 21.6 Maternal mortality ratio(per 100000 live births), 2010–2012 178 Infant mortality rate (per 1000 live births), 2012 42 HIV adult prevalence rate (age 15–49 years), 2005–2006 0.28% Sources: Census of India 2011; NFHS-3, 2005–2006; Sample Registration System (SRS), 2012; and SRS, 2010–2012. Total fertility rate (TFR) Due to intense efforts to control population growth in India, the TFR has been steadily declining over the past few decades. The current TFR of 2.4 in 2012 is down from 3.1 children per woman in 2001, but is still above replacement level fertility. In urban areas, the TFR has reached below replacement levels at 1.8, but in rural areas the TFR is 2.6. In di a an d Fa m ily P la nn in g: A n ov er vi ew 3 Contraceptive prevalencerate (CPR) According to NFHS-3 in 2005–2006, the CPR among currently married women was 56.3% for any method and 48.5% for modern methods of contraception. CPR for modern methods has been increasing steadily from 36.5% in 1992–1993 (the time of NFHS-1), to 42.8% in 1998–1999, and reaching 48.5% in 2005–2006. CPR varies considerably with socioeconomic parameters. For example, in 2005–2006 use of any modern methods of family planning was signifi cantly less among Muslims (36%) as compared to Hindu women (50%),while it was highest among Sikh women (63%). Similarly, CPR for modern methods was only 35% among women in the lowest wealth quintile, compared to 58% among women in the highest wealth quintile. An urban–rural divide in the use of contraception was seen to exist in all rounds of NFHS, with 56% of urban women using modern methods of contraception compared to only 45% of rural women in 2005–2006. The use of contraception has increased steadily in both urban and rural areas, but the pace of change has been somewhat faster in rural areas. The geographical diversity of this vast country is also refl ected in the CPR, which varies substantially across the states from a low of 19% in Meghalaya to a very high 71% in Himachal Pradesh for modern methods. Figure 2: Trends in TFR, 1971–2011 Source: SRS, 1971–2011. 5.2 4.5 3.6 3.1 2.4 To ta l F er ti lit y R at e 6 5 4 3 2 1 0 1971 1981 1991 2001 2011 Year Figure 3: Trends in modern contraceptive use, 1992–2006 Source: NFHS-3, 2005–2006. Pe r ce nt o f m ar ri ed w om en a ge 1 5– 49 100 80 60 40 20 0 Total Urban Rural NFHS-1 NFHS-2 NFHS-3 36 .5 42 .8 4 8. 5 45 .3 5 1. 2 55 .8 33 .3 39 .9 4 5. 3 4In di a an d Fa m ily P la nn in g: A n ov er vi ew Contraceptive method mix Contraceptive use by type of method indicates a dominance of female-oriented contraceptive methods in India. In 2005–2006, female sterilization was reported to be the most used method (37%). Conversely, male sterilization was least used. Among temporary modern methods, use of condoms was 5%, followed by pills (3%) and IUDs (2%). A signifi cant proportion of current users were using traditional methods (8%), primarily the rhythm method (5%) and withdrawal method (3%)(Figure 4). Condom use was three times higher in urban than rural areas. Since 1998–1999, the CPR due to female sterilization has increased by 3%; on the other hand, male sterilization has declined by 1%. Use of condoms and pills has increased by 3 and 2 percent points since 1992–1993 (Figure 5). Other modern methods of contraception such as IUDs and vasectomy continue to fi nd very few takers. Figure 4: Contraceptive method use by married women, 2005–2006 Source: NHFS 3 2005–2006. Condom, 5.2% Any traditional method, 7.8% Not currently using, 43.7% Pill, 3.1% Female sterilization, 37.3% IUD, 1.7% Injectable, 0.1% Male sterilization, 1% Figure 5: Trends in contraceptive use, 1992–2006 Source: NHFS-3, 2005–06 Pe rc en ta ge 60 50 40 30 20 10 0 Pills IUD Injectables Condom Female sterilization Male sterilization Any traditional method 1. 2 2. 1 3. 1 1. 9 1. 6 01 .7 0. 1 2. 4 3. 1 5 .2 3. 5 1. 9 1 27 .4 34 .2 3 7. 3 7. 8 NFHS-1 NFHS-2 NFHS-3 In di a an d Fa m ily P la nn in g: A n ov er vi ew 5 Unmet need for family planning In 2005–2006, nearly 13% of currently married women had an unmet need for family planning. The unmet need for limiting (7%) is slightly higher than unmet need for spacing (6%). With the increase in CPR, total unmet need for family planning has declined by 3% since 1998–1999; a higher decline is observed in unmet need for spacing than for limiting methods. The decline in unmet need for family planning is slower than the increase in CPR, revealing that overall demand for family planning has increased; however, the system has not been able to address the increased demand fully. Unmet need in 2005–2006 varied from 5% in Andhra Pradesh to 35% in Meghalaya. Urban women have a lower unmet need than rural women. It is particularly high for Muslim women and low for Sikh and Jain women, and decreases with an increase in wealth quintiles. Adolescent fertility The adolescent fertility rate is relatively high in India. Most teenage pregnancies occur within the confi nes of marriage, due to the cultural practice of early marriage. The adolescent fertility rate has declined, from 42 births per 1000 girls aged 15–19 years in 2008 to about 32 in 2012 (Figure 6). In India, according to the law, the minimum age of marriage is 18 years for girls and 21 for boys. Despite such a law governing the age of marriage, early and teenage marriages are common. In 2005–2006, 47% of women aged 20–24 were married before the age of 18. The median age at marriage for women (aged 20–49 years) was 17 years and median age at fi rst birth was 19.8 years. More than a fi fth (22%) of women in the age group 20–24 years had already given birth before the age of 18. Moreover, 16% of adolescent girls (aged 15–19 years) have begun childbearing1 in India; this percentage ranges from 3% in Himachal Pradesh to more than 25% in Bihar, Jharkhand and West Bengal. 1Were either pregnant at the time of the survey or had already given birth to a child. Figure 6: Trends in adolescent fertility rate, 2008–2012 Source: SRS 2008, 2010, 2011 and 2012. B ir th s pe r 10 00 w om en a ge d 15 –1 9 45 40 35 30 25 20 15 10 5 0 2008 2010 2011 2012 41.6 37.2 31.530.7 6In di a an d Fa m ily P la nn in g: A n ov er vi ew Access to family planning information and services In India, knowledge of permanent methods of contraception is high among both men and women. More than 90% of men know about condoms compared to three quarters of women. Similarly, about 70% of women and half of men know about intrauterine devices, a female-oriented method. Less than half of men and women know about injectable contraceptives. In 2005–2006, only 7% of women in the age group 15–19 years were currently using any modern method of family planning as compared to 64% of women aged 35–39 years (Figure 7). Figure 8: Knowledge of modern contraceptive methods, 2005–2006 Percent of women and men aged 15–49 aware of family planning methods Female sterilization Male sterilization Condom/Nirodh IUD Pill Emergency contraception Female condom Injectables NFHS-3, India, 2005 Women Men 95 97 87 79 93 74 51 69 83 85 20 11 17 8 45 49 Figure 7: Women using modern methods by age category, 2005–2006 Source: SRS 2008, 2010, 2011 and 2012. Pe rc en t 100 90 80 70 60 50 40 30 20 10 0 15–19 20–24 25–29 30–34 35–39 40–44 45–49 Age group 6.9 26.1 48.4 61.2 63.8 60.7 59 In di a an d Fa m ily P la nn in g: A n ov er vi ew 7 In 2005–2006, nearly 61% of women and 92% of men acknowledged that they had read, seen or heard family planning messages through mass media in the few months preceding the survey. Television was the most common source of family planning messages for both men and women. Nearly half of women saw a family planning message on television; one-third heard a family planning message on the radio; about one-quarter saw a family planning message on a wall painting or hoarding; and, 22% saw a family planning message in a newspaper or magazine. Two-thirds (67%) of currently married women and more than four-fi fths (82%) of currently married men who are not currently using contraception know a place where a method of contraception can be obtained. However, less than one-fi fth (18%) of women said they were ever informed by a health or family planning worker about any method of family planning. Current Family Planning Eff orts The current family planning programme in India is run under the National Health Mission. The programme has been repositioned from being a means for population stabilization to being an important intervention for reducing maternal and newborn mortality and improving maternal and childhealth. The family planning programme focuses on the strategies listed below. • Increasing use of spacing methods (reversible contraceptives). To enable this, the Government has started a programme for doorstep delivery of contraceptives through community-based health workers, known as accredited social health activists (ASHAs). • Owing to a phenomenal increase in institutional deliveries, utilizing the increased access to women in the postpartum period to promote postpartum family planning, especially postpartum IUD insertion and postpartum female sterilization. • Availability of fi xed day static services for sterilization at all facilities. • Emphasis on minilaptubectomy services, due to its logistical simplicity and requirement of only MBBS doctors and not postgraduate gynaecologists/surgeons. • A rational human resource development plan is in place for provision of IUD, minilap and no-scalpel vasectomy to empower health facilities (district hospitals, community health centres, primary health centres, sub-health centres) with at least one provider each for each of the services and sub-centres with auxiliary nurse midwives trained in IUD insertion. • Ensuring quality of care in family planning services by establishing quality assurance committees at state and district levels. • Accreditation of more private/non-governmental facilities to increase the provider base for family planning services under public private partnerships. • Increasing male participation in family planning and promoting no-scalpel vasectomy. • Compensation scheme for sterilization acceptors – under the scheme, the Ministry of Health and Family Welfare provides compensation for loss of wages to both the benefi ciary and service provider (and team) for conducting sterilizations. • National Family Planning Insurance Scheme under which clients are insured in the eventuality of death, complications and failures following sterilization. The providers/ accredited institutions are indemnifi ed against litigations in such eventualities. • Focusing on adolescents and young couples. To enable this, the Government has initiated an incentive scheme for ASHAs called “Ensuring spacing of birth”, where in the ASHA is given a monetary incentive if she is able to convince a young couple in her catchment area 8In di a an d Fa m ily P la nn in g: A n ov er vi ew References: 1. World Bank. India. Reproductive health at a glance. Reproductive health at a glance; India. Washington, DC: World Bank. 2011 http://documents.worldbank.org/ curated/en/2011/06/14703604/india-reproductive-health-glance 2. International Institute for Population Sciences (IIPS) and Macro International (2007), National Family Health Survey-3(NFHS-3), India Volume II. Mumbai: IIPS. 2005-06. 3. International Institute for Population Sciences (IIPS) and ORC Macro (2000), National Family Health Survey-2 (NFHS-2), India. Mumbai: IIPS. 1998-99: 4. Offi ce of the Registrar General & Census Commissioner, India, Sample Registration System Statistical Report 2012 , Report No 1 of 2013. 5. Offi ce of the Registrar General & Census Commissioner, India (2013) , Sample Registration System. Special Bulletin on Maternal Mortality in India. 2010-12. 6. Ministry of Health and family Welfare (MoHFW), Framework for Implementation, National Health Mission. 2012-2017. 7. Ministry of Health and family Welfare (MoHFW), Material for Annual report Family Planning. 2012-13 to delay their fi rst childbirth to beyond 2 years of marriage, and space the subsequent birth by at least 3 years. • Improving contraceptives supply management up to peripheral facilities. • Demand generation activities in the form of poster displays, billboards and other audio and video materials in the various facilities. Challenges and Opportunities 1. Limited method mix: India is a signatory to the Family Planning 2020 (FP2020) commitment, and is responsible for increasing contraceptive access to an additional 48 million girls and women by the year 2020. This is 40% of the global target, and will require a signifi cant increase in CPR. Although past surveys have shown a gradual but steady increase in CPR, the rate of increase will need to be accelerated signifi cantly if India hopes to achieve the FP2020 goals. Apart from strengthening the existing programme, India needs to add more products to the contraceptive basket available within the public health sector, as global evidence shows a signifi cant jump in CPR with the addition of any new product. 2. Focus on adolescents: India has the largest number of adolescent population in the whole world. While it can prove to be a great demographic dividend, investing in adolescents would necessarily mean taking steps to reduce adolescent pregnancy rates so that these girls and women can actively contribute to the nation’s economic growth. Beyond the provision of contraceptives to adolescent boys and girls, the country also needs to focus on intersectoral linkages to delay age at marriage. Investing in girls’ education is a known strategy to delay marriage. Also, adolescents will need comprehensive sexual education to enable them to make informed choices regarding contraception. 3. Linkages with the private sector: Survey data show that while public health facilities account for the provision of a signifi cant proportion of sterilization services, women and couples access reversible methods through the private sector. Thus linkages with the private sector, whether through initiatives such as social marketing and social franchising or through accreditation, will go a long way in increasing access to services. 