Africa Faces Reproductive Crisis

Abstract

There are three major crises in sub-Saharan African reproductive health which the region — and this journal — must face: (1) the world’s highest maternal mortality; (2) the world’s highest fertility levels that, at a regional level, have not fallen significantly if at all; and (3) the most serious AIDS epidemic, and probably the most serious endemic STDs, in the world.

I will comment only in passing on maternal mortality which arises primarily from poor birthing practices in poor conditions. Few births are attended by trained persons and fewer still occur in modern institutions or with the potential back-up of such institutions. This situation has, with that of the whole health sector, worsened in southern Nigeria, and probably in many other parts of the region, as economic structural adjustment programs have introduced “user-pays” principles. These programs were introduced in an effort to stimulate economic growth. Such growth may, indeed, provide the long-term solution for inadequate health care. But the present generation cannot be entirely sacrificed for the sake of their descendants, and there is an urgent need to contrive a substantial degree of protection for both health and education sectors from the full rigors of economic rationalism. This is especially the case when the potential users cannot pay.

African women still average well over six births during their reproductive years. This owes some-

thing to the cultural and social milieu, but it is also a reaction to high infant and child mortality, and the product of low levels of education and inadequate access to contraceptive services. In sub-Saharan Africa both the old and the new contraceptive messages are relevant. Certainly, as the International Conference on Population and Development at Cairo (1994) emphasised, women have a right to protect their health by being able to use contraception, and a right to begin contraception in a condition of good reproductive health and to maintain that health. This is a message not only for family planning programs, but for the broader health system and economic planners.

In addition the old message is also still of relevance, probably more so in sub-Saharan Africa than in any other major world region. Fertility is falling in most of southern Africa, Kenya, and probably Ghana. But these countries contain little more than one-sixth of the population of the region and their declines have only lowered regional fertility marginally. Furthermore, the best socioeconomic indicators for reaching the threshold of decline appear to be at least 89 percent of all children born surviving to five years of age and at least 30 percent of adult girls attending high school.1’2 Even before new estimates of the impact of the AIDS epidemic, there were only two other countries likely to reach these levels within a decade, Cameroon and Senegal. Twenty years

Coordinator, Health Transition Centre, National

Emeritus Professor of Demography, University Fellow and Coordinator, Health Transition Centre, National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia (AfriReprod Health 1997;1(2):10—1 1)

from now, another ten countries will probably have achieved these levels, but almost half the countries of the region will still not be there, Of course, fertility decline may progressively begin at lower socio-economic thresholds, a kind of domino effect which certainly took place in Asia and perhaps Latin America.3 The reason why the old message is still relevant is that projected future population growth in sub-Saharan Africa is far greater than in any other part of the world, with population more than tripling by 2050 according to the United Nations Medium Projection, and most likely quadrupling before growth comes to an end.4 Given poor soils over much of the region and economic growth too slow to make an easy transition to capital-intensive, scientific farming, it is doubtful whether food production will be able to grow as rapidly as is needed.

Finally, African reproductive health is being assaulted by the AIDS epidemic to an extent unparalleled elsewhere. Almost two-thirds of all persons in the world infected by HIV/AIDS are found in the region, and over half in the main AIDS belt of East and southern Africa, a group of countries with only three percent of the world’s population. The demand for greater reproductive health initiatives comes from the need not only to curb AIDS, but also to reduce the very high level of other sexually transmitted diseases found in the region. A major forward movement against STDs is needed not only because they act as catalysts or cofactors for HIV infection, but also because these diseases themselves add to human misery, often cause sterility, and may cause death directly.

The disturbing new finding about AIDS is that HIV infection almost certainly has a biomedical impact on fertility, probably reducing it by more than one-third.5 Because of these findings, the US Bureau of the Census has released new population projections showing likely population decline in Zimbabwe and Botswana.6 This situation will make the already complex relationships between family planning programs and AIDS programs even more difficult.

These are all reproductive health matters which need sound research and the adequate reporting of research results. None of them are restricted to Africa, but the sub-Saharan African context is a specific one that is best served by a journal focused on the region. That is why I welcome the advent of this journal. It will report on the most challenging reproductive health problems found anywhere.