Financial Times: Special Report on Sexual and Reproductive Health

Publication date: 2012

FT HEALTH Sexual & Reproductive Health FINANCIAL TIMES SPECIAL REPORT | Monday July 9 2012­reproductive­health­2012 | Inside this issue Products Of 818m sexually active women who want to avoid pregnancy, a quarter use no contraception Page 2 Delivery Unmet demand is not just about insufficient resources Page 2 Female genital mutilation Egytian activists are concerned that advances may be rolled back Page 3 Guest column Melinda Gates considers prospects for the London summit Page 3 Education African girls have a very short time to learn about safe sex Page 3 India and Bangladesh A loss of focus has diverted resources Page 4 Nigeria The difficulties of a swelling population and entrenched attitudes Page 4 HIV/Aids Rhetoric is not always matched in the field Page 4 China One-child policy could threaten economic growth Page 5 Care The number of women dying in childbirth has halved since 2000 Page 5 The US Hardening moral positions are creating uncertainty Page 5 A s World PopulationDay approaches onWednesday, themedium – a UN web- site – may be glossier than ever, but the message is the same. There is wide agreement on what is required to provide reproductive health to all, but the reality is falling far short. Nearly 20 years after govern- ments reached consensus at an international conference in Cairo on family planning in 1994, progress has been limited and, in some cases, the trend has gone into reverse. About 215m women in devel- oping countries seeking contra- ception cannot get it. That means 75m unintended pregnan- cies every year, threatening the health and lives of millions of mothers and their children. Meanwhile, the world popula- tion has exceeded 7bn, placing fresh pressure on economic growth, the environment and the wellbeing of communities. The realisation of ambitious health-related targets set at international meetings since Cairo has also proved disap- pointing. The UN Millennium Development Goals agreed at the turn of the century called for significant reductions in infant and maternal mortality by 2015. In many countries, it is clear these targets will not be met. Yet there are signs of fresh determination to boost contra- ceptive assistance. Following meetings in Uganda and Sen- egal, London is host to a high- level family planning summit on July 11. The aim is to increase contra- ceptive access for the poor from 260m women a year today to 380m by 2020. “Since Cairo, we have had conflicts and economic crises that have hindered progress,” says Tewodros Melesse, director- general of the International Planned Parenthood Federation. “Now is an opportune moment to create political momentum, bring major donors together and mobilise civil soci- ety.” Across much of the world in the past, industrialisation, improved nutrition and sanita- tion pushed down family size with the help of contraception. But while significant advances in immunisation and medical treatment since the second world war have sharply cut infant mortality, that has not always translated so rapidly into falling birth rates. While some women still want large families, many more do not. Aside from the health risks, there are economic conse- quences of this “unmet demand”. Teenage mothers tend to drop out of school, depriving themselves, their families and societies of a more educated workforce and the prospect of stronger economic growth. “Family planning has been a huge determinant of long-term development,” says Raj Shah, head of USAID, the world’s larg- est donor which gives $625m a year to the field. “We have an obligation and a real need to do a better job.” Andrew Mitchell, the UK’s international development min- ister, adds: “In cost terms, fam- ily planning is excellent value for money. The relevant serv- ices, including the provision of contraception, cost on average less than £1 per person per year – far less than treating the com- plications of an unintended pregnancy.” Mobilised by fears that over- population would limit develop- ment, however, India ran a coer- cive sterilisation campaign in Renewed effort to boost birth control There is an increased determination to spread the benefits of contraception, says Andrew Jack Continued on Page 2 Seeking attention: 215m women who want contraception cannot get it. These Ethiopian women are waiting at a clinic IPPF/Chloe Hall 2 ★ FINANCIAL TIMESMONDAY JULY 9 2012 FT Health: Sexual & Reproductive Health Contributors Andrew Jack Pharmaceuticals Correspondent Christopher Cook Education Correspondent Abeer Allam FT Correspondent Kanupriya Kapoor Mumbai Correspondent Xan Rice West Africa Correspondent Sarah Murray FT Contributing Editor Patti Waldmeir Shanghai Correspondent Charis Gresser FT Contibutor Stephanie Gray Commissioning Editor Steven Bird Designer John Wellings Picture Editor For advertising details, contact: Ian Edwards Phone +44 020 7873 3272 Fax +44 020 7873 4336 Email: or your usual representative All FT Reports are on Go to: Follow us on twitter at ftreports All editorial content in this supplement is produced by the FT. Our advertisers have no influence over, or prior sight of, the articles or online material. the 1970s. China still oper- ates a one-child family pol- icy, highlighted last month by a widely publicised case of a compulsory abortion. Apart from the human rights abuses that such pol- icies represent, evidence from other countries such as Bangladesh has shown that significant progress can be achieved voluntarily, as long as there is the polit- ical will. But if the Cairo confer- ence condemned coercion and reached a clear consen- sus on how to help women meet their own desire to limit family size, momen- tum to provide them with the necessary support has slowed. Some argued at the time that birth rates were already falling and greater action was no longer required. Donors began to switch to different causes. Ideology and religion also played a role, with US pol- icy requiring recipients of aid to condemn prostitution and not undertake abor- tions; and the hierarchy of the Roman Catholic church critical of contraception. Gary Darmstadt, director of family planning at the Gates Foundation, which has upped its own contribu- tion, says: “There was pretty broad support for family planning in the 1970s and 1980s across people of various political back- grounds and ideologies, but then the issue became more polarised. Abortion was linked to contraception and it began to create a divide that persists today.” For him and others focused on this week’s con- ference, a first priority is renewed political commit- ment linked to fresh fund- ing. It will cost $10bn between now and 2020 for the world’s poorest 69 coun- tries to maintain current levels of contraceptive sup- port for 260m women. A fur- ther $4.5bn will be required to help 120m more, includ- ing $2.3bn from donors. Efforts are focused on a combination of new money and better use of existing resources, with countries putting forward plans tai- lored to their own needs. Participants will also seek greater accountability and co-ordination, pushing for better scrutiny of govern- ments and charities to increase efficiency. But many also argue for a bigger role for both the pri- vate sector – where many women turn for contracep- tives – and faith-based organisations. “Many people think that religious leaders are against family planning,” says Ray Martin, head of Christian Con- nections for Inter- national Health. “Of course, some are, but many, probably most, are not.” A second issue at the London summit is “market shaping” to remove regulatory hurdles, ease pro- curement, improve forecasting and strengthen distri- bution. That should help reduce uncer- tainty, boost volumes and push down prices for con- traceptives. A third tack will be to foster improved technolo- gies, whether by using mobile phones to track sup- ply shortages better or new longer-lasting contraceptive implants that are discreet, reversible, reliable and min- imise the inconvenience. Given tough economic times and the longstanding reluctance of