ALL-PARTY PARLIAMENTARY GROUP ON POPULATION

MINUTES OF PROCEEDINGS

at a

PARLIAMENTARY HEARING

held at

The Palace of Westminster

on

Monday 22 May 2006

Population, Development and Reproductive Health Inquiry

Before:

Richard Ottaway MP, in the Chair

Viscount Craigavon

Baroness Tonge

Paul Flynn MP

Ms Catherine Budgett-Meakin

Ms Patricia Hindmarsh

Ms Jennifer Woodside

Ms Ann Mette Kjaerby

(From the Shorthand Notes of:

W B GURNEY & SONS LLB

Hope House

45 Great Peter Street

London SW1P 3LT)

Witnesses: PROFESSOR JOHN CLELAND, London School of Hygiene and Tropical Medicine; DR HILARY STANDING, Institute of Development Studies, University of Sussex; and DR NDOLA PRATA, University ofCalifornia, Berkeley, examined.

CHAIRMAN: Can I give a warm welcome to today’s three witnesses at the third of our hearings. I particularly welcome Ndola who has come across the Atlantic to be here; it is very much appreciated, and also Hilary Standing, from Sussex, and John Cleland, from the London School of Hygiene and Tropical Medicine. This is a relatively relaxed session. We have the room until 5.30 pm. If for any reason we dry up and do not get there, we are not necessarily going to try and spin it out. What I would like is to invite you all to make a five-minute opening contribution and then we will throw it open to questions. It would help us if people could keep their questions relatively snappy because that way we can have a dialogue. We have got a lot of questions we want to ask and it makes it, I hope, more fun for you as well. I tend to do this in alphabetical order so John you are number one, if you would like to kick off.

PROFESSOR CLELAND: I would like to talk to one sheet of paper. In my five minutes I want to persuade you, as I am persuaded, that international investment and national investment in family planning has been shockingly neglected in the last ten years and deserves a much higher profile from the World Bank, from DFID and from USAID. I have tried to summarise my case in this single display. What it shows is all 75 low and middleincome countries grouped according to rate of population growth (which defines the horizontal rows) and grouped also according to unmet need for contraception (which defines the vertical columns). The countries in the top right-hand box are, I think, the most urgent countries for family planning assistance because they share high population growth of over two per cent a year, which means a doubling every 35 years. I think there is very good evidence that that rate of population growth jeopardises nearly all the MDGs. Most of the countries at the top of this table are going to double and some of them are going to treble in size by the middle of the century. Happily for us, most of them also fall into the high unmet need for family planning. That is a subjective measure. It expresses the percentage of married women who do not want another child for at least two years but are doing nothing to prevent pregnancy. It is the most commonly used and robust measure of subjective need for contraceptive services. A very large fraction of these 75 countries are defined as high need, both in terms of personal welfare and in terms of macroeconomic threat to the whole prosperity of the nation. The colours denote the liberality of the abortion laws: red being highly restrictive, to save the woman’s life only; orange being permissible when the women’s health is at threat; and blue much more liberal abortion allowed on socio-economic grounds or other grounds or on request.

You will see immediately as you look at that display of countries that those with the highest need, both economically and in humanitarian terms, are the ones where abortion laws are most restrictive and therefore there is a double jeopardy to unmet need insofar as a lot of unintended pregnancies to women in those countries are going to end up in unsafe abortions. The figure in brackets for some countries where data are available expresses the percentage of birth intervals that are dangerously short to the health and survival of the children, ie under 24 months, so that is the fourth criterion, to express the priority and need for family planning. I would reckon that family planning can save one million lives of babies and children per year if short birth intervals were eliminated. It is a huge and rather cost-effective contribution to one of the Millennium Development Goals.

In terms of mothers’ health, we know that family planning to prevent unintended pregnancies can prevent about 33 per cent orone-third of all maternal deaths, be they obstetric or abortion-related. On the grounds of poverty reduction, on the grounds of maternal health and on the grounds of child health - and I do not have time to talk about the environment - family planning investment should be far higher up the international agenda for this country and for all development agencies and for all the governments of developing countries that fall towards the top of this table. The world has lost its way in the last decade to a scandalous extent. Thank you.

CHAIRMAN: Thank you very much. Ndola, in alphabetical order, you are next.

