World Population Awareness

Voluntary Family Planning

NLiS Country Profile: India
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Data sources and methods

Today, any woman in Delaware can get access to the method of birth control she wants for free. Reducing access to birth control hurts women, families, and the economy. Our work is dedicated to ensuring providers offer all women - no matter where they live, their income, or their insurance status - easy, affordable access to the full range of birth control options.

Doing anything less harms us all. Population growth can be slowed, stopped and reversed, even though it has rocketed in this century and last.

A sustainable reduction in global population could happen within decades, according to the United Nations' most optimistic scenario. Its main population prediction is in the middle of that range - 9. But if there were just half-a-child less, on average, per family in the future than assumed, there woud be two billion fewer of us than expected by - and five billion fewer of us by the end of the century.

Countries have had dramatic success in reducing their birth rates. Over million women who want to avoid pregnancy are not using modern contraception. Reasons for this include lack of access, concerns about side-effects and social pressure not to use it. Most of these women live in poor countries, where population is set to rise by 3 billion by Overseas aid support for family planning is essential - making sure supplies are adequate.

People choose not to use contraception because they are influenced by assumptions, practices and pressures within their nations or communities. In some places, very large family sizes are considered desirable; sometimes the use of contraception is discouraged or forbidden.

However programs that change attitudes towards contraception and family size have been very successful. Religious barriers may also be bypassed. In Iran the country's religious leader declared the use of contraception was consistent with Islamic belief and a very successful family planning campaign was initiated.

Portugal and Italy have some of the lowest fertility rates in spite of the fact that they are predominantly Catholic. Escaping poverty is a vital way to bring birth rates down. Decreasing child mortality, improving education and providing people with economic opportunities all help to reduce fertility.

International aid, fair trade and global justice will help bring global population back to sustainable levels. Where women and girls have economic empowerment, education and freedom, they normally choose to have smaller families. Greater freedom usually leads to greater uptake of family planning and ending child marriage pushes back the age at which women have their first child, which often reduces family size. African women with no education have, on average, 5.

When family sizes are smaller, that also empowers women to gain education, take work and improve their economic opportunities. In the developed world, most of us have the power to choose the size of our families [Note: We also have a disproportionate impact on the global environment through our high level of consumption and greenhouse gas emissions - in the UK, for instance, each individual produces 70 times more carbon than someone from Niger.

Many of the rural people do not understand Swahili. This would be true in many African and Asian countries where the rural population speaks languages different from the national language. I wonder if Health surveys take that into account when they tabulate reasons women don't use contraception. It is not just a matter of 'choosing a smaller family'. It is likely a matter of having access to affordable and effective contraception.

Bangladesh has grown from 75 million people in to almost million today, more than double in 46 years. The United Nations estimated in that the population of Bangladesh would be about million in Bangladesh has a population an average population density of 1, persons per sq.

The life expectancy at birth is 71 years, with women having slightly higher lifespan than men 72 years vs. Bangladesh is now experiencing a demographic transition with the continuous decline trend of the natural growth rate.

The population growth rate in Bangladesh was 1. Bangladesh is an intermediate position between low-growth countries, such as Thailand, Sri Lanka and Myanmar and medium growth. Medium growth countries in the region are India and Malaysia. Bangladesh's Family Planning Program has had a tremendous role in slowing population growth over the last 50 years. Bangladesh's progress in the family planning movement has been cited as one of the role models to follow.

Family Planning was introduced in Bangladesh then East Pakistan in the early s through the voluntary efforts of social and medical workers. The government of Bangladesh, recognizing the urgency of its goal to achieve moderate population growth, adopted family planning as a government sector program.

Beginning in , the FP program received virtually unanimous, high-level political support. In , the government declared the rapid growth of the population as the country's number one problem and adopted multi-sectoral FP program along with National Population Policy. From extremely high levels of 6. According to the Population Reference Bureau PRB in , even if Bangladesh reached replacement level fertility, population stabilization would take another 15 years, and the growth is being fuelled by the large young population of the country.

PRB predicted the replacement level fertility by which did not take happen. The s saw a steep decline in TFR. This was followed by a decade-long plateau which was the consequence of a 'tempo effect'. The adoption of FP by Bangladeshi couples has always been after the first birth. The age at marriage did not change and there was no delay in age at first birth, and as such, no tempo effect was operating on first births.

Now, however, fertility levels are quite uneven - remarkably low in the west of the country below replacement, on average and worryingly high in the east up to 1. In order to attain any of the reasonable population estimates projected for mid-century which range from to million a substantial increase in the contraceptive prevalence rate CPR will be required in the next five years by Bangladesh has considerable built-in population momentum because of high fertility in the past, and even with reduced fertility, many young women will pass through reproductive ages over the coming decades.

During the first decade of the 21st century, the number of women of reproductive age increased from around 32 million to 41 million as the children born in the higher fertility s and early s entered their childbearing years, according to UN estimates. Investments in female primary and secondary education in Bangladesh manifest themselves in improved opportunities for formal sector employment for young women, and parents will tend to favor smaller families, investing more per child in education-quality versus quantity.

This trend will also be influenced by the saturation of the rural labour force and the fragmentation of agricultural land holdings such that there will be decreasing employment opportunities for unskilled workers. Having a huge mass in the youth age population is worrying. If they don't get the job on time or get the opportunity to have the skills for future earnings, some of the social menaces will continue, like dropping out from the schools, early marriages followed by early pregnancies.

This vicious cycle will become the hindrances of our national programs that contribute to continue fertility decline and population growth. A stagnating CPR is a cause for concern. While the government through its new plans to expand the contraceptive mix by specially promoting permanent methods, it should also think of fertility awareness based methods, such as long acting methods LAM , which mimic traditional methods and may be more acceptable to users of traditional methods.

To increase levels of unmet need, 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 for family planning services and supplies.

Bangladesh has a high adolescent fertility rate, one of the highest amongst the south-east Asia region 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 the government plans to make special efforts to reach out to adolescents with family planning messages and individual and community level counseling services.

One of the main reasons that fertility rates stalled at around 3. A woman who has a high school education will have two fewer children than her non-educated peers. Long-term contraceptives or the pill can also make periods irregular or stop them all together which can mask the symptoms of pregnancy. This could be why women are having late-term abortions past 20 weeks because they were using long-term methods so didn't take notice of pregnancy symptoms. As policymakers, donors, and advocates gather for the Family Planning Summit in London, new data released by Marie Stopes International reveals the 1.

If all of the 69 FP focus countries provided contraception to every woman who wants it by , as agreed under the UN's Global Goals for Sustainable Development SDGs , family planning would prevent:. Marjorie Newman-Williams, vice-president and director of international operations at Marie Stopes International said:. Without access to contraception, women are likely to have more children than they want or can care for.

Frequent births in quick succession imperils a woman's health, stresses her family's well-being and future prospects, and overwhelms countries' social and economic resources.

Over the last five years, the world has made impressive progress in expanding access to modern contraception. Despite population increases, for the first time in history, unmet need for contraception has fallen, with a record million women and girls across 69 of the world's poorest countries now using modern contraceptives. But huge numbers of women are still missing out, particularly the young, people in humanitarian crises and women in the most remote places on earth.

Laos, Nepal and Myanmar have the next-to lowest number of contraceptive users in Asia. Growth in the number of contraceptive users is projected to be specifically high for south Asia.

Bhutan is similar, so it is amazing that its contraceptive prevalance is so high. I was also surprised that Myanmar had such a low ranking in view of its fertility rate of 2. Fertilty rates for these Asian countries in order of fertility rate are: Bill Ryerson, founding Director of the Population Media Center, has been gathering Demographic and Health Surveys on the reasons people in high-birthrate nations give for not using available Family Planning FP services.