donors to co- operate and pool resources, finding money will be one challenge for richer and poorer countries alike in meeting the latest objectives. Another will be fear that a renewed “verti- cal” focus on family plan- ning risks diverting thinly stretched medical workers and undermining a more holistic “horizontal” approach to the provision of healthcare, including other still more neglected infec- tions such as syphilis or schistosomiasis, which can in turn boost susceptibility to HIV. A final issue is the broader question of women’s power. Pam Barnes, head of Engender- Health, a New York charity, says: “Family planning is not just about commodities. It’s about health, education and empowerment. I’ve lived in places where women can’t even walk to the health post without per- mission. Male involvement is vital.” Ironically, while many organisations working in family planning are heavily staffed by women, they are often run by men. British officials have dropped the phrase the “golden moment” to describe the London sum- mit’s efforts to remobilise global support for family planning. But, in the build-up to the Olympic Games, participants are hoping at least for a bronze medal in effort and funding. If they succeed, the leg- acy could be far longer last- ing than the sporting event that follows. If they fail, human suffer- ing and economic stagna- tion will certainly be greater. Renewed effort to boost birth control Pill power: 215m women cannot get protection ‘Family planning is not just about commodities. It is about health, education and empowerment’ By their method, you shall know them. Around the world, family planning tech- niques vary widely, reflect- ing cultural factors and medical attitudes as well as more practical issues of for- mulation, price and access. In Japan, condoms and abortion are common. In China, the coil is wide- spread and the oral pill has almost no role. In India, sterilisation is the preferred method, while, in Africa, injectables dominate. “Culture, religion, the social environment and the position women have in society all play a role,” says Klaus Brill from Bayer Healthcare, a leader in hor- monal contraceptives and the developer of the birth control pill, which by vol- ume remains the most important product it has in the field. According to a survey by the Guttmacher Institute in 2008, of the 818m sexually active women across the developing world who wanted to avoid becoming pregnant, more than a quar- ter used no contraceptive at all or a traditional method with limited efficacy, such as withdrawal or periodic abstinence. That reflects not only high costs and limited avail- ability, but also sometimes misplaced suspicion of side effects and a low perception of risks of pregnancy among those having sex infrequently or still breast- feeding a previous child. For those using “modern” methods, the pattern also varies widely by geography. In sub-Saharan Africa, for example, injectable contra- ceptives and implants domi- nate, accounting for 38 per cent and the pill for another 26 per cent. In south central Asia, sterilisation is the most widely used, making up 64 per cent and the pill just 12 per cent. Among the world’s poor- est 69 countries, a study by the Population Reference Bureau showed that sterili- sation was most widespread at 17 per cent of women using modern methods, fol- lowed by oral contracep- tives at 7 per cent, injecta- bles and then intra-uterine devices (IUDs) at just over 5 per cent, with condoms at nearly 4 per cent. Overall, contraceptives are big business. A recent report by GIA, a market research group, estimates the economic downturn has done nothing to flatten sales, as couples defer or avoid having children to reduce costs. It forecasts demand will rise to $17bn by 2015. The market for some of the leading products has been dominated by a small number of large western companies, including the pharmaceuticals groups Pfizer, Merck and Bayer. That is beginning to change, through both generic competition and innovative products from new as well as existing pro- ducers. Terrie Curran, general manager for women’s healthcare at Merck, says: “In the past five years, there has been a significant increase in investment. “There was a period when many companies were get- ting out, but many are now reinvesting, realising there is unmet need and a need for innovation.” Many see IUDs and long- lasting implants as the most promising techniques. While the initial cost is higher than the alterna- tives, they have the advan- tages of reversibility, relia- bility and discretion, impor- tant if sexual partners object to contraception. Merck and Bayer have developed matchstick-sized devices that fit under the skin and release hormones. The Gates Foundation is studying Sino-Implant (II), a low-cost version made by Shanghai Dahua Pharma- ceuticals. While the short- term costs of purchase and insertion are higher, main- tenance is then low. Fresh debate over prob- lems with current contra- ceptives and the need for more detailed research has been sparked by a study published last year suggest- ing women taking hormo- nal injections such as Depo-Provera have twice the rate of HIV of those using alternative methods. Researchers argue as to what extent the difference is due to the product or other issues such as differ- ences in condom use and sexual frequency. In the absence of a costly new clinical trial that raises practical and ethical chal- lenges, the World Health Organisation has taken the view that current guide- lines should remain, but that women using hormo- nal injections should also use condoms. Promising developments include “dual purpose” products that can piggy- back off research in related fields. Zeda Rosenberg, head of the International Partner- ship for Microbicides, which is co-ordinating clinical tri- als for the use of a vaginal ring that slowly releases antiretroviral drugs to pre- vent HIV, sees potential in adding a contraceptive product too. “Advancing a product that could expand both women’s HIV prevention and family planning options could have profound bene- fits,” she says. Such a device is still some years away at best, how- ever. While not neglecting innovation, greater impetus is required to ensure exist- ing products are used more widely. Market expected to reach $17bn by 2015 Contraception Andrew Jack looks at the wide variety of methods used around the world Contraceptive needs of women in the developing world Sources: Guttmacher Institute; UNFPA Per cent Use modern contraceptives Has unmet need for modern contraceptives Unmarried and not sexually active Pregnant, post-partum or intending pregnancyInfecund 42 15 24 118 Developments include ‘dual purpose’ products that can also combat HIV For more than a year,Edward Wilson and histeam at John Snow Inchave been struggling with the paperwork to import condoms into Ethiopia, risking supply problems even in one of the countries widely seen to have made big advances in fam- ily planning. “It’s taken a long time to understand the regulatory requirements and submit docu- ments that suppliers are not used to,” he says. “We’ve been limited in our ability to ship with only one or two manufac- turers registered. If there’s a last-minute order, than means it can be difficult to meet.” He highlights problems often neglected in the discussion over access to products. “Unmet demand” for contraceptives is not just about insufficient resources for purchases or the need for newly designed variants, but also innovation in the less sexy “back office” to smooth the delivery of existing stocks. “Countries have been strengthening their regulatory systems in the past five years,” says Mr Wilson, whose company oversees via USAID some of the largest purchases of family plan- ning products in the world. “It’s a good thing for them to have more ownership, but registra- tion can be long and compli- cated.” Terrie Curran, general man- ager for women’s healthcare at Merck, agrees. “The regulatory environment is a critical bottle- neck,” she says. “Standardised methods of reviewing would help access. Each country has unique