Taming the wild west of family planning | World news

 

In Senegal, 43% of the population is under the age of 15. Photograph: Moussa Sow/AFP/Getty Images

At the back of a clinic in the densely populated Guediawaye, where a tide of rural incomers washes up on the edge of urban Dakar, a woman sits waiting with the undemanding endurance of poverty and old age.

Nene Ba looks in her 60s. The small child on her lap could be her grandson. But she is 44 and the one-year-old boy is the last of her 10 children.

"I am so tired," she says, adding that she had not wanted all these babies. "I didn't know how to stop." Now she does: at the family planning clinic where she is waiting, her tubes were tied, freeing her of the curse of endless childbearing. Her husband, who sells fish while she takes in washing, was indifferent, she says.

Just 20 minutes away, at a conference centre in downtown Dakar, the world's largest-ever gathering of experts, advocates and campaigners in birth control is under way. Senegal was chosen because this is what one conference participant called "the wild, wild west of family planning".

Sub-Saharan Africa teems with small, skinny, ragged children – 43% of the population is under 15 – but in the francophone west just 10% of women have access to the hormonal birth control methods which since the 1960s have enabled women elsewhere to take control of their fertility and live the life they chose. Some 40% of pregnancies in the developing world are unintended and nearly half of those end in abortion, most of which are unsafe. Complications kill an estimated 47,000 women a year – 13% of all deaths in pregnancy and childbirth.

In the year when the planet welcomed its seven billionth baby, some may see this as a scandal. When the prime development goal of the moment is cutting maternal mortality, it seems inexplicable.

At the Dakar conference there is evidence that things have begun to shift. The Gates Foundation is putting in $70m a year – Melinda Gates has said it is now one of her top priorities and speaks forcefully about the need for women to have control over their lives. Britain, the Netherlands and France are all putting in new money.

But the need for birth control still outstrips the resources. A poster presentation at the conference reports that only 48.2% of women who had an abortion in Accra, Ghana, went home with contraception. Below that stark fact is a quote from the Cairo population conference of 1994. "If the woman we treat for post-abortion complications is there because she could not get contraception, we have failed her. If she leaves without family planning, we have failed her twice."

In Pikine, another district on the outskirts of Dakar, children throng the dusty streets. Sewage and sanitation are bad and some of the concrete houses regularly flood.

Fatou Sann, 46, is the only person working in a house of 26 people. She sells fish which she gets from the central Dakar market. A four-day-old baby is brought out and another of maybe six months sits on someone's lap.

Sann has six children herself, which she says with a robust laugh is "definitely enough", but these are the babies of sisters-in-law.

Her father, Anfang San, 74, has progressive views. "I think that limitation is a good option. Four is quite enough – or three. Some have eight or nine. You don't know how to feed them."

The local mayor, Aliou Diouck, talks of families where eight children sleep on the floor – "they do not know the taste of a bed", he says.

"Here we are in a very poor environment. Men and women do not work. What's going to happen? They will just have sex. When you have nothing to do, it's the main occupation."

His own father had several wives – Senegal is 95% Muslim – and 21 children. Diouck has four of his own and says he and his wife have decided to have no more. He hopes to set an example.

But at the health centre in Pikine they say that only 5% to 6% of local women come for family planning. And last year they had hormonal contraceptives for 80% of the time.

One of the reasons, says Monica Kerrigan, head of family planning at the Gates Foundation, was that orders for supplies went in on the basis of past consumption – which dropped off when stocks ran out.

"We have to learn a lot from the HIV world. They made ARVs [antiretroviral drugs to keep HIV in check] a top priority."

HIV comes up a lot when you ask why family planning seems to have made so little progress. George Bush in his State of the Union address in 2003 announced a colossal $15bn to fight Aids over five years. Most of the money was for drug treatment, which, says Professor Duff Gillespie of the Bloomberg school of public health at Johns Hopkins University, "allowed evangelicals and George Bush to suddenly start making large announcements because they were no longer dealing with sexual behaviour.

"Why was so much money put into HIV treatment but not prevention – ABC – abstinence, be faithful, wear a condom? There was a little on prevention – around 17%. But most of that (10%) went to prevention in terms of things other than ABC. What happened [with treatment] is that it took sex out of Aids."

But Gillespie says that the stagnation of family planning was not solely due to HIV campaigns – the real stagnation came after the Cairo population conference in 1994.

That meeting put family planning into a framework of reproductive health rights which focused on sexually transmitted diseases, the empowerment of girls and maternal health issues. Women's groups were delighted by the move, but actual birth control slipped down the agenda.

"Cairo changed the vocabulary and the way people think about reproductive health and that was good," says Gillespie.

Unease about sex, religious beliefs in the US and elsewhere, women's low status and cultural issues in poor countries have all made family planning a difficult issue to push forward.

Dan Pellegrom, who has been president of the family planning charity Pathfinder International for 26 years, says the movement can be too passive. "I do think we need to push the envelope.

"In recent years we as a movement have said let's hang on to what we have achieved. That is an argument for retaining the status quo," he says. "You don't mobilise people by retaining the status quo."

He would like to see the fight about abortion taken on – the most contentious area of them all, but more family planning means fewer terminations and fewer women's deaths from backstreet abortions. And it would expose some agendas. "It is so important for Americans to understand that most of the people who claim to be opposed to abortion are equally opposed to family planning – they just don't talk about it," he says.