Senior Research Associate
Vaccines are one of the simplest, most cost-effective tools to improve public health. Vaccine-preventable diseases can lead to illness, disfigurement, disability, and death. Globally, immunization rates improved dramatically in the 1980s and 1990s, but progress has stalled in recent years. There has been a resurgence of some diseases once thought to be on the path to elimination. This webinar explored trends in vaccination and vaccine-preventable childhood disease globally, in the United States, and in California, and the policy implications of these trends.
In this recording of the webinar, Beth Jarosz, research associate at the Population Reference Bureau, and Reshma Naik, senior policy analyst at the Population Reference Bureau, presented trends in vaccination coverage and vaccine-preventable childhood diseases for major world regions. Regan Foust, senior manager for Data and Research at the Lucile Packard Foundation for Children’s Health, highlighted trends for the U.S. and California and provided a brief demonstration of the kidsdata.org website.
Webinar: Vaccination and Vaccine Preventable Childhood Diseases
This webinar was co-hosted by the Population Reference Bureau and the Lucile Packard Foundation for Children’s Health.
(February 2008) Each year, nearly 10 million children die, mostly from preventable and treatable causes. Millions of children in low-income countries suffer from long-term illnesses, malnutrition, and injuries that limit their life options. What can we do to improve children’s health and save lives in low-income countries? What are the links to mother’s health?
2008) Each year, nearly 10 million children die, mostly from preventable and treatable causes. Millions of children in low-income countries suffer from long-term illnesses, malnutrition, and injuries that limit their life options. What can we do to improve children’s health and save lives in low-income countries? What are the links to mother’s health?
In a PRB Discuss Online, Dr. Nils Daulaire, president and CEO of the Global Health Council, answered participants’ questions about ways to improve child health.
February 13, 2008 1 PM EST
Transcript of Questions and Answers
Olalla Bohigas: Hello Dr. Daulaire, I’m a Geography student from Spain. I would like to ask yo if you think that a totally public-funded sanitary system improves child health and in which ways. Thank you.
Nils Daulaire: I don’t think the critical question is whether it’s totally public-funded or not. I think the critical question is whether a given sanitary system actually works to provide clean water and safely remove sewage, whether it is maintained and operationally sustainable, whether it responds to the real needs of people at highest risk of water-borne diseases (e.g. the poorest) or serves only those who are better off. In many instances, this will indeed be mostly or totally public-funded, but the devil is in the details. The ways in which a working sanitary system improves child health is in the reduction of water-borne diseases, notably diarrheal diseases which still claim 2 million lives a year, and which account for a massive impact on undernutrition.
Richard Cincotta: “Low-income” has become a broad category due to emerging differences in these countries’ progress along the demographic and epidemeological transitions. Is there a basic intervention (or set of interventions) most needed in the lowest of the low-income group (such as Niger, Chad, Guinea), and other child-health investments more marginally effective for the middle-low and upper-low income categories?
Nils Daulaire: Firstly, the Global Health Council defines “low income” as people living on less than $2 per day (roughly 2.5 billion people). These are the people at highest risk of child mortality and morbidity, and they are our stated priority. Clearly those living at the lowest end of this scale will benefit most from the broad and proven cost-effective approaches to the most common childhood killers— childhood immunization, oral rehydration therapy for diarrhea, case management of pneumonia and malaria, vitamin A supplementation, and basic nutritional education and support. However, these programs do not significantly address the 40% of childhood deaths which occur in the perinatal and neonatal period; these require stronger systems for maternal and birth care and rapid response to early signs of neonatal problems. While these approaches are still quite basic, they require a level of infrastructure and health systems capability that may be more readily applied in middle-low income and higher settings.
Jane Roberts: In the long term, isn’t comprehensive reproductive health care and access to family planning the best long term solution? After all 40% of those 10 million deaths happen in the first month of life which means to me that the mothers were not healthy.
Nils Daulaire: I would challenge the presumption that any single approach is the “best long term solution.” What is needed is a systemic, and systematic solution that recognizes there is a spectrum of issues that need to be addressed. That said, family planning is indeed a vitally important contributor to improving child health and reducing child mortality. We know that increased child spacing and reduction in family size has a direct and very positive impact on child health and survival, as well as on nutritional status of children and their mothers, and on the prospects for education and economic opportunity. But let’s not imagine that we can reduce by two-thirds the nearly 10 million under-five deaths through family planning and reproductive health care alone. For that, we need simple but integrated programs that also work to address the leading causes of child illness and death, delivered in the same clinics and programs that are providing RH care to the mothers.