Some of the DHS surveys include women who would like to become pregnant, so the surveys taken in some nations show "desire for pregnancy. The surveys estimated that million women in the surveyed regions had an "unmet need" for FP services. They defined unmet need as not wanting to be pregnant in the next two years, but not using any modern method of contraception. In most countries the most common reasons for not using contraception given by married women in this category were: Referring to a article published by several demographers concerning the studies, Mr.

Ryerson quotes two excerpts stating reasons for non-use:. Cost was not a frequently cited obstacle to use among married women with an unmet need: A substantial proportion of these married women were sexually active within the three months preceding the survey, including about half of women with an unmet need in Latin American and Caribbean countries. A June paper by two of the authors of the paper essentially came to the same conclusions.

There is still need for expanded FP services, especially if the informational and cultural barriers to use of FP methods can be overcome. Today the reasons for non-use are quite different from those given in The mission of the Population Media Center PMC is to use entertainment-education and mass media to promote social and cultural change. PMC sponsors dramatized communication campaigns that, without telling people what to do, provide attractive role modeling.

PMC's soap opera-type programs focus largely on women's rights, including education for girls, and communication between husbands and wives about the future of their families - promoting more awareness that smaller families lead to better health and greater prosperity.

It may be that the pastoral peoples in remote areas were not included in the survey. PMC serves people who have access to radio. The people in the Maasai Harmonial project area do not have access to radio. In addition, the pastoral Maasai culture is very different from the culture of the people who live in the areas where radio is available. The majority of the Maasai do not speak the national language of Swahili or English, so they would not benefit from a radio program produced in Swahili.

PMC has done wonderful things, but it must be recognized that a large part of population growth in Africa comes from hard-to-reach rural areas where a large variety of languages are spoken. Oregon and Washington may follow suit. The US average is similar: Global health experts call unintended pregnancy an epidemic because it's so common, and the toll on physical health, mental health, and child development so large.

Reducing unsought pregnancies results in: After implementation of the Colorado Family Planning Initiative, teen births and abortions dropped by nearly half. High-risk births, including preterm births, also diminished. Unsought pregnancy is four times as common and unsought birth seven times as common among poor women as among their more prosperous peers, so poor families benefited the most.

In Colorado, much of the improvement came from switching away from error-prone family planning methods that require action every day or every time they have sex -- such as pills and condoms-- to long-acting IUDs and implants that make pregnancy prevention easy. These methods are "get it and forget it.

When a woman wants to get pregnant, her healthcare provider can remove the implant or IUD, usually in a five-minute procedure, and normal fertility returns almost immediately. Louis a study of 9, women called the Contraceptive Choice Project demonstrated that long-acting contraceptives dramatically reduce unplanned births and abortions. It also showed that most women prefer these technologies when high cost and other barriers are removed.

The US Centers for Disease Control and Prevention CDC and the American Congress of Obstetricians and Gynecologists have declared these methods far more effective and safer than any other method and far safer than the risks from pregnancy itself.

One of these methods, the hormonal IUD, has bonus health benefits, including protection against some cancers. Women were able to access services wherever they might encounter the healthcare system.

All sorts of health care workers were trained in improved counseling and to insert and remove implants and IUDs. More flexible hours at these health centers improved access for working women. CFPI integrated family planning into primary care, labor and delivery, and post-abortion care. CFPI funding made all methods available with no co-pay, a standard that later would be incorporated into Obamacare now on the chopping block, of course.

Implants and IUDs are cheaper in the long run than other forms of birth control, especially if you include the costs associated with an unplanned pregnancy. But until recently, the up-front price of long acting contraceptives has made these methods unavailable to many women. CFPI worked to normalize conversations about sexual health and promote healthy decisions and planning. Young Latinas, who have a higher-than-average teen pregnancy rate, talked with each other in culturally proficient after-school programs.

Social service agencies offered sexuality workshops or provided onsite access to educators. A website, BeforePlay, offered practical information about contraception and sexual health, as well as specific resources available across the state.

Reimbursement policies were changed so that women could get an IUD or implant of their choice immediately postpartum in hospitals. Oregon Governor Kate Brown recently affirmed that she and the Oregon Health Authority "place a high priority on improving women's health and reducing unintended pregnancies by implementing pregnancy intention screenings and providing effective contraceptives to women who do not wish to become pregnant.

The Oregon Foundation for Reproductive Health has developed a technique -- now a national model -- that makes it easier for primary care, chronic care, and mental health providers to open up conversations about family planning.

It is called One Key Question, and the question is: Would you like to get pregnant in the next year? If a woman says yes, this leads to a conversation about preparing for a healthy pregnancy, called "preconception care".

If she says no, she has an opportunity to explore contraceptive options, including top-tier methods that might not be familiar. A new Oregon law allows retail pharmacists to prescribe oral contraceptives or patches. A second law, the first in the nation, requires insurers to cover a month supply of birth control at a single prescription fill.

Oregon also has a mandate for comprehensive sexual health education in public schools and expansion of family planning coverage through Medicaid. Despite promising trends, the US teen pregnancy rate is far higher than any of the other 34 countries in the Organization for Economic Cooperation and Development.

National funding cuts could make things worse: But there will be opportunities to increase intentional parenthood through practice improvements and better public awareness.

Oregon's One Key Question could make the state a national leader in healthcare integration. This will mean incorporating routine pregnancy-intentions screening into primary care, labor and delivery, chronic care, mental health, and drug treatment programs. Public officials in the state of Washington have paid close attention to the models in St.

Louis, Colorado, and Delaware. Washington Governor Jay Inslee's office has voiced support for upgrading contraceptive care statewide.

When Planned Parenthood showed that low reimbursement for IUD insertions had become an obstacle for clinics serving poor women, the state changed reimbursement rates. School-based clinics in Seattle now offer the full-range of birth control options to high school students, and Neighborcare Health, which runs several of these clinics, employs educators who help teens and their parents explore options.

In , King County Public Health secured a small grant to train and provide technical assistance to school-based health centers so they could offer IUDs and implants on-site, with follow-up support from Public Health. Three of these health centers hired half-time sexual health educators, who taught in biology and health classes, and provided contraceptive counseling to teens and their parents.

One Washington State imperative addresses the epidemic of opioid addiction. Neonatal care units are overflowing with newborns suffering from Neonatal Abstinence Syndrome, a form of withdrawal. With long-acting methods offering years of protection and with each person in charge of his or her own fertility, children will come into the world by the mutual consent of two people who want to create a child together.

But even if Planned Parenthood is spared, Trump's proposed rollback in Medicaid and contraceptive coverage will inevitably increase unintended pregnancies and the demand for abortion services. The AHCA, on the other hand, by making contraception more expensive and less accessible, would roll back some or all of those gains.

In addition Congress may also eliminate funding for comprehensive sex education in schools. The House of Representatives has been trying to do just that for the past four years, and this year it may be able to override Senate opposition.

Humanitarian programs, including international family planning, could face draconian cuts. USAID's family planning program helps parents better feed, educate and care for their children. US-supported family planning programs are slowing rapid population growth in some of the least stable countries in the world, including Afghanistan, Democratic Republic of Congo, Ethiopia, Mali, Nigeria, Pakistan, South Sudan and Yemen.

Cutting international programs to pay for increased defense spending will undermine US security and likely increase the demands on the Defense Department. Defense Secretary James Mattis once declared: Two years after Texas slashed its support for family planning by two-thirds in , Medicaid expenditures soared because of the increase in unplanned pregnancies.