requirements. Every dossier has to be different, and the level of work that goes into changing them is signifi- cant.” All along the supply chain, obstacles restrict the efficient distribution of relevant com- modities. Before donors will even approve the purchase of contraceptives, they often require them to be “pre-quali- fied” as meeting the standards established by the World Health Organisation. Dana Hovig, chief executive of Marie Stopes International, says: “The pre-qualification process is broken for family planning and is letting women down. There are hundreds of antiretrovirals approved for HIV, which has brought prices down sharply, but there is a handful of mostly northern [industrialised countries] family planning manufacturers. That’s a travesty that keeps prices up.” He and others have been pushing for an accelerated “expert review panel” of inter- national agencies that would scrutinise the quality of family planning products and allow donors to provide funding to purchase them, even while approval is pending. A UN commission on 13 life- saving commodities for women and children concludes that reg- ulation is proving a barrier by delaying registration or by doing little to prevent low- quality commodities. The high cost of “bio-equiva- lence” studies to show that cheap generics are the same quality and efficacy as original versions can deter companies from launching rival products. That is one contributor to the so-called “market trap”: a vicious cycle in which manufac- turers anticipate high costs and low returns, so they do not invest and rivals do not enter the field. It affects manufacturers of contraceptives and other impor- tant products for mother and child health. Many point to high prices lim- iting access to essential prod- ucts. But Klaus Brill from Bayer Healthcare says: “There’s often a tendency to argue only about price, but other elements have a bigger impact. Even if manufac- turers were to give products away, it would be hard to get them to women.” He says that poor forecasting and erratic orders make it diffi- cult to plan, produce and charge lower prices. “We can’t produce within a couple of days. Donors have to give a commitment for longer than 12 months.” John Skibiak, director of the Reproductive Health Supplies Coalition, a non-profit group try- ing to tackle such problems, says procurers such as the UN population fund place an order only when they have received money from donors, “which is erratic and comes in dribs”. One response has been Pledge Guarantee for Health, providing letters of credit for rapid fund- ing after donors have agreed disbursement but before the cash arrives. That has helped Merck offer significant price cuts on its contraceptive implants. Others are discussing “market shaping” through glo- bal pooled procurement with volume guarantees. But even if products are funded, authorised, ordered and given national regulatory approval, there is still no guar- antee they will consistently reach women seeking them. “Stock-outs” are frequent, reflecting poor procurement and supply-chain management, trig- gering experiments such as the “informed push model” in Senegal to provide better co- ordination and information from regions to the distribution cen- tre. “For a long time, people have thought it’s just something that happens in the back office,” says Mr Wilson. “We need to persuade stake- holders that, while they need to be able to control the supply chain, they don’t need to do all the work: it could be private, public or through NGOs.” Bottlenecks that block the chain of supply Delivery Price is not the only problem hindering access to products, says Andrew Jack Contraceptive prevalence 70% or more 50% to less than 70% 20% to less than 50% Less than 20% No data Percentage of women using some method of contraception Among those aged 15-49 who are married or in a union: most recent data available Source: United Nations Department of Economic and Social Affairs Continued from Page 1 FINANCIAL TIMESMONDAY JULY 9 2012 ★ † 3 FT Health: Sexual & Reproductive Health In the run-up to the Egyp- tian presidential election, Mohamed Morsi, the Mus- lim Brotherhood candidate who became president last month, was asked on televi- sion to comment on the state-imposed ban on female genital mutilation. He said it was a private issue between mothers and daughters, adding that fam- ilies, not the state, should decide. His response caused uproar, particularly among children’s and women’s rights advocates who have been working for years to change the perception of the procedure in the soci- ety. Human rights groups are increasingly concerned that Islamist parties are seeking to roll back women’s rights and reverse laws passed under the former regimes to appease their ultraconserv- ative base. While this is true, Mr Morsi’s views are com- monly held across the coun- try. A law banning female genital mutilation, or FGM, was passed five years ago after several girls who bled to death after the cutting of their clitoris, but FGM is still rampant among rural and lower socioeconomic classes. The practice is passed down from one female gen- eration to the next. Mothers who were forced by their mothers and grandmothers to undergo the cutting before they reached puberty do the same to their daugh- ters. For them, tradition and custom overrides the law, even religion. They believe FGM curbs sexual desire and “purifies” the girl and prepares her to be a chaste wife, a “treasure” much sought after by eligible grooms. Although support for FGM is still widespread there has been considerable change since the mid-1990s. In 1995, 82 per cent of women aged (15-49) believed FGM should continue. This dropped to 75 per cent in 2000 and to 62.5 per cent in 2008, according to Unicef. Meanwhile, those who try to challenge the practice, eventually succumb to soci- etal pressure. “I didn’t want to circumcise my younger daughter because I felt it was an outdated custom from my mother’s time, not hers. “But her father insisted,” says Iman Attar, 38, a housekeeper who lives in a working class Cairo neighbourhood. “Everybody told me it was unfair to leave her like this.” The practice is often per- formed without girls’ con- sent. But female relatives portray FGM as rite of pas- sage to womanhood and marriage. About 90 per cent of all women of child-bearing age in Egypt have undergone female genital mutilation, according to the 2008 Egypt Demographic and Health Survey. Years of campaigns in which religious scholars pr eached against the practice (the Grand Mufti issued a fatwa in 2009) have resulted in a drop from 77 per cent to 74 per cent in the number of girls who under- went FGM between 2005 and 2008. The survey sug- gests that the FGM will eventually decline to 60 per cent among girls currently under three. “It’s difficult to end, because it’s rooted in a toxic mix of culture and religion,” says Mona Elta- hawy, a feminist writer. “As much as many Muslims deny it has anything to do with Islam, you’ll find many clerics advocating it. When parliament criminal- ised it in 2007, some of the fiercest opponents of the law were from the Muslim Brotherhood.” In May, the Brotherhood’s Freedom and Justice Party (FJP) was accused of launching a medical cam- paign for FGM in the south- ern governorate of Minya. The party denied the report, but human rights groups filed a complaint to the attorney-general and gover- nor of Minya to stop the campaign. Doctors, however, com- plain that most people ignore the ban and perform the procedure anyway. One public hospital doc- tor says: “It is impossible to change tradition overnight. At least they should allow only doctors to perform it to control the damage and avoid death. Sometimes par- ents ask me to circumcise their daughters and I know when I say ‘no’, they will go straight to any untrained paramedic to do it for them anyway.” It is usually performed on girls between the ages of nine and 12. In the past, it involved removing the clito- ris, together with labia minora. The operation was frequently performed using knives or razors. In recent years, however, more than 