4. Focus on quality: The Government of India’s programmeis focusing on quality of services, especially in relation to quality of services for clinical and surgical methods of contraception, by training service providers, and ensuring infection prevention practices etc. Greater focus is needed on important areas of quality, especially ensuring informed choice through good quality counselling, so that the programme adheres to the commitments made under the ICPD programme of action. In do ne si a an d Fa m ily P la nn in g: A n ov er vi ew 1 Background Indonesia comprises a cluster of about 17 000 islands that fall between the continents of Asia and Australia. Of these, fi ve large islands (Sumatra, Java, Kalimantan, Sulawesi and Papua), along with two island groups (Maluku and Nusa Tenggara) host the majority of the population, while most of the other islands are small and uninhabited. This means that the country sees extremely uneven population densities not only between islands, but also within an island. From an administrative viewpoint, the country is divided into 33 provinces, each of which is further subdivided into districts and municipalities. According to the 2010 census, the population of Indonesia is 237.6 million (Statistics Indonesia), of which 50.17% are male and 49.83% are female (Population percentage by Province & Gender, 2009, 2010, 2011). The annual population growth rate is declining. It was 1.98% in the decade 1980– 1990, and reduced to 1.49% over the next decade. The projected average annual growth rate in the decade starting in 2000 was 1.28% (Statistics Indonesia). As can be seen from Figure 1, a large proportion of the Indonesian population is constituted of children and people in the reproductive age group. Situation Analysis The national DHS are one of the most important sources of information on family planning and related matters. In 2007, the Government of Indonesia with support from donors such as United States Agency for International Development (USAID) and UNFPA conducted the sixth DHS, which captured data from a sample of ever-married women aged 15–49 years as well as currently married men in the age group 15–54 years. Indonesia and Family Planning: An overview Figure 1: Population pyramid, 2010 Source: UN Population Projections 2010. A ge ( in y ea rs ) Per centMale Female 5 0 5 105 100 90 80 70 60 50 40 30 20 10 0 2In do ne si a an d Fa m ily P la nn in g: A n ov er vi ew Table 1: Key indicators Total population (in millions), 2010 census 237.6 Population growth rate, 2005–2010 1.08% Population density (people per square km), 2010 126 Urban population, 2010 44% Population <15 years of age, 2010 27% Total fertility rate, 2012 2.6 Contraceptive prevalence rate, 2012 61.9% – Female sterilization 3.2 – Male sterilization 0.2 – Pill 13.6 – IUD 3.9 – Injectable 31.9 – Implant 3.3 – Male condom 1.8 – Periodic abstinence 1.3 – Withdrawal 2.3 – Folk method 0.4 Unmet need, 2012 11% Median age at fi rst marriage (in years), 2012 20.1 Median age at fi rst birth (in years), 2012 22.0 Crude birth rate (per 1000 population), 2005–2010 19.1 Maternal mortality ratio (per 100 000 live births), 2010 220 Infant mortality rate (per 1000 live births), 2012 32 HIV adult prevalence (age 15–49 years), 2013 0.43% Source: Achieving the Health-related, Millennium Development Goals in the South-East Asia Region: Measuring Indicators 2014 Total fertility rate (TFR) As can be seen in Figure 2, the TFR has been gradually declining in Indonesia over the years. DHS 2007 showed that the TFR was 2.6, which was no change from the previous DHS in 2003–2004. However, an urban–rural differentiation shows that while the TFR in urban areas has reduced from 2.4 to 2.3, it has increased from 2.7 to 2.8 in rural areas. The signifi cant inter-provincial differences in TFR refl ected in DHS 2003–2004 were also refl ected in DHS 2007, with TFR being 1.8 in the Special Region of Yogyakarta and as high as 4.8 in East Nusa Tenggara. In do ne si a an d Fa m ily P la nn in g: A n ov er vi ew 3 A comparison of age-specifi c fertility rates between the last two surveys shows that (a) women are choosing to delay childbirth to their late twenties, and (b) women in urban areas start having children later than their rural counterparts. The 2007 survey shows an unusual inverted U-shaped relationship between education and fertility, wherein women with no education and those with the highest level of education have the lowest fertility rates. There was no clear-cut association seen between fertility rates and wealth quintiles. Global evidence says that the ideal birth interval for reducing maternal and infant mortality ranges from 3 to 5 years. In Indonesia, DHS 2007 found that for second and higher order births that took place in the 5 years preceding the survey, the median birth interval was 54.6 months, and 70% of the births took place after a gap of 3 years or more. Figure 2: Trends in TFR, 1991–2012 Source: Indonesia DHS 2012. 3.0 2.9 2.8 2.62 2.6 2.6 To ta l f er ti lit y ra te 1991 1994 1997 2003 2007 2012 Year 3.1 3.0 2.9 2.8 2.7 2.6 2.5 2.4 Contraceptive prevalence rate (CPR) According to DHS 2007, about 61% of currently married women were using a contraceptive method. Of these, 57% were using a modern method of contraception. As can be seen in Figure 3, these rates are similar to those found in the 2003 survey, and about 4% higher than the 1997 survey results, thus refl ecting a plateauing in the uptake of contraceptives. The urban–rural difference in CPR was not high, at 63% and 61%, respectively. Source: World Health Statistics 2005, 2006, 2007, 2008, 2009 and 2011. Figure 3: Trends in CPR, 2005–2011 70 60 50 40 30 20 10 0 49.7 54.7 57.4 60.3 61.4 61.9 Year 1991 1994 1997 2003 2007 2012 Pe rc en ta ge o f cu rr en tl y m ar ri ed w om en ag e 15 -4 9 w ho a re c ur re nt ly u si ng a co nt ra ce pt iv e m et ho d South-East Asia regional average: 57.5% 4In do ne si a an d Fa m ily P la nn in g: A n ov er vi ew Contraceptive method mix As can be seen from Figure 4, Indonesian women largely rely on reversible methods of contraception. Injectable contraceptives are the most preferred method, with about one third of the women opting for the same. Figure 5 shows that the use of injectables had increased by 4% in 2007, compared to the previous survey in 2003. On the other hand, IUD use has been constantly declining over the years. Unlike many countries in the South-East Asia Region, permanent methods are not very popular in Indonesia and only 3% of women are opting for female sterilization, and another 0.2% are opting for male sterilization as the contraceptive method of choice. The contraceptive method mix varies among urban and rural women in Indonesia, with urban women opting for IUD, condoms and female sterilization, while rural women prefer injectables and implants. Also, younger women (aged 20–34 years) are more likely to use injectables, pills and implants, whereas older women (35–44 years) prefer longer acting contraceptives such as IUDs or permanent methods such as female and male sterilization. Use of reversible contraceptives, especially hormonal contraceptives, requires regular intake of pills or timely repetition of shots to ensure protection against pregnancy. DHS 2007 found that 80% of women using the pill were regular with their daily pill intake and over 90% of injectable users were current with their doses at the time of the survey. Figure 4: Contraceptive method mix used by currently married women, 2007 Source: Indonesia DHS, 2012 Withdrawal, 2.3% Other, 0.4% Injectables, 31.9% Periodic Abstinence, 1.3% Implants, 3.3% Female Sterilization, 3.2% Male Sterilization, 0.2% Male Condom, 1.8% IUD, 3.9% Pill, 13.6 In do ne si a an d Fa m ily P la nn in g: A n ov er vi ew 5 Unmet need for family planning Both DHS 2003 and 2007 showed that 54% of couples wanted to limit their family size at the time of the survey. The wanted fertility rate was about 2.2 children on average compared to the actual TFR of 2.6. The total unmet need for family planning in Indonesia has been stagnant at 9% since 1997. Of this unmet need, 4% is for spacing and 5% is for limiting. Also, of all the pregnancies in the 5 years preceding the survey, about 10% were mistimed (a further subindicator refl ecting unmet need for spacing), and 10% were not wanted at all (indicating unmet need for limiting). If all the unmet need of the population is covered, the CPR in Indonesia would be 71%. Adolescent fertility Figure 6 shows that adolescent fertility in Indonesia is reducing over the years, and is lower than the regional average. In 2007, 9% of married teenage girls (15–19 years) had begun childbearing, with 7% already having delivered a live child and 2% pregnant with their fi rst child. This represents a 1% reduction in teenage childbearing rates compared to 2003. The proportion of teenage girls entering the childbearing phase increases rapidly with age. The survey of DHS, 2007 found that while only 1% of girls aged 15 years had begun childbearing, about one in fi ve girls aged 19 years had done so. DHS 2007 found that the median age at marriage (measured for women aged 25–49 years) was 19.8 years, which had increased from 19.2 years as per DHS 2003–2004, indicating an increasing preference of girls and women to delay their fi rst marriage. As most childbearing in Indonesia occurs within the context of marriage, this change in age at marriage is also refl ected in the median age at fi rst birth, which increased from 21.0 years to 21.5 between the last two surveys. This shift was also seen in the age-wise disaggregated data of the DHS, 2007 survey, which showed that while the median age at fi rst birth was 20.4 years for women aged 45–49 years, it was 22.5 years for women aged 25–29 years. Figure 5: Trends in contraceptive method use, 1987–2007 Source: Indonesia DHS, 2012 Pe rc en ta ge o f c ur re nt ly m ar ri ed w om en a ge 1 5- 49 y ea rs 35 30 25 20 15 10 5 0 Contraceptive methods Pills Injectables Implants IUD Female Sterilization Male Sterilization Condom Periodic Abstinence Withdrawal Other 1991 1994 1997 2003 2007 2012 14 .8 17 .1 15 .4 13 .2 13 .2 13 .6 11 .7 3. 1 4 .9 6 4. 3 2. 8 3. 3 13 .3 10 .3 8. 1 6. 2 4. 9 3. 9 2. 7 3. 1 3 3 .7 3 3. 2 0. 6 0. 7 0. 4 0. 4 0. 2 0. 2 0. 8 0. 9 0. 7 0. 9 1. 3 1. 8 1. 1 1. 1 1. 6 1. 5 1. 3 0. 7 0. 8 0. 8 1. 5 0. 9 0. 8 0. 8 0. 5 0. 4 0. 4 2. 1 2. 3 15 .2 21 .1 27 .8 31 .8 31 .9 1. 1 6In do ne si a an d Fa m ily P la nn in g: A n ov er vi ew Women in urban areas begin childbearing about 2 years later than their rural counterparts. While the median age at fi rst birth was 22.9 years for the women living in urban areas, it was only 20.6 years for those living in rural Indonesia. The gradual and steady increase in age at fi rst marriage since the 1970s can be attributed to improvement in the educational attainment of girls. In 1971, 62% of boys and 58% of girls aged 7–12 years were enrolled in schools. These proportions had increased to 93% and 98%, respectively, by 2007. This is also refl ected in the survey results, wherein a positive relationship was observed between women’s educational status and a delay in childbearing. On an average, women who had no education gave birth to their fi rst child at the age of 19.6 years, whereas those with at least some secondary education had their fi rst childbirth at 21.2 years. Access to family planning information and services Family planning-related messages are disseminated in Indonesia through both interpersonal communication led by family planning-related grass-root level functionaries as well as through the use of mass media such as radio, television and print. Men and women from urban areas, those with a higher educational status and those belonging to a higher wealth quintile have greater exposure to mass media messages on family planning. Knowledge about contraceptive methods is very high among Indonesian women and men, with over 98% of married women and 94% of married men able to identify at least one modern contraceptive method. The most common methods quoted were injectables and pills, which tallies closely with the actual method mix in use. However, very few people were aware of emergency contraception in 2007, as it had been newly introduced into the programme at that time. Most Indonesian women (69%) rely on private medical sources such as private midwives or pharmacy and drug stores for procuring contraceptive supplies. Only 22% rely on government sources, and this proportion decreased by 6% between the last two surveys. Almost all contraceptive users (91%) pay for the services they receive. This payment is highest among users of injectables and pills (96% and 97%, respectively), and lowest for IUDs (69%) Figure 6: Trends in adolescent fertility, 2008–2011 Source: Indonesia DHS 2012 A do le sc en t f er ti lit y ra te (p er 10 00 w om en a ge d 15 -1 9 ye ar s) 80 70 60 50 40 30 20 10 0 Year 1991 1994 1997 2003 2007 2012 South-East Asia regional average: 54 67 61 62 51 51 48 In do ne si a an d Fa m ily P la nn in g: A n ov er vi ew 7 Current Family Planning Eff orts Family planning activities were initiated in 1957 by the Indonesian Planned Parenthood Association, which provided family planning counselling and services along with maternal and child health care. The Government committed to promoting family planning, in order to control population size to result in economic development, and formed the National Family Planning Institute in 1968, which was later re-named the National Family Planning Coordination Board (BKKBN in Bahasa Indonesia). BKKBN is an autonomous body that reports directly to the President of Indonesia, thus according the programme the highest national importance. The family planning programme focuses not just on controlling births, but on improving family welfare through delaying marriage, spacing births and fostering family resilience. With the decentralization of Government programmes to the district level in 2004, BKKBN reformulated its family planning strategy and promoted community participation and involvement (“All Families Participate in Family Planning”) as the cornerstone of the programme. The fi ve strategies of the family planning programme are given below. 1. Mobilizing and empowering the community. 2. Readjustment of family planning management. 3. Strengthening human resources for the programme. 4. Enhancing resilience and welfare of families. 5. Increasing fi nancial resources for family planning at all levels. Challenges and Opportunities 1. Reliance on supply-centric methods: Most contraceptive users are opting for reversible methods of contraception. While this means that contraception is used to ensure appropriate spacing between births rather than only as a tool to limit the number of births, it also means that the Government needs to focus on provision of a regular and assured supply of contraceptives. The programme also needs to ensure uptake of other methods such as IUDs, condoms, etc. The general population also needs to be informed about emergency contraception through an extensive communication campaign. 2. Unmet need: Despite the rising CPR, unmet need has been stagnant at 9% since 1997. This means that services have not been able to keep pace with the rising demand for family planning services. The Government would benefi t from conducting an assessment of the epidemiology of this unmet need, and planning programmes to address the same. 3. Population growth momentum: The large young population base means that even if Indonesia achieves replacement fertility levels, the population will continue to grow. Indonesia needs to ensure that the trend seen in increasing CPR and decreasing TFR is maintained in the coming years. 8In do ne si a an d Fa m ily P la nn in g: A n ov er vi ew References 1. Statistics Indonesia (Badan Pusat Statistik). http://www.bps.go.id/eng/tab_sub/view.php?kat=1&tabel=1&daftar=1&id_subyek=12&notab=1 – accessed 7 December 2015. 2. Badan Pusat Statistik. Population percentage by province & gender 2009,2010, 2011. http://www.bps.go.id/eng/tab_sub/view.phpkat=1&tabel=1&daftar=1&id_ subyek=40&notab=1 - accessed 7 December 2015. 3. Statistics Indonesia (Badan Pusat Statistik - BPS) and Macro International. Indonesia demographic and health survey 2007. Calverton, Maryland, USA : BPS and Macro International, 2008. 4. World Health Organization. World health statistics 2005. Geneva: WHO, 2005. 5. World Health Organization. World health statistics 2006. Geneva: WHO, 2006. 6. World Health Organization. World health statistics 2007. Geneva: WHO, 2007. 7. World Health Organization. World health statistics 2008. Geneva: WHO, 2008. 8. World Health Organization. World health statistics 2009. Geneva: WHO, 2009. 9. World Health Organization. World health statistics 2011. Geneva: WHO, 2011. 10. Statistics Indonesia (Badan Pusat Statistik - BPS) and Macro International. Indonesia demographic and health survey 2003-04. Calverton, Maryland, USA : BPS and Macro International, 2004. 