While the state was forced to do an about-face and re-fund family planning, it persisted in its attacks on Planned Parenthood, forcing dozens of clinics to close, leaving many women in Texas without access to family planning services.

Unless Congress stands down on cutting contraceptive services, it will find itself in the perverse position of driving up teen pregnancy rates and Medicaid costs.

In most states, hormonal contraception requires a prescription. Getting that prescription takes time and money for doctor visits that some women just don't have. Oral contraceptive pills are well-studied, and The American College of Obstetricians and Gynecologists, the American Medical Association, and the American Academy of Family Physicians agree that they are safe for over-the-counter use.

The idea even has bipartisan support in Congress, except on issues like whether insurance companies should have to pay the bills. The next step was to find a pharmaceutical company willing to go through the long and costly process of seeking FDA approval.

That too has now been done. HRA Pharma in Paris is partnering with advocates and experts from Ibis Reproductive Health to start the process, which may take several years to complete.

There are two major types of oral contraceptives, progestin-only and pills that contain both progestin and estrogen. Ibis and HRA plan to seek FDA approval for a progestin-only pill similar to others already approved for emergency contraception. Progestin-only pills present the fewest barriers for the broadest population, Ibis president Kelly Blanchard said. Both types of pills are equally effective, but combined pills with estrogen can cause potential problems for women who smoke or have high blood pressure.

Blanchard said that after the first OTC pill is approved, it shouldn't be difficult to get other forms of birth control approved, too. That would allow women more than one over-the-counter option, since not every pill or every birth control method is right for every woman. Not making women pay extra on top of their insurance premiums makes birth control much more accessible. But repeal of the ACA may eliminate that benefit. Republicans proposed legislation in to speed up the FDA's over-the-counter approval process for contraception - but Democrats and women's health advocates called that bill a ploy to undermine the ACA while only appearing to support birth control and women's health.

That bill would also have imposed an and-over age restriction, which Blanchard says is completely unnecessary. As for whether Trump's appointees could cause political problems for approving over-the-counter contraception, Blanchard said she hopes that the FDA "will follow their process and judge it on its merits.

And we think the merits are strong. For at least a decade the national trend has been to put off having kids and have fewer of them. But in California, the lingering recession of the late s and high real estate prices have created obstacles for young couples looking to have kids.

While California's population grew to According to the state Department of Finance, between July 1, , and June 30, Californians had just The lowest birth rates occurred in California's small northern counties, where jobs for young families are scarce.

But coastal spots, including the booming bay area and the central coast had affordability problems. Though the state figures don't specify ethnicity, U. Even among the Hispanic population, among the nation's fastest growing, birthrates have been falling since The rate of population growth has declined along with the birthrates. People continue coming, but since the late s migration to California has been relatively low. Between July of and July of , the state gained , people through migration from another country.

But it lost , people due to migration between states. In all, about 70, more people arrived than left. Schwarm said that even if the state's fastest growth is in the past, California has plenty to lure the best and brightest. This video features key experts in the family planning field, including Melinda Gates, Ellen Starbird, Anju Malhotra, Latif Dramani, and Jason Bremner, making the case for investing in family planning in urban areas and explaining how this can impact the environment and economy of countries, as well as add to women's empowerment.

The Zika virus outbreak in Brazil had some world class female athletes considered staying home from the Summer Olympics to avoid the disease that can cause profound birth defects in children of infected women.

But what of the millions of Brazilian women of childbearing age, especially those in the poor and overcrowded neighborhoods, who were adviced by health experts: Unfortunately for women in Brazil and many other developing nations, birth control can be hard to obtain. And research shows that millions of people around the world want more access to family planning. Unplanned pregnancies can create severe economic hardships that perpetuate poverty, and they result in millions of abortions every year, many of them performed under unsafe conditions by untrained people.

Having one baby after another often causes complications and even death. Inadequate pre-natal care and unsafe births and abortions are among the biggest killers of women globally. For women to exercise the right to decide when to get pregnant, they need access to contraception and information about family planning. About million women worldwide who are either married or in a partnered relationships want to delay or stop having children, but aren't using contraception.

A bigger obstacle is the lack of knowledge, particularly in developing nations, about family planning. Many women fear the potential side effects of contraceptives. They may not understand the risks that come with pregnancy and how to minimize them.

They be worried about reactions from husbands or families, or religious leaders. Education and counseling go a long way toward overcoming these obstacles.

For many women, the first opportunity to learn about family planning comes during a visit to a clinic to have a baby, an abortion or treatment for a miscarriage. It's essential to seize that opportunity and present information on how to delay or prevent another pregnancy to any woman who wants it.

Women who become pregnant less than five months after giving birth are 2. Of the million women worldwide who become pregnant each year, nearly 80 million do not intend to.

About half of those unintended pregnancies end in abortion. Many of those abortions are performed under unsafe conditions, contributing to the deaths of nearly 67, women each year. Modern contraceptives could reduce unplanned births in developing countries by 22 million and maternal deaths by 90, each year, sccording to the Guttmacher Institute. Family planning also reduces gender inequality, enables girls and women to stay in school and find better employment.

Better educated girls and women are better equipped to understand and make their own life choices and less dependent on their families and husbands. Children from planned families often benefit from greater parental attention, nutrition and other resources, helping them grow and develop into more productive adults with a better chance of breaking the cycle of poverty. Their communities, in turn, have reduced need for social services, allowing them to spend scarce resources on more productive development programs.

Melinda Gates' mission has been to provide poor women in developing countries with access to contraception. Since , she has helped lead an international campaign to get birth control to million more women by A recent report tells that goal is proving tougher than expected. Allowing a woman to have a contraceptive tool with which she can space births unlocks the cycle of poverty for her. While Melinda Gates was talking to women about vaccines for their children, the women would ask about contraception.

Statistics showed that contraception prevented tens of millions of unsafe abortions by preventing unwanted pregnancies. Melinda Gates is a Roman Catholic, and her Church doesn't believe in these forms of modern contraceptives. But she saw, while touring the slums,townships, and rural areas that women and children were suffering needless deaths because they literally didn't have contraception like what we use in the United States.

The moral imperative is that we give these women what we believe in and actually use. She found that there is resistance among the leaders of countries who are overwhelmingly men and often don't want to give up control of a woman's fertility. Even in the United States, some men want to take control of women's health.

We can't do the top-down planning that happened in the world in the s, where we told women what to do.

It was about population control, it was about coercion. Long-acting contraception such as IUDs and implants which are changing the face of family planning in the United States, particularly for poor women, didn't seem to be making it into developing countries because the funding had stagnated.

So the partners, the philanthropists, have been investing in long-acting tools. There is now an injectable that's a tiny, little blister pack with a tiny, little needle, sort of like you'd give yourself a diabetes drug. We're working on a formulation that could go in a health community care worker's kit. When she goes out into these villages, she can give it to women. A woman doesn't have to go to a clinic and get it from a nurse or a doctor.

And eventually, a woman could give it to herself. So you could give her a two-year supply, and she can just take it home and administer to herself every three months. This tiny, little injectable is very near-term.

That's happening now and will continue to roll out over the next three to five years. Buffett, who has has made a huge commitment to the Gates Foundation, is also very excited about this. If you can get contraception to million women you will see the cycle of poverty broken. Look at what contraception did in the United States to women going into the work force.

All over Africa, young girls getting pregnant early when they don't want to, keeps them out of school. So you'd keep more girls in school, and then you'd have educated girls who would go into the work force. When a girl or woman has economic means in her own hands, it shifts the whole power dynamic in the family, whether it's with her mother-in-law or her husband.

