This is part I of a two-part blog. To read part II of this piece, click here.

Wrapping up earlier this month, the International Conference on Family Planning brought together more than 2,000 participants for three days of science and advocacy on family planning. This largest-ever global family planning conference was held at Le Méridien in Senegal’s capital city, Dakar. The importance of holding this conference in West Africa cannot be overstated: it is what The Guardian columnist Sarah Boseley referred to in a column as the "the wild, wild west of family planning," quoting a conference participant. Women in sub-Saharan Africa have the greatest unmet need for modern methods of family planning. Sub-Saharan Africa has the highest fertility rates and the lowest use of modern methods of contraception in the world. Women in sub-Saharan Africa have more than twice as many children as women in other regions: 5.2 on average, compared with 2.2 in Latin America and 2.7 in South Central Asia. Across sub-Saharan Africa, 19% of women use modern contraception; in West Africa, only half that many, or 10%, use modern contraception.¹

Senegal, a country of 12 million people, has one of the highest fertility rates in the region. Over the past 25 years, the total fertility rate in Senegal has decreased from 6.6 children to 5 children per woman. This represents a decrease of less than a tenth of a percentage point per year. In many countries around the globe, fertility rates have dropped significantly over the past 25 years. Modern contraception is used by 12.1% of married women in Senegal, according to the 2010 Demographic and Health Survey.

Presidential Support for Family Planning

The importance of holding the global conference in Dakar—and its potential lasting impact—was evident during the opening plenary session, presided over by Senegal’s President Abdoulaye Wade. He spoke of the acute need for family planning, not only to improve maternal and child health, but also to contribute to gains in economic development and the reduction of poverty. In a speech that surprised many Senegalese with its audacity, the 85-year-old president acknowledged that it was controversial to talk about population control but suggested that “couples voluntarily limit the number of children they have.” He added, “Our economic development is advancing less quickly than the population. Population growth not accompanied by the growth of resources creates problems of poverty.”

I talked with my colleagues about Wade’s speech as we headed out of Le Méridien hotel along one of the country’s new highways to Dakar’s neighboring urban centers of Pikine and Guédiawaye. We were headed out for the site visits IntraHealth International staff had organized for a team from the Bill & Melinda Gates Foundation, and for other donors, journalists, and other conference participants who expressed interest in seeing life outside the hotel walls and beyond the well-to-do neighborhood surrounding the conference hotel. From health workers in clinics, to religious leaders in the mosques, to teenage boys on the streets, everyone had heard the president’s speech and the debates that followed on the radio.

Building Family Planning Supply and Demand in Cities

IntraHealth is working in urban areas of Senegal through the ISSU project. ISSU, or the Initiative Sénégalaise de Santé Urbaine, is a five-year initiative that promotes family planning in six cities in Senegal. ISSU works in synergy with USAID and other donor-funded projects to support Senegal’s Ministry of Health in satisfying unmet need for family planning. The initiative is funded by the Bill & Melinda Gates Foundation, which also supports urban family planning projects in India, Nigeria, and Kenya.

An estimated 42% of Senegal’s 12 million citizens live in cities. This population is rapidly increasing and is expected to grow by more than 45% by 2015. ISSU works in the cities of Dakar, Guédiawaye, Kaolack, Mbao, Mbour, and Pikine to address the supply side of family planning, ensuring that services are available in public clinics as well as private-sector clinics. ISSU also works to grow demand for family planning by supporting activism around family planning, engaging religious leaders, working with local community radio stations, and mobilizing under-served populations, especially youth.

We started the field visits on Thursday afternoon in Pikine, a bustling sandy city with a population of 1.2 million living in less than 100 km². Thanks to the new highway, the trip to Pikine took about 20 minutes, a vast improvement from the one- to two-hour trip before the new road. Pikine is a predominately poor, overcrowded urban area with a weak educational system, a large migratory population from rural areas, and hygiene and sanitation problems. Large parts of Pikine experience spontaneous and regular flooding, and many houses are built on former river beds. Many neighborhoods in Pikine have no access to the city sewer system.

After visiting health care providers, mothers, and newborns in Pikine’s Dominique health center, we were welcomed by Aliou Diouck, mayor of the commune of Djiddah Thiaroye Kao, one of 16 communes in Pikine. Diouck has collaborated closely with ISSU to promote family planning.

Following Diouck around the neighborhood, it is easy to see that he is a popular mayor; he calls out to men, women, and children by names and nicknames. Diouck was a university mathematics professor who decided a few years ago that he wanted to do something to make a difference in the lives of the urban poor. The literacy rate of Djiddah Thiaroye Kao is about 10%. Diouck said that educating the population is one of the biggest challenges he faces in addressing poverty, and that family planning can have an impact on education in different ways.

“When children, especially girls, stay in school, pregnancy is delayed. And when young people are educated, they aspire to jobs and a better standard of living—and choose to have fewer children,” Diouck said. He spoke of his own parents, and the 21 children on his father’s side. He and his wife decided to have four children, and he laughed, saying, “That’s plenty these days.”

After visiting Diouck’s office, the group set out to visit the homes of several families in Pikine. Along the way, we ran into several teenagers, who offered us tea and a place on a long bench. The young men, students who ranged in age from 15 to 18, had all heard President Wade on the radio.

“He went too far,” one young man said. “People are not ready to even think about limiting the number of children they have.”

One of his friends seemed to disagree. “No, it’s good. It’s time. None of us want to have a lot of children. Look at this neighborhood: there’s no room for more children.”

The consensus among the group seemed to be that it was good that the president talked about family planning but that more needed to be done to actually change things.

“The politicians should ask us what we think,” said Issa, one of the young men. “We could help change things.”

Reference

1. Population Reference Bureau, 2011. 2011 World Population Data Sheet. Washington D.C.