This blog was originally posted on the CapacityPlus blog.

A recent New York Times article featured an updated United Nations forecast that projects the world’s population will reach 10.1 billion by the end of the century, rather than stabilizing at nine billion midcentury as previously predicted. In part, these high rates of population growth are fueled by lower than expected declines in fertility in some of the poorer regions of the world—with the slowest fertility declines observed in West and Central Africa.

Behind the data

Demographers and other global health professionals argue that these sustained high rates of fertility and population growth are the result of a weakened commitment to family planning (FP) programs in the last two decades following a significant focus on FP during the 1970s and 1980s.

Although the need for FP has grown, availability of and access to modern contraceptive methods has actually declined for the people most in need. In West Africa, for example, the Demographic and Health Survey data show:    

• Total fertility rates are very slowly declining in the region. In Mali and Niger, the total fertility rates of approximately 6.6 and seven children per woman, respectively, have remained stagnant over the most recent decade for which data are available. The total fertility rate of 5.7 in Nigeria has also remained constant between the country’s 2003 and 2007 demographic survey reports.

• Use of modern methods of contraception is below 10% in Benin, Burkina Faso, Mali, Niger, and Nigeria. Use of modern methods has actually declined in some countries, including Benin, Burkina Faso, and Ghana. The unmet need is very high—over 28%—in Benin, Burkina Faso, Ghana, and Mali, and has increased between the last two surveys in each country.

• Overall, total fertility rates are higher in rural areas of West and Central Africa compared to urban settings. Some of the larger gaps in urban-rural total fertility rates are found in Burkina Faso, Cameroon, Liberia, Mali, Senegal, and Sierra Leone, where women in rural areas have at least two more children than those in urban areas.    

Why health workers matter

In order for FP programs to effectively scale up service provision to meet current and future needs, an adequate number of trained health workers must be available. However, the global health worker crisis hinders FP service provision, most notably in rural areas in sub-Saharan Africa.

The World Health Organization has defined 2.3 health workers per 1,000 population as the minimum ratio necessary to achieve desired levels of coverage for key health interventions. Not surprisingly, West and Central Africa, which have among the lowest health worker density ratios in the world, also have the highest levels of unmet need for FP and lowest modern method contraceptive prevalence.

Community-based programs

A dire need for FP services, especially in rural West and Central Africa, coupled with severe health worker shortages create a global health quandary: What will it take to provide services to rural communities?

Perhaps the answer to this question lies in the documented impact of community-based contraceptive distribution programs in the 1980s and 1990s, which were successful in increasing contraceptive prevalence among rural populations in sub-Saharan Africa. Given the technological advances in contraceptive methods and community health worker education, productivity, and effectiveness, the global health community has the opportunity to expand reproductive health services.

A 2005 paper by Prata et al. reviewed over 30 years of community-based distribution programs for FP services and found that these programs are still needed in both urban and rural areas of developing countries. One of their most interesting findings was that where the unmet need for FP services in rural areas was relatively low, the percentage of all modern methods provided by community-based distribution agents or outreach programs was notably higher.

Task-shifting

Much of the success of the community-based distribution programs in the 1980s and 1990s was attributed to task-shifting or task-sharing. In these programs, nonclinical health workers successfully distributed and monitored adherence to contraceptive methods at the community level, thereby greatly reducing barriers to FP access experienced by rural populations. A 2009 World Health Organization technical consultation concludes that community health workers can safely and effectively administer progestin-only injectable contraceptives, in addition to condoms and pills. This finding is important because injectables constitute one-third of modern contraceptive use and 25%-50% of the unmet contraceptive need among women in sub-Saharan Africa.

Given the woefully inadequate health worker density ratios, persistently high fertility rates, and increasing demand for modern methods of contraception in West and Central Africa, effective scale-up of community-based programs appears to be a high-impact strategy that will simultaneously address the very high levels of unmet need for FP and the health worker crisis in the region.