FAKOREDE AYODEJI: SOMETIMES THE PROBLEM CAN BE TRACED TO THE POOR HEALTH CONDITION OF THE MOTHERS IN SUB-SAHARAN AFRICA.CAN IMPROVING MOTHER’S HEALTH BRING GREAT CHANGE? IF SO IN WHICH WAY?
Nils Daulaire: Without a doubt, a critical determinant of the health of children is the underlying health of their mothers. If they are well nourished and have the opportunity to space and limit their pregnancies according to their own family needs and wishes, their children will have a higher likelihood of surviving and growing up healthy. However, materhal health alone will not resolve the enormous burden of childhood disease. Malaria-carrying mosquitoes will continue, whatever maternal health status. Poor sanitation will continue to make diarrhea a major killer. The area where maternal health care has the greatest potential to impact the health of children is in care of HIV-positive mothers, not only to prevent the transmission of HIV to their newborns, but also to assure the health and survival of the mothers upon whom these children depend for their own survival.
Raina Phillips: What would be your advice to a resident physician interested in making an impact on global health?
Nils Daulaire: Join the Global Health Council, come to the annual international conference on global health in Washington, DC in the end of May, meet with as many health practitioners and implementers there as you can, work toward an opportunity to serve the poor in low-income countries so that you can gain a first-hand experience that goes beyond first impressions, and THEN figure out where you might be able to provide a critical input—either in direct service, in critical areas of research, or in support for advocacy efforts to direct attention and resources to the critical health needs of the world’s poorest citizens. You can find more at www.globalhealth.org.
Victoria Sekitoleko: The communiies beligered with Poverty encourage very early marriages, say as soon as the girl is thirteen years of age, when she cannot even look after herself, she gets a kid to be fully responsible for! Is it any wonder that the babies die?
Nils Daulaire: Of course you are correct. Child marriage is bad for the girl, bad for the children she has before she is fully ready to be a mother, and bad for societies. It is a widely practiced and sadly accepted form of extreme child abuse and should be fought by legal means and changes in cultural norms. This shows that the answer to issues of child health are about more than just medical interventions. We must also look at, and respond to, the social determinants. However, all children, even those of mothers who are themselves children, benefit from essential child health services, and we should not wait for society to make the changes that are needed before we respond to the very immediate health needs of the children.
Md. nuruzzaman Haque: Dear Dr. Daulaire, I am a citizen of Bangladesh and a student of Demography in China. I would like to ask you should we focus more on infant health than child health in low income countries?
Nils Daulaire: It depends very much on the patterns of child death. In very low income societies, a considerable proportion of all child deaths—sometimes as much as one half—takes place in children between the ages of 12 and 59 months. In these situations, addressing the leading causes of death among these somewhat older children is often the quickest and easiest way to begin to lower childhood mortality. You can find more information on our website at www.globalhealth.org/childhealth. As a rule, death rates decrease dramatically above the age of 5, so older children are not a major focus of efforts. However, in most instances, it is children less than a year of age (infants) who suffer the largest proportion of child deaths, and in those instances it is appropriate to focus on their needs and health determinants. As noted in another question, addressing the health needs and survival of neonates is the largest piece of the “unfinished agenda” of child health, and should be addressed when the fundamental and inexpensive interventions addressing immunizable and readily treatable diseases are on the way to being handled.
Agnes M. Kotoh: Since most of the child health problems are in developing countries and among the poor, how can we use subsidises and exemption to ensure children from poor families have access to healthcare?
Nils Daulaire: I’m afraid you are asking a question best answered by a health economist; I am just a doctor. Clearly, we need ways to finance essential health services for poor children, who cannot themselves pay for anything, and whose families are often unable to pay for services. My personal view is that a package of essential child health services should be made universally available at no cost to those in need. That way we avoid market barriers as determinants of unnecessary illnesses and deaths, and ultimately this contributes to healthier, more productive, and ultimately more affluent societies. However, since many of these societies are very poor, this is why external support is critical to move past this conundrum, and the reason that the Global Health Council has called for affluent countries to invest an additional $7 billion a year (with $2 billion of that from the U.S) in maternal and child health programs in the world’s poorest countries (see our analysis at http://www.globalhealth.org/child_health/needs_costs/).
Amouh: Why [do] we keep on talking about the same problem over the years and we are not seeing improvment; and why are we doing it the same way?
