Family Planning: Succeeding in Meeting Needs To Make a Better World Amy Tsui April 12, 2011
Family Planning, One of the Ten Best Public Health Achievements of the 20 th Century and Now Remarkable health innovation since 1960-65 Behavioral change among couples Efficacy of modern contraceptives Growing use among young sexually active persons Health and economic benefits Meeting prevailing and unmet needs regionally, equitably and securely
The number of couples using contraception in the developing world has increased ten-fold since the early 1960s. % using 90 80 70 60 50 40 30 20 10 0 707m ~70m 85 72 63 54 57 14 17 11 15 2 5 1960-65 2008 23 Total East Asia Latn Amr So Asia ME & Nafr S-Sah Afr 3
There is much inter-regional variation in the growth of contraceptive use in sub-saharan Africa. Modern contraceptive prevalence % 70.0 60.0 50.0 40.0 30.0 20.0 Sub-Saharan Africa Northern Africa (excluding Sudan) Eastern Africa Middle Africa Northern Africa Southern Africa Western Africa 10.0 0.0 1980 1985 1990 1995 2000 2005 2009 Source: United Nations World Contraceptive Use 2010
Contraceptive use is primarily responsible for the recent rapid fertility decline in Iran. Source: Erfani and McQuillan, 2007
Contraceptive use at 73%, primarily with modern methods (59%), is among the highest in the world. Other Withdrawal Condom Pill IUD Vasectomy Tubal ligation Source: Erfani and McQuillan, 2007
The Clinical Science behind Contraceptive Development and Practice
Contraceptive Method Efficacy under Perfect and Typical Use Conditions: USA Method % women experiencing unintended pregnancy in 1 st year of use Perfect use Typical use Combined Pill 0.3% 9.0% Implanon 0.2% 0.2% IUD 0.2-0.6% 0.2-0.8% Injectable 0.2% 6.0% Implant 0.05% 0.05% Condom 2% 18.0% Female Sterilization 0.5% 0.5% Male Sterilization 0.1% 0.15% Withdrawal 4.0% 22.0% No method 85% 85% Source: Trussell, 2011 8
Expanding Access with Newer Contraceptive Technologies NES-EE 1-year hormonal ring Depo-subQ injectable in Uniject Subdermal contraceptive implant Source: Spieler, 2011
Introducing New Methods Increases Contraceptive Choice and Use: Indonesia, 1973-2007 Percent of Women in Union Using Contraception by Method. % using 70 60 50 40 30 20 10 0 54.7 57.4 60.3 61.4 49.7 47.7 38.5 31.2 26.8 18.3 8.6 1973 1976 1979 1980 1985 1987 1991 1994 1997 2002 2007 Sterilization Pill Injectable IUD Condom Traditional Implants 10
What continues to challenge universal access to contraception?
There remain major economic inequalities in access to contraceptive and other reproductive health services. Source: Lule, World Bank, 2011 12
Despite increased access and use of modern methods, the incidence of unintended pregnancies remains high. % USING MODERN CONTRACEPTION 70 60 50 40 30 20 10 0 Figure 2. Relationship between national rates of unintended pregnancy and modern contraceptive prevalence among women aged 15-49 across 158 Demographic and Health Surveys in developing countries, 1991-2007 Modern contraceptive prevalence among women aged 15-49 in 158 Demographic and Health Surveys, 1991-2007 0 10 20 30 40 50 60 70 % OF RECENT PREGNANCIES UNINTENDED (MISTIMED OR UNWANTED) Source: MEASURE DHS StatCompiler, http://www.statcompiler.com/, accessed January 11, 2010 Source: Tsui et al., 2010
Most unintended pregnancies occur among women who were not using any contraceptive. Modern method 20% Traditional method 14% 66% No method Unintended pregnancies in developing countries, by women s contraceptive use Source: Guttmacher Institute, 2009
Concentration index Limiting Earlier survey Later survey Family planning programs in sub-saharan Africa show varying success in reaching all social segments, but inequities persist in all countries. Spacing Less inequality More inequality Source: Creanga et al., Bulletin of the WHO, 2011
Youth and contraception
The World s Youth Population Will Become More Concentrated in Africa (and Asia) Population Ages 15-24 by World Region: 1950 and 2050
There is an increasing trend in sexual activity among unmarried youth. Earlier survey Later survey 20 18 16 14 12 10 8 Percentage 6 4 2 Dominican Rep Malawi Peru Cambodia Guatemala Niger Mali Rwanