This article is an overview of 4 chapters of part I of the 1991 World Bank publication entitled Disease and Mortality in Sub-Saharan Africa. It discusses what the health community currently knows about the levels trends and patterns of mortality in Sub-Saharan Africa. In fact it points out that only limited data are currently available. Demographic techniques have evolved to overcome data limitations however. These chapters also identify important information gaps that must be filled to plan interventions. These chapters reveal that mortality levels are higher in Sub-Saharan Africa than in other developing regions. Mortality of children <5 years old has decreased since the 1940s in most Sub-Saharan African countries except for countries who have experienced war and civil unrest. Further Sub-Saharan Africa exhibits a specific mortality pattern: higher levels of infant young child and adult mortality exist in western Africa than in eastern or southern Africa. Nevertheless adult mortality in western Africa fell considerably between the 1950s-late 1970s but it did not fall much in eastern African countries (their levels were lower initially though). This article suggests that donors could greatly contribute to developing planning ability in Sub-Saharan Africa by supporting the establishment of a vital registration system. Health planners often have access to hospital record and community survey data however but these data are biased. Further these chapters show that interventions to reduce mortality do not necessarily result in a reduction in morbidity. Rapid population growth and high fertility pose further problems for health planners.

By expanding use of family planning Sub-Saharan Africa, countries can limit the expected growth in population to below 1.8 billion by 2050: evidence for unmet needs, as well as feasible means of improving use of family planning are discussed. Government generally support family planning, but actually provide limited services, usually restricted to maternal-child health clinics. They need to expand services to adolescents, young married women and men, to offer more choices including sterilization, and to utilize other means of distribution. Evidence for unmet need for family planning, that is numbers of women who do not currently use, but who express desire for no more children, is suggested by the rising abortion rates. Educated women especially are increasingly resorting to clandestine abortions. A few areas and pilot studies indicate high contraceptive rates, when services are provided effectively. People fear contraceptives because they think they cause infertility. People fear contraceptives because they think they cause infertility, while unprotected women actually are at higher risk of infertility because of illegal abortions and problem pregnancies. Governments need to supply more choices of contraceptives, and especially female sterilization. Vasectomy is virtually unused. Community-based and non-governmental distribution are untapped resources. Clinics are known to be less effective in motivating people to come for preventive care. In contrast, community women can provide services at lower financial and psychological cost, while improving the community's sense of control over health.

An official call for action was issued at the end of the conference on Safe Motherhood held in Nairobi, Kenya, in February 1987. The conference was organized to draw attention to the half million maternal deaths that occur each year. Women in developing countries run 50-100 times the risk of dying in pregnancy or childbirth than their counterparts in developed countries. There are only 2.9 maternal deaths/100,000 live births in developing countries compared to 300-1000 maternal deaths/100,000 live births in developing countries. Illegal abortion from unwanted pregnancies accounts for 25-50% of these deaths. The causes of maternal mortality are rooted in the adverse social, cultural, economic, and political environment women face in the Third World. These causes must be addressed if women's health and status are to be improved in the long term. On the other hand, there is an immediate need for low-cost, effective interventions that can have a major impact on reducing mortality and morbidity from obstructed labor, hemorrhage, toxemia, infection, and complications of abortion. A political commitment must be generated to reallocate resources so that maternal mortality can be reduced by 50% in 1 decade. Needed is an integrated approach to maternal health care that makes it a priority within the context of primary health care services and overall development policy. Women need to be involved in planning and implementing programs and policies to ensure that their needs and preferences are taken in account. In addition, family planning and family life education programs need to be expanded and made socially, culturally, financially, and geographically accessible. These activities need to involve both governments and take advantage of the flexibility, responsiveness, and creativity of nongovernmental organizations.