Nils Daulaire: 1. We are seeing improvement. If we had not had child health and survival programs that started in the 1980s, we would today be experiencing more than 16 million child deaths a year. For the first time IN HISTORY this year, child deaths fell below the 10 million mark. That is insufficient progress, given that we have the tools to reduce child deaths by another 2/3 with thoughtful but very limited investments, but it is progress. 2. We are not doing it the same way. As an example, 20 years ago nobody knew about the value of Vitamin A supplementation, which could reduce child deaths by a million a year of more. Today, vitamin A programs are widely accepted and promoted. 15 years ago, few countries knew what to do about the leading cause of child deaths, pneumonia. Today, a growing number of countries have initiated effective and low-cost programs for case management with first line antibiotics. Ten years ago, more than a million children were dying each year because they did not have access to measles immunization. Today, that death toll is under 400 thousand. This is a progressive process, not an overnight miracle, but we are on the right path. What is needed now are the resources and the commitment to get the job done, which is why support for maternal and child health programs are the top priority of the Global Health Council.
Upendra: Developing contries like Nepal have high child mortality along with chronic health problems associated with low income [and] confilct. How can we deccrease child mortality in such country?
Nils Daulaire: I spent five years working on issues of child health in Nepal during the 1980s. I am gratified to know that the programs started in that period — vitamin A supplementation, case management of childhood pneumonia, maternal and child health services provided through a network of female community health volunteers—have dramatically decreased childhood mortality in Nepal over the past 2 decades despite the political turmoil that has taken place there. Nepal is definitely on the right path, and has a record of which it should be proud in the international arena. That’s not to say that there isn’t much more that could and should be done, but you should recognize that Nepal is a model for many other countries struggling to address the same problems.
Angela Albright: My observations from spending several months in East Africa is that child health (and all others) problems are heavily impacted by a lack of qualified professionals, especially nurses. Sadly, the nursing students are bright and motivated but do not have textbooks, adequate internet access, qualified teachers, and other “basics” of nursing education that are sorely needed. Most of the funding sources I saw are focused on training lowest level community workers to address a particular disease or health problem. What is the value of directing resources toward least trained community workers rather than toward a solid, sustainable education for nurses at a higher level who in turn will be able to build a healthcare system that could address child health in the context of comprehensive health programs.
Nils Daulaire: I do not believe the answer lies “just” in training community workers, nor in “just” training nurses. In order to address the health needs of children living in the poorest communities, a thoughtful and thorough analysis is needed, country-by-country, into what the principal health needs are, where people go for their care and counsel, whether nurses or community workers are more likely to be where they are needed when they are needed, and what the essential skill sets are to have an impact on health status. In other words, we need to approach this as a system, rather than as discrete and unconnected parts. Certainly, we need more well-trained, well-supervised, well-supplied and well-supported nurses—but in communities and clinics where the people are, not principally in capital city hospitals. We also need more well-trained, well-supervised, well-supplied and will-supported community workers, since they are often the first line of care and engagement, but not rank amateurs with no effective skills. I think the programs that will succeed will look at all the levels in the healthcare system, where the barriers to care and effective action lie, and what mix of health workers will best and most cost-effectively serve those needs. Even the occasional doctor may have some value.
Léon: Does IMCI (Integrated Management of Childhood Illness) really reduce child morbidity and mortality in developing countries?
Nils Daulaire: IMCI has been shown to work in clinical settings. It is based on a substantive and conceptual base that is very solid in terms of research into the individual components of IMCI. However, while it has been shown to be effective at the individual care level at facilities which have received good training and supervision, the answer is not as clear as to whether this approach works to have a significant impact on morbidity and mortality on a larger scale nationwide. I believe this will need to be tailored to individual national, and sub-national, realities (both the disease epidemiology, and the realities of health care workers and facilities) in order to get its optimal impact. One formula rarely works universally, so I would advise that you look at the situation you are in, and make appropriate adjustments that takes your own realities, as well as the scientific evidence, into account.
Chuck Woolery: Achieving, even exceeding, the Millennium Development Goals for maternal and child health is doable IF the political will exists. What will the Global Health Council do to ensure that sufficient political will is generated prior to 2015—to ensure we don’t repeat the failure of meeting similar goals established at the 1990 World Summit for Children for the year 2000?