60 per cent of circumcisions have been performed by physicians and nurses, Unicef says. Besides the psychological scars, the practice leads to difficulties with menstrua- tion, intercourse and child- birth. Activists are worried by lukewarm attitudes to the law among newly- elected officials. Azza el-Garf, one of the few Brotherhood’s Freedom and Justice female parlia- mentarians, described the procedure as “plastic sur- gery or a form of “beautifi- cation” that women are entitled to do if they opt to, attracting harsh criticism. A toxic mix of tradition and religion Egypt Abeer Allam considers prospects for ending female genital mutilation President Mohamed Morsi’s attitude to FGM caused uproar What would happen if, at the stroke of midnight tonight, every woman in Europe lost access to contraceptives? How many girls would drop out of school? How many women would quit their jobs? Could parents provide for their children? What new phrase would we have to coin to express the catastrophe that would befall economies that are already in “crisis”? More than 200m women and girls in poor countries, mostly in Africa and south Asia, do not have access to contraceptives. That is more than all the women of reproductive age in Europe. I have made family planning my priority, because the women I meet when I travel consistently tell me that having the power to decide when to have a child is central to achieving their goals in life. They want to be able to feed their children, take them to the doctor when they are ill, and send them to school so they can fulfil their potential. This week, our foundation is joining the UK’s Department for International Development in sponsoring the London Summit on Family Planning, which brings together thousands of partners around a single ambition: to provide 120m additional women with access to contraceptives by 2020. The summit builds on a long history of success in extending access to contraceptives to poor women. Family planning programmes have been around for more than 50 years, and they have helped transform most of Asia, Latin America and the Middle East. But progress has slowed in recent years. Among many donors, especially in Europe, the idea of access to contraceptives is so uncontroversial that it hardly seems worth investing in. Conversely, in countries such as the US, the issue has become a proxy for the fight over abortion, so it is too controversial to invest in. Meanwhile, hundreds of millions of women are unable to make basic decisions about their future. Our objective is to remind everyone that there should be no controversy – but a strong sense of urgency – around giving women the power to make a better life for themselves and their children. Over the years, we have learnt countless lessons about how to do this work better. There are three big themes running through the summit. First, and most important, we are putting women and girls at the centre. In the past, some programmes put too much emphasis on trying to manage population growth. Some of these set specific population targets, and some even resorted to coercion to reach them. Participants in the summit agree that empowering women and girls to make their own decisions is the best and only way to encourage large-scale economic and social improvements. Second, the work is being led by stakeholders in the countries where it is happening. More than 20 countries have been reviewing data and pinpointing weaknesses in their family planning programmes. They are announcing plans to address these gaps at the summit. None of the investments we are discussing is being imposed; we are relying on the commitment and expertise of those in the countries where women who do not have access live. Third, there is a diverse group working more collaboratively to break through the barriers blocking progress. In particular, the private sector is playing a much bigger role. In Senegal, for example, our foundation is working on a pilot project that provides incentives to small businesses to make sure contraceptives are always in stock at the health clinics, which has been a serious problem. Drug companies are working with countries to supply high-quality products at affordable prices. UN agencies are working with countries to streamline the regulatory approval processes, so that more companies can enter the market. Companies are also working with universities and non-profit groups on research and development to create products that meet more of women’s needs. For example, injectable contraceptives that could be administered by women in their homes would be more practical for women who live far away from health clinics. What if 120m women such as these had access to contraceptives by 2020? How many more girls could go to school? How many more women could work? How many more parents could provide for their children? What new phrase would we have to coin for the economic progress in some of the poorest parts of the world? Melinda Gates is co-chair of the Bill & Melinda Gates Foundation Women should be given the power of choice Guest Column MELINDA GATES A t root, all sexual healthproblems are educationproblems. There is littlethat anyone can do to mitigate the risks of sexually transmitted disease or unwanted pregnancy if they do not first understand the dangers associ- ated with sex or the technologies available to render it safer. Sadly, according to Demo- graphic and Health Surveys in the developing world, agencies and governments are failing to spread this life-saving information. Igno- rance about sexual health and HIV prevalence too often go hand- in-hand. There are areas where knowl- edge is relatively good: 82 per cent of young women in Gabon in 2000 knew there were effective ways to prevent the spread of HIV. How- ever, some areas are appalling: a similar survey taken a year later found only 54 per cent of their contemporaries in Mali had such knowledge. Moreover, this understanding is often theoretical or vague. While 35 per cent of female respondents in Mali knew that condoms were an effective means of preventing the spread of HIV, only 8 per cent were sexually active and knew where to get one. Sex education appears, too often, to be an abstract discipline. There is also a problem with knowledge about HIV, in particu- lar. In Niger, only 19 per cent of teenage girls and 36 per cent of young men knew that the disease could be carried by a healthy- looking person. Only 23 per cent of women in that survey knew that the virus could be transmit- ted from a mother to her child. Part of the problem for Africa is the relatively narrow window for formal sex education across much of the continent. Childhood and schooling end more rapidly in the developing world than in the developed. This means that the opportunity for agencies wishing to impart sex education in good time is limited. Susheela Singh, vice-president of the Guttmacher Institute, which specialises in reproductive health, writes of “the need for sex education to begin at a minimum before age 15, and, to be most effective, significantly before this age. Sexual coercion is probably quite widespread and that it occurs at quite young ages.” In a survey taken in Niger in 1998, only 7 per cent of 15- to 19- year-old women attended a school, and only 7 per cent of respondents already had seven years of education behind them. But 60 per cent of those young women were cohabiting or mar- ried, whether formally or by com- mon law tradition. The same was not quite true for young men: surveys find negligi- ble numbers of teenaged men set- tled down – but large numbers were sexually active, and many with multiple partners. In Malawi in 2000, only 4 per cent of young men were in a union, but 61 per cent reported in surveys that they had already had sex. Heather Boonstra, a senior asso- ciate at the Guttmacher Institute, says: “In a country such as Burkina Faso, many adolescents never make it beyond primary school – especially girls. So, although schools are a good place to focus our efforts, it’s important that sex education starts early, in an age-appropriate fashion.” This education is likely