11. Statistics Indonesia (Badan Pusat Statistik - BPS) and Macro International. Indonesia demographic and health survey 2012. Calverton, Maryland, USA : BPS and Macro International, 2013. 12. United Nations. World population prospects: the 2010 revision. New York: UN, 2011. 13. World Health Organization, Regional Offi ce for South-East Asia. Achieving the health-related millennium development goals in the South-East Asia region: measuring indicators 2014. New Delhi: WHO-SEARO, 2015. 4. Decentralized programme: The recent initiative to decentralize the family planning programme gives an opportunity for planning, implementing and monitoring the programme at the local level, thus ensuring that the services are in sync with local needs. However, in order for this approach to be successful, district- and municipal-level offi cials need to be trained in planning and management of the family planning programme. M al di ve s an d Fa m ily P la nn in g: A n ov er vi ew 1 Background The Republic of Maldives is an archipelago in the Indian Ocean, located 600 kilometres south of the Indian subcontinent. It consists of 1192 tiny islands that form a chain stretching 820 kilometres in length and 120 kilometres in width. Currently, a total of 187 islands are offi cially inhabited. In addition, another 107 islands are designated as tourist resorts and around 14 islands are used for industrial purposes (Maldives Demographic Health Survey 2009). In the fi rst census enumeration in 1911, the population of Maldives was just 72 237; by 2010, the population had grown fourfold to 326 000. In 2010, young people aged 15 years and below comprised a relatively large proportion of the population (30%), while 58.4% of women were in the reproductive age group (15–49 years) (World Population Prospects, 2012). Situation Analysis In 1986, the Republic of Maldives adopted a policy to promote and implement family planning programmes in the country. By 1990, all the islands were covered under the programmes. The Maldives DHS 2009 is the most recent source of data available for Maldives. Maldives and Family Planning: An overview Figure 1: Population pyramid, 2010 Source: CIA World Factbook Male Female 100+ A ge (i n ye ar s) Population (in thousands) Population (in thousands) 95 – 99 90 – 94 85 – 89 80 – 84 75 – 79 70 – 74 65 – 69 60 – 64 55 – 59 50 – 54 45 – 49 40 – 44 35 – 39 30 – 34 25 – 29 20 – 24 15 – 19 10 – 14 5 – 9 0 – 4 35 28 21 14 7 0 0 7 14 21 28 35 2M al di ve s an d Fa m ily P la nn in g: A n ov er vi ew The relevant demographic and health indicators are presented in Table 1. Table 1: Key indicators Total population, 2013 336 000 Annual population growth rate, 2006 1.69% Population density (persons per square km), 2006 2.59 Urban population, 2006 35.0% Population below 15 years of age, 2006 31.4% Total fertility rate, 2009 (MDHS) 2.5 Contraceptive prevalence rate (%) , 2009 (MDHS) 34.7% – Pill 4.6 – IUD 0.8 – Female sterilization 10.1 – Male sterilization 0.5 – Condom 9.3 – Injectable 1.2 – Any modern method 27.0 – Any traditional method 27.8 – Not currently using 65.3 Unmet need for family planning, 2009 28.1% – Unmet need for spacing 14.9 – Unmet need for limiting 13.2 Median age at fi rst marriage for girls (in years), 2009 20.0 Median age at fi rst birth (in years), 2009 22.5 Crude birth rate (per 1000 population), 2012 22 Maternal mortality ratio (per 100 000 live births), 2012 13 Infant mortality rate (per 1000 live births), 2012 9 HIV adult prevalence rate (age 15–49 years), 2002 <0.01%* * Maldives country reported data for Core Health Indicators brochure ; Country update, August 2013 (VRS) (Reported for MDG Analytical kit 2014); Joint United Nations Programme on HIV/AIDS (UNAIDS), Report on the Global HIV/AIDS Epidemic, 2002. Total fertility rate (TFR) Over the past few decades, Maldives has made signifi cant progress in human and social development. Credible macroeconomic and public investment policies as well as a largely favourable external environment has facilitated this progress, lifting Maldives from its status as one of the 20 poorest countries in the world in the 1970s to one that shares characteristics of a lower middle-income country today. As a result of the socioeconomic development that Maldives has experienced during the past few decades, the fertility level is falling steadily in the country. The decline in fertility was especially rapid between 1990 and 2006. As shown in Figure 2, the TFR was 6.4 in 1990 and progressively declined to 2.2 in 2006. M al di ve s an d Fa m ily P la nn in g: A n ov er vi ew 3 The latest TFR is 2.5,1 and the rate is lower among urban women (2.1 births per woman) than rural women (2.8 births per woman). The peak age for childbearing in urban women is age 25–29 years, while for rural women it is age 20–24 years. Among almost all age groups, the age-specifi c fertility rates for urban women are lower than those for rural women (Maldives Demographic and Health Survey, 2009). Figure 2: Trends in TFR, 1990–2006 Source: Census 1990, 2000 and 2006. To ta l F er ti lt y R at e 7 6 5 4 3 2 1 0 6.4 2.8 2.2 1990 2000 2006 Year 1Figure 2 does not show the latest TFR of 2.5 as the source of earlier fi gures is the census, while the source for the latest data (Maldives Demographic and Health Survey, 2009). Contraceptive prevalence rate (CPR) Figure 3 shows trends in the use of contraceptive methods among currently married women during 1999–2009. Surprisingly, contraceptive use among currently married women has declined progressively by 3–4%, from 42% in the Reproductive Health Survey (RHS) 1999 to 35% in DHS 2009. Overall, around one third of currently married women in Maldives were using contraception in 2009. The socioeconomic and demographic differentials in CPR among currently married women were clearly observed in MDHS 2009 data. Unlike in most other countries in the South-East Asia Region, rural women were slightly more likely than urban women to use family planning (35% and 34%, respectively). Use levels varied markedly by region, from 28% in the South to 42% in the Central region. According to the 2009 RHS, and in contrast to other countries, CPR showed a general declined with rising education levels. While 44% of uneducated women were using contraception, only 27% of women with secondary education were using a contraceptive. This fi gure though rose up slightly to 33% for women who were educated beyond the secondary level. Though it still did not come close to the CPR levels of women with no education. Figure 3: Trends in CPR, 1999–2009 Sources: RHS 1999 and 2004; and Maldives DHS 2009. C on tr ac ep ti ve p re va le nc e ra te 60 50 40 30 20 10 0 RHS 1999 RHS 2004 MDHS 2009 42 39 35 South-East Asia regional average: 57.5% 4M al di ve s an d Fa m ily P la nn in g: A n ov er vi ew Contraceptive method mix Figure 4 illustrates the pattern of contraceptive use among currently married women aged 15–49 years. Overall, MDHS 2009 indicated that around one third of currently married women were using contraception. Female sterilization was the most popular contraceptive method, followed closely by the male condom (10% and 9%, respectively). Five per cent of married women used the pill. A smaller percentage of women were using other modern methods: 1.2% used injectables, 0.8% used IUDs and 0.5% used implant contraceptive methods. About 8% of women reported use of traditional methods of contraception, with 4.2% using the withdrawal method and 3.4% using the rhythm method. Figure 5 presents trends in use of specifi c contraceptive methods among currently married women during the period 1999–2009. As noted earlier, use of any method by currently married women decreased from 42% in 1999 to 35% in 2009. There was a shift in the use of some modern methods. In 1999, the pill was used by 13% of currently married women; this rate has decreased steadily since, with only 5% of currently married women using the pill in 2009. Use of condoms increased from 6% in 1999 to the current rate of 9%. The proportion of married women who were sterilized declined from 10% in 1999 to 7% in 2004, but increased again to 10% in 2009. Use of traditional methods also declined slightly, from 9% in 1999 to 8% in 2009, after dipping to 5% in 2004. While the pill was the most commonly used modern method in RHS 1999 and 2004, female sterilization had become the most commonly used modern method by MDHS 2009. Figure 4: Contraceptive method use by married women aged 15–49 years, 2009 Source: Maldives DHS 2009. Not currently using, 65.3% Female sterilization, 10.1% Male sterilization, 0.5% Male condom, 9.3% Rhythm, 3.4% Withdrawal, 4.2% Folk method, 0.1% Pill, 4.6% IUD, 0.8% Implants, 0.5% Injectables, 1.2% Figure 5: Trends in contraceptive use, 1999–2009 Source: Maldives DHS 2009. RHS 1999 RHS 2004 MDHS 2009 Any method Any modern method Pill IUD Injectable Implan Condom Female sterilization Male sterilization 42 39 35 33 3 4 27 13 13 5 1 2 1 3 3 1 0 0 1 6 7 1 1 19 9 1 0 10 Contraceptive methods M al di ve s an d Fa m ily P la nn in g: A n ov er vi ew 5 Unmet need for family planning The major concerns of family planning programmes include defi ning the size of potential demand for contraception and identifying the women who are most in need of contraceptive services. In 2009, the total unmet need among currently married women in Maldives was 28%; 15% were in need of family planning because of a desire to space the next birth, and the remainder were in need due to an interest in limiting births. Although the drop was not uniform, the level of unmet need declined with age. Unmet need was slightly higher among rural women than urban women, and varied from a level of 25% in the North and Central regions to 36% in the South. Adolescent fertility In recent years, the proportion of adolescents and youth in Maldives has increased substantially, and is rapidly approaching 40% of the country's total population. The percentage of adolescents and young people between the ages of 15 and 24 now constitute approximately more than 25% of the country’s total population (World Population Prospects, 2012). These statistics clearly show that the current period is crucial for policy interventions and strengthening programmes that meet the needs of Maldivian youth, who represent the future and are an inexhaustible resource for the nation. Tapping into and nurturing young people's talent and energy in a positive way will enable Maldives to achieve its national potential and boost its competitiveness in the global economy in the years to come. Unlike many other countries in the Region, pregnancies among adolescents are relatively rare in Maldives. Only 2% of adolescents have begun childbearing, 1% are mothers and less than 1% are pregnant with their fi rst child. The proportion of teenagers who have entered motherhood varies little across subgroups of women. Women in the South begin childbearing earlier than women in other regions. Although the differences are small, there is an inverse relationship between early childbearing and education level. In terms of economic status, the proportion of teenagers who have begun childbearing is highest in the lowest wealth quintile (4%). In 2009, the adolescent fertility rate in Maldives was 12 births per 1000 adolescent women aged 15–19 years (Maldives Demographic and Health Survey, 2009). Access to family planning information and services Awareness of family planning methods is crucial when deciding to use contraception and then in selecting which method to use. Figure 6 shows that knowledge of family planning methods is virtually universal among married women in Maldives. Almost all currently married women aged 15–49 knew at least one modern family planning method. The male condom was the most widely recognized method (98%), followed closely by the pill (96%). More than 90% were also aware of female sterilization and injectables, more than 80% knew about IUDs and male sterilization, and 71% had heard of implants. Implants were introduced in 2002 and are only available in Malé. Emergency contraception, introduced in Maldives in 2007, was the least widely recognized, with only 29% of married women aware of this method. The mean number of methods known by women was 7.7. Seven in 10 married women had heard of at least one traditional method of contraception (Maldives Demographic and Health Survey, 2009). 6M al di ve s an d Fa m ily P la nn in g: A n ov er vi ew Current Family Planning Eff orts The unique geographical situation poses a challenge for the Government of Maldives. Although the size of the population is relatively small (compared to some other countries in the Region), it is dispersed in scattered settlements across a large number of tiny islands making health-care delivery, including reproductive health, a major challenge. The Government of Maldives recognizes reproductive health as a crucial component of the overall health needs of the population. It aims to provide reproductive health services in a manner that ensures affordability, equitable access and quality of care corresponding to the needs of each individual through the principles of primary health care. The goal of the Maldives national reproductive health strategy is “Reproductive health and rights for all Maldivian women, men and adolescents.” Under the reproductive health programme of the Republic of Maldives, the following seven broad thematic approaches have been adopted. 1. Safe motherhood and newborn care 2. Family planning 3. Adolescent sexual and reproductive health 4. Sexually transmitted infections and HIV/AIDS 5. Gender-based violence 6. Partnering with men in sexual and reproductive health 7. Reproductive morbidities (including infertility and cancers) Figure 6: Knowledge of modern contraceptives, 2009 Source: Maldives DHS 2009. Implants Emergency contraception Male condom Implants Injectables IUD Pill Male sterilization Female sterilization 0 20 40 60 80 100 120 Currently married Ever-married 71 70 29 29 98 97 71 70 93 93 86 86 96 96 82 81 94 94 Pre centage of women aged 15–49 years M al di ve s an d Fa m ily P la nn in g: A n ov er vi ew 7 A policy to implement family planning programmes was adopted in Maldives in 1986. By 1990, the programmes had reached all islands. Most family planning outlets are in the public sector, while private pharmacies are registered to provide contraceptives prescribed by private physicians. Contraceptives are also available through the Society for Health Education, a non-governmental organization. Oral contraceptive pills, injectables and male condoms are available in all government facilities. IUD insertion and removal and female and male sterilization are performed in all hospitals. Implants, however, are available only in Malé. All contraceptive methods offered by government health facilities are provided free of charge (Maldives Demographic and Health Survey, 2009). Challenges and Opportunities With the signifi cant reduction in the maternal mortality ratio over the last 8 years, Maldives has performed well in achieving MDG 5. However, some challenges still remain. Fertility levels continue to be very high; contraceptive use remains low among women and has even declined in recent years; and issues of accessibility to essential obstetric care and quality of care, especially at the very peripheral level, remain to be addressed. Ensuring delivery by skilled birth attendants in small peripheral islands is also still a challenge. A focus on adolescents’ reproductive health needs is crucial to reduce unwanted pregnancies that lead to maternal morbidity and mortality. It is also diffi cult for those who are not married, and for youth in general, to get access to family planning information. References: 1. Country Fact Sheet Family Planning Maldives. WHO. 2003 2. Healthy Expectations, International Conference on Population and Development @15 years later. http://countryoffi ce.unfpa.org/maldives/drive/ICPD+15.pdf 3. Millennium Development Goals, Maldives Country Report. 