Nils Daulaire: We have prioritized our advocacy efforts on maternal and child health, in other words MDG’s 4 and 5. This past year, the Global Health Council advocacy efforts succeeded in getting the US Congress to increase appropriations for MCH by nearly $100 million, the first increase in nearly 15 years. This is just a down payment, and we have established a goal of an additional $7 billion for this purpose from all international sources, with $2 billion of that from the U.S. We have worked actively to increase the levels of funding for PEPFAR and the Global Fund, and to support significant increases in funding for malaria and TB (MDG 6). As you know, getting money rather than words on the table is the real challenge in political advocacy, and we are working with our members (we now have Global Health Council members in over 140 countries, with over 500 organizational members who are on the front lines of services as well as advocacy) to prioritize influencing their governments, both donor and low-income, to prioritize the health needs of the poorest—e.g. MDG’s 4, 5, and 6, with a significant nod as well to the importance, neglected in the initial MDGs, of addressing reproductive health and family planning as a critical aspect of reducing global poverty. We have recently started an active dialogue with partners in Europe to establish a similar advocacy effort at the level of the EU, and have worked to strengthen indigenous advocacy efforts throughout the global South.
Michael MacHarg: Nils – thank you for sharing the time. I wondered what role you see for Ready to use therapeutic foods (RUTF) to address severe child malnutrition – especially as many advocate to bring this treatment to the community level? What obstacles do you see in implementing a broader reach for RUTFs?
Nils Daulaire: I can’t say I’m a qualified nutritionist, but based on my observations in Niger and elsewhere over the past few years, it appears that RUTF is an appropriate intervention in crisis and severe malnutrition situations. However, this does not replace the need for thorough and consistent food security and nutrition efforts that will assure two critical elements: that enough food of sufficient quality is widely available and affordable to the poorest families, and that mothers and other caretakers are educated and engaged in appropriate nutritional behaviors, ranging from early and exclusive breastfeeding, to appropriate weaning foods, to useful and valid nutritional supplementation where appropriate. I do not think that RUTFs have much of a role in addressing widescale mild to moderate undernutrition, since they will not help to build up the sustainable food production and utilization practices that are essential for long-term improvement in nutritional status. In that sense, I see RUTF as similar to essential drugs for high priority diseases.
Rahat Bari Tooheen: There are many aspects of health which do not require a lot of funds, such as raising awareness. Will raising only awareness in the developing countries improve child health? What other attributes, other than the link to mother’s health, need to be focused on?
Nils Daulaire: I disagree that raising awareness does not require funds. This is why advertisers spend billions upon billions of dollars. The critical question is: raising awareness of what, and to what end? Breastfeeding promotion is largely a matter of awareness, and has made substantial progress. Diarrhea awareness requires access to the constituents of oral rehydration solution, and appropriate education in its mixing and administration. Immunization awareness requires the presence of working vaccination programs and the infrastructure to support them. Pneumonia awareness requires the availability of trained health workers and antibiotics. Child spacing awareness requires access to safe and effective contraceptives. The point I am making is that awareness is a critical, but not a sufficient, ingredient in improving health. It needs to be a part of a larger, and well-considered health strategy, in which the healthcare system must also be an integral part.
email@example.com: The public is confused about pulse polio immunisation. When it would yield the proposed complete eradication [of the] polio epidemic?
Nils Daulaire: Nobody knows when polio eradication will be completed. As we have learned over the past decade, the complications of reaching the final resistant sites of polio are daunting, and are requiring far more time, resources and energy than had previously been thought. The latest reports I have seen from WHO and Rotary International indicate that significant progress is being made in northern India and Nigeria, but that transmission has not yet been broken. This requires ongoing surveillance and vigilance. If someone is giving a date for final polio eradication, they are in touch with some higher order intelligence. I believe that polio eradication in the next several years is likely, but by no means certain, and I cannot be any more definitive than that.
Satvika Chalasani: What do you think is the most important obstacle in improving child health in low-income countries? The lack of funding? The lack of basic infrastructure needed for implementing interventions? Cultural resistance? The lack of research on delivery systems?
Nils Daulaire: I believe there are a set of interrelated obstacles. First, that children and their health are truly not a political priority for many countries. Second, that resources are often not deployed for maximum impact (consider the amount of money spent on national children’s hospitals in many low-income countries compared to the money spent on first-line interventions in communities and clinics where most of the ill children are seen). Third, that effective and proven interventions are often not implemented, due to lack of analysis and information among those who set national policies as well as inadequate training and oversight of those who implement. Fourth, that the overall level of resources are still inadequate to meet the need. Fifth, that understanding and effective interventions to influence the behaviors of caretakers are often limited because of a lack of cultural understanding. There are more, but the bottom line is that child health requires a systems approach, not simply addressing one particular link in the chain, and systems thinking is often lacking among those charged with the responsibility to improve the end product: children’s health and survival.