It's the beginning thing that unlocks a woman's potential. Sierra Leone, one of the world's poorest nations, has the highest maternal mortality. But change is on the way. Two arm bandages may not look all that cool, but young girls in this rural clinic display them proudly.

They want to postpone having children so they can finish their studies and start a career, and the bandages are the only sign of the contraceptive implant they have queued up to get.

Raised in the UK, I learned in school about sexual and reproductive health in a non-judgmental way. This empowered me as a teenager to make good choices. I could access contraception when I needed it, knowing that I had exactly the same right as boys to study and work in the way I wanted. Many young girls don't have those options.

Faced with early marriage and pregnancy, they are first to drop out of school. Nearly one in five adolescent girls in low or middle-income nations gets pregnant by age For over 40 years, from Bangladesh to Zambia, MSI has been helping nations expand their sexual and reproductive health services.

Contraception has become more available and, in some countries at least, legal restrictions to safe abortion have started to ease. Today six out of ten married women in the developing world use contraception, up from around one in ten in This has helped contribute to a much lower percentage of women who die in pregnancy. From the girls in Sierra Leone excited about their future, to a woman in Zimbabwe who had walked for five hours to have an IUD fitted, and a mother of four in Bolivia whose baby I held as she had a tubal ligation, women and girls have told me how proud they feel about taking more control over their own lives.

Although they had made different choices at different life stages in different countries, they all felt empowered by their choices. MSI has been taking contraceptive services to where women need them.

Since opening our first clinic in London in , we have expanded to serve 37 nations. From training private healthcare providers, to caring for some of the world's most under-served people, and being first to pilot outreach for family planning, we have pioneered ways to reach women and girls and help remove the policy and clinical barriers that prevent them from accessing services.

This year we helped secure ten policy changes including: Family Planning FP recently reported that million women and girls now using modern contraception in the world's 69 poorest countries. This is 30 million more women and girls than in This milestone has taken the health and development sectors decades to reach.

The Summit called for global political commitments and resources to enable million more women and girls to use contraceptives by In West Africa, where contraceptive use has been historically low, the Ouagadougou Partnership has surpassed its goal of reaching 1 million additional women and girls with modern contraception from to , and is now aiming to reach 2. Unfortunately, the FP goal is short by some 19 million women and girls due to a sizable financing gap.

The problem is how to ensure that enough contraceptives supplies are available for the unprecedented numbers of women and girls who need them. This is largely due to currency fluctuations and the appreciation of the US dollar. The government of Germany, International Planned Parenthood Federation, Intrahealth International, and FHI renewed their commitments this year, pledging to build on the contributions they have already made and go even further.

In , modern contraceptive use in the target area averted an estimated 82 million unintended pregnancies, 25 million unsafe abortions, and , maternal deaths. Access for women and girls to voluntary contraception will have ripple effects for families, communities and countries, and will help determine if countries are able to achieve the United Nations Sustainable Development Goals SDGs for health, human rights, prosperity, and the environment.

Every woman has the right to determine the size of her family. For any leader to say differently can push back the country's progress on many fronts. These fronts include India's goal for population stabilisation, FP - an international partnership of more than 20 governments on family planning, and the UN's Sustainable Development Goals commitments. Andhra Pradesh has shown a significant reduction in population growth, due to the fact that the desired fertility rate for the state is 1.

It is no longer a matter of numbers. It is an issue of respecting rights and choices and treating women with dignity. Family planning advances sexual and reproductive health, saves lives and empowers communities, especially women. More than , maternal deaths per year have been averted globally by family planning and children's health and economic outcomes of families have been positively affected. Reproductive choice is a fundamental human right - it frees women from incessant cycles of pregnancy, breastfeeding and childcare.

Family planning and its voluntary use represent a giant step towards gender equality. The post world is moving away from the narrow prism of targets and numbers to enhance sustainability. The rights-based approach to family planning provides an overall framework and set of universal values including, equality, non-discrimination, participation and accountability, on which to base contraceptive service provision and delivery.

FP's implementation is in alignment with the principles of the International Conference on Population and Development Program of Action held in Cairo in ICPD abandoned demographically driven population policies, asserting that people mattered more than numbers.

Population is not just about counting people, but about making sure every person counts irrespective of the wealth quintile they represent. The state's emphasis within the Family Planning Program needs to move towards a choice and access to spacing methods as opposed to primarily terminal methods. Family welfare is a mutually shared responsibility where there is an imminent need for parliamentarians, policy makers, civil society organizations, the media and other stakeholders to work together towards the pursuit of a common vision.

To get away from numbers is to get away from targets, which are distractions from the need to address unintended pregnancies and rights-based health and education. More articles like this one are needed. Next month marks the halfway stage of the Family Planning initiative, an attempt to get million more women and girls in 69 countries using contraception.

The initiative was launched at a London conference in According to the UN's population fund, there are twice that number who would like to be able to avoid getting pregnant if they could.

But cost, availability and lack of knowledge as well as, in some countries, cultural taboos and social pressures that make pregnancy even for young teenagers a desirable objective, all contribute to making it impossible. Breaking down the barriers that stop women and girls having the right to choose should be at the heart of every development project. Unfortunately, the debate around immigration has damaged the campaign.

In among a legitimate airing of anxieties about overstretched public services, crowded GP surgeries and full entry classes at primary school, problems whose causes lie at least as much in austerity as in migration, there has been a crude and distasteful attempt to undermine a compassionate response to the global humanitarian crisis and depict migrants as a threat.

The same people who do this also criticize the British commitment to spending 0. This is money would promote security and help economies to grow, building the essential foundations of global justice. Without it, life will remain so bleak and hopeless for hundreds of thousands of people that they will flee elsewhere. Some - often the better off or the better educated - take the terrible risk of getting into a small boat to cross the Mediterranean to try to reach Europe.

In addition to war, climate change and corruption, population pressures are also part or the reason behind unprecedented movement of people around the globe, and also 65 million displaced people. Giving women and girls the power to choose for themselves when they get pregnant is not only a fundamental human right, but a big part of the solution. The family planning part of women's health often feels like the poor relation in development. The plan was to preventing hundreds of thousands of unwanted pregnancies and thousands of deaths.

But the department's main focus in women's health tends to be on eradicating female genital mutilation and ending child marriage - important, of course, but only a small part of a much bigger story.

Refugee camps are among the least safe places in the world for girls and young women. An unwanted pregnancy is one more nightmare for a displaced woman; campaigners argue that contraception and access to safe abortion should be treated with the same urgency as water, food and shelter.

In many countries and many societies the status of women allows men to feel entitled to deny them control of their own fertility. The size of the task of breaking down the barriers that stop it being a universal right is daunting. But for women and girls everywhere, it must become a development priority.

The article downplays the importance of ending child marriage and eradicating female genital mutilation, yet one third of girls in the developing world are married before the age of 18 and 1 in 9 are married before the age of Delaying marriage of these girls could not only prevent 2 or 3 pregnancies per each girl, but allow that girl to go to school and have a more empowered future.

Eradicating FMG is part of the empowerment. Masai women at Embulbul village are asking for family planning. The Masai's other requests for development help included: Masai Harmonial Development and Sustainability: She also serves as Vice President of the Population Program at Venture Strategies for Health and Development, a California-based non-profit organization, where she oversees the "Rebirth of Population Awareness" initiative.

And she is a research fellow for Project Drawdown, analyzing the potential contribution of family planning for reducing greenhouse gas emissions. Climate change presents an existential threat to our species.

There is no doubt left about that. Activists around the world are grappling with the issue in many ways - by protesting coal powered plants and blocking oil tankers, promoting renewable energy like solar and wind, or even changing ones own lifestyle with growing one's own food and adopting plant based diets.