2007. Government of Maldives, Ministry of Planning and National Development. 4. Ministry of Health and Family Maldives and ICF Macro. Maldives demographic and health survey 2009. Male: Ministry of Health. 2010. (http://www. aidsdatahub.org/dmdocuments/MOHF_2010_Maldives_Demographic_and_Health_Survey_2009.pdf - accessed 25 July 2011). 5. Improving Maternal, Newborn and Child Health in South East Asia Region. World Health Organization. 2005 6. United Nations, Department of Economic and Social Affairs Population Division, World Population Prospects: The 2012 Revision http://esa.un.org/unpd/wpp/index. htm 7. World Health Statistic. World Health Organization 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014. 8. The World Factbook, CIA https://www.cia.gov/library/publications/the-world-factbook/geos/mv.html 8M al di ve s an d Fa m ily P la nn in g: A n ov er vi ew M ya nm ar a nd B ir th S pa ci ng : A n ov er vi ew 1 Background Myanmar is bordered by three of the world’s most populous countries: China, India and Bangladesh. The total population of Myanmar is 59.13 million and, with an annual population growth rate of 1.29%, the TFR is 2.03. Approximately 30% of Myanmar’s population live in urban areas. The population is made up of the majority Bama ethnic group who live predominately in the lowlands and the central dry zone, and some 135 ethnic groups who live mainly in the highlands and on the far eastern and western borders of the country. In 2014, 25.6% of the population is below 15 years old and 56.8% of women are in the reproductive age group (15–49 years) (Figure 1). There are 14 states and regions in Myanmar, which are divided into 330 administrative units known as townships. Each township has a hospital providing tertiary-level health services and at least one maternal and child health centre. Situation Analysis Myanmar formulated draft national population policies in 1992, shifting from a pro- nationalist policy to a health- oriented approach. This included the promotion of birth spacing to improve the health status of women and children; community- level information, education and communication; promotion of responsible reproductive behaviour; male involvement in reproductive health; and, addressing adolescent and youth needs. Reproductive health, as an inclusive and coherent approach, has been in place in Myanmar since 1996. Myanmar and Birth Spacing: An overview Figure 1: Population pyramid 2014 Source: CIA World Factbook. Male Female 100+ A ge (i n ye ar s) Population (in millions) Population (in millions) 95 – 99 90 – 94 85 – 89 80 – 84 75 – 79 70 – 74 65 – 69 60 – 64 55 – 59 50 – 54 45 – 49 40 – 44 35 – 39 30 – 34 25 – 29 20 – 24 15 – 19 10 – 14 5 – 9 0 – 4 3 2.4 1.8 1.2 0.6 0 0 0.6 1.2 1.8 2.4 3 2M ya nm ar a nd B ir th S pa ci ng : A n ov er vi ew Source: CIA World Factbook; World Health Statistics, 2014. The overall situation is shown by the relevant indicators in Table 1. Table 1: Key indicators Total population (in millions), 2012 52.79 Population growth rate, 2012 1.29% Population density (people per square km), 2010 76.8 Urban population, 2012 33% Population <15 years of age, 2012 25% Total fertility rate, 2012 2 Contraceptive prevalence rate, 2012 46% – Pill (daily) 10.1 – Pill (monthly) 0.7 – IUD 1.8 – Injectable (monthly) 0.4 – Injectable (3-monthly) 19.3 – Female sterilization 4.4 – Male sterilization 1.0 – Condoms 0.7 – Traditional or natural methods 2.6 Unmet need, 2001 19.1% – For spacing births 6.3 – For limiting births 12.8 Average age at fi rst marriage (in years), 2003 22.8 Median age at fi rst birth (in years) 22 Crude birth rate (per 1000 population), 2012 17.4 Maternal mortality ratio (per 100 000 live births) (2013, UN estimation) 200 Infant mortality rate (per 1000 live births), 2012 41 HIV adult prevalence, 2012 (USAID) 0.6% Total fertility rate (TFR) Myanmar has made a progress in terms of decreasing the TFR, from 4.7 in 1987 to 2.0 in 2012 (Figure 2). M ya nm ar a nd B ir th S pa ci ng : A n ov er vi ew 3 Figure 2: Trends in TFR for women (aged 15–49), 1983–2012 Source: Myanmar Fertility and Reproductive Health Survey 2001; The Status of Birth Spacing in Myanmar, UNFPA, 2010; World Health Statistics 2014. Contraceptive prevalence rate While the TFR is declining, trends show that the contraceptive prevalence rate (CPR) has been progressively increasing, from 16.8 % in 1991 to 46% in 2012 (Figure 3). Figure 3: Trends in CPR, 1991–2012 Source: The Status of Birth Spacing in Myanmar, UNFPA 2010; World Health Statistics 2014. In Myanmar, knowledge of at least one modern method of contraception is almost universal. While knowledge of most modern methods of birth spacing has increased, knowledge about use of condoms to prevent pregnancy has remained the same. Condoms tend to be associated with the prevention of sexually transmitted infections and for use by men with sex workers, and are not seen as a birth spacing method. South-East Asia regional average: 57.5% C on tr ac ep ti ve P re va la nc e R at e 60 50 40 30 20 10 0 1991 1997 2001 2007 2012 16.8 32.7 37 41 46 To ta l F er ti ly R at e f or w om en a ge d 15 –4 9 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 1983 1991 1997 2001 2006 2012 4.7 2.9 2.7 2.4 2.03 2 4M ya nm ar a nd B ir th S pa ci ng : A n ov er vi ew Early childbearing in Myanmar is unusual. Only 10% of women aged 15–49 years have given birth before the age of 18. The low proportion of women giving birth in their teens can be attributed to the high age of fi rst marriage, which has been around the age of 22 for the past 15 years. Median age at fi rst birth is also 22 years. Only 1.9% of women had their fi rst birth before the age of 15, and slightly more than 25% before the age of 20 years. Forty fi ve per cent of married women had given birth before the age of 22, and another 41% had their fi rst birth between the ages of 20 and 24. Abortion is illegal in Myanmar and it is the leading cause of maternal mortality, with at least 50% of maternal deaths and 20% of all hospital admissions resulting from complications due to unsafe abortions. One study found that the smaller the health institution, the higher the abortion rate in the surrounding area, due to lack of access to contraceptive methods. Resorting to the use of illegal and unsafe abortion is in large part the result of unmet contraceptive need among women in Myanmar. The Fertility and Reproductive Health Survey (FRHS) 2007 found that of the 17.7% of women who did not want to get pregnant but were not using contraception and were at risk of pregnancy, 13.3% wanted to limit their births and 4.9% wanted to delay their next pregnancy. This suggests a lack of acceptable long-term methods of contraception. Contraceptive method mix According to FRHS 2007, approximately 40.9% of currently married women are using a method of contraception, including traditional methods. The use of birth spacing methods continues to increase, but at a slower pace. Method failure appears to be a common problem in Myanmar, as 37% of women seeking treatment for complications of abortion report contraceptive use at the time the pregnancy occurred. The Department of Health is currently conducting a study on safety and effi cacy of the one-month injectable approved by WHO, in the hope of adding it to Myanmar’s contraceptive method mix. Figure 4: Contraceptive method use by married women, 2007 Source: FRHS 2007. Not using any method, 59% Pill (daily), 10.1% Pill (monthly), 0.7% Injectables (monthly), 0.4% Injectables (3 monthly), 19.3% Condom, 0.7% Female sterilization, 4.4% Male sterilization, 1%Any traditional method, 2.6% IUD, 1.8% M ya nm ar a nd B ir th S pa ci ng : A n ov er vi ew 5 The rise in the use of birth spacing methods since 1997 is mostly due to increased use of the pill and injectables, the two most common methods of contraception in Myanmar. Use of female and male sterilization is low, due to a lengthy and diffi cult approval process. Female sterilization is only available after approval by a sterilization board. Male sterilization is restricted by law to those men whose wives have been approved for, but are not able to undergo, sterilization. The CPR increased from 16.8% in 1991 to 40.9% in 2007, mainly due to an increase in the use of injectables and oral contraceptive pills. In 2007, the 3-monthly injection was the most common method used by 19.3% of the women. Figure 5: Trends in modern contraceptive methods, 1991, 1997, 2001 and 2007 Source: FRHS 2007. Adolescent fertility In 2011, the adolescent fertility rate was 17 births per 1000 girls aged 15–19 years, which is well below the regional average of 54. Figure 6: Adolescent fertility rate Sources: World Health Statistics 2008, 2009, 2010, 2011, 2012, 2013 and 2014. B ir th s pe r 10 00 g ir ls a ge d 15 –1 9 ye ar s 60.0 50.0 40.0 30.0 20.0 10.0 0.0 23.7 19.3 16.2 1995–2000 2000–2005 2010–2015 South-East Asia regional average: 54 Any methods Any modern methods Pill (daily) Pill (monthly) IUD Injectable (1 month) Injectable (3 month) Condom Female sterilization Male sterilization 16 .8 32 .7 37 40 .9 28 .4 13 .6 4 1. 2 0. 7 0. 9 1. 3 1. 8 1. 8 0. 3 0. 1 0. 1 0. 7 3. 7 5 .5 4. 6 4. 4 2. 2 1. 8 1. 5 1 3. 1 0. 4 32 .8 7. 4 8. 6 1 1. 7 1 4. 8 19 .3 10 .1 38 .4 1991 PCFS 1997 FRHS 2001 FRHS 2007 FRHS Pe rc en ta ge o f cu rr en tl y m ar ri ed w om en us in g co nt ra ce pt iv e m et ho ds Contraceptive methods 6M ya nm ar a nd B ir th S pa ci ng : A n ov er vi ew Current Family Planning Eff orts Birth spacing methods have been available in the public sector since 1991 in Myanmar. That same year, the Government initiated a birth spacing project. By 1995 the project covered 33 townships, by 2001 it covered 117, and by 2011 it covered 132 of the country’s 320 townships. A draft reproductive health policy was debated in 2001 and 2003, but has not yet been fi nalized and offi cially adopted. The key features of this policy are listed below. • Integration of reproductive health services into existing services. • Partnership between the Government, non-governmental organizations, and the private sector. • Research and monitoring of services to identify priorities and needs. • Assuring that services are accessible, acceptable, and affordable. • Incorporation of a gender-based approach to ensure equity and equality. • Implementation of appropriate sociocultural approaches. • Sustainability of services. There are six main aspects of reproductive health that have been identifi ed as priority areas for policy implementation, including birth spacing. Future actions include the approval of a national fi ve-year strategic plan for reproductive health, focusing on four strategic approaches to improve the enabling environment, the evidence base for decision-making, the health system and capacity for delivery of quality reproductive health services, and community and family practices. A separate fi ve-year adolescent health and development strategic plan will focus on adolescent reproductive health as a major component. Reproductive health services are provided by the public sector, private sector, and national and international nongovernmental organizations. A number of nongovernmental organizations are involved in reproductive health services and advocacy. For example, in UNFPA-supported townships birth spacing services are provided at urban health centres, maternal and child health centres, rural health centres and sub-centres. In townships that are not externally supported there is very little provision of birth spacing services in the public sector. Training in birth spacing methods was not included in pre-service midwifery training until 1998. Midwives are now trained in the provision of contraceptive methods, including injection of DMPA (although they are not legally authorized to give injections) and insertion of IUDs. They have also been trained in indications, contraindications, side-effects and warning signs. In addition, there is in-service training of all basic health staff in UNFPA-supported townships. Provision of birth spacing services has increased dramatically over the last decade and provider knowledge and practice has improved as birth spacing services have been introduced in more townships across Myanmar. M ya nm ar a nd B ir th S pa ci ng : A n ov er vi ew 7 Challenges and Opportunities Myanmar has an explicit pro-natalist policy as there is concern in the political circles that it continues to be under populated. However, use of contraception to space births has been adopted as part of efforts to improve maternal and child health. Hence, the country uses the term “Birth spacing” for its programmes as opposed to “Family Planning”. One of the challenges in Myanmar is to improve the consistent and correct use of birth spacing methods in order to reduce unplanned pregnancies and the recourse to abortion. 1. Limited data and resources: Myanmar is data-poor, and offi cial statistics are often dated and inaccurate.1 It is a conservative country with strong cultural norms regarding sexual behaviour. As a result, research to identify priorities is diffi cult. Social and cultural values can serve as barriers, particularly for young women, in accessing reproductive health services including those for birth spacing. While there is a shortage of funds, nongovernmental organizations are playing an increasing role in birth spacing. 2. Limited method mix: Due to its pro-natalist policy, methods like sterilisation are not easily available, both due to policy barriers and provider biases. Provider opinion is also a barrier to women receiving a suitable method of contraception. Due to cultural sensitivities, providers refuse to provide contraceptives to unmarried women. 3. Lack of secure contraceptive commodities in the public sector: Even where contraceptive services are available in the public sector, commodities may not be, leading most women to turn to the private sector as an alternative source. It is normal practice for providers or clients to buy IUDs or injectables from drug shops for later insertion or injection. Oral contraceptives and injectables are readily available from general shops, drug shops and markets. 1The main sources of demographic data for Myanmar are the vital registration and statistics system and population censuses. The last population census was in 1983. Other sources of demographic data in Myanmar are the Fertility and Reproductive Health Survey (FRHS) conducted in 1997 and 2001. 8M ya nm ar a nd B ir th S pa ci ng : A n ov er vi ew References: 1. Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Infections: Myanmar, 2002. UNAIDS, UNICEF & WHO. http://www.unaids.org/EN/ geographical+area/by+country/myanmar.asp 2. Fertility and Reproductive Health Survey (FRHS). 2001. 3. Fertility and Reproductive Health Survey (FRHS), 2007. Country Report. Ministry of Immigration and Population, Nay Pyi Taw. October 2009. 4. Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report. Ministry of Immigration and Population, Yangon 2003 5. Fertility and Reproductive Health Survey (FRHS), 1997. Department of Population and UNFPA, Yangon; Ministry of Immigration and Populations, Yangon. 1999. 6. Health in Myanmar, 2011, Ministry of Health, Myanmar 7. Myanmar Country Profi le, 2003. International Planned Parenthood Federation: http://ippfnet.ippf.org/pub/IPPF_Regions/IPPF_CountryProfi le.asp?ISOCode=MM 8. National Human Development Report (NHDR), 2003. United Nations Development Programme (UNDP). 2003 9. “Reproductive Health Profi le for the Union of Myanmar” Prepared for WHO/ SEARO by The Population Council, Bangkok. November 2003 10. Population Changes and Fertility Health Survey (PFCS), 1991. Ministry of Immigration and Population, Yangon. 1995 11. Statistical Year Book (2009), Ministry of National Planning and Economic Development, Nay Pyi Taw, Myanmar. 2010 12. United Nations, Department of Economic and Social Affairs Population Division, Population Estimates and Projections Section. http://esa.un.org/wpp/unpp/p2k0data.asp 13. USAID Country Profi le, Myanmar: http://www.usaid.gov/locations/asia_near_east/countries/burma/burma.html 14. WHO/SEARO, Myanmar Country Health Profi le, Intranet site: http://intranet/cntryhealth/myanmar/index.htm 15. World Bank Country Profi le: http://lnweb18.worldbank.org/eap/eap.nsf/deeaaea3bebd97b4852567c900776c37/b223b3c3ec55596c852567cb000e3227?OpenDocument 16. World Contraceptive Use, United Nations, Population Division, Department of Economic and Social Affairs. 2003 17. World Population Data Sheet, Population Reference Bureau. 2003 www.prb.org 18. World Population Policies, United Nations, Population Division, Department of Economic and Social Affairs.2003 19. World Health Statistic. World Health Organization. 2008, 2009, 2010, 2011, 2012, 2013 and 2014. 20. The World Factbook, CIA https://www.cia.gov/library/publications/the-world-factbook/geos/bm.html 21. United Nations, Department of Economic and Social Affairs Population Division, World Population Prospects: The 2012 Revision http://esa.un.org/unpd/wpp/index.htm 22. The Status of Birth Spacing in Myanmar, UNFPA. 2010 N ep al a nd F am ily P la nn in g: A n ov er vi ew 1 Nepal and Family Planning: An overview Background Located in the mighty Himalayas, Nepal has a largely rugged terrain. With relatively little cultivable land to support its 30-million-plus population, Nepal too is fi ghting the problem of population explosion due to its high fertility rate, like many other countries in the South- East Asia Region. The population pyramid (Figure 1) reveals a Nepalese population that is largely constituted of children and youth. With such a high proportion of the population either currently in the reproductive age group, or on the threshold of it, the growth momentum will continue to increase the population size for at least a generation to come, even in the face of best efforts to contain the fertility levels. Situation Analysis The overall situation is shown by relevant demographic and health indicators in Table 1. Table 1: Key indicators Total population (in millions), 2011 26.5 Population growth rate, 2001–2011 1.35% Population density (people per square km), 2011 180 Urban population, 2011 17% Population <15 years of age, 2011 34.9% Total fertility rate, 2011 2.6 Contraceptive prevalence rate, 2011 49.7% – Pill 4.1 Figure 1: Population pyramid, 2010 Source: World Population Prospects The 2010 Revision. Per centMale Female 5 0 5 105 100 90 80 70 60 50 40 30 20 10 0 A ge ( in y ea rs ) 2N ep al a nd F am ily P la nn in g: A n ov er vi ew Figure 2: Trends in Fertility 5 4 3 2 1 0 1996 NFSH 2001 NDHS 2006 NDHS 2011 NDHS 4. 6 4. 1 3. 1 2. 6 B ir th s pe r w om an f or t he 3 y ea rs p ri or t o th e su rv er y Source: Nepal DHS 2011 (Key fi ndings). Injectable 9.2 – Implants 1.2 – IUD 1.3 – Female sterilization 15.2 – Male sterilization 7.8 – Condom 4.3 – Traditional or natural methods 6.6 Unmet need 27% – Spacing 10 – Limiting 17 Median age at fi rst marriage 17.8 Median age at fi rst birth 20.2 Crude birth rate (per 1000 population), 2011 24.3 Maternal mortality ratio (per 100 000 live births), 2011 170 Infant mortality rate (per 1000 live births), 2011 46 HIV adult prevalence (age 15–49 years), 2011 0.3% Source: Nepal Population and Housing census 2011, Nepal DHS 2011, Nepal in Figures 2013 Total fertility rate (TFR) Fertility rates in Nepal have been gradually dropping over the decades. While the TFR was 5.8 in the 1970s, it gradually reduced to 5.1 births per woman in 1985 and then to 4.1 in 2001. In the past few years, owing to intense efforts towards population stabilization by the Government of Nepal as well as partner agencies, the country saw a sharp decline in TFR to 3.1 in 2006 and to 2.6 in 2011 (Nepal DHS 2011) (Figure 2). The fertility rate shows an inverse trend when mapped against the socioeconomic status of women, with women in the lowest wealth quintile having a fertility rate of 4.1 as against 1.5 for women in the highest quintile (Figure 3). The reduction in TFR is also refl ected in the gradually changing shape of the population pyramid of the country. In 2001, children under 15 years of age accounted for about 45% of the total population. This has reduced to less than 40%, with the “bulge” in the pyramid shifting upwards towards the adolescent and youth population. N ep al a nd F am ily P la nn in g: A n ov er vi ew 3 Contraceptive prevalence rate (CPR) The steep reduction in TFR can be attributed to an impressive increase in the use of contraception in Nepal over the past 10 years. As can be seen in Figure 5, the CPR in Nepal for modern methods showed a marked increase in the decade from 1996 to 2006. Based on the national DHS in 2006, CPR for modern methods stood at 44.2%, while overall CPR (including traditional methods) had increased to 48%. A large proportion of this success in improving women’s acceptance of modern contraceptive methods can be attributed to the Nepal Health Sector Programme Implementation Plan launched by the Government of Nepal in 2004. The rising trend in CPR, however, was not refl ected over the next 5 years. According to DHS 2011, the CPR for modern methods remained almost unchanged at 43%. Owing to an increase in acceptors of traditional methods of contraception to 7% of all women, half of all married women were using some method of contraception during the 2011 survey. Figure 3: Trends in TFR, 1985–2010 Source: Nepal DHS 2006; World Health Statistics 2011. To ta l f er ti lit y ra te 6 5 4 3 2 1 0 1985 1990 1994 1999 2004 2006 2010 3.13.1 4.1 4.8 4.6 5.1 2.6 Figure 4: TFR by wealth quintile Source: Nepal DHS 2011 (Key fi ndings). 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Lowest Second Middle Fourth Highest 4. 1 3. 1 2. 7 2. 1 1. 5 To ta l f er ti lit y ra te Poorest Richest 4N ep al a nd F am ily P la nn in g: A n ov er vi ew While the interregional differences within the country were minimal, the use of contraception by women residing in urban areas was signifi cantly higher than by their rural counterparts. While over 54% of urban women in the reproductive age group were using a modern method of contraception, only 42% of rural women were doing so in 2006 (Figure 4). Source: Nepal DHS 2006 and 2011 Figure 6: Trends in CPR, 1991–2006 South-East Asia regional average: 57.5% Pe rc en ta ge o f m ar ri ed w om en cu rr en ty ly u si ng c on tr ac ep ti on 60 50 40 30 20 10 0 1991 1996 2001 2006 2011 22.7 28.5 39.3 48 49.7 Source: Nepal DHS 2011 (Key fi ndings). Figure 5: Trends and urban-rural divide in modern contraceptive use Urban Rural Total Pe r ce nt o f m ar ri ed w om en cu rr en tl y us in g a m od er n m et ho d of f am ily p la nn in g 60 50 40 30 20 10 0 1996 NHFS 2001 NDHS 2006 NDHS 2011 NDHS 45 50 24 33 43 42 26 35 44 43 56 54 Contraceptive method mix The method mix pattern observed in DHS 2006 and 2011 in Nepal was similar to the fi ndings of DHS 2001. Permanent methods, that is, female and male sterilization accounted for more than half of the modern method mix (15% and 8%, respectively). Among temporary/spacing methods, injectable contraceptives were the method chosen by one fi fth of all contraceptive users. As seen in fi gure 6, there has been an increasing acceptance of the pill over the years. While pills and condoms each accounted for contraceptive preferences of about 4% of all married women, IUDs and implants – despite showing an improving trend over the years – continue to fi nd very few takers in the overall picture of contraceptive use mix in the country. N ep al a nd F am ily P la nn in g: A n ov er vi ew 5 Source: Nepal DHS 2011 (Final report). Figure 7: Trends in modern contraceptive method mix used by currently married women, 1996–2006 10 20 30 40 500 1 0 0 1 1 0 1 1 44 26 35 43 18 12 15 15 6 5 6 8 10 5 8 9 5 2 3 4 4 1 2 4 Any Modern Method Female sterilization Male sterilization Pill Injectables Condom Implants IUD 1996 NHFS 2001 NDHS 2006 NDHS 2011 NDHS Source: ORC Macro, 2007, MEASURE DHS STAT compiler. http://www.measuredhs.com, September 28, 2007. Figure 8: Proportion of wanted versus unwanted fertility in Nepal 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Nepal 1996 Nepal 2001 To ta l F er ti lit y R at e Pe r W om en 1. 6 Wanted total fertility reate Unwanted total fertilty rate 2. 5 2. 9 1. 7 Unmet need for contraception As can be seen from Figure 7, almost 40% of all births in 2001 were the result of an unwanted pregnancy. The 2011 survey found that while the fertility rate was 2.6, the ideal family size for a Nepalese couple is about 2 children (2.1 for women and 2.3 for men). About half of married women do not want any more children and, of these, 23% are already sterilized. Another 14% want to wait for at least 2 years before the next birth. Overall, about 27% of married women had an unmet need for family planning, signifying a minimal improvement from the 28% found in the 2001 survey. Of this, 10% have an unmet need for spacing the next birth for at least 2 years, while 17% have an unmet need for limiting the family size. 6N ep al a nd F am ily P la nn in g: A n ov er vi ew Source: World Health Statistics 2008, 2009, 2010 and 2011. Figure 9: Trends in adolescent fertility rate, 2008–2011 South-East Asia regional average: 54 120 100 80 60 40 20 0 2008 2009 2010 2011 106 106 106 106 Adolescent fertility rate (per 1000 girls aged 15-19 years) Adolescent fertility The adolescent fertility rate in Nepal is relatively high and the second highest, after Bangladesh, in the South-East Asia Region (Figure 8). According to DHS 2011, it stood at 81 births per 1000 girls aged 15–19 years, which although a reduction from 98 per 1000 as estimated in DHS 2006, is still high compared to the regional average of 54. While the median age of girls at fi rst birth is 20.2 years in Nepal, 23% of women aged 25–49 had given birth to their fi rst child before they were 18 years of age, while 2% had become mothers before they were 15 years of age. According to DHS 2011, 17% of women aged 15–19 had either already had a baby or were pregnant with their fi rst child. As most births take place within the realm of marriage, age at marriage is a very important determinant of age at fi rst birth. The median age at marriage is gradually increasing in Nepal. DHS 2011 pegged the median age at marriage at 17.5 years for girls and 21.6 years for boys. More than half of girls (55%) are married before the age of 18. The median age at fi rst sexual intercourse is 17.7 years for girls and closely follows their median age at marriage, thus signifying that for most girls sexual debut takes place within the context of marriage. However it is not so for the men, whose age at sexual debut is 20.5 years and is about a year before their marriage. The relatively high teenage pregnancy rate is linked to the low use of contraception among married adolescents. Less than 18% of married girls in the age group 15–19 years were using a contraceptive according to DHS 2011. It needs to be mentioned that the unmet need for contraception at more than 41% (largely for spacing methods) is highest in this age group as compared to other age groups in the reproductive span. Access to family planning information and services According to DHS 2011, knowledge of family planning methods is almost universal among Nepalese men and women, with 100% of currently married women and 99.8% of currently married men able to identify at least one method of contraception. Men and women were more familiar with N ep al a nd F am ily P la nn in g: A n ov er vi ew 7 modern methods of contraception especially female sterilization, injectables, condoms and male sterilization. Relatively few men and women had heard about emergency contraception (39% and 29%, respectively). It is interesting to note that never-married men and women were more familiar with this method than currently married ones. The public health sector is the largest provider of contraceptive services. For example, about four fi fths of men and women in Nepal accessed the government health facilities for sterilization procedures, with the rest reaching out to hospitals run by nongovernmental organizations or the private sector. However, the private sector (hospitals and pharmacies) plays a larger role in the supply of product- based contraception such as pills, injectables and condoms. Current Family Planning Eff orts Family planning services have been available in Nepal for over 50 years. At the start of this millennium, the Government of Nepal set a goal to meet the health-related MDGs in the context of Nepal’s country-specifi c challenges. In 2004, the Ministry of Health and Population committed themselves to the Nepal Health Sector Programme Implementation Plan phase 1 (NHSP-IP, 2004–2009), supported by 11 external development partners. This was extended and expanded in its second phase (NHSP-IP 2010–2015). The NHSP-IP focuses on reproductive, maternal and child health. The national family planning programme is an integral component of the same. Due to inadequate funds as well as a loss of focus on family planning, the targets set for CPR and TFR have not been met. With an eye to reinvigorating family planning efforts, the Family Health Division of the Ministry of Health and Population is focusing on expanding the reach of family planning services through its chain of public health facilities such as primary health centres, health posts, subhealth posts, primary health centre outreach clinics and mobile surgical contraception camps. Satellite clinics have been initiated in all districts. Community health volunteers provide family planning counselling services and also act as depot holders of family planning products. The public health sector is supported by various nongovernmental organizations such as Marie Stopes and the Family Planning Association of Nepal. A vibrant private sector that includes not just private clinics and hospitals, but also pharmacies, is also involved in the provision of family planning services and products. For example, the Sangini Franchising Network provides injectable contraceptives (local brand name: Sangini-Tin Mahine Sui) through a network of pharmacies present in all 75 districts of Nepal. Other special efforts include the postpartum intrauterine contraceptive device programme launched by the Government of Nepal to meet the special demands of postpartum women. The pilot programme was implemented in six hospitals (fi ve government and one private) in June 2011, and is now in the process of expanding through private-sector facilities nationally. Challenges and Opportunities 1. Sustaining the programme momentum: The massive increase in CPR between 1996 and 2006 and concomitant reduction in TFR can be credited to the efforts of the Government of Nepal and non-governmental partners. However, the slight decline in CPR between 2006 and 2011 refl ects a loss of momentum of the programme. Political will, with a focus on ensuring adequate fund allocation to the family planning effort, will go a long way in sustaining and building on previous efforts. 