to require a broad curriculum, Ms Boonstra says: “Evidence built up over the past 15 years shows that abstinence-only-until-marriage programmes do not help teenag- ers to delay sex. By contrast, there is a strong body of evidence on the effectiveness of more com- prehensive approaches.” A Unesco study of abstinence- only programmes found that “two of the 11 studies reported that the evaluated programmes delayed sexual initiation, while nine revealed no impact”. Meanwhile, programmes that only stressed that not having sex- ual intercourse as the safest option but also discussed contra- ceptive use were more likely to delay sex, reduce intercourse, and cut the number of partners These programmes tend to be much broader-based than many of their critics would imagine, Ms Boonstra says. She adds: “Comprehensive sex education is not just about delay- ing sex and teaching contracep- tion, but also about teaching ado- lescents how to communicate, have healthy relationships, and reduce the risk of violence.” Difficulty spreading education is not confined to Africa: Latin America has a significant number of weak school systems. But it is particularly pronounced in Africa. This makes sex education some- thing that needs to go beyond school. This creates other problems: the rise of the mobile phone and the spread of the radio continues apace. But there are still areas where young people – especially women – lack access to newspa- pers, radio or television. As recently as 2000, 81 per cent of teenage women in Ethiopia were reporting that they had no access to these media. The existing infrastructure needs to be deployed effectively. Ms Boonstra says: “Adolescents say they want information about sex-related matters to be reliable and to come from trusted sources – such as clinics and hospitals. “In fact, some health clinics are trying to reach young people in their communities and create safe and supportive environments.” Education needs to go well beyond schools. Safe sex needs to be taught beyond the schoolroom Education Childhood and classes often end at an early stage in the developing world, says Chris Cook Early learning: the opportunity is limited in Africa for agencies to impart sex education in good time Getty 4 ★ † FINANCIAL TIMESMONDAY JULY 9 2012 FT Health: Sexual & Reproductive Health Ethiopian policy makers, faced with a rapidly expanding population and rising numbers of HIV-Aids infections, decided to tackle both problems together. They introduced family planning into the counsel- ling and testing pro- grammes that are a core part of HIV-Aids prevention and treatment. When counselling women on reproductive health or child immunisation, family planning clinics can also discuss HIV testing and pre- vention, particularly con- dom use, as well as intro- ducing pregnant women to mother-to-child HIV trans- mission prevention serv- ices. HIV prevention and treat- ment service providers could talk to HIV-positive couples about how to have more children safely or how to prevent unwanted preg- nancies. “There’s plenty of room for synergy,” says Christo- pher Purdy, executive vice- president at DKT Interna- tional, which uses social media to improve access to reproductive health prod- ucts and services in Latin America, Africa and Asia. “If a young woman wants to come in for a cycle of pills, that’s a great time to talk about HIV-Aids – and promote a barrier method if she has multiple partners,” he says. “Or if a young man has multiple partners, that’s a good time to talk about family planning.” International donors acknowledge the need for more integrated services. Guidelines recently issued by Pepfar, the US programme to tackle HIV- Aids abroad, endorse provi- sion by family planning centres of counselling and testing, referrals for preven- tion of mother-to-child transmission and HIV care and treatment services. The Pepfar guidelines also endorse provision of family planning counselling and referrals for contracep- tives for women in HIV pro- grammes. However, experts say pol- icy rhetoric on integration is not always matched by practices on the ground. Use of funding for contra- ceptives is prohibited even in the Pepfar guidelines, says Heather Boonstra, sen- ior public policy associate at the Guttmacher Institute, a US-based policy group, in a research paper.* She also says it is easier for family planning professionals to add HIV-related services than the other way around. “One direction of the equation, which is HIV test- ing in family planning clin- ics, is politically feasible and may be happening more,” says Ms Boonstra. “What has not been as prev- alent is counselling within HIV programmes around reproductive health and family planning.” In the US, part of this can be ascribed to political sen- sitivities and conservative resistance to expanding family planning services. However, logistical fac- tors also come into play. HIV counsellors may not be trained to have conversa- tions with women or cou- ples on family planning or may not have strong refer- ral networks. Social and cultural pre- conceptions can also ham- per integration of family planning and HIV preven- tion and treatment services. “Ironically, these two fields have had a hard time seeing eye to eye,” says Mr Purdy. “A lot of this centres around the fact that trans- mission routes for HIV – drugs, extra-martial sex, commercial sex, young peo- ple having sex – are loaded with behaviours that are deemed socially difficult.” Another barrier is the stigma attached to diseases. Funding priorities can also limit what organisa- tions can do on the ground. “Sometimes funds come with certain labels,” says Ade Fakoya, HIV-Aids spe- cialist at the Global Fund to Fight Aids, Tuberculosis and Malaria, a multilateral donor organisation. “So if the funding comes with an HIV label, you can’t provide an integrated service for maternal and child health.” However, all agree that these barriers need to be overcome, not least because of the mounting cost of delivering healthcare serv- ices globally. In this respect, the Ethiopian example demonstrates great potential, since only modest incremental investment was required to integrate family planning into HIV- Aids programmes. According to the World Health Organisation, the one-off cost for Ethiopia’s family planning training was $325 per trainee and the only substantial recur- ring costs were regular monitoring visits by Path- finder International, a non- governmental organisation that was involved in the programme – and these amounted to only $1,562 a year per facility. Looking beyond costs, however, broader policy tar- gets – such as the Millen- nium Development Goals to reduce child mortality, improve maternal health, and combat HIV-Aids, malaria and other diseases – cannot be met without greater co-ordination between family planning and disease prevention pro- grammes. “Everyone accepts that we won’t reach Millennium Development Goals 4, 5 and 6, unless we have better integration,” says Dr Fakoya. *Linkages Between HIV and Family Planning Services Under PEPFAR: Room for Improvement, Heather Boon- stra, Guttmacher Policy Review, Fall 2011 Links with family planning bring benefits HIV-Aids Sarah Murray considers efforts to provide more integrated services Potential: combination policy costs little IPPF/Chloe Hall Targets cannot be met without more co-ordination between different programmes India and Bangladesh Uneven quality of care Faiza keeps up a stream of chatter as she takes off her burka for a physical examination at a clinic in central Mumbai run by an NGO. She is in the first month of her fifth pregnancy and has come in to schedule an abortion, which the clinic can perform legally and safely at a subsidised rate of Rs500 (about $9). “I have two children already. My husband and I don’t want any more, because otherwise we would have to work more than we already do to earn enough money,” says Faiza (not her real name), having miscarried and aborted two previous pregnancies. She confesses to limited knowledge of contraception, but listens carefully to the doctor’s description of everything from sterilisation