Meghan Reppond: Given the relationship between poverty, education and nutrition, or nutrition as it relates to health, where should the intervention be made given limited development dollars, and why? Where can the intervention be most cost-effective?
Nils Daulaire: Wow, that’s a question worthy of a PhD thesis! As I have stated in response to other questions, I do not believe that there is a single “best answer” to what to do about child health. Child health and survival are the consequence of a complex set of interacting factors, several of which you have cited. Others have been cited in other questions. As a child health practitioner in low-income societies myself for many years, I came to recognize that you have to address multiple points in the causal chain, and that there is not a single formula that can pop out the “optimal solution.” This is not the same as saying nothing can be done without doing everything. In fact, I have myself participated in programs where fairly simple and straightforward interventions (vitamin A supplementation, as an example) had major and significant impact. However, those interventions are not a replacement for the reality that improved economic status, improved status of women, improved education, improved overall food security and nutrition at the household level, and improved political voice for those at the lower end of society’s ladder, all have major and lasting impacts on the health and survival of children, and of their mothers. Instead of looking for the “most cost-effective” intervention for universal application, I think we are better advised to look for what is do-able and has been proven to have impact, what meets the perceived needs of the society being served, and what is possible in the near and middle terms by the national health programs and local health efforts that are actually in place.
Birungi Beatrice: Is it possible to send me more material on children issues, like child abuse, and child development. Thank you
Nils Daulaire: Please refer to our website, http://www.globalhealth.org/childhealth/
Birungi Beatrice: Mr Nils, in most countries attention to recieve ARVS is mostly given to adults,or sometimes people with money. What do you have to say?
Nils Daulaire: Children with HIV infection have as much right to care and treatment as adults. Poor people have as much right as rich people. The focus of so many efforts over the past decade have been to focus on the RIGHT TO HEALTH, rather than on healthcare as a commercial commodity. We devote a considerable portion of our advocacy efforts to the issue of health equity, which is central to our view of a just and healthy world.
ABIOU Ulrich: Why [is it that], despite the progress of science today, too many people in underdeveloped countries haven’t information on the best way to threat their children suffering from Diarrhoeal Disease?
Nils Daulaire: I believe this is because we, as health professionals and health educators, have not fulfilled our full responsibilities. It is not sufficient to have the answer yourself if you have not effectively transmitted that answer to those who need it, in a form and manner that they can use. It is the responsibility of every healthcare worker, every government and NGO health official, and in fact every political leader, to make sure that accurate, usable information is shared with those who need it most. We should be judged on the basis of what results—in other words, on the basis of decreased cases and deaths of diarrhoeal disease—rather than on what we have said, or what we have tried. If we were all held to that standard, it would be likely that our efforts would become more effective.
Professor Miriam Labbok, MD, MPH: Dear Nils: Given the Lancet series showing that exclusive breastfeeding is the number one intervention to save children’s lives, the Horta meta-analysis on long-term benefits and the Ip meta-analysis on breastfeeding in the developed countries, and given the solid evidence reivewed at Innocenti + 15 on the need for a comprehensive program response if we wish to see sustainable impact, and givent that the ACSD and Ending Hunger approaches of UNICEF offer only that we should educate on breastfeeding, an approach that is known to have a limited impact, what can be done to increase the global funding for a comprehensive approach, including health professionals and systems, community mobilization, maternity protection and national oversight for this vital area?
Nils Daulaire: I know that you are one of the world’s experts in this arena, and I would look to you, as a longstanding member and enthusiastic supporter of the Global Health Council’s mission, to help guide us in this arena. We have made early and exclusive breastfeeding an important aspect of our advocacy efforts, and would be delighted to work with you to figure out effective ways to make this “stick” in operational terms. Let’s discuss in follow-up.
Ye Mon Myint: Why isn’t family planning been considered as one of the child health interventions?
Nils Daulaire: It is, and should always be. Please see my to Jane (above). Child spacing and family planning are a critical element of reducing child mortality, undernutrition, and chronic illness.
Dr. Papiya Mazumdar: Dear Dr. Daulaire, the recent round of National Family Health Survey (NFHS-3) in India showed high level of malnutrition and anemia among mothers and children, in-spite of the nationwide programme implemented since 1997.What you suggest should be an immediate focus for India and what ways could proved to be more effective?