8N ep al a nd F am ily P la nn in g: A n ov er vi ew References: 1. Adolescent Health, WHO SEARO Country Fact Sheet. January 2007. 2. Federal Democratic Republic of Nepal and External Development Partners. February 2009. http://www.mohp.gov.np/english/projects/nhdp2009_signfi nal.pdf 3. International Planned Parenthood Federation. Realising MDG 5b in Nepal for young people. London: IPPF, 2011. http://www.ippf.org/en/Resources/Reports-reviews/Realisin g+MDG+5b+in+Nepal+for+young+people.htm - accessed 25 July 2011. 4. Ministry of Health and Population and ICF Macro. Nepal demographic health survey 2006. Kathmandu: Ministry of Health. 2007. http://www.measuredhs.com/pubs/pdf/ FR191/FR191.pdf - accessed 25 July 2011. 5. Ministry of Health and Population, New Era, ICF Macro and USAID. Nepal demographic health survey 2011. Kathmandu: Ministry of Health. 2011 6. Unicef. http://www.unicef.org/infobycountry/nepal_nepal_statistics.html 7. United Nations, Department of Economic and Social Affairs Population Division, Population Estimates and Projections Section. http://esa.un.org/wpp/unpp/p2k0data.asp 8. World Bank. Reproductive health at a glance: Nepal. New York: World Bank 2011 April. http://siteresources.worldbank.org/INTPRH/Resources/376374-1303736328719/ Nepal42111web.pdf - accessed 25 July 2011. 9. World Bank. Reproductive health at a glance: Nepal. New York: World Bank. 2011 April. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/ EXTHEALTHNUTRITIONANDPOPULATION/EXTPRH/0,,contentMDK:22897731~menuPK:376861~pagePK:148956~piPK:216618~theSitePK:376855,00. html - accessed 25 July 2011. 10. World Health Organization. Nepal country profi le. Geneva: WHO. http://www.who.int/making_pregnancy_safer/countries/nep.pdf - accessed 25 July 2011. 11. World Health Organization, Regional Offi ce for South-East Asia. Nepal national health system profi le. New Delhi: WHO-SEARO. http://www.searo.who.int/LinkFiles/ Nepal_Profi le-Nepal.pdf - accessed 25 July 2011. 12. World Health Statistic. World Health Organization. 2008, 2009, 2010, 2011. 2. Access to information and services: Despite universal awareness about family planning efforts, uptake remains relatively low and there is a high unmet need. The Government, with support from non-governmental organizations and the private sector, needs to expand the reach of family planning products and services. The relatively recent initiatives by the Government of Nepal to provide family planning services through satellite and mobile clinics, as well as using community health volunteers as distributors of family planning products, provide the ideal platform to expand the reach of services to cover women even in the lowest wealth quintile. 3. Appropriate method mix: Like in many other countries in the South-East Asia Region, there is a high reliance among Nepalese couples on sterilization as a family planning method. Data show that a large proportion of women undergo sterilization after their third or fourth child, which does not have much impact on reduction in fertility rates and population stabilization. Focus on spacing methods, including relatively long-term spacing methods such as IUDs and implants, will go a long way towards population stabilization. It will also contribute to reduction in maternal and child mortality by increasing the inter-pregnancy gap. 4. Adolescent fertility: The gradual increase in age at marriage and age at fi rst birth is an encouraging trend. The Government of Nepal, through its efforts to expand the reach of family planning services, has to focus on the special needs of both married and unmarried adolescents as unmet need for contraception is very high in the teenage group. In addition, as sexual activity among men begins before marriage, educating young boys about responsible sexual behaviour and increasing their access to contraceptives will contribute towards a reduction in overall fertility. Sr i L an ka a nd F am ily P la nn in g: A n ov er vi ew 1 Background Sri Lanka is an island country that has made heavy investments in the public health system to ensure the access of primary health care to the majority of the population. The results of this are seen in the form of a steep reduction in mortality rates, especially maternal and infant mortality, along with a decline in fertility rates. Nonetheless, as can be seen from the population pyramid (Figure 1), about 25% of Sri Lanka’s population are below the age of 15 years, and therefore have yet to enter the reproductive lifespan (Population Reference Bureau, 2012). Situation Analysis The Government of Sri Lanka began its programmatic initiative into the family planning arena in 1965, when family planning was integrated with the national maternal and child health programme. The national population policy was formulated in 1977 and focused on population reduction as a means to sustainable development. The fi rst Sri Lanka DHS was carried out in 1987, followed by two more in 1993 and 2000. The latest DHS was conducted in 2006–2007, in which the respondents were ever-married women 15–49 years of age and children under the age of 5 years. This survey is not refl ective of the Northern Province of Sri Lanka, as no data collection could be done in the area due to unsettled political conditions. Comparison to the previous DHS in 2000 also needs to be made with caution, as DHS 2000 did not capture the Eastern Province. Sri Lanka and Family Planning: An overview Figure 1. Population pyramid, 2010 Source: Population Projections 2010. A ge ( in y ea rs ) Per centMale Female 5 0 5 105 100 90 80 70 60 50 40 30 20 10 0 2Sr i L an ka a nd F am ily P la nn in g: A n ov er vi ew The overall situation is shown by relevant indicators in Table 1. Table 1: Key indicators Total population (in millions), 2012 20.3 Population growth rate, 2012 0.9% Population density (people per square km), 2012 324 Urban population, 2012 18.3% Population <15 years of age,2012 25.2% Total fertility rate, 2006–2007 2.3 Contraceptive prevalence rate, 2006–2007 68% – Female sterilization 16.9 – Male sterilization 0.7 – Pill 7.9 – IUD 6.3 – Injectable 15 – Norplant 0.3 – Male condom 5.5 –LAM 0.1 –Periodic abstinence 9.6 – Withdrawal 5.5 – Folk method 0.1 Unmet need 7.3% - Spacing 3.5 - Limiting 3.8 Median age at fi rst marriage, 2006–2007 23.3 Median age at fi rst birth, 2006–2007 25.1 Crude birth rate (per 1000 population),2012 17.5 Maternal mortality ratio (per 100000 live births), 2012 37.7 Infant mortality rate(per 1000 live births,2012) 9.2 HIV adult prevalence (age 15–49 years), 2012 <0.1% Source: Sri Lanka Statistical Data Sheet 2013; Census of Population and Housing 2012; Sri Lanka DHS 2006-07 Total fertility rate (TFR) The TFR of Sri Lanka (excluding the Northern Province) as measured in 2006–2007 was 2.3. According to more recent data published by the Population Reference Bureau in 2012, the TFR has further reduced to 2.2. DHS 2006–2007 showed a geographical variation in the TFR, with estate areas showing the highest levels (2.6), followed by rural areas (2.4) and urban areas (with a TFR of only 2.2). As can be seen from Figure 2, the TFR has shown a signifi cant reduction from close to 8 in the 1970s to almost replacement levels in current times. Sr i L an ka a nd F am ily P la nn in g: A n ov er vi ew 3 A study of age-specifi c fertility rates shows that childbearing begins relatively late in SriLanka, with maximum fertility seen in women in the age group 25–29 years (Figure 3).The trends in age-specifi c fertility rate across urban and rural areas are very similar, as can be seen by the almost overlapping lines in the graph. However, childbearing for women living in the estate areas not only starts relatively early, but also shows a steep decline at the age of 30 years and beyond. Figure 3. Age-specifi c fertility rates by residence, 2006–2007 Source: Sri Lanka DHS 2006–07. Age group Fe rt ili ty r at e pe r 1 00 0 w om en 180 160 140 120 100 80 60 40 20 0 15–19 20–24 25–29 30–34 35–39 40–44 45–49 Urban EstateRural Total Contraceptive prevalence rate (CPR) Most Sri Lankan women in the reproductive age group are currently using contraceptives. The decline in TFR is linked to a gradual rise in CPR, from about 35% in 1975 to 68% in 2006–2007. A comparison of two consecutive DHS data shows a slight reduction in CPR of about 2 percentage points between 2000 and 2006 (Figure 4). Contraceptive use varies with age and with other demographic factors, such as place of residence. Figure 5 shows that the proportion of women using contraception rises with increasing age up to the age of 40 years, after which a declining trend is seen. Unlike other countries in the South-East Asia Region, contraceptive use is relatively more prevalent among rural women (70%) compared to women living in estate areas (64%). Out of the three areas, urban women are the least likely to use contraception (59%) (Figure 6). There is a gradual declining trend in contraceptive use concomitant with increasing education levels of women up to GCE Ordinary Level, following which an increase in use is seen. Women with three or four children are the most likely to use contraception. Even about one-fi fth of women with no living children use contraception, refl ecting a social trend towards the delaying of fi rst pregnancy. Figure2. Trends in TFR,1980–2006 Source:Sri Lanka DHS 1987, 1993, 2000 and 2006–2007http://www.statistics.gov.lk/social/DHS%20200607%20FinalReport.pdf To ta l f er ti lit y ra te 3 2.5 2 1.5 1 0.5 0 1987 DHS 1993 DHS 2000 DHS 2006–07 DHS 2.8 2.3 1.9 2.3 4Sr i L an ka a nd F am ily P la nn in g: A n ov er vi ew Contraceptive method mix Of the 68% of currently married women using a contraceptive in 2006–2007, about 15% were using a traditional method while the remaining 53% were using a modern method of contraception. It is also clear from Figure 8 that the reduction in overall CPR between DHS 2000 and DHS 2006–2007 is due to a reduction in the use of traditional methods, as the use of modern contraceptive methods during the same period actually increased from 49.5% to 52.5%. Source: Sri Lanka DHS 2006–2007. Figure 6.Contraceptive use by demographic factor, 2006–2007 Percentage of women age 15–49 using contraceptive method 20 40 60 80 1000 68.8 83 70.2 20.5 66.6 64.6 69 71.5 72.7 64.7 69.9 59.9 Residence Uraban Rural Estate Education No Education Primary Secondary Passed G.C.E. (O/L) Higher Wealth Quintile No living children 1-2 living children 2-4 living children 5+ living children B ac kg ro un d ch ar ac te ri st ic s Source: Sri Lanka DHS 2006–2007. Figure 5. Contraceptive use by age group, 2006–2007 Any traditional method Any modern method Total Age group 100 90 80 70 60 50 40 30 20 10 0 15–19 20–24 25–29 30–34 35–39 40–44 45–49P er ce nt ag e of w om en a ge 1 5- 49 us in g co nt ra ce pt iv e m et ho d Sources: Sri Lanka DHS 2006–2007; World Health Statistics 2006 and 2011. Figure 4. Trends in CPR, 1975–2011 South-East Asiaregional average: 57.5% Pe rc en ta ge o f cu rr en tl y m ar ri ed w om en a ge 1 5– 49 80 70 60 50 40 30 20 10 0 1975 2006 2011 34.4 70 68 Sr i L an ka a nd F am ily P la nn in g: A n ov er vi ew 5 Despite a relatively steep drop in the proportion of women accepting female sterilization, from 23% in 2000 to about 17% in 2006, it still continues to be the most popular contraceptive method chosen by Sri Lankan women. An increasing proportion of women are opting for injectable hormonal contraceptives, and it is now the second most prevalent method in the country, used by 15% of married women. For male-centric methods, while condom use shows a gradual increase over the years, the acceptance of male sterilization is gradually losing ground and only 0.7% of women stated in 2006 that they were relying on the latter as their contraceptive method of choice. Unmet need for family planning DHS 2006–2007 refl ects relatively low levels of unmet need, which is in tandem with the relatively high levels of contraceptive use. Overall, 7.3% of married women had an unmet need for family planning. Of this, about half (3.5%) was for spacing the pregnancy and childbirth, while the rest (3.8%) was for limiting the family size. This correlation between CPR and unmet need is clearly refl ected in Figure 9. Districts such as Anuradhapura (North Central Province) and Ratnapura (Sabaragamuwa Province) that have relatively high CPRs of 73–74% also have low unmet need of 3–5%. In contrast, districts such as Batticaloa and Trincomalee (both in the Eastern Province) that havesome of the lowest CPRs in the country also have high levels of unmet need at about 23% and 19%, respectively. Source: Sri Lanka DHS 1987, 1993, 2000 and 2006–2007. Figure 8.Trends in contraceptive method mix,1987–2006 Pe rc en ta ge o f w om en a ge 1 5– 49 us in g co nt ra ce pt iv e m et ho d 80 70 60 50 40 30 20 10 0 1987 1993 2000 2006 24 .2 4. 6 0 0 38 .8 19 .6 58 .4 2 1. 83. 8 2. 5 23 .5 3. 7 0 0 43 .6 22 .5 66 .1 3 3. 35. 5 4. 6 23 .1 0 0. 1 0 49 .5 20 .5 70 5. 1 3. 76. 7 10 .81 6. 9 0. 7 0. 3 0. 1 52 .8 15 .2 68 6. 3 5. 57. 9 15 Female Sterlilisation Male Sterlilisation Pill Injectables Implant IUD Condom LAM Any modern method Any traditional method Any methods Figure 7. Contraceptive method mix, 2006–2007 Source: Sri Lanka DHS 2006–2007. Norplant, 0.3% Male condom, 5.5% Not currently using, 32.0% Female sterilization, 16.9% Male sterilization, 0.7% Pill, 7.9% IUD, 6.3% Injectable, 15.0% LAM, 0.1% Periodic abstinence, 9.6% Withdrawal, 5.5% Folk method, 0.1% Contraceptive methods 6Sr i L an ka a nd F am ily P la nn in g: A n ov er vi ew The relatively low levels of unmet need can also be understood by comparing the fertility preferences of women with the CPR. As seen in Figure 10, about 78% of women either want to delay having another child for at least 2 years, or do not want any more children. As over 68% of the women are already using contraceptives, it follows that unmet need levels in the country are less than 10%. DHS 2006–2007 also shows that the unmet need for family planning is highest among women in the age group of 35–49 years. Following this information, the Family Health Bureau has now started to integrate family planning services to reach older women through the Well Women’s Clinics programme. 1Wants next birth within 2 years 2Wants to delay next birth for 2 or more years Adolescent fertility Sri Lanka is one the leading countries in Asia as far as delaying fi rst marriage for women (and therefore fi rst birth) is concerned. Even as early as 1901, the mean age at fi rst marriage was 18.3 years. By the mid-seventies, most Sri Lankan girls were getting married not at puberty, but a decade later. By 2000, only 7% of girls aged 15–19 years were married (The Journal of Family Welfare, 2000). This custom of delaying marriage, and the fact that most childbearing in Sri Lanka occurs within the context of marriage, can explain the relatively low adolescent fertility rates, especially when compared to neighbouring countries in the South-East Asia Region. Source: Sri Lanka DHS 2006–2007. Figure 9. Correlation between CPR and unmet need in four districts, 2006–2007 Unmet need CPR 80 70 60 50 40 30 20 10 0 Anuradapura Batticaloa Ratnapura Trinocomalee 4. 