But, my guest has another idea altogether. She calls it "green sex" for the sake of the climate. During the same time period, there was an increase in contraceptive, likely from expanded access to birth control, which is supported by the Affordable Care Act. More women have been able to delay or prevent pregnancy and build the families they want as a result of improved access to contraception, say the authors of the study.

However, women living in poverty in were five times more likely to experience an unintended pregnancy than higher-income women. Black and Hispanic women were roughly 2. And even when income was taken into account, Black women had higher rates of unintended pregnancy than both white and Hispanic women. Under the ACA, most private health plans are required to cover contraception without a co-pay, as Medicaid has done for years. But, in order to see progress for women of color, we must overcome social and systemic inequity that contributes to varying levels of health-care access, contraceptive use, and unintended pregnancy.

Lawrence Finer, director of domestic research at the Guttmacher Institute, stated, "These disparities Systemic change will require targeted efforts to expand Medicaid, improve health-care access and quality, and close racial disparities in income and wealth. Women of color, particularly low-income Black and Latina women, are still more likely to be uninsured, which may be attributed to lower incomes and lack of access to employer-sponsored health insurance.

Also, most of the 17 states that have refused to expand Medicaid have a higher percentage of residents of color. Some women may be unable to afford the birth control of their choice or access the most reliable methods.

Highly effective methods like the intrauterine device and implant are more expensive up front than other methods, and women without consistent access to birth control may rely on condoms, withdrawal, or emergency contraceptive pills, which are not as dependable. There is a Medicaid coverage gap for some childless adults that needs to be closed: In the past, women of color have been used as test subjects and mistreated by the medical establishment.

And even today, when some women of color seek care, they are met with insensitivity, disrespect, and neglect from health-care workers. The disproportionate rates of unintended pregnancy among women of color, who are already more likely to live in poverty, may contribute to lower educational attainment and higher economic insecurity. Delaying, spacing, or avoiding pregnancy helps women to achieve their educational and career goals.

When women of color lack health care and don't earn enough to make ends meet, they often find themselves choosing between things like paying the bills to keep the lights on or paying for birth control. Most of the growth will be in the least developed regions of south and west Asia including in India and Pakistan , and Africa. The largest increase is projected in sub-Saharan Africa with a quadrupling of population - from just under a 1 billion today to 3.

Rapid population growth, with attendant consumption and waste, has pervasive adverse effects on societies and the world's ecosystems. Countries with lower population growth, such as the east Asian 'tiger' economies, including South Korea and Taiwan, have seen rapid increases in per capita incomes as birth rates declined. Programs to provide voluntary family planning education and services, along with investments to improve education and health, have been the main policy response to rapid population growth since the'60s.

These programs address the substantial level of unwanted and unplanned pregnancy, as well as an unsatisfied demand for contraception.

About 74 million unplanned pregnancies occur each year in the developing world. About half of these end in induced abortions. Low levels of female education, lack of knowledge about and access to contraception, insufficient supplies and services and cost and fear of side effects are the main reasons for unwanted and unplanned pregnancies.

Additional reasons are opposition from spouses and family and traditional gender roles that support a desire for large families. Family planning programs must go beyond simply providing supplies and services; they must also reduce or eliminate these obstacles. Evidence that such programs work comes from field experiments, such as the one the Matlab region of Bangladesh that began in' People in the Matlab experimental area were provided with free services and supplies, home visits by well-trained female family-planning workers, and comprehensive media communication.

Outreach to husbands, village leaders and religious leaders addressed potential social and familial objections. Among the long-term consequences of this reduction in births were that the children in the experimental area being educated to higher levels, families having greater household assets, and the greater use of preventive health services. Similarly, other countries that have suddenly implemented comprehensive family-planning programs such as Iran in'89 and Rwanda in the mids have seen rapid subsequent changes in reproductive behavior.

Iran's fertility declined from 5. In Rwanda, fertility dropped from 6. Both countries' information programs shifted norms by including messages about the benefits of smaller families, raising the demand for family-planning services. With major investments in family planning, the fertility trajectory could easily be reduced by 0. This would lead to a population of 2. That is around 1 billion fewer people than the current projection.

Education of girls is a powerful brake on fertility. Educated women marry later, tend to want smaller families and are more capable of overcoming obstacles to their use of family planning. A normally nourished individual placed on a diet that is deficient in iron undergoes first a loss or depletion of body stores. There is increasing evidence that stored iron may have a role in human susceptibility to, and morbidity from, infections.

Anaemia, together with malnutrition, is among the major causes of childhood morbidity and mortality in many developing countries. When anaemia occurs in infancy or childhood it is associated with significant loss of cognitive abilities as well as decreased physical activity and reduced resistance to disease. Providing iron supplements to schoolchildren with iron deficiency results in improvement in selective learning and school achievement tests.

Iron supplementation can also improve appetite in undernourished children and thus speed up their rate of recovery from malnutrition and their subsequent physical growth. Iron deficiency in women of child-bearing age increases the hazards associated with complications of pregnancy, premature birth and low birth weight and causes infants to enter life with sub-optimal iron reserves.

Frequent pregnancies often compound this problem and result in further deterioration in the health and nutrition status of the mother and her subsequent children.

The assessment of the prevalence of anaemia in a community is often based on surveys of women and children, as these are the groups most at risk. Figure 32 shows the prevalence of anaemia in pregnant women, assessed on a global basis. It is estimated that 60 percent of pregnant women and 45 percent of non-pregnant women in developing countries are anaemic Figure The symptoms of anaemia vary significantly and can be caused by conditions other than iron deficiency. The most practical form of assessment is therefore based on the determination of the blood haemoglobin level.

Table 54 shows the haemoglobin levels generally accepted to indicate anaemia in different members of the family. Haemoglobin levels rarely exceed 16 g per ml.

Blood tests are normally taken at health clinics and are carried out routinely for pregnant women. Children may be tested at school during special surveys or as an initial action before the definition of a treatment and control programme for a number of nutritional disorders.

Analysis of the causes of anaemia may involve dietary surveys to establish the level and type of iron intake from the diet, together with analysis of the health situation to determine the causes of loss of iron or of poor assimilation from the diet.

The analysis may also include a study of the social and environmental situation, including the educational and income levels of the population and the local sanitation conditions such as availability of clean water and use of latrine facilities. On the basis of this analysis, and within the constraints of the programme's financial resources, a number of actions may be proposed. Whenever possible, the target community should be involved at all stages of the assessment and analysis of the community's nutritional situation.

The final choice of priorities in the actions to be taken should also rest with the community, under guidance from the programme staff and from local organizations. Selecting interventions for control and prevention of iron deficiency anaemia. One of the primary strategies available for intervention is nutrition and health education to improve dietary intake of foods rich in iron, folate and vitamin C and to reduce the consumption of interfering substances.

In a nutrition education programme, topics that should be covered in relation to the prevention of iron deficiency anaemia in young children include support for breastfeeding and home preparation of suitable weaning foods. Other supporting interventions include supplementation, which is the provision of medicinal iron to the individual, and fortification, which is the addition of the micronutrient, in this case iron, to a suitable food see Box In areas where parasitic diseases and malaria are major contributors to anaemia, their control will form an important part of the overall strategy.

Where hookworm infections are prevalent, regular, periodic deworming will help reduce iron losses. Depending on the extent of the problem, a medical supplementation programme may be appropriate. However, large-scale supplementation requires an adequate support and delivery programme, which is often expensive.