Nils Daulaire: I can’t claim meaningful personal knowledge of the situation in India, but I do know that malnutrition has been a persistent problem among the poor, particularly children and mothers. I also know that efforts are now underway to revitalize primary health care services, and would hope that they prioritize basic nutrition and health interventions. Clearly the potential for immediate impact from certain targeted supplements (vitamin A, zinc, iron folate) are important elements, but need to be part of a larger and more comprehensive package that include basic immunization and acute care, family planning, and nutrition education.
Kate Tallant: What is the role of advocacy in reducing childhood death and illness caused by diarrheal disease? What are the political and practical barriers to creating an advocacy strategy that will increase global resources and support for strategies aimed to reduce diarrheal disease?
Nils Daulaire: Advocacy has two important roles, which play out in very different parts of the system. One is advocacy for resources and attention to diarrheal disease. The other is advocacy among those whose children are at risk of diarrheal death. The barriers to an effective advocacy strategy to increase resources, attention and support are, to a considerable extent, based on the MISperception among policymakers and the public that diarrhea is not a major problem. In focus group work we have done at the Global Health Council, people routinely believe that AIDS is a far greater health threat to children living in poverty than diarrhea. As you are well aware, the opposite is in fact the case. But because diarrhea does not have the same kind of political activists and celebrity support as AIDS (I once called for a celebrity spokesperson for diarrhea—guess how well that went over?), it has not entered the public consciousness in the same way. We have a lot of work to do, and I hope those reading this Q&A have ideas that they would be willing to share with the ongoing policy and advocacy efforts of the Global Health Council. The barriers to effective advocacy among those who most need to learn about and use oral rehydration therapy, and improved sanitation practices, have more to do with inappropriate or misguided health education efforts. I recall when I was working on ORS in Nepal in the 80s, we proposed that since mothers were more comfortable giving their children ORS in containers smaller than one liter, consideration should be given to a campaign to promote 1/2 liter packets and mixing cups, which we had tested and found appropriate to mothers
(December 2007) In the South, Texas, Florida, and Georgia are poised to gain seats in the U.S. House of Representatives after the 2010 Census. Texas is on track to add two seats, while Florida and Georgia could add one seat each. In the West, Arizona, Nevada, and Utah could each gain one more seat.
After each decennial census, population totals in each state are used to reallocate the 435 House seats. Therefore, regional shifts in population affect the balance of political power across states. For example, after the 2000 Census, Pennsylvania and Florida lost two seats each, while Arizona, Florida, Georgia, and Texas each gained two seats.
Some States Could Gain or Lose Power in Congress
If the 2007 census estimates accurately foretell the 2010 Census results, then 13 states will gain or lose House seats and votes in the Electoral College, which picks the president after the election. Louisiana is one of the states at risk of losing a seat—a consequence of people fleeing New Orleans after Hurricane Katrina. The Census Bureau estimates that between 2000 and 2007, Louisiana lost 176,000 people, although the population has rebounded slightly in the past year.
Six states in the Northeast and Midwest could also lose House seats, including Iowa, Massachusetts, Missouri, New York, Ohio, and Pennsylvania.
These projections reflect a continuing pattern of rapid growth in the South and West, and slow or declining populations in parts of the Northeast and Midwest. In 2006, the U.S. population topped 300 million, and with an annual population growth rate of nearly 1 percent per year, the United States is one of the fastest-growing developed countries in the world. But population growth within the United States varies across different states and regions.
States in the South and West grew by 1.4 percent during the past year, compared with a 0.3 percent growth rate among states in the Midwest and Northeast. Arizona, Nevada, and Utah were the fastest-growing states from 2006 to 2007, with annual population growth rates more than 2.5 times the national average (see table). Population declined in Michigan and Rhode Island because of net migration out of those states. With the exception of Louisiana’s recent population loss, the trends we are seeing today are a continuation of the westward/southward expansion that took place during the past century.1
Population Growth Rates for Selected States, 2006-2007
|Slow growth or decline|
Source: U.S. Census Bureau.
Migration From Other States Fuels Growth of South and West
What drives rapid population growth in the U.S. South and West? Immigration from Mexico is typically cited as the top factor. But census estimates show that net domestic (state-to-state) migration to Nevada exceeds international migration to that state by a 4-to-1 margin. In Idaho, the margin is more than 8-to-1. Not all domestic migrants were born in the United States; some are immigrants who arrived in New York, Los Angeles, or other gateway cities, and then fanned out to other parts of the country. However, a Population Reference Bureau analysis of data from the American Community Survey showed that only 11 percent of people who moved across state lines in 2005 and 2006 were born outside the United States.