3 74 22 .9 34 .5 3. 5 73 .4 18 .7 52 .8 C on tr ac ep ti ve p re va la nc e ra te a nd u nm et n ee d Figure 10. Fertility preferences of currently married women, 2006–2007 Source: Sri Lanka DHS 2006–2007. Have another soon1, 15% Wants no more sterlized 60% Have another later2, 18% Undecided 5% In fecund 2% Sr i L an ka a nd F am ily P la nn in g: A n ov er vi ew 7 Access to family planning information and services DHS 2006–2007 showed that knowledge of contraception is almost universal in Sri Lanka. More than 97% of women knew about the pill and injectable contraceptives as potential methods to prevent pregnancy. On the other hand, relatively fewer women were aware of “newer” and “less available” methods such as female condoms and implants. Only a third of the women knew about emergency contraception, refl ecting a great need to educate people about the same. Current Family Planning Eff orts Family planning efforts in Sri Lanka date back to the 1950s, with the establishment of the Family Planning Association. A survey conducted in 1958 by the Government of Sri Lanka, with support from the Government of Sweden, revealed no religious opposition to family planning and a high latent demand for contraception among married couples. This, coupled with rising youth unemployment rates due to the population increase, led the Government to formally launch the family planning programme in 1965. Even 30 years before ICPD, this programme was integrated with the maternal and child health programme of the Ministry of Health. In 1975, the country carried out its fi rst fertility survey under the aegis of the Registrar General that revealed a CPR of 34.4% (Reproductive Health and Family Planning Programme in Sri Lanka, 2009). In 1979, the management of the family planning programme was shifted to the Population Division of the Ministry of Plan Implementation. While this shift provided the much needed thrust and focus to family planning efforts in the country, it also led to de-linking of the programme from other maternal and child health efforts. Following ICPD, in 1995, the control of the family planning Table 2. Awareness of ever-married women about contraceptive methods, 2006–2007 Method Percentage of women who know about method Female sterilization 94.5 Male sterilization 74.0 Pill 97.5 IUD 90.1 Injection 97.3 Norplant 47.7 Male condom 82.5 Female condom 16.6 LAM 38.9 Safe period 66.7 Withdrawal 67.4 Emergency contraception 33.8 Source: Annual Health Statistics, 2006. Source: World Health Statistics 2008, 2009, 2010 and 2011. Figure 11. Trends in adolescent fertility rate, 2008–2011 South-East Asia regional average: 54 60 50 40 30 20 10 0 2008 2009 2010 2011 28 28 28 Pe rc en ta ge o f cu rr en tl y m ar ri ed w om en a ge 1 5– 49 Adolescent fertility rate (per 1000 girls aged 15–19 years) 8Sr i L an ka a nd F am ily P la nn in g: A n ov er vi ew programme was back with the Family Health Bureau under the Ministry of Health. The current family planning programme is embedded in the national Maternal and Child Health Policy and involves the delivery of a complete package of services as defi ned under reproductive health. Enabling all couples to have the desired number of children, with optimal spacing, while preventing unwanted pregnancies, is an important goal of the Maternal and Child Health Policy. The strategies for achieving this goal ate given below (Family Health Bureau). 1. Ensuring availability of, and accessibility to, quality modern family planning services. 2. Addressing the unmet need for contraception. 3. Ensuring availability of sterilization services in institutions. 4. Establishing an appropriate system for post-abortion care. 5. Ensuring the uninterrupted availability of contraceptive commodities (Reproductive Health Commodity Security). 6. Strengthening, rationalizing and streamlining services for subfertile couples. Challenges and Opportunities 1. Reaching the unreached pockets: The survey data reveal signifi cant geographic variation in family planning services. Even within geographic areas, certain ethnic groups have reduced access to services. The Government of Sri Lanka needs to identify such populations and ensure a more equitable distribution of services. 2. Logistic management: Ensuring a regular supply of contraceptives has been a long-standing challenge in Sri Lanka. The introduction of Reproductive Health Commodity Security, as an important element inmaternal and child health programme strategy, provides the right platform to solve this problem. 3. Focus on adolescents: Even though early marriage and adolescent fertility rates are signifi cantly low in Sri Lanka, the programme needs to focus on other reproductive health needs of this population group, including provision of life skills education. 4. Gender equity: Data show that the burden of family planning lies largely with women and that the uptake of male-centric contraception methods is relatively low. The current programme states that ensuring gender equity is an important policy goal, and thus can be the base for ensuring male participation in the programme. 5. Sustainability: Sri Lanka has come a long way in increasing the CPR and reducing the TFR of the country. With the integration of family planning efforts with larger reproductive health effort, the Government of Sri Lanka needs to ensure that programmatic focus on family planning is further strengthened and not lost in the provision of a broader spectrum of services. References: 1. Population data sheet 2012. s.l. : Population Reference Bureau. 2. Government of Sri Lanka. Sri Lanka Demographic and Health Survey - 2006/7 (Preliminary Report). Department of Census & Statistics, in collaboration with Ministry of Health Care & Nutrition. May 2008. 3. Correlates of Marital Postponement in Sri Lanka. DeSilva, Prof. W. Indralal. 2, October 2000, The Journal of Family Welfare, Vol. 46, pp. 42-50. 4. Abeykoon, Dr. A.T.P.L. Reproductive Health and Family Planning Programme in Sri Lanka: Achievements and Challenges.Institute for Health Policy. 2009. 5. Family Health Bureau - Government of Sri Lanka. Family Health Services - Goals and Objectives. Family Health Bureau. [Online] [Cited: February 04, 2013.] http:// www.familyhealth.gov.lk/web/index.php?option=com_content&view=article&id=90&Itemid=58&lang=en. 6. Sri Lanka Statistical Data Sheet 2013 (http://www.statistics.gov.lk/DataSheet/) 7. Census of Population and Housing 2012 (http://www.statistics.gov.lk/PopHouSat/) T ha ila nd a nd F am ily P la nn in g: A n ov er vi ew 1 Th ailand and Family Planning: An overview Background The Thai mainland is bordered by Cambodia, Lao People’s Democratic Republic, Malaysia and Myanmar; the country also includes hundreds of islands. According to the 2010 Thai census report, the population is 65.98 million (The 2010 Population and Housing Census). It is also one of few countries in the South-East Asia Region where the female population (33.63 million) marginally exceeds the male population (32.35 million). The population is unevenly spread across the country, with the capital Bangkok being the most densely populated region. The success of the family planning programme in Thailand is acknowledged worldwide. The population pyramid seen in Figure 1 shows a smooth distribution of the population across age groups, which is typical of populations that have not only managed to tackle issues related to excessive fertility, but have also made tremendous progress in terms of health improvement and increased life expectancy. Situation Analysis Thailand introduced its fi rst population policy in 1970, and it is one of the most successful programmes in the South-East Asia Region. The programme has moved beyond a focus on family planning to include other vital components of reproductive health. In 2006 and 2009, the National Statistical Offi ce of Thailand in collaboration with the Reproductive Health Division of the Department of Health, conducted special surveys focused on various aspects of reproductive health of the population (Reproductive Health Survey, 2009). Earlier fertility- related surveys were conducted in 1975, 1985 and 1996. Figure 1: Population pyramid, 2010 Source: UN Population Projections 2010. A ge (i n ye ar s) Percent FemaleMale 5 0 5 105 100 90 80 70 60 50 40 30 20 10 0 2T ha ila nd a nd F am ily P la nn in g: A n ov er vi ew The relevant demographic and health indicators are presented in Table 1. Table 1. Key indicators Total population (in millions), 2010 65.98 Population growth rate, 2000–2010 0.8% Population density (people per square km), 2010 127.5 Urban population, 2010 45.7% Population <15 years of age, 2010 19.8% Total fertility rate (TFR), 2011 1.5 Contraceptive prevalence rate (CPR), 2009 79.6% – Pills 35 – Injectable 14 – Implants 0.4 – IUD 0.8 – Female sterilization 23.7 – Condom 2.3 – Emergency contraceptive pill 0.3 – Traditional or natural methods 2.2 Unmet need, 2001 1.2% – For spacing births 0.9 – For limiting births 0.3 Average age at fi rst marriage (in years), 2009 22.2 Average age at fi rst birth (in years), 2009 24.8 Crude birth rate (per 1000 population), 2011 12.4 Maternal mortality ratio (per 100 000 live births), 2010 31.8 Infant mortality rate (per 1000 live births), 2012 11 HIV adult prevalence, 2001 1.8% HIV prevalence among female sex workers, 2010 2.82% HIV prevalence among indirect female sex workers, 2010 2.05% HIV prevalence among male sex workers, 2010 21.0% HIV prevalence among pregnant women, 2010 0.7% HIV prevalence among blood donors, 2010 0.17% HIV prevalence among intravenous drug users, 2010 26.0% HIV prevalence among fi shermen, 2010 2.52% Source UN/IGME, Levels & trends in child mortality Report 2013, http://www.childinfo.org/fi les/Child_Mortality_Report_2013.pdf; Trends of maternal mortality 1990–2010 World Health Organization Total fertility rate (TFR) The Reproductive Health Survey (RHS) 2009 revealed that the average number of children ever born for women aged 15–49 years was 1.30 per women, which was slightly higher than the 1.23 found in the 2006 survey. There was a slight difference between municipal and non-municipal areas, with the former showing lower fertility rates of 1.11 compared to 1.40 in non-municipal areas. Thailand is amongst the countries that largely maintained TFR (Figure 2) though non-signifi cant slight variations were noted between results of 2006 and 2009 survey. T ha ila nd a nd F am ily P la nn in g: A n ov er vi ew 3 Thailand is also one of few countries in the South-East Asia Region where the actual fertility is lower than the wanted fertility. In RHS 2009, ever-married women aged 15–49 years wanted 1.93 children, but actually had 1.67 children on average. There was an interregional difference in these levels, with women in the Southern region wanting the highest number of children (2.33) and Bangkok the lowest (1.69). Similarly, older women had slightly higher wanted fertility than younger women, suggesting declining fertility norms. Figure 2: Trends in TFR, 1990–2009 Source: World Health Statistics 2011. To ta l F er ti lit y R at e (p er w om an ) 3 2 1 1990 2000 2009 2.1 1.8 1.8 Contraceptive prevalence rate (CPR) The low fertility rates in Thailand can be directly attributed to the high rates of contraceptive usage by women in the reproductive age group. According to RHS 2009, 79.6% of married women aged 15–49 years were using some method of contraception. This represented a slight decline from the 81.1% found in the 2006 survey. However, as seen in Figure 3, the World Health Statistics 2011 report that CPR is back to over 81%. Figure 3: Trends in CPR, 2005–2011 Source: World Health Statistic 2005, 2007 and 2011. Pe r ce nt 100 95 90 85 80 75 70 65 60 55 50 2005 2007 2011 70 72.2 81.1 South-East Asia Regional average 57.5 4T ha ila nd a nd F am ily P la nn in g: A n ov er vi ew Figure 4 shows that contraceptive usage rates by married women are close to 80% in almost all regions of Thailand; the Southern region is an exception, with a CPR of only 72%. Nonetheless, it is encouraging to note that while national fi gures and those for all the regions show declining rates from 2006 to 2009, the Southern region is the only one to show an increase in CPR during this timeframe. Source: National Statistical Offi ce, Thailand. Key Findings: Reproductive Health Survey. Department of Health, Ministry of Public Health, Government of Thailand. Bangkok: s.n., 2009 Figure 4: Regional differences in CPR for women aged 15–49 years, 2006 and 2009 Contraceptive method mix Almost all women in Thailand that use contraception are relying on a modern method. The proportion of women using a traditional method of contraception has hovered around 2% for the past 25 years or so. In 2009, among the 2.2% of women using traditional methods, 1.7% relied on periodic abstinence and 0.5% used other traditional methods. The pill continues to be the most preferred contraceptive method, with more than one third (35%) of women relying on the same (Figure 5). About 24% of women used female sterilization as their contraceptive method of choice. Despite a thriving commercial sex market in Thailand, condom usage was relatively poor at only 2.3%. As shown in Figure 6, the increase in the use of the pill over the years has resulted in a proportionate decline in the usage of IUDs and male vasectomy as contraceptive methods. Figure 5: Contraceptive method mix, 2009 Source: National Statistical Offi ce, Thailand. Key Findings: Reproductive Health Survey. Department of Health, Ministry of Public Health, Government of Thailand. Bangkok: s.n., 2009 2006 2009 100 90 80 70 60 50 40 30 20 10 0 Whole kingdom Bangkok Central North Northeast South 81 .1 79 .6 81 .3 78 .0 8 4. 2 80 .0 84 .3 81 .3 81 .3 81 .6 69 .7 72 .1 South- East Asia regional average: 57.5%P er c en t Not using any method, 20.40% Female sterlization , 23.70% Injection, 14% Condom, 2.30% Vasectomy, 0.90% IUD, 0.80% Implant, 0.40% Emergency pill, 0.30% Others, 2.2% Pill, 35% T ha ila nd a nd F am ily P la nn in g: A n ov er vi ew 5 Unmet need for family planning According to RHS 2009, 16.2% of ever-married women aged 15–49 years with an infant reported that their last pregnancy was unintended. Of these, 5.5% had wanted to delay the last pregnancy and 10.7% wanted to limit their family size. On disaggregating the data by age, the rate of such unintended pregnancies was nearly twice this level in girls aged 15–19 years. However, in the Thai context, where the access to contraceptive services is almost universal, rates of unintended pregnancies cannot be directly extrapolated as unmet need. On the contrary, this survey clearly showed that most of these pregnancies were due to contraceptive failure (such as due to women forgetting to take the pill or missing an appointment for contraceptive injection). Even in the adolescent age group, only 25.6% stated that the unwanted pregnancy resulted because they had planned on having sex, thus refl ecting some degree of “unmet need” for this age group. Adolescent fertility The adolescent fertility rate in Thailand is much lower than the regional average, and is declining further (Figure 7). The mean age at fi rst birth is 23.3 years. Only 16% of all births in Thailand are to mothers aged less than 20 years (Figure 8). There are many reasons for this, some of which are listed below. • Delayed marriage: According to RHS 2009, the mean age at fi rst marriage was 22.2 years. Even though this represents a slight decrease over the 2006 results, it is much higher than in other countries of the Region (Figure 9). • High use of contraceptives among youth (aged 15–24 years): About 83.5% and 70.3% of currently married and ever-married youth, respectively, have used contraceptives. Even 16.2% of never-married adolescents acknowledge having used a contraceptive. Of the young people Source: Fertility surveys 1985, 1996, RHS 2009 Figure 6: Trends in contraceptive method mix Pe rc en ta ge o f ev er -m ar ri ed w om en us in g co nt ra ce pt io n 90 80 70 60 50 40 30 20 10 0 Pi ll Fe m al e St er liz at io n In je ct io n Im pl an t IU D Va se ct om y C on do m A ny m od er n m et ho d A ny tr ad iti on al m et ho d O th er m et ho ds A ny m et ho ds 1987 1996 2009 35 23 .1 17 .7 14 22 .4 22 23 .7 65 .5 6 9. 