DR PRATA: I am originally from Angola and it is an honour for me to be here. I received in 1995 a scholarship from the British government to study medical demography at the London School of Tropical Medicine with Professor Cleland, so I was his student. In the next five minutes I am going to focus on the impact of population growth on maternal health, and I will focus mostly on sub-Saharan Africa where maternal mortality is the highest. In my view, the greatest hope for decreasing maternal mortality in order to achieve the Millennium Development Goals in poor countries, specifically in sub-Saharan Africa, lies on two fronts: decreasing fertility because we can see that maternal mortality is highest where fertility is highest; and tackling the main cause of maternal mortality, which is postpartum haemorrhage(women who go into labour and then have excessive bleeding after delivery).

One other thing I would like to mention is that most of the women in developing countries where maternal mortality is the highest deliver at home, very far away from health care centres or skilled health care providers. The interventions that we have today for decreasing maternal mortality are focused on increasing the number of health facilities and increasing the number of skilled attendants at delivery. In the last two or three decades we have not been able to respond to the demands for health care infrastructure and also skilled providers to attend to the deliveries in developing countries. The World Health Organisation estimates that it will take about 20 years if we invest heavily in education in health care in order to decrease the number of deliveries at home or attended by unskilled professionals.

Given all those constraints, what we can focus on today is decreasing fertility. By decreasing fertility we will decrease, as Professor Cleland mentioned, the unmet need for family planning and unwanted pregnancies. We will decrease the mortality attributed to unsafe abortions in developing countries because most of the unsafe abortions are the result of unwanted pregnancies. We will also decrease mortality at the extremes. Maternal mortality distribution by age follows a U-shaped curve, its high among very young women and also high among relatively older women who are at the end of reproductive life, over 40, who continue to have births. Those two groups of women are at greatest risk of dying frompregnancy related complications. Family planning will decrease the number of deliveries that very young and relatively older women will have and therefore help reduce maternal mortality. In addition, we would also reduce mortality due to unsafe abortions. Between 13 per cent and 25 per cent of maternal mortality in developing countries can be attributed to unsafe abortions. The other link with the main cause of maternal mortality, which is postpartum bleeding, is also directly related to population growth. Poor countries have not been able to train health care forces in adequate numbers. The lack of economic development also reduces the ability for countries to invest heavily in health care infrastructure. What we can do today with the knowledge that we have is to make Misoprostol available for women and save them from dying from postpartum haemorrhage. Unlike the current drugs that needto be delivered by skilled providers, nurses, physicians and midwives in a health care facility, Misoprostol can be delivered by all levels of providers including traditional attendants. Women can also take this drugby themselves in their homes. In this way we could decrease maternal mortality attributed to postpartum haemorrhage. I would say that investment in family planning should be at the top of the list of any assistance programmeto improve maternal health, decrease poverty and improve women’s reproductive health status. Thank you.

CHAIRMAN: Thank you very much indeed. Hilary Standing?

DR STANDING: I also will talk to one and a half sheets.

CHAIRMAN: I recognise the first two figures from your paper.

DR STANDING: Thank you very much for inviting me. I want to reinforce the case that my colleagues have made, and particularly John Cleland, regarding the serious impact of the under-investment in sexual and reproductive health services and I want to broaden it and say that I think not only contraception services but basic reproductive health services themselves are seriously under-funded. I want to make three points. The first is that there are strong indicative links between poverty, gender inequality and poor sexual and reproductive health. Although we have been rather tardy in the past in developing a good economic case for investment in sexual and reproductive health, we do now have a growing evidence base which is supporting that. What Figure 1 on the sheet shows is the global sexual and reproductive health burden which, as you will see, is both high overall and it is the leading cause of morbidity and mortality for women in the age group 15 to 44. This is particularly relevant to thinking about the adverse impacts on poverty and gender of poor sexual reproductive health because these are actually the years of women’s maximum social and economic contribution to society. This is very important in showing how very high this burden of morbidity and mortality is.