to intra- uterine devices and injectables. It does not take much thought before she considers getting an IUD. Variations of Faiza’s story abound, especially among low-income families. Over the past 40 years, rigorous campaigning for family planning and, more recently, an emphasis on sexual and reproductive health has, drastically reduced rates of fertility, and maternal and infant mortality. But vast gaps persist in the supply of quality services, and the country, with a population of 1.2bn, is set to overtake China as the world’s most populous by 2025. Having come down from nearly six children per woman in 1960, India’s average fertility rate has stood at 2.6 for the past five years. Though this is an achievement in itself, experts say much work remains to be done to achieve the replacement rate of 2.1. “We don’t yet see the desired level of achievement, in the country’s total fertility rate,” says Vishwanath Koliwad, secretary-general of the Family Planning Association of India (FPAI). “The biggest challenges are in educating the people. Nearly 60 per cent of women are married before the age of 18 and, in many parts, there’s a preference for male children. There’s often opposition to family planning from religious leaders. All that kind of culture is difficult to change.” Some regions fare better than others, depending on female literacy, better awareness of birth-spacing methods and contraceptives, and low infant mortality. For instance, according to government data, the southern state of Kerala is close to achieving the UN’s millennium development goals: its fertility rate is 1.7, maternal mortality ratio 95 per 100,000 live births, and infant mortality 12 of 1,000 births. By contrast, Bihar in the north has 3.9 children per woman and maternal and infant mortality rates of 312 and 56 – all well above the national average. With the spectre of forced sterilisations looming large in its recent history, India adopted a rights- based approach to stabilising the size of its population – a strategy espoused by most countries after a UN conference in Cairo in 1994 emphasised sexual and reproductive health over targets-oriented population control. In Bangladesh, the rights-based approach ended up shifting focus away from a highly successful family planning programme. For the next 10 years, the country’s fertility rate would plateau at 3.0 after decades of a continuous fall brought about through door-to-door campaigning, a combination of domestic and foreign funding and political commitment “at the highest levels”, according to experts. Arthur Erken of the UN Population Fund in Bangladesh, says: “The broadened concept of a human rights- based approach is good in theory, but it created challenges, such as diverting resources and the need to integrate education and contraceptive promotion programmes.” According to the last demographic survey in Bangladesh, the desired fertility rate expressed by the public is already at 1.9, while the actual rate stands at 2.3. “This means people already understand the importance of having two children, but more resources need to be invested in getting the services to those who need it,” says Mr Erken. A similar loss of policy focus in India has limited the development of services and their distribution, especially in neglected urban areas and remote rural areas. “The government of India is now working to enhance access to contraceptives and adopting [birth] spacing methods,” says Mr Koliwad. “But even there, the lack of infrastructure and medical expertise makes service delivery a problem.” Some women, such as Faiza, manage to find legitimate healthcare. But many Indian women still end up in poorly-equipped government hospitals or worse still, in shifty “facilities” run by quacks. “I know some women in my neighbourhood who have been in my situation,” Faiza says as she tucks her hair into her headscarf at the end of the consultation. “Honestly, if more people knew about clinics like this, they would be full.” Kanupriya Kapoor It was only mid-morning but thereception area of the small hospi-tal in the Nigerian city of PortHarcourt was already packed. Those waiting for the doctor were all women; some in their teens, some who looked closer to 40. all but a few of them had a baby on their laps. Decades of high population growth have made Nigeria easily Africa’s most populous country, with more than 160m people. In 1982, the fertility rate was 6.4; 30 years on and it has dipped only slightly to 5.7. According to a forecast by the Popu- lation Reference Bureau, Nigeria will be the world’s third most populous country by 2050, with 433m people, behind India and China. The conse- quences of the continued baby boom are profound, given that more than six in 10 of Nigeria’s people already live in poverty and steady economic growth appears to be doing little to change that. The government is aware of the dif- ficulties the swelling population presents. On June 27, President Good- luck Jonathan said Nigerians should have smaller families, and backed birth control measures. But he also acknowledged it will be not be easy to change people’s attitudes because of religious and cultural beliefs. Indeed, the continued preference for large families rather than unmet demand for contraception is the main obstacle to reducing fertility rates. Figures bear this out. Fewer than 10 per cent of married women between the ages of 15 and 49 use a modern method of contraception, according to the latest Nigeria Demographic and Health Survey, conducted in 2008. The average across sub-Saharan Africa is 17 per cent. About half the women surveyed who were not using family planning services said they had no intention to do so in future. A further 27 per cent were unsure about further use. Only 24 per cent said they wanted to use contraception at a later date. Religion plays a strong role in this. The country is roughly equally split between Christianity and Islam, and influential leaders of both faiths have historically been opposed to family planning. Although views are changing, it is happening slowly, as President Jonathan acknowledged when he said that most Nigerians still see children as gifts from God and “it is not expected to reject God’s gifts”. As elsewhere in the world, urban women typically have fewer children than their rural counterparts, while the fertility rate drops as education levels rise. But there are also huge differences based on where in Nigeria the women live. In the mostly Muslim north, for example, the average mother has seven or eight children. In Jigawa state, in the far north, fewer than one in 300 women uses modern contracep- tion. Richard Boustred, country director for Marie Stopes International, says efforts by his and other organisations to promote family planning were sometimes hampered by perceptions that they were part of a conspiracy by western countries to stop Nigeria achieving its potential. The dominant social position of men, especially in the north, was another difficulty. “We encourage women to involve their husbands in family planning decisions and some say ‘there’s no way I can tell my hus- band’. So they prefer invisible meth- ods of contraception, such as injec- tions,” Mr Boustred says. In the mostly Christian and more prosperous south, the fertility rate is 4.6, with women more inclined to make decisions independently of the church. “We are seeing changes. Peo- ple are now saying ‘four children is enough, three is enough’,” says Mr Boustred. They are doing more plan- ning.” Besides religion and culture, lack of knowledge about birth control meth- ods, and myths about them – espe- cially a belief that they can damage a woman’s health – were among the main reasons given in the survey for not using contraception. Fewer than 1 per cent of respond- ents cited cost as a factor, suggesting that the government’s announcement last year of free family planning serv- ices may not have much effect, even if primary healthcare clinics are prop- erly stocked with contraceptives. Overall, the total unmet demand for family planning services is only about 20 per cent, and most of