8 77 .4 67 .5 7 2. 2 79 .6 9. 2 0 0 0. 4 7. 2 3. 2 0. 9 5 .5 2 0. 9 1. 2 1. 8 2. 3 1. 9 2. 4 2. 2 0 0 0. 3 20 6T ha ila nd a nd F am ily P la nn in g: A n ov er vi ew who use contraceptives, 91.9% used them during their last sexual intercourse refl ecting that contraceptive use is a “regular” practice for them when indulging in sex. This fi gure is even higher (98.8%) among “single” adolescents. • Reproductive health education: The 2009 survey revealed that 85.2% of youth aged 15–24 years had received some formal instruction in sex education, family planning and reproductive tract infections. Most of them had received this information while at school. Sources: World Health Statistics 2008, 2009, 2010, 2011. Figure 7: Trends in adolescent fertility rate, 2008–2011 South-East Asia regional average: 54 B ir th s pe r 10 00 g ir ls a ge d 15 –1 9 ye ar s 70 60 50 40 30 20 10 0 2008 2009 2010 2011 46 46 43 Source: National Statistical Offi ce, Thailand. Key Findings: Reproductive Health Survey. Department of Health, Ministry of Public Health, Government of Thailand. Bangkok: s.n., 2009 Figure 8: Percentage of women aged 15–49 years, by age group at fi rst birth 40 35 30 25 20 15 10 5 0 2006 2009 No live birth Under 20 20-24 25-29 30-34 35+ 37 .9 34 .2 15 .1 15 .8 28 .4 29 .8 13 .3 14 .3 4. 2 4. 6 1. 2 1. 3 A ge a t fi rs t bi rt h (y ea rs ) T ha ila nd a nd F am ily P la nn in g: A n ov er vi ew 7 Current Family Planning Eff orts Thailand offi cially launched its family planning programme in 1971, with the release of the national Population Policy. The next 15 years saw an impressive halving of the growth rate from 3.2% to 1.6%. The success and sustainability of the programme can be attributed to factors and initiatives, as follows. • Innovative family planning campaigns: Tying up with the Population and Community Development Association, a large non-governmental organization, the Department of Health launched one of the acclaimed marketing and distribution campaigns for contraceptives. • Increasing the basket of choice: Thailand was the one of the fi rst few countries globally to introduce the use of injectable contraceptives on a large scale. It also conducted revolutionary research into simpler and quicker methods for female sterilization, such as minilap, and was a pioneer in no-scalpel vasectomy. • Inclusion of the private sector: Upon payment of a small fee, the distribution network of the private sector was tapped into to ensure access to contraceptives even in far-fl ung areas. Other innovative and commercially viable ventures were also introduced. • The social fabric of Thailand: A more egalitarian and equitable social structure where women are respected, and where the dominant religion (Buddhism) emphasizes personal responsibility for behaviour, individual autonomy and decision-making (International Family Planning Perspectives) Currently, family planning is one of many reproductive health efforts, which include relatively newer initiatives such as screening for breast and cervical cancer and pre-marital counselling, including voluntary counselling and testing of the couple for their HIV status and other genetic disorders especially thalassaemia. Source: National Statistical Offi ce, Thailand. Key Findings: Reproductive Health Survey. Department of Health, Ministry of Public Health, Government of Thailand. Bangkok: s.n., 2009 Figure 9: Mean age of women at fi rst marriage, 2006 and 2009 30 25 20 15 10 5 2006 2009 Whole kingdom Municipal area Non-municipal area 23 .1 22 .2 25 .3 24 .2 22 .0 21 .4 8T ha ila nd a nd F am ily P la nn in g: A n ov er vi ew References: 1. National Statistical Offi ce, Thailand. The 2010 Population and Housing Census (Whole Kingdom) - Executive summary. 2. United Nations, Department of Economic and Social Affairs, Population Division, Population Estimates and Projections Section. Population Estimates and Projections. 3. National Statistical Offi ce, Thailand. Key Findings: Reproductive Health Survey. Department of Health, Ministry of Public Health, Government of Thailand. Bangkok: s.n., 2009. 4. World Health Organization. World Health Statistics. 2005–2011. 5. Thailand's family planning program: An Asian sucess story. Rosenfi eld A, Bennett A, Varakamin S, Lauro D. 2, June 1982, International Family Planning Perspectives, Vol. 8, pp. 43-51. 009316. 6. World Health Organisation - Department of Making Pregnancy Safer. Thailand Country Profi le. World Health Organisation. [Online] http://www.who.int/maternal_child_ adolescent/countries/tha.pdf. Challenges and Opportunities 1. Increasing the scope of reproductive health services: Thailand has achieved worldwide recognition for running a successful and sustainable family planning programme. Even though the process has begun, Thailand needs to build on this success to ensure that access to other reproductive health initiatives such as emergency obstetric care, diagnosis and management of reproductive tract infections, screening for cervical cancer, etc. are made as accessible as contraceptives. The challenge here is twofold: fi rst, is the relative shortage of health personnel in the Thai health system; and, second is educating communities on the importance of these services. 2. Improving services in the Southern region: For most health services, including access to contraception, the Southern region lags behind the rest of the country and therefore needs special attention from policy-makers and programme implementers. 3. Ensuring male participation: The use of male-dependent family planning methods, such as condoms and vasectomies, has been reducing over the years and the burden of family planning is being shifted solely to women. Male involvement in other reproductive health interventions, such as accessing antenatal care services, is also less than ideal. Health programmes should take advantage of the general social and religious fabric of the country, which encourages equality of the sexes, to increase male participation in decision-making and taking on greater responsibility for the reproductive health of the couple. T im or -L es te a nd F am ily P la nn in g: A n ov er vi ew 1 Background Timor-Leste is a small country primarily occupying the eastern half of the island of Timor, with West Timor being part of the Republic of Indonesia. Timor-Leste also includes the nearby islands of Ataúro and Jaco, as well as Oecussi, an exclave in Indonesian West Timor. “Timur” in Malay and “Leste” in Portuguese mean “east”. Timor-Leste is divided into 13 administrative districts, 65 subdistricts, and 442 sucos and 2225 aldeias. The 13 districts are Ainaro, Alieu, Baucau, Bobonaro, Cova-Lima, Dili, Ermera, Lautém, Liquiçá, Manatuto, Manufahi, Oecussi-Ambeno and Viqueque. Thirty per cent of the population live in urban areas, and the rest live in rural areas. Dili is the capital. According to the 2010 census, the population of Timor-Leste is 1066409. The annual population growth rate is 2.4%. As can be seen from Figure 1, a large proportion of the population is constituted of children or people in the reproductive age group. Situation Analysis Timor-Leste conducted its fi rst national DHS in 2003 and a second in 2009–2010. The latest is in tandem with other DHS conducted as part of the global programme, supported by many bilateral and multilateral agencies. The relevant demographic and health indicators are presented in Table 1. Timor-Leste and Family Planning: An overview Figure 1: Population pyramid, 2013 Source: CIA World Factbook. Male Female 100+ A ge (i n ye ar s) Population (in thousands) Population (in thousands) 95 – 99 90 – 94 85 – 89 80 – 84 75 – 79 70 – 74 65 – 69 60 – 64 55 – 59 50 – 54 45 – 49 40 – 44 35 – 39 30 – 34 25 – 29 20 – 24 15 – 19 10 – 14 5 – 9 0 – 4 95 76 57 38 19 0 0 19 38 57 76 95 2T im or -L es te a nd F am ily P la nn in g: A n ov er vi ew Source: CIA World Factbook; World Health Statistics, 2014; Country MDG Report 2010. Table 1: Key indicators Total population, 2014 1 201 542 Population growth rate, 2014 2.44% Population density (people per square km), 2010 76 Urban population, 2014 28.3% Population <15 years of age, 2010 44.8% Total fertility rate (TFR), 2014 5.11 Contraceptive prevalence rate (CPR), 2010 22.3% – Pill 1.7 – IUD 1.3 – Injectable 15.7 – Implant 0.8 – Condom 0.2 – Standard days 0.4 – Traditional methods 2.5 Unmet need, 2010 31% Median age at fi rst marriage (in years), 2010 20.9 Median age at fi rst birth (in years), 2010 22.4 Crude birth rate (per 1000 population), 2014 34.48 Maternal mortality ratio (per 100 000 live births), 2010 557 Infant mortality rate (per 1000 live births), 2014 38.79 HIV adult prevalence, 2014 NA Total fertility rate (TFR) The TFR of Timor-Leste (as per latest Demographic and Health Survey 2010) is the highest in Asia at 5.7 (Figure 2). At this rate, the total population of the country is expected to increase by more than 50% (from 1.2 million to 1.9 million) by 2025. Fertility differentials are seen between urban and rural areas (TFR of 4.9 and 6.0, respectively), between districts (highest in Ainaro at 7.2, and lowest in Covalina at 4.4), and with reference to the educational and socioeconomic status of women. Women with no education give birth to about three times the number of children born to women with at least secondary education (6.1 versus 2.9). Similarly, women in the lowest wealth quintile have a TFR of 7.3 compared to 4.2 for women in the highest wealth quintile. T im or -L es te a nd F am ily P la nn in g: A n ov er vi ew 3 Figure 2. Trends in TFR, 1997–2010 To ta l f er ti lit y ra te 8 7 6 5 4 3 2 1 0 1997 IDHS 2002 MICS 2003 DHS 2009–10 TLDHS 4.4 7.4 7.8 5.7 Source: Timor-Leste DHS, 2009–2010. Contraceptive prevalence rate (CPR) According to DHS 2006, about 10% of currently married women were using a contraceptive method. These rates are similar to the CPR found in subsequent surveys, up until 2010. By 2011, CPR had increased to 22.3% (Figure 3). Figure 3. Trends in CPR, 2006–2011 Pe rc en ta ge o f w om en u si ng co nt ra ce pt iv e 60 50 40 30 20 10 0 2006 2007 2008 2009 2010 2011 10 10 10 10 10 22.3 South-East Asia regional average: 57.5% Source: World Health Statistics 2006, 2007, 2008, 2009, 2010 and 2011. 4T im or -L es te a nd F am ily P la nn in g: A n ov er vi ew Contraceptive method mix More than one in fi ve currently married women (22%) use a method of family planning, with 21% using a modern contraceptive method. This indicates that modern methods are highly favoured over either natural family planning methods or other traditional methods. Only 1% of women report currently using a traditional method. The rhythm method is slightly more popular than withdrawal. Injectables are by far the most popular modern method, and are used by 16% of currently married women. The pill is used by 2% of women, while IUDs, implants and sterilization are each used by about 1% of women. Most women who are sterilized are over the age of 30. Injectables are popular among women aged 20–44 years. Figure 5. Trends in contraceptive use, 1997–2010 Modern method Any method Pe rc en ta ge o f cu rr en tl y m ar ri ed w om en 30 25 20 15 10 5 0 1997 IDHS 2002 MICS 2003 DHS 2007 TLSLS 2009–10 TLDHS 25 27 7 7 7 10 14 20 21 22 Source: Timor-Leste DHS, 2009–2010. Figure 4. Contraceptive method mix, 2009–2010 Source: Timor-Leste DHS, 2009–2010. Implants, 0.8 LAM, 0 Male condom, 0.2 Standard days method, 0.4 Female sterlization, 0.8 Pill, 1.7 IUD, 1.3 Any traditional method, 1.2 Any modern method, 21.1 Injectables, 15.7 T im or -L es te a nd F am ily P la nn in g: A n ov er vi ew 5 Figure 6. Trends in adolescent fertility rate, 2009–2011 B ir th s pe r 10 00 g ir ls a ge d 15 –1 9 ye ar s 70 60 50 40 30 20 10 0 2009 2010 2011 59 59 59 South-East Asia regional average: 54 Unmet need for family planning One in three currently married women has an unmet need for family planning, with 21% having an unmet need for spacing and 10% having an unmet need for limiting. If all currently married women who say they want to space or limit their children were to use a family planning method, the CPR would increase to 53% from the current 22%. Currently, only 42% of the family planning needs of currently married women are being met. Adolescent fertility Adolescent fertility in Timor is close to the average in SEAR region. While in-depth information is lacking due to absence of detailed demographic surveys, UN estimates show that the adolescent fertility has reduced from 59 births per 1000 girls in the age group 15–19 years in the early 2000s to 54 in the time period 2007–2012. Current Family Planning Eff orts Adolescent reproductive health is a key area for UNFPA youth programming in Timor-Leste, focusing on the promotion of available, quality and sustainable sexual and reproductive health information and services. Youth-friendly services are being provided, and there are plans to incorporate an adolescent sexual and reproductive health module into pre-secondary and secondary school curricula. Overall assessment shows that UNFPA plays a crucial role in the procurement and distribution of reproductive health commodities, and strengthening of maternal health care, at both the central and district levels through the training of health-care workers. The supply of adequately trained and qualifi ed health-care workers is integral to the functioning of the system and the overall improvement of health outcomes in Timor-Leste. The UN funds, programmes and specialized agencies should continue to support the efforts of the Government of Timor-Leste to improve the quality of care in the districts. 6T im or -L es te a nd F am ily P la nn in g: A n ov er vi ew Challenges and Opportunities Key challenges include the unmet need for family planning and the relatively high rates of HIV infection among youth. Poor infrastructure, a restrictive environment, sustainability and cost also remain important challenges. Co-fi nancing and partnerships between UN organizations and the Government fi ll the gap, based on needs assessment and comprehensive planning. Collaboration with the government, coordination between UN organisations is a good opportunity to provide fi nancial and technical support. References: 1. Timor-Leste Demographic and Health Survey 2009–2011. http://www.measuredhs.com/pubs/pdf/FR235/FR235.pdf 2. World Health Statistics. World Health Organization. 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014. 3. Improving Maternal, Newborn and Child Health in the South-East Asia Region. World Health Organization. 2005 4. The World Factbook. https://www.cia.gov/library/publications/the-world-factbook/geos/tt.html