That takes us to Figure 3 which is over the page which I will not go through in detail but I would just try to summarise there from the available literature what are the social and developmental benefits of investing in sexual and reproductive health services which have already been documented by research. You will see that they have been divided between the individual household and the wider society economy level. Individual impacts relate particularly to those on gender equality and greater empowerment of women to make choices in their lives. At household level, the microeconomic impacts of investment in sexual and reproductive health services are very strong in terms of improving overall household welfare and productivity. The links at the macroeconomic level are somewhat more tortuous. They are a little bit harder to make but there is no doubt again that they lead into improvements in both economic productivity but also in a number of important social dimensions such as issues around not having high levels of poorly socialised, economically poor children, faster economic growth due to the demographic window which opens up, and overall decreased social and economic inequality. I think it is worth noting that when one looks at the disposition of sexual reproductive health services in most developing countries, they are extremely unequal and they feed these serious inequalities that there are. So there is a very strong social and economic case for increasing support to basic social and sexual reproductive health services, including contraception, within a framework which respects human rights and encourages social dialogue.

However, if we move to Figure 2, what we see is an overall global picture of declining resources in family planning and basic reproductive health services. Those are the most up-to-date figures that I am aware of, and even then some of them are projected, and you will see that the only one which is going in an upwards direction is the HIV/AIDS one. The others are all tending to go downwards. That brings me to my third point which is the implications of current aid instruments for thinking about how we track and finance sexual and reproductive health services. There are two issues here. What Figure 2 cannot tell us is what is actually happening in terms of the bilateral budgets and the multinational budgets which are going through things like sector-wide approaches to health or through direct budget support. In fact, we have a very big information gap on expenditure on sexual and reproductive health services because we do not have any very good ways of tracking within those broader aid instruments whether funding is actually going to SRH services and how much is going and where it is going.

I would like to draw the Group’s attention to that because I think people who work in this area are very well aware that sexual and reproductive health is one of those areas that very easily slips between the cracks. It is often not in the same ministry; it is spread around diverse parts of government; it often has rather weak stakeholders; and there might be quite a lot of resistance to it and so on. So there are some serious issues about whether within those broader aid instruments sexual and reproductive health services are getting neglected or whether they are there but we do not know where they are and we do not know what impact they are having. So again I want to draw attention to two important needs for the future, which is improvement of the monitoring indicators that we are using both for tracking aid, and also for improving the capacity in developing countries themselves for seeing what is happening to their services, and at the same time the need for a much stronger dialogue with governments around priorities particularly within health sector spending. Thank you.

CHAIRMAN: Thank you all very much. It is very commendable for keeping to the clock. Can I start with a general question to all three of you: is there a consensus amongst you that if population growth is stabilised we are far more likely to achieve the Millennium Development Goals? What you have said may be self-evident but you have all spoken in your own way. Do you think that this will give a lot more momentum to achieving the MDGs?

PROFESSOR CLELAND: For sure, absolutely. The only doubtful one is HIV/AIDS. It just so happens that it is an awkward fact of life that high contraceptive use countries in Africa have the worse HIV epidemics, so we must conclude that family planning has not done much to curtail HIV and could have done a lot more, but with that exception on every other one.

DR PRATA: I agree.

DR STANDING: Yes.

CHAIRMAN: Your paper focuses more on maternal health. Do you have a general view on some of the other MDGs?

DR PRATA: Absolutely and I think that controlling population growth would make a tremendous impact on all of the MDGs.

CHAIRMAN: You spoke of the unmet need for contraception. Is this common in Africa? To what do you put it down?

DR PRATA: It is very common. Right now in Africa even among married couples we have an estimated 150 million married couples that are in need of family planning services and there are 100 million more that have inadequate services or services that are interrupted so that throughout the year they sometimes have them and sometimes do not have them. There is a tremendous need for family planning. It is also important that if you look at most of the demographic and health surveys from sub-Saharan Africa, wanted fertility is usually lower than achieved fertility and wanted fertility is a moving target. As fertility goes down the wanted fertility also falls, so there is always a need for family planning.

CHAIRMAN: Hilary, you are looking slightly unsure.

DR STANDING: I agree broadly with the comments. I should say I am not a demographer ---

CHAIRMAN: This is a very broad inquiry.

DR STANDING: I will not argue from a demographic perspective. I would not doubt that the impact of HIV, particularly in the case of sub-Saharan Africa, is probably going to be somewhat variable,but if one looks at other countries such as those countries in South Asia where you have already got a relatively high level of contraceptive use then the picture is different. So I would agree, with the proviso that one might want to look at different countries because they have very different demographic profiles already. For instance, I think one would say something very different about meeting the MDGs on maternal mortality in China because that is a low fertility country already.