High rates of natural increase (the excess of births over deaths) also feed rapid population growth in high-migration states. Migrants tend to be younger, and populations with younger age structures have a built-in population momentum. Lots of young people moving into a state contribute to lots of births, which further increase a state’s population and capacity for growth.
Migration trends in slow-growing or declining states look very different. As domestic migrants leave these states to seek opportunities elsewhere, international migrants are moving in to fill the gap. In New York, for example, for every two people leaving the state during the past year, there was one person arriving from another country to help offset the population decline.2
Population Trends Linked to Job Growth
Although people move for a variety of reasons, most long-distance moves are job related.3 Therefore, it is not surprising that states with the highest rates of population growth since 1990—Arizona, Idaho, Nevada, and Utah—have also experienced the fastest rates of employment growth (download related graph, PDF: 96KB). Jobs attract new residents to high-growth states, and then those residents create further opportunities for employment through increased demand for new homes, infrastructure, and services for the growing population.
Interestingly, in a cluster of states in the Mountain West and Upper Great Plains (Montana, North Dakota, South Dakota, and Wyoming), employment growth has consistently outpaced population growth. Although these states benefit from low unemployment rates, they face challenges in attracting and retaining young adults and families, especially in rural farming communities that have been losing population for several decades.4
Mark Mather is deputy director of domestic programs at the Population Reference Bureau.
- Frank Hobbs and Nicole Stoops, Census 2000 Special Reports, Series CENSR-4, Demographic Trends in the 20th Century (Washington, DC: U.S. Government Printing Office, 2002).
- These figures do not represent the actual number of people arriving from other countries or leaving the state. Rather, they reflect the net gain/loss from international migration and the net gain/loss from domestic migration.
- Jason Schachter, “Why People Move: Exploring the March 2000 Current Population Survey,” Current Population Reports (May 2001): 3.
- Richard W. Rathge, “The Changing Population Profile of the Great Plains,” The Great Plains Sociologist 16, no. 1 (2005): 82-99.
December 27, 2007
Population Reference Bureau
(Octobre 2007) Les taux de besoins en services de planification familiale non satisfait demeurent élevés dans les pays en développement : c’est ce que révèle un rapport que vient de publier le Guttmacher Institute, institution basée aux Etats-Unis.1 Selon les enquêtes, une femme mariée sur sept dans ces pays n’a pas accès à la contraception. Mais en Afrique sub-saharienne, ce ratio est de près de une sur quatre.
Les femmes ayant des « besoins non satisfaits en services de planification familiale » sont des femmes en âge d’avoir des enfants qui préfèrent reporter ou éviter une grossesse, mais n’utilisent pas de méthode de contraception. Depuis les années 1960, lorsque ce concept a commencé à faire son apparition, répondre aux besoins non satisfaits est devenu la base de nombreux programmes de planification familiale et de population du monde.2
Des progrès limités
Sur la base de données tirées des Enquêtes démographiques et de santé, les auteurs du rapport Guttmacher ont conclu qu’entre 1990 et 1995 et entre 2000 et 2005, les besoins non satisfaits ont enregistré un déclin de près de 2 % en Afrique sub-saharienne. Dans d’autres régions du monde en développement — notamment l’Amérique Latine et les Caraïbes, l’Afrique du Nord et l’Asie de l’Ouest, et l’Asie du Sud et du Sud-est — les progrès ont été supérieurs et le taux de besoins non satisfaits a baissé d’entre 4 et 7 %.
Pourcentage de femmes mariées ayant un besoin non satisfait de services de contraception, ventilé par région, 1990-1995 et 2000-2005
Note : Les femmes sont considérées comme ayant un besoin non satisfait si elles déclarent qu’elles préfèrent éviter une grossesse mais n’utilisent aucune méthode de contraception.
Source : Gilda Sedgh et al., Women With an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method (New York : Guttmacher Institute, 2007).
Les moyennes régionales dissimulent parfois des écarts considérables dans les taux de besoins non satisfaits des différents pays. Par exemple, dans la région Amérique Latine et Caraïbes, 6 % seulement des femmes au Brésil présentaient des besoins non satisfaits, contre 40 % des femmes en Haïti.
Obstacles à l’amélioration de la réponse aux besoins
Selon les auteurs du rapport, il reste encore des obstacles à la mise en application efficace des programmes de planification familiale et de réduction des besoins non satisfaits de services contraceptifs pour diverses raisons :
- Une femme ne pense pas courir de risque de tomber enceinte, elle n’est pas informée des méthodes de contraception ou bien elle s’inquiète des risques pour sa santé et des effets secondaires éventuels.
