Family Planning in Sub-Saharan Africa: Reducing Risks in the Era of AIDS

By Richard P. Cincotta and Sarah Haddock

Ideological issues and shifting attention to HIV/AIDS have led to a diminution of U.S. leadership in [international family planning assistance]. Yet the demographic projections in Africa should give the United States serious concern. Famine-prone countries like Ethiopia and Niger have doubled their population in the past two decades and the projections suggest further sharp increases in the future. In particular, the social and political impact of the growing youth bulge should garner more attention to population policy, as this bulge presages more conflict, unemployment, and potential recruitment for extremist activity.

— Independent Task Force commissioned by the Council on Foreign Relations, 2005

A recent report by an independent task force enlisted by the Council on Foreign Relations (CFR, More Than Humanitarianism: A Strategic U.S. Approach toward Africa, 2005) recommends that the U.S. government step up funding to international family planning programs in sub-Saharan Africa as part of a strategy to increase U.S. engagement and prioritize assistance to that region (see p. 16, pp. 119-120).1

The task force’s recommendations may be the strongest call for action on these programs in nearly two decades – since the rise of HIV/AIDS as a major source of morbidity and mortality and as an impediment to human capital formation. But is a re-emphasis on family planning actually appropriate in a region where AIDS, particularly in southern and eastern Africa, has driven adult mortality rates to unprecedented levels and halted an otherwise declining rate of infant mortality?

Yes, unequivocally. Alongside comprehensive HIV/AIDS prevention, care and treatment efforts, African nations (with hefty support from the U.S. and other development donors) should expand the capacity and quality of family planning services in their countries. The objective should be to reduce the proportion of unwanted pregnancies, promoting much needed declines in fertility and in maternal and infant mortality. Better access to modern contraception and counseling served East Asian women in their transition to improved health status, increased educational attainment and greater participation in labor markets. It could also help strengthen the status of African women, as well as contribute to ameliorating Africa’s troubled economic and political conditions. A practically designed linkage of family planning services to efforts in HIV prevention and testing promises to increase the efficacy of both programs.

Reducing Risks to Families and Individuals

The most immediate, measurable and direct positive effects of reductions in unwanted pregnancies are on the health status of women and children – and it is on the improvement of these indicators that African countries need a great deal of assistance.

For African women, the lifetime risk of dying during pregnancy is one in 16 while among North American women the risk is about one in 3,700.2 More than 37 percent of maternal mortality is estimated to occur in sub-Saharan Africa, yet African women of childbearing ages (ages 15 to 49 years) account for just 10 percent of that age group worldwide.

While dependable maternal health data are difficult to obtain in many developing countries,3qualitative research has shown (and logic suggests) that providing women and couples with access to reproductive health information and contraception increases their capacity to prevent high-risk pregnancies and to adjust their reproductive intentions to changes in economic conditions, shifting social situations and declines in their health status (including HIV infection or other debilitating illnesses). Quantitative research has shown that adolescent pregnancies can erode women’s health status and adversely affect the health of their children4 and that extended birth spacing, for lengths up to three years, can significantly diminish the likelihood of childhood death.5

In African countries’ efforts to mobilize against the HIV/AIDS pandemic, programs to combat this disease have eclipsed women’s other health needs. Recent estimates of the components of maternal mortality suggest that in parts of West Africa, where HIV prevalence has remained lower than in other African regions, fewer women may be dying from AIDS than from unsafe abortions6 – a situation that exposes the gravity of the risk associated with women’s lack of access to contraceptives and counseling.

Collaboration between family planning programs and HIV/AIDS programs could improve the results of both interventions. Family planning organizations, because of their proven success in promoting behavioral changes, their experience in brokering public dialogues about sex, their proven capacity to conduct confidential testing, counseling and services, and their knowledge of contraceptive marketing, could play a greater role in the fight to roll back the rate of HIV infection.7

Reducing Risks to States and Regions

As a group, the 49 countries8 of sub-Saharan Africa trail most others in their progress through the demographic transition – which is the transformation of a population with large families and short lives, to one with small families and longer lives. These countries also exhibit extremely youthful age structures, rapid growth in the working-age population and rapid urban population growth, yet lack appreciable foreign investment and job growth.