that relates to a desire to space births rather than limit them. The natural demographic growth is already straining resources in the country, with education and health systems unable to keep up. The major- ity of the millions of young people entering the Nigerian job market each year have no chance of finding formal employment. In the north, increasing poverty and lack of prospects for young people is one reason that the leaders of an Islamist insurgency have found it easy to attract recruits. “The government needs to educate the general public in the advantages of having fewer children,” says Akin Bankole, at the Guttmacher Institute, a US-based research group. Stymied by culture and faith Nigeria Xan Rice considers the reasons behind the country’s baby boom ‘The government needs to educate the public in the advantages of having fewer children’ Health care: fewer than 10 per cent of married Nigerian women between the ages of 15 and 49 use a modern method of contraception Reuters FINANCIAL TIMESMONDAY JULY 9 2012 ★ 5 FT Health: Sexual & Reproductive Health On the face of it, China’s one-child system looks like one of the most successful social policies of all time. Not only does the govern- ment credit it with reducing the number of births by 400m over the past 30 years – about 100m more than the current population of the US – but it has so thor- oughly penetrated the national psyche that mil- lions of Chinese who are permitted to bear a second child, choose not to have one. Inspired or diabolical – depending on your point of view – few can dispute the effect the policy has had on China’s population. Like all social experi- ments, it has had unfore- seen consequences: the drop in the birth rates has cre- ated an imbalance between young and old, producing an ageing crisis so serious that it could imperil eco- nomic growth. Birth limits, coupled with a traditional preference for sons, have also led to a sharply skewed gender ratio and a shortage of brides. The impact of the policy has been intensified by ris- ing wealth, since growing prosperity always depresses birth rates. In many big cit- ies, for example, young peo- ple who were themselves only children are allowed to bear two offspring – but they do not even want one child, let alone two. Shanghai, for example, is said by demographers to have the lowest birth rate in the world. Most of those who do not want children cite the high cost of child rearing – but many can- didly admit that, having grown up pampered, they simply do not want to make the sacrifice to be parents. Some are delaying child- bearing so long that China now has 50m infertile cou- ples. The one-child policy is something of a misnomer because of the many excep- tions: if both spouses are only children, they can have two offspring; rural families can have a second if the first is a girl or handi- capped; and ethnic minori- ties can have more than one. Whatever the number, population control has had an impact well beyond the size of the population: the slowdown in births has led to a big rise in the ratio of pensioners to the young workers needed to support them. According to the 2010 census, the number of peo- ple over 60 has risen to 13.3 per cent of the population compared with just over a 10 per cent a decade ago; children under 14 comprise less than one-sixth of the population, down from almost a quarter 10 years ago. In big cities the situa- tion is far more unbalanced: a fifth of Shanghai’s popula- tion is already over 60, and that figure is forecast to rise to 29 per cent by 2030. The 2010 census also showed 34m more men than women – also the indirect result of the policy. Families forced to limit their family to only one child – especially those in more traditional rural areas – often prefer their single offspring to be a boy. Girls are sometimes aborted before birth, skew- ing the sex ratio and raising the risk of social instability caused by men who cannot find wives. The gender imbalance may not be as bad as it seems. Cai Yong, a demog- rapher at the University of North Carolina, says many girls’ births were simply never registered. “School enrolment data suggest that the number of school-aged boys is not as high as the number of male births reg- istered, suggesting that a considerable number of girls are ‘hidden’ in the pop- ulation,” he says. But no one would dispute that the shortage of wives is serious even so: it has fuelled considerable cross- border trafficking of brides from south-east Asian coun- tries such as Vietnam. The impact of the policy on society is so broad and profound it has even affected seemingly unre- lated areas such as sport. China’s soccer industry suf- fers from a shortage of play- ers who engage in soccer throughout their schooling – because Chinese parents do not want to see their only child make a career in sports. Beijing has been consider- ing relaxing the policy for years – although there are still isolated cases of brutal forced late-term abortions such as one that recently went viral on the internet. But the irony is that, even if Beijing decided today to abolish the policy, there is little chance that the Chi- nese would resume having many more children – partly because they have simply become accustomed to smaller households. China has been interna- tionally reviled for the pol- icy for the past 30 years. But it still has plenty of supporters within govern- ment circles, especially at local level. It seems safe to say that they will not be declaring it a failure in the near future. Additional reporting by Shirley Chen One-child policy is a threat to growth China Skewed population ratios are leading to problems, writes Patti Waldmeir The policy is either inspired or diabolical – depending on your point of view L ike chaos theory’s butter-fly – flapping its wings inone place to cause a hur-ricane in another – politi- cal shifts in one country can shape people’s lives elsewhere. As moral positions on abortion harden in the US, the prospect of renewed restrictions on federal support for international family planning assistance is casting uncertainty over many overseas development programmes. Opposition to abortion also has an impact at home and, among some socially conservative politi- cians, is being extended into resistance to contraception serv- ices. In February 2011, the House of Representatives voted in favour of cutting funding for Planned Parenthood, a large women’s healthcare provider, and disquali- fying its affiliates from participat- ing in any federally subsidised family planning programmes. “Those policies were rebuffed by the Senate and the president, so none has taken effect,” says Susan Cohen, director of govern- ment affairs at the Guttmacher Institute, a policy group focusing on health and reproductive rights. “But [social conservatives] have made it clear they’re waging a war on family planning.” Meanwhile, US states are intro- ducing restrictions of their own. The number of reproductive-age American women living in a state hostile to abortion rights rose from 31 per cent in 2000 to 55 per cent last year, the institute says. Terminations are not the only services being affected. Five states have introduced legislation creating or expanding exemptions to contraceptive cover, it says. These include provisions exempt- ing employers who cite religious objections from having to provide contraception cover as part of an employee healthcare package. Much of the opposition to Planned Parenthood has arisen because it offers abortion serv- ices, although the organisation says this accounts for just 3 per cent of its offerings. But, Ms Cohen says: “A lot of conservative-dominated state leg- islatures and states run by con- servative governors are enacting restrictions because they have adopted a view that Planned Par- enthood is only about abortion and they don’t want anything to do with it.” While most Americans are in favour of banning use of federal funds for abortion, political resist- ance to contraception services does not appear to reflect broader public opinion. In a poll conducted in June for the National Women’s Law Centre