- Les services de contraception ne sont pas facilement accessibles ou la gamme des méthodes offertes est limitée.
- La femme, son partenaire ou d’autres membres de la proche famille s’opposent aux méthodes de planification familiale.
Les raisons avancées par les femmes qui n’utilisent pas la contraception varient d’une région et d’un pays à l’autre. Par exemple, en Afrique du Nord et en Asie de l’Ouest, plus de 60 % des femmes ayant un besoin non satisfait en services contraceptifs, n’ont pas recours à la contraception parce qu’elles ne pensent pas courir le risque de tomber enceinte. En Amérique Latine, environ la moitié des femmes ont avancé le même argument. Et en Asie du Sud et du Sud-Est et en Afrique sub-saharienne, environ 35 % des femmes ont fait de même.
Les femmes sont aujourd’hui mieux informées de leurs options contraceptives. La proportion des femmes mariées qui attribuent leur non utilisation de contraceptifs au manque d’informations a chuté en flèche depuis les années 1980. À la fin des années 1980, 25 à 44 % des femmes donnaient cette raison. Selon les enquêtes réalisées depuis 2000, zéro à 12 % des femmes déclarent ne pas utiliser la contraception par manque d’information.
Pourquoi les femmes n’utilisent-elles pas la contraception ?
Cependant, un plus grand nombre de femmes optent aujourd’hui contre la contraception en raison de leurs inquiétudes quant aux risques de santé et aux effets secondaires de différentes méthodes ou considèrent la contraception trop contraignante. À la fin des années 1980, 6 à 28 % des femmes mariées citaient une de ces raisons liées à la méthode, mais entre 19 et 36 % des femmes ont donné cette même réponse plus récemment. Ceci semble indiquer que, malgré le succès des programmes d’éducation des femmes concernant leurs options de planification familiale, les risques réels et perçus liés à certaines méthodes de contraception continuent à en entraver l’utilisation.
Un changement tactique
Pour résoudre le problème continu des besoins non satisfaits, les promoteurs de la planification familiale ont cessé de se concentrer exclusivement sur la réduction des pressions environnementales, économiques et sociales de la croissance démographiques et se tournent maintenant aussi vers l’incitation des couples à atteindre leurs propres objectifs de fécondité en aidant ceux-ci à choisir le nombre et l’espacement des grossesses. Selon les spécialistes des sciences sociales, la lutte contre les besoins non satisfaits sera utile aux femmes, en particulier celles des pays en développement.
Si une femme peut décider du nombre d’enfants qu’elle aura ou de l’espacement entre les naissances, elle peut ainsi limiter les risques pesant sur sa santé, notamment la mortalité ou l’invalidité associée aux avortements à risque pour mettre fin aux grossesses non souhaitées ou inopportunes, renforcer son niveau d’éducation et améliorer ses chances d’emploi ; participer davantage à la vie sociale et politique et améliorer ses conditions de vie.
Sur la base des attitudes et des comportements des femmes dans le monde en développement, les auteurs suggèrent la réponse suivante aux besoins non satisfaits :
- Se concentrer sur les populations les moins desservies, en particulier les femmes de l’Afrique sub-saharienne, en incluant à la fois les femmes les plus pauvres de toutes les régions et celles qui vivent dans les zone rurales.
- Diversifier et améliorer les méthodes contraceptives et offrir des services de conseil pour permettre à chaque femme de sélectionner la méthode lui convenant le mieux.
- Renforcer la sensibilisation et poursuivre les efforts d’éducation sur la planification familiale en abordant notamment les perceptions excessives des niveaux de risque.
- Offrir de meilleures opportunités éducatives et économiques aux femmes, notamment pour les démarginaliser et pour promouvoir des changements culturels en faveur de la planification familiale.
Sara Maki était stagiaire au PRB pendant l’été 2007.
- Gilda Sedgh et al., Women With an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method (New York : Guttmacher Institute, 2007), consulté en ligne à www.guttmacher.org le 27 août 2007.
- John B. Casterline et Steven W. Sinding, « Unmet Need for Family Planning in Developing Countries and Implications for Population Policy », Policy Research Division Working Paper 135 (2000), consulté en ligne à www.popcouncil.org le 27 août 2007.
Voir également : Lori Ashford, Besoin insatisfait en planning familial : les tendances récentes et leurs répercussions sur les programmes (Washington, D.C. : Population Reference Bureau, 2003). Disponible en ligne à http://www.prb.orghttps://www.prb.org/wp-content/uploads/2003/02/UnmetNeed_French.pdf .