These conditions put African states at an elevated risk of political instability and civil conflict9and diminish their attractiveness to foreign investors. In fact, 19 of the sub-Saharan African states experienced civil conflict between 2000 and 2004.10

Rapid population growth and increasingly high rural population density in agricultural areas are outstripping the labor-absorbing capacity of sub-Saharan agricultural and natural resource production systems and promoting rural-to-urban migration. Currently, 11 sub-Saharan African countries are regarded as freshwater stressed or scarce countries, in terms of availability on a per capita basis, and 22 are regarded as cropland stressed or scarce.11

Three of sub-Saharan Africa’s four regions (according to the United Nations categorization: western, central, eastern and southern Africa) are those with the highest rates of fertility and infant mortality (figure 1). The exceedingly high levels of childhood dependency (the ratio of dependent children to working-age adults)12 experienced by African states tend to dampen household savings, strain school systems, and depress growth in per capita income.13

Although UN demographers expect high rates of AIDS-related mortality to continue in the southern and eastern regions, they project sub-Saharan Africa’s total population will grow from approximately 750 million in 2005, to between 1.4 and 1.9 billion by 2050.14

Admittedly, surveys suggest that in many sub-Saharan countries women continue to desire a relatively large family size.15 Yet, three countries (South Africa, Mauritius, and Réunion) have already reached total fertility rates16 under 3 children per woman (figure 2), while others – including Botswana, Burkina Faso, Cameroon, Ghana, Madagascar, Malawi, Mozambique, Namibia, Tanzania, Uganda, Zambia and Zimbabwe – have experienced substantial upturns in contraceptive use over the past decade.17

In several of these countries increased use of contraception may relate, in part, to national and community leaders, women’s groups and celebrities who have used public media to promote the positive aspects of raising small families, spacing childbirth, delaying marriage and practicing safe sex, as well as communicating concerns about some of the negative aspects of continued rapid population growth in their country.


There is no time like the present to step up global funding for family planning programs in sub-Saharan Africa. The severity of the ongoing HIV/AIDS pandemic only makes Africa’s needs more imperative. The U.S. could lead the way in helping encourage Africa’s demographic transition – much as it did in East Asia four decades ago.18 A recent article by demographer John Cleland and Steven Sinding, executive director of the International Planned Parenthood Federation,19 recommends that African states, bilateral and multilateral donors, foundations and non-governmental organizations collaborate to:

  • make family planning information and services more widely available;
  • fund communications efforts providing clear and credible public messages that legitimate smaller families and contraceptive use; and
  • more closely link family planning and HIV-prevention programs.

Today, more than 175 million women of childbearing age (ages 15 to 49 years) live in sub-Saharan Africa. According to the UN Population Division that number is projected to rise to about 220 million by 2015, despite the assumption of continued HIV infection and AIDS-related mortality.20

Rather than preparing to meet this challenge, U.S. assistance in family planning has actually declined. Since 1995, U.S. international funding for family planning services, contraceptives and related programs, which serve both women and men in more than 50 countries, has fallen by more than $100 million – a 35 percent reduction when adjusted for inflation. During fiscal year 2005, the U.S. spent $437.3 million on its international family planning program, an amount equivalent to about 9 hours of U.S. defense spending.21

Certainly, our country could do better. The U.S. government would be strategically wise to prioritize its spending on a program that has already demonstrated its successfulness, at a time when sub-Saharan Africa countries, and African women and their children, are desperately in need of success.

Richard Cincotta, PhD, is a senior research associate at Population Action International. He worked in USAID’s Office of Population and Reproductive Health from 1992 to 1996.

Sarah Haddock is a research assistant at Population Action International and has worked in the Caribbean and Spain on health sector issues.