A supplementation programme may be possible for a limited period under project financing, but for sustainability it must be incorporated into an effective community health care system. Otherwise, it risks collapse when project funds are withdrawn. A further challenge involves ensuring that the medication is taken for the four to five months of treatment that are often prescribed. Improving dietary intake is a more long-term approach and is the preferred and more sustainable strategy.

The production and consumption of food plants rich in iron and folic acid, particularly green leafy vegetables, together with fruits rich in vitamin C to enhance iron absorption, should be promoted. Production and consumption of animal and dairy products should also be encouraged whenever possible.

Poor diets result more often from poverty than from ignorance, however, and the ultimate solution lies in economic and social measures that can ensure a more equitable distribution of resources, including food. Box 62 - Considerations in the selection of an intervention programme for the control of iron deficiency anaemia. Usually medicinal supplements to at-risk groups such as pregnant and lactating women, children or occasionally labourers. A suitable food and a suitable nutrient preparation must be found.

More difficult with iron than with some other nutrients. Treatment of those infected with hookworms, with Schistosoma haematobium, S. Interventions to improve economic status and levels of living. In the medium-term perspective, the most cost-effective intervention for the alleviation of iron deficiency anaemia in urban and rural areas is food fortification.

This strategy requires identification of a suitable food, which should already be in use by the majority of the target groups on a regular basis. For example, iron-fortified salt has been used in India. A major advantage is that no special distribution system is necessary, as distribution is provided through the existing food markets for the selected commodity. Box 63 provides a brief review of the national programme for the control of nutritional anaemia in the United Republic of Tanzania.

The nature and causes of IDD, including endemic goitre and cretinism, have been examined from a dietary viewpoint in Chapter 7. The cause of these disorders, and potential methods for their control and elimination, have been known for many decades.

Nonetheless goitre, often accompanied by crippling endemic cretinism in the community, still affects millions of people throughout the world. The characteristics of hypothyroidism are described in Chapter 7. The immediate cause of IDD is a deficiency of iodine in the diet. The underlying cause is a deficiency of iodine in the local soil on which vegetation grows, animals graze and crops are cultivated, which results in a shortage of iodine in local foodstuffs.

The effects of iodine deficiency are most seriously manifest during pregnancy and parturition. Iodine deficiency disorders also have economic and social consequences for development see Box The severity of IDD is classified on the basis of the prevalence of goitre and the mean level of urinary iodine in the test population.

Box 63 - Causes and control of nutritional anaemia in the United Republic of Tanzania. The cause of iron deficiency anaemia in Tanzania has been found to be a combination of low dietary intake; low big-availability due to the plant origin of the iron; poor absorption due to the presence of inhibitors such as phytates, tannins and caffeine; and increased losses due to the presence of blood-depleting parasites like hookworm. Folic acid deficiency is mainly due to the increased requirements during pregnancy which are not balanced by adequate dietary intake, and the high prevalence of malaria.

The programme for the prevention and control of nutritional anaemia in Tanzania has a national coverage but is targeted mainly to pregnant women and children under five years of age.

The programme aims at addressing the major causes of anaemia in a fashion which ensures sustainability. The dietary approach aims at iron and folic acid deficiency anaemia IFADA and consists of the promotion of the production and consumption of iron and folic acid rich foods, particularly green leafy vegetables and vitamin C rich foods like fruits which enhance iron absorption.

Animal and dairy products are also encouraged whenever possible. A pharmaceutical approach through the supplementation of iron folate tablets targeted to the most vulnerable group, pregnant women, through the Essential Drug Programme EDP and the Maternal and Child Health MCH system has also been implemented for a number of years. General public health measures aimed at the strengthening of control measures against malaria, schistosomiasis and intestinal parasites like hookworm form an important component of the programme.

The integration of these measures with the vitamin A programme and in particular with other existing health and nutrition programmes, coupled with adequate research, information, communication and education and management information systems, ensures community participation and programme sustainability. In many areas of the world, particularly in Africa, iodine deficiency occurs but has not yet been fully recognized.

According to recently revised estimates of the Micronutrient Deficiency Information System MDIS , about 1 million people globally are at risk of iodine deficiency: In Africa alone, 86 million people Figure 34 indicates the estimated national status of IDD prevalence for countries in continental Africa. Box 64 - Why combating iodine deficiency disorders is important. They grow more slowly and reproduce less. It is more difficult to motivate them. Severely disabled children who survive can be a burden on their families and communities.

Less disabled people, if they are physically strong, may be able to do simple manual tasks. In Tanzania, an estimated 6. Pregnant and lactating women have the highest incidence of IDD, 52 percent, and children under five years of age have the lowest incidence, l 3 percent. In an Ethiopian study, the overall prevalence of goitre in seven provinces of Shoa Region was found to be The treatment and prevention of IDD depend on increasing the intake of iodine in the affected population, either by medicinal supplementation or by fortification of a component of the diet.

Iodization of salt has greatly reduced the prevalence of goitre in Argentina, Colombia, Mexico and Guatemala, but this approach may not always be easy to implement. Tanzania chose to use a targeted distribution of iodinated oil capsules as a short-term measure. The results and costs of that programme are given in Box Table 45 in Chapter 7 shows the daily needs for iodine.

Table 55 - Prevalence of goitre, xerophthalmia Bitot's spots and anaemia in seven provinces of Shoa Region, Ethiopia. In remote areas, a long-term intervention in the form of injection of iodized oil may be justified. The advantage of the treatment is its prolonged effect, lasting for three or more years, but there are also associated problems such as high cost and the risk of transmission of needle-borne infections.

On a global basis, it has been estimated that at least million children of preschool age are at risk of VAD, as shown biochemically, and 2. In Africa 52 million children are at risk of VAD, and an estimated 1. Figure 35 shows the geographical distribution of vitamin A deficiency in Africa in Every year, to children become partially or totally blind from VAD, and two-thirds of these children die within a few months of going blind.

Apart from these victims, many more children - ten to 20 times more - are at risk in terms of health and survival because VAD impairs resistance to infection. Xerophthalmia comprises a range of disorders in which the mucous membranes of the eye become abnormally dry. It is caused most immediately by a deficiency of vitamin A in the diet, and if it is not promptly treated it can lead to blindness. More than 50 percent of children who develop xerophthalmia become very ill with other infections because lack of vitamin A reduces their natural resistance, and many die.

See Box 66 for the clinical signs used in the assessment of the prevalence of xerophthalmia. Box 65 - The use of iodinated oil capsules in the United Republic of Tanzania.

Tanzania chose to use iodinated oil in areas of severe IDD because a salt iodation programme had taken a long time to implement. The objective was to eliminate severe IDD areas by The advantage with the oral preparation is that it can be delivered by even non-medical personnel and avoids the use of needles which have a potential and real risk in spreading diseases such as acquired immunodeficiency syndrome AIDS and hepatitis B.

The target group for the iodinated oil capsule distribution is everybody aged one to 45 years in districts severely affected by IDD. The younger age group, below one year, was excluded in the hope that since there is nearly universal breastfeeding for children under one year of age, they will get their iodine from breastmilk. For the older age group, above 45 years, the requirements for iodine are low, and members of this group are more prone than the younger age groups to the effects of excessive iodine which the programme wanted to avoid.

The dose given is mg of iodine two capsules for the target population once every two years. The criteria for choosing the severely affected districts was initially based on a visible goitre rate VGR of 10 percent or more, but owing to political and public pressure this was lowered to a prevalence of combined grade 1 b and VGR of 10 percent or more.

According to these criteria 30 districts were categorized as having severe IDD. The population involved is about 5 million. The iodinated oil capsules are distributed through the primary health care PHC system or in a campaign using the primary schools and the government and Chama Cha Mapinduzi CCM Party infrastructure for mobilization and compliance.