and Planned Parenthood, almost 73 per cent of voters agreed that all women should have access to affordable birth control. Political views are also having an impact abroad. Debates centre on the so-called “global gag rule”, which restricts federal funding for non-governmental organisations (NGOs) overseas that promote or provide abortions, and on US funding for the UN Population Fund (UNFPA). The global gag rule has become something of a political football. Introduced in 1984 by Ronald Rea- gan, the restrictions were lifted when Bill Clinton took office in 1993, but then put back in place by George W. Bush in 2001. In 2009, President Barack Obama signed an executive order once again repealing the restriction rules. However, given statements this year by Mitt Romney, the Repub- lican presidential candidate, promising to cut federal funding to Planned Parenthood, many believe that if he becomes presi- dent, the global gag rule could once again be reinstated. For NGOs and donors the uncertainty creates difficulties, since the processes needed to establish a programme – includ- ing negotiating with health minis- tries and finding local organisa- tions to deliver services – eat up a great deal of time. It takes about two years to get a programme up and running once Congress has appropriated the funding, says Latanya Mapp Frett, head of Planned Parent- hood’s global programmes. “And if there’s possibility that, after investing those two years in what you hope will be a sustaina- ble programme, you’re faced with a policy that changes your direc- tion, that can be a significant challenge,” she says. Despite the uncertainty, the US remains a generous provider of funding for international family planning assistance and reproduc- tive health programmes, with $610m appropriated for the finan- cial year 2012. This, says the Guttmacher Insti- tute, will make it possible to pro- vide more than 31m women and couples with contraceptive serv- ices and supplies to prevent 9.4m unintended pregnancies and 4m induced abortions (of which 3m are unsafe). The institute says this could avert 22,000 maternal deaths, preventing 96,000 fewer children from losing their moth- ers. With 222m women lacking mod- ern family planning services, according to the UNFPA, the development community is dependent on the generosity of donor countries such as the US. For this reason, those working in women’s health and reproduc- tive rights can only hope for a more stable political approach to funding. “The challenges are maintain- ing the resources and understand- ing that development happens over decades,” says Ms Mapp Frett. “You have to be there for the long haul and [US policy changes] make that difficult.” Funds for services held back by dogma The US Sarah Murray outlines the repercussions of entrenched moral positions Politics: a protest against Mitt Romney, Republican candidate, who has promised to cut federal funding Getty Concerted action to reduce deaths from childbirth is making a difference, accord- ing to a recent report by Countdown to 2015, an initi- ative that tracks progress towards the UN Millennium Development Goals on deaths of mothers and chil- dren under five. The number of women dying because of complica- tions from pregnancy or birth has nearly halved since 1990 to 287,000 a year. While the rate of progress is still not good enough to meet the Millennium pledge, some countries, such as Nepal, Vietnam and Equatorial Guinea, have shown big reductions maternal mortality rates. The reasons behind the trend are twofold, says Joy Lawn, director of global evi- dence and policy at Save the Children, a UK charity, and a co-author of the report. “The world has really changed in the past few years. Maternal mortal- ity is falling by 4.2 per cent a year. This change is being driven by improvements in Latin America and south Asia and there are two big factors behind this: the first is falling fertility and access to family planning – in Bangladesh and Nepal for instance,” she says. “The second is care at birth, with some countries, such as Malawi and Rwanda, really upping the proportion of births attended by mid- wives.” But for many countries, meaningful progress towards cutting maternal mortality is proving elusive, despite cheap and effective therapies for complications during childbirth. Mickey Chopra, chief health officer at the UN Children’s Fund (Unicef) and co-chair of the initia- tive, says: “There are three major causes of maternal mortality in developing countries: bleeding after childbirth; infections [such as malaria or sepsis during birth]; and complications of childbirth [where the baby gets stuck and you need a caesarean section].” He adds: “There are interven- tions that are not expensive and can be delivered in low- resource settings for these: antimalarials and iron tab- lets, for instance.” There are straightforward treat- ments, too, for haemor- rhages. Experts argue that the same holds true for the care of newborn babies. “For neonatal care,” says Dr Chopra, “there are interven- tions that don’t require hos- pitals. There are effective ways of preventing hypo- thermia, and cleaning the cord, which can have a big impact on reducing deaths from infection. “There are cheap and sim- ple drugs that are not being used: for instance steroids for pre-term babies. We don’t need large budgets to have a big impact. We need to use the resources in a smarter way and target the interventions at the women who are not receiving them.” A bottleneck in improv- ing the safety of childbirth is getting enough trained midwives, medical assist- ants and health workers to keep pace with birth rates. Trained professionals can mean the difference between life and death. Cae- sarean sections, for in- stance, can be performed by trained clinicians who are not necessarily doctors. Prompt care for new- borns, who die in far greater numbers than moth- ers [nearly 2m a year either during labour or shortly thereafter] means frontline healthcare workers need to be trained in resuscitation and care of pre-term babies. What is preventing greater use of interventions that experts say are both cheap and effective? Funding plays a part, especially if there are “out- of-pocket” payments that women have to make for treatment. Another is the way health services are delivered. Immunisations and vita- min supplementation can achieve broad coverage, partly because they can be delivered via big campaigns aimed at all children in a community. But maternal and new- born care is different. It is more unpredictable, requires follow-up and may also need access to special- ised equipment, if surgery or blood transfusions are needed. Cesar Victora, professor of epidemiology at the Fed- eral University of Pelotas in Brazil and another co-au- thor, believes in the impor- tance of local care. “A hot topic in global health is whether to save child lives you can move interventions out of hospitals and health facilities and into communi- ties via community-based management.” There are many complex factors that complicate pregnancy for women in low-income countries. These include the relatively poor health state of many pregnant women, perhaps because of poor nutrition, micronutrient deficiencies, or because they are too young. Save the Children says that girls under the age of 15 are five times more likely to die in pregnancy than women in their 20s and that pregnancy and childbirth are the leading cause of death for teenage girls between 15 and 19. In addition, the shortage of health workers, the sta- tus of women and their access to family planning services, government in- vestments in health and education, all play their part in the struggle of mil- lions of women and their babies to survive childbirth. Charis Gresser is head of research at Meteos, a non- profit think-tank working on pharmaceutical and public health policy. Maternal mortality rates are in sharp decline Care The number of women dying in childbirth has halved, writes Charis Gresser 6 ★ FINANCIAL TIMESMONDAY JULY 9 2012 SEX_1 SEX_2 SEX_3 SEX_4 SEX_5 SEX_6

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