Table of Contents

  • Introduction
  • Reducing Risks to Families and Individuals
  • Reducing Risks to States and Regions
  • Conclusions


  • Independent Task Force, Council on Foreign Relations. More Than Humanitarianism: A Strategic U.S. Approach toward Africa. Washington, DC: Council on Foreign Relations, 2005, on the web at: Task Force Web.pdf
  • AbouZahr, C. and T. Wardlaw. 2004. Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA. New York: United Nations.
  • UN, Department of Economic and Social Affairs. 2005. The World’s Women 2005: Progress in Statistics. New York: United Nations.
  • Conde-Agudelo, A.and J.M. Belizán. 2000. “Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study.” British Medical Journal321(18 November):1255-1259; Meade, C.S., and J.R. Ickovics. 2005. “Systematic Review of Sexual Risk among Pregnant and Mothering Teens in the USA: Pregnancy as an Opportunity for Integrated Prevention of STD and Repeat Pregnancy.” Social Science and Medicine 60: 661-678.
  • Rutstein, S.O. 2005. “Effects of Preceding Birth Intervals on Neonatal, Infant and under-Five Years Mortality and Nutritional Status in Developing Countries: Evidence from the Demographic and Health Surveys.” International Journal of Gynecology and Obstetrics 89 (Apr), Suppl. 1:S7-S24.
  • Mayhew, S.M. and S. Adjei. 2004. “Sexual and Reproductive Health: Challenges for Priority-setting in Ghana’s Health Reform.” Health Policy and  Planning, 19(Suppl. 1), i50-i61.
  • Piotrow, P.T., D.L. Kincaid, J.G. Rimon, and W. Rhinehart. Health Communication: Lessons from Family Planning and Reproductive Health. Westport, CT: Praeger, 1997.
  • The United Nations list of Sub-Saharan African countries includes several geographically distinct territories that are not independent states. All countries in this region are listed here .
  • Cincotta, R P., R. Engelman, and D. Anastasion. The Security Demographic: Population and Civil Conflict after the Cold War. Washington, DC: Population Action International, 2003.
  • Uppsala Conflict Data Program. Uppsala Conflict Database. Harbom, L. ed., Uppsala Univ.: Uppsala, 2005, on the web at
  • Countries denoted as freshwater stressed have less than 1,667 cubic meters of renewable fresh water per capita; those denoted as freshwater scarce have less than 1,000 cubic meters per capita. Countries denoted as cropland stressed have less than 0.21 hectares of cropland per capita; those denoted as cropland scarce have less than 0.07 hectares per person; see Cincotta, R P., R. Engelman, and D. Anastasion. 2003. The Security Demographic: Population and Civil Conflict after the Cold War. Washington, DC: Population Action International; Engelman, R., D. Anastasion, and S. Haddock. People in the Balance, 2005 Update. Population Action International, forthcoming to the web.
  • Childhood dependents are assumed to be the population from ages 0 to 14 year. Working-age adults are those aged 15 to 64 years.
  • Lee, R.D., A. Mason, and T. Miller. 2001. “Saving, Wealth, and Population,” inPopulation Matters: Demographic Change, Economic Growth and Poverty in the Developing World, Birdsall, N., A.C. Kelley and S. W. Sinding, eds., pp. 137-164. London: Oxford Univ. Press; Bloom, D., and D. Canning. 2001. “Cumulative Causality, Demographic Change and Economic Growth,” in Birdsall et al., eds., pp. 165-97; Hausmann, R., and M. Székely. “Inequality and the Family in Latin America,” in Birdsall et al., eds., pp. 260-295.
  • This latter range represents the spread between the UN Population Division’s low variant and high variant projections.
  • Demographic and Health Surveys (DHS). “Statcompiler,” Measure DHS, 2006, on the web at
  • Total fertility rate (TFR) is the expected average lifetime fertility of all women in the population of childbearing age, assumed to between 15 and 49 years.
  • Demographic and Health Surveys (DHS), 2006.
  • Harkavy, O. 1996. Curbing Population Growth: An Insiders Perspective on the Population Movement. New York: Plenum Press.
  • Cleland, J, and S. Sinding. 2005. “What Would Malthus Say About Africa?” The Lancet, 366, no. 9500: 1899-1901.
  • UN Population Division. 2005. World Population Prospects: 2004 Revision. New York: United Nations,
  • For this calculation, U.S. annual expenditures on international family planning are compared to U.S. Dept. of Defense expected outlays for FY2005 are compared to hourly rates of expenditure, estimated from the annual estimated rate in the Dept. of Defense’s “Green Book”; see Nowels, L. 2005. “Population Assistance and Family Planning Programs: Issues for Congress: Update, May 2005,” Washington, DC: Congressional Research Service; Office of the Undersecretary of Defense. 2004.National Defense Budget Estimates for FY2005, Washington: U.S. Dept. of Defense, on the web here.