There were marked differences between the views expressed at the 1974 Bucharest World Population Conference and those expressed at the 1984 Mexico City World Population Conference. At the 1974 conference there was considerable disagreement between delegates who emphasized the need to control population growth directly through the development of effective family planning policies and programs and other delegates who argued that a decline in fertility would occur automatically in response to vigorous development programs. By 1984 most participants had acquired a deeper understanding of the complex relationship between development and population growth, and most recognized the need to develop comprehensive family planning programs and policies. Ironically, the US, which in 1974 had taken a strong family planning stance, reversed its position, and in 1984 adovacated the less popular developmental approach. The 1974 participants did affirm that all couples and individuals had the right to freely limit and space their children, but the 1984 participants adopted specific recommendations to promote and strengthen family planning initiatives. They recommended that governments make all appropriate and medically approved family planning methods available to all couples and individuals, and especially to the most vulnerable and most difficult to reach segments of their populations, that governemnts ensure that all children have the opportunity to grow up in healthy and supportive environments, and that public and private organizations use their resources to help governments meet these goals. They further recommended that governments 1) improve the quality, effectiveness and safety of their family planning programs 2) utilize all appropriate and available channels to promote the delivery of family planning services, 3) provide family life, sex education, and appropriate family planning services for both male and female adolescents; 4) ensure that all couples and individuals have the right to freely and responsibly limit and space their children, and 5) refrain from using any family planning strategies which are coercive or discriminatory. The delegates also called on governments to translate family planning goals into specific policies and operational activities and to develop policies to help parents meet their child rearing responsibilities, to improve child welfare and child care services, to promote the establishment of adequate maternity and paternity leaves, and to help parents acquire suitable housing. Delegates also recognized the need to formulate development policies which supported each country's population policies, advocated upgrading the status of women, and dealt with the problem of maternal mortality. After considerable discussion, the participants recommended that abortion should not be promoted as a family planning method, but that women who have abortions should be treated humanely and provided with counseling. Many delegates from the developing countries criticized the conference for failing to deal adequately with the issue of funding. Many countries lack the resources needed to implement the conference's recommendations.

Although family planning has been practiced throughout the world since earliest times, the population and family planning field is still confronted by difficult ethical issues. More contraceptive research is needed within developing countries so that the resulting technology will reflect local conditions. The politicization of contraceptive development and testing impedes consideration of the ethical issues. High ethical standards must be maintained, with attention to such aspects as the choice of human subjects to avoid double standards or discriminatory practices. The World Health Organization is helping to resolve ethical problems of contraceptive testing through its network of test centers in both developed and developing countries. Those who argue that it is unethical to offer contraceptives without providing health coverage as well overlook the contribution of birth spacing to health. Access to full and accurate information and services for family planning has been accepted as a basic human right. The consent of the individual choosing a contraceptive method must remain inviolate. There should be no preselection of method by program or service personnel, and no information on the contraceptive should be withheld. The issues of spousal and parental consent and withholding services from unmarried persons must be faced in diverse social and cultural contexts. In the debate over abortion, the ethics of withholding a technique known to be less hazardous than carrying a pregnancy to term should be considered, as should the morality of denying to the poor a service available to wealthier women regardless of its legality. Governments or programs which manipulate the availability of family planning information or services for demographic or other reasons are acting unethically.

The food situation in Africa is discussed in light of the demographic realities of the region. The unique demographic situation of Africa, the continuing dependence of the region on grain imports, the low nutritional quality of food consumed over the greater part of the region, and the poor health conditions of most African children and mothers are underlined. The importance of the food situation to political stability is noted and the concern is expressed over the increasing time lag between the realization of the problem and action. The low priority given to Family Planning Programs is discussed. The urgency of increasing quality and quantity of food production in Africa and in particular the need for additional measures to decelerate the rate of population growth are underlined.

The vicious circle of poverty, very fast population growth rates, tenuous hold on life, and absence of health and fertility regulation services will be analysed. Studies have indicated that in most developing countries a maximum of 30% of women in the fertile age group are being reached and this is considered over-optimistic. Further figures are quoted to show how very poorly contraceptive services are being received in many developing countries. The differences between urban and rural areas are indicated. The reasons for poor contraception are discussed with reference to : imperfections of contraceptive technology in relation to the developing world ; unsuitable delivery systems and a lack of true identification of the total complex of needs within the different cultural backgrounds. Some suggestions are made as to what is needed and how to overcome present problems.