The iodinated oil capsule supplementation programme has been shown to have had a positive impact on the problem of IDD. Specific studies have also shown a normalization of urinary iodine excretion and thyroid hormone levels in those given the capsule within 56 days. An estimate of the costs involved showed that they are modest. By any standards, this cost is a modest one for preventing the birth of cretins and for increasing the educability and productivity of a population.

The designations do not necessarily imply that VAD seventy is uniformly distributed throughout each country. See Table 52 for definition of levels of severity. Box 66 - Signs of xerophthalmia. The child cannot see in the dim light of evening dusk. Families describe how the child falls over things or knocks them over when he or she moves around.

The child cannot see to eat. Often there is a local name for night blindness - such as "chicken blindness". It is an important sign because families recognize it and because it can easily be cured. To find out if a child has night blindness, ask the relatives. Night blindness is cured in one to two days by vitamin A.

These are foamy, soapy whitish patches on the white part of the eye. Bitot's spots may not disappear completely after treatment, especially in older children and adults, but they do not affect the sight. The conjunctive the covering of the white part of the eye looks dry and slightly rough or wrinkled, instead of wet, smooth and shiny.

It is difficult to recognize conjunctival xerosis without special training. Bitot's spots, which usually occur at the same time, are easier to see. Conjunctival xerosis is cured in one to two weeks by vitamin A. The cornea is the clear part of the eye which you see through, in front of the brown iris. If the cornea is damaged, the person cannot see properly and may be blind. The surface of the cornea is cloudy and dry. Some people call this condition "fish scales over the eye".

Early corneal xerosis can be cured in one to two weeks. However, it can become more serious very quickly, in hours or days. More serious lesions are incurable. Thus a child with corneal xerosis needs treatment urgently with large doses of vitamin A. If xerosis is not treated early enough, ulcers holes may form on the surface of the cornea. Vitamin A can cure the ulcers, but usually a scar remains which may affect the eyesight. It xerosis or ulcers are not treated, the whole cornea becomes cloudy and soft.

The cornea may burst and part of the inside of the eye may come out. Often one eye is worse than the other. Giving vitamin A immediately stops keratomalacia becoming worse and may save some sight, especially in the better eye. The cornea is white, and the person can see little through it. There are several causes of corneal scarring, and it can be difficult to know which is responsible. If the family can tell you that the scars appeared after the child had measles or another infection or undernutrition, then they are probably due to vitamin A deficiency.

Prevalence of VAD in affected communities is also assessed by analysis of the level of retinol in the blood serum. However, serum retinol levels are difficult to interpret since most vitamin A is stored in the liver, and ideally it is these stores that should be estimated.

Costly laboratory techniques exist for this estimation. Where these techniques are not available, it is better to use an assessment based on food consumption surveys to provide further information on the intake level of vitamin A and of beta-carotene in the diet of specific population groups IVACG, The reasons for low vitamin A intake vary among countries; therefore situational analysis is necessary to understand and subsequently to design and implement appropriate intervention programmes.

However, most situations where VAD occurs as a public health problem share some common characteristics. Poverty is in most cases the root cause, as VAD primarily occurs in countries, areas and families that cannot afford the quantity and variety of foods needed to meet their vitamin A requirements. Particular problems include lack of dietary fat and of foods of animal origin that contain preformed vitamin A beta-carotene and the seasonal fluctuations in the availability of many beta-carotene-rich fruits and vegetables.

An inadequate water supply may often limit home and community gardening and as a consequence the availability of inexpensive sources of vitamin A.

Thus countries or parts of countries with long dry periods and relatively constant hot temperatures are more likely to have vitamin A deficiency problems. Poor living conditions and inadequate hygiene and sanitation often contribute to the problem of VAD. FAO food balance sheets indicate that the supply of vitamin A has improved in most developing countries over the past 20 years.

To assess vitamin A supplies in sub-Saharan Africa a clear distinction has to be made between countries in West Africa, where red palm oil is produced, and the rest of the region. Per caput vitamin A supplies in East Africa are generally low and even decreasing. One of the major reasons is that red palm oil is not marketed widely in many of these countries and does not reach vitamin A-deficient areas see Box In recent years, many activities to reduce micronutrient deficiency disorders have been implemented in developing countries, but these have mainly consisted of traditional health-based approaches focusing on supplementation, i.

Longer-term preventive interventions have also been implemented by the agriculture, education and food technology sectors, but the widespread application of these interventions has been constrained, primarily because of a lack of awareness by donors and affected countries regarding their effectiveness and sustainability and a consequent lack of funds committed to such activities.

Box 67 - The vitamin A supply situation in Africa. The vitamin A situation in Africa requires careful examination. First, it is essential to distinguish between those countries where red palm oil is produced - in West Africa - and the other countries.

When this is done, it becomes clear that East and southern Africa have very low availability of vitamin A. In southern Africa availability is probably on average below requirements, so that vitamin A deficiency is likely to be widespread. In addition, there are some indications that the overall supply is actually decreasing in East Africa, which would exacerbate the problem. In West Africa and the Sahel the apparently high availability does not preclude the coexistence of deficiency. As noted above, this is related to the fact that red palm oil is not marketed widely in a number of these countries.

The retinol supply assessed from food balance sheets should, however, be treated only as potential supply. Effective levels of physiological intake are determined by many factors including the state of maturation of certain fruits and vegetables, effects of dietary fats on the intestinal absorption of vitamin A, and intake of enriched foods.

In the period to , the developing regions of the world derived more than 70 percent of vitamin A from plant sources. These include green leafy vegetables, carrots, various fruits, sweet potatoes and palm oil.

In contrast, developed countries obtained only 45 percent of vitamin A from food of vegetable origin. The proportion coming from animal products tends to be higher in higher-income countries. In order to combat micronutrient deficiency diseases effectively and in a sustainable manner, governments and decision-makers need to be made aware of all the different approaches for reducing micronutrient deficiencies. The World Summit for Children, held in New York, USA, in , drew greater attention to micronutrient deficiencies and called for new integrated strategies to solve this problem.

The International Conference on Nutrition translated this awareness into a coherent strategy, making a real commitment to the use of sustainable food- and agriculture-based actions to ensure access to food and increased food consumption by the at-risk groups. The implementation of this strategy will require improved coordination and integration between health measures and activities in food and agriculture and will also require the allocation of adequate resources for undertaking food-based activities.

The strategy of choice to prevent and combat micronutrient malnutrition should be based on promotion of the production and consumption of micronutrient-rich foods, on food fortification and on nutrition education and related activities.

This is the only effective and sustainable solution to the problem. Supplementation also has to be considered as a component of the strategy for areas or populations with clinical vitamin A deficiency, but there should be a clear commitment to withdraw this activity except in special conditions, e. The importance of each component of the strategy will vary according to the situation of the country, with account taken especially of the sustainability of the programme, the availability of personnel and cost-effectiveness.

In many African countries agricultural policies have for the past 30 years largely focused on income generation for the farmer, foreign exchange earnings from exported foods and national food security see also Chapter 2. Food policies have been most concerned with promoting increased production of staple grains.

While all of these considerations are important for good nutrition, food and agriculture policies have done too little to improve dietary diversity and increase consumption.

Work is needed in this area, specifically to promote desirable nutrition outcomes through such means as land tenure, diversification of production, access to small-scale credit and nutrition education. Food and agriculture policies can also directly affect the consumption of micronutrient-rich foods by altering their availability and price.