The following currently available reversible methods of fertility regulation are discussed: 1) combined oral contraceptives 2) minipills 3) postcoital administration of diethylstilbestrol 3) IUDs 4) diaphragms 5) Depo Provera injections 6) calendar method and BBT method of periodic abstinence 7) condoms and 8) withdrawal. The method of functioning side effects and effectivenes for all these methods are discussed. The following new methods of fertility regulation for future use are discussed briefly: 1) immunological control of fertility and 2) hypothalamic-releasing hormones. The method chosen for each couple should involve a joint decision of the couple and their adviser. This would depend on which phase of fertility the couple is in-premarital eary marital or postfamily completion.

Danfa Comprehensive Rural Health and Family Planning Project: Ghana ALFRED K. NEUMANN, M.A., M.D., M.P.H., F.A.B.P.M., ALFRED K. NEUMANN, M.A., M.D., M.P.H., F.A.B.P.M. Co-Director 1970-, Associate Professor, Division of Population, Family and International Health, School of Public Health, University of CaliforniaLos Angeles Search for other works by this author on: Oxford Academic PubMed Google Scholar FREDERICK T. SAI, M.B., B.S., F.R.C.P., M.P.H., D.T.M. & H., FREDERICK T. SAI, M.B., B.S., F.R.C.P., M.P.H., D.T.M. & H. Former Professor, Preventive and Social Medicine, University of Ghana Medical School, Present Assistant Secretary General, International Planned Parenthood Federation Search for other works by this author on: Oxford Academic PubMed Google Scholar SILAS R. A. DODU, M.B., CH.B., M.D., F.R.C.P., D.T.M. & H. SILAS R. A. DODU, M.B., CH.B., M.D., F.R.C.P., D.T.M. & H. Acting Co-Director 1972-, Dean, University of Ghana Medical School, August 1973 Search for other works by this author on: Oxford Academic PubMed Google Scholar Journal of Tropical Pediatrics, Volume 20, Issue 1, February 1974, Pages 39–54, https://doi.org/10.1093/tropej/20.1.39 Published: 01 February 1974

2 years after the founding of the Ghana Medical School in 1964 it was decided that a community health project in a rural area would be a useful adjunct to the teaching hospital. The present state of the health of the Ghanaian community indicated that the community health services were inefficient and ineffective. The project was planned with the idea of demonstrating how successfully a rural transformation can be achieved by communities themselves aided by several agencies and institutions and under the leadership of health workers utilizing existing resources more effectively. The objectives of the project are: 1) to investigate the state of the rural community; 2) to train health workers; 3) to provide competent and well-oriented manpower to handle the problems of the community; and 4) to make available by means of the Danfa Health Center comprehensive and preventive health services. From the beginning it was believed that the success of the project would depend greatly on the willingness of the local community to participate. The Danfa group of villages was chosen for this reason and because it best qualified on the basis of the other criteria: 1) location near the medical school; 2) characteristic rural features; 3) p resence of common bondage and kinship among the various villages; and 4) existence of village development groups and self-help projects supported by various government agencies. Numerous problems were encountered in the projects development but in spite of all difficulties the main clinic and staff quarters were completed by December 1969; the health center staff was recruited in this same month; and the clinic officially opened January 16 1970. Although the research and service c omponents of the project have evolved more slowly the teaching program has developed quickly. Agreements have been made with the Agency for International Development for funding various research aspects of the project and with the University of California at Los Angeles for assistance with research development and evaluation aspects of the project along with paramedical staff training. Although the Danfa Rural Health and Family Planning Project has generally developed along traditional lines it does offer the following added features: 1) involvement of the community from the planning stages; 2) careful baseline demographic survey conducted prior to the initiation of most activities in the project area; 3) prospective studies that are expected to run for 6-7 years as a major component; 4) an addition to the clinical record system of a family folder system which is amenable to automatic data processing and easy and accurate retrieval; 5) cost benefit analysis of most of project activities; and 6) a built-in family planning research component.