In particular, these policies can promote horticultural crops, legumes, small animals, fish and edible tree crops as well as social forestry and cropping patterns and preservation practices that alleviate seasonal food shortages and lead to greater availability and intakes of micronutrient-rich foods at household level see also Chapter 5, on food diversification. Nutrition objectives should also be integrated into the agricultural research agenda.

Ways of maximizing the micronutrient output of agricultural systems should be explored through research to enhance the big-available micronutrient content of major crops and to develop integrated small-scale farming systems that maximize production of micronutrient-rich crops, small-scale environmentally sustainable livestock enterprises and agro-forestry techniques for the production of both food and fuel Combs et al.

Horticultural-sector development can be used to increase production of fruits and vegetables, legumes and tree crops bearing edible leaves. Box 68 provides an account of observed relationships between cropping patterns and the prevalence of vitamin A deficiency in Ethiopia as a guide for food-based intervention programmes. More households could be encouraged to grow dark-green leafy vegetables, such as amaranth, and orange or yellow fruits and vegetables such as pumpkin, papaya and mango for family use.

Promotion of home gardens, fish ponds and poultry rearing, as well as small animal production, is also seen as a viable strategy to improve the consumption of beta-carotene and of retinol on a long-term basis. In areas of West Africa where red palm oil is widely consumed there is no deficiency of vitamin A. Promotion of oil-palm cultivation in other climatically suitable areas should be encouraged.

Box 68 - Vitamin A deficiency in Ethiopia: Clinical and biochemical data from the nationwide survey indicated that the prevalence of vitamin A deficiency was very low in the ensete staple areas.

Dietary studies carried out previously have shown that ensete foods are supplemented with kale and cheese which can supply provitamin A and vitamin A, respectively. The cereal staple areas, referred to as the cropping zone, and the pastoral areas are those most affected as they have the highest prevalence of vitamin A deficiency. An even higher prevalence of vitamin A deficiency was found in Melkaye village which is in the cereal cropping zone in Hararge Region.

This village does have the potential to grow coffee and chat Khat edulis which would enable it to have a cash-crop economy.

The prevalence of vitamin A deficiency in the area was high not only because of the crops grown but also because of the failure of rains over a six-year period which resulted in total dependence of the inhabitants on relief food supplies. The food distributed contained very little vitamin A. From these studies we can conclude that vitamin A deficiency is a problem of public health significance in the cropping and pastoral zones of the country and was exacerbated in the relief-food-aid-dependent areas.

On the other hand, the ensete staple areas are relatively non-affected. Distribution of vitamin A capsules should not overshadow other approaches that could be used to control vitamin A deficiency. Until now, most efforts have been directed towards the use of vitamin A capsules, but food-based intervention programmes are more appropriate in countries like Ethiopia.

The relatively low prevalence of vitamin A deficiency in the ensete areas, as a result of the consumption of kale and cheese, provides an indication of the approach that could be followed in combating the problem of vitamin A deficiency. For example, in Kobo and Robi in the cropping area, the prevalence of vitamin A deficiency was not particularly high, probably because of the establishment of small irrigation schemes which enable production of vegetables that are rich in provitamin A.

Some green leafy vegetables may also be gathered regularly from wild plants. Early arable weeds are a particularly valuable source of "pot-greens", as they grow very quickly with the first rains and are harvested before there is any serious competition with the growing crops.

In addition to these herbaceous plants, a wide variety of trees and shrubs are often used, especially the baobab, Adansonia digitata. Many of these shrubs and trees are identified only by their local names which vary from country to country. In Upper Shaba, former Zaire, it was found that leaves from 50 different tree species were eaten Malaise and Parent, , and in Swaziland more than half the adults interviewed reported that they ate wild leaves at least twice weekly when they were in season Ogle and Grivetti, The nutritional values of selected East African green leafy vegetables are shown in Table In addition to increases in production, major improvements are also needed in the preservation, processing, distribution and marketing of micronutrient-rich foods to reduce waste, post-harvest losses and the effects of seasonality.

Particular attention needs to be paid to marketing of perishable foods. The vitamin content of harvested vegetables and fruits is inevitably substantially lowered, especially if they have been exposed to direct sunlight for extended periods.

In harvesting green leaves from legume and root crops, care must be taken to avoid overdepletion of the photosynthetic resources of the plant. Many farmers have developed their own well-tried methods of leaf harvesting that minimize risks of crop reduction for the main food product. Table 56 - Nutritional values of selected East African green leafy vegetables.

West, Pepping and Temalilwa. In general, traditional methods for processing, preservation and storage of vegetables cause significant losses of nutrients. Much food is wasted because of the lack of appropriate village-level food preservation technologies. However, there is good evidence that careful preservation and processing helps fruit, especially mangoes, retain good vitamin A activity. Results of a study from Senegal show that sun-dried mangoes can be an excellent source of both beta-carotene and vitamin C as well as a relatively good source of iron Ranking, Hopkinson and Diop, Beta-carotene retention after solar drying using specially designed low-cost solar dryers was found to be much higher than retention following traditional methods of drying see Chapter 5, Box Solar drying can be readily adapted to developing environments.

It offers good potential for improving family nutrition, especially during seasonal shortages of vegetables and fruits, and for improving family income, since dried foods can fetch a good market price. Nutrition education is a complementary activity and is fundamental for ensuring the effectiveness of a food-based approach.

The consumer should understand that in order to achieve and maintain good health, several principles should be followed. These include eating a variety of food; preparing and eating diets to meet physiological requirements; maintaining food safety and hygiene in food preparation; and finally keeping active and fit.

These basic messages are part of FAO's nutrition education and information package for the general public Get the best from your food FAO, e. The package acknowledges that while local food habits and traditional dietary customs and practices can vary, virtually all local food systems can supply the food necessary to prevent micronutrient malnutrition.

A comprehensive list of different food-based approaches and activities that can be implemented to increase the supply and consumption of micronutrient-rich foods in the community is given in Box See also Chapter 9 for details on nutrition education. Food fortification - the addition of essential nutrients to foods offers another element of the food-based approach to the prevention and control of dietary micronutrient deficiencies. Fortification is not the appropriate solution in all situations, and it must generally be used in combination with other techniques in order to obtain the best results.

It may be especially useful and appropriate in those cases e. IDD where deficiencies cannot be corrected through growing or purchasing fresh and high-quality nutritious foods fruits, vegetables, meat and fish or in emergency situations. Fortification should be viewed as part of a range of measures influencing the quality of food, including improved agricultural practices, better processing and storage methods and consumer education. Several foods - cereal products, rice, salt, sugar, milk, oil and condiments - have been identified as vehicles for fortification.

In industrialized countries a wide range of foods are fortified with many different micronutrients including vitamin A, vitamin B complex, iron and iodine. Iodization of salt has been highly effective in both developed and developing countries for decades.

Cooking oil is an obvious candidate for fortification, but as indicated in the section on African diets in Chapter 7, the consumption of oils and fats in the African diet is usually low, especially for poorer consumers, as these items are expensive. Vitamin A fortification of sugar was successfully implemented in Guatemala, and after years of interruption it has been resumed.

In the United Republic of Tanzania efforts are under way to fortify tea with vitamin A. These include dried skimmed milk powder enriched with vitamin A and various blended foods [e. Box 69 - Food-based approaches to micronutrient deficiency. The following list presents possible food-based approaches and activities that may be taken into account to combat micronutrient deficiencies.

Activities should be selected based on geographic, demographic and socio-economic conditions. Community participation in design and implementation is a crucial component of successful, sustainable programmes. These materials and guidelines should be addressed to the general public as well as specifically to women, farmers, small-scale merchants and community workers. Fortification does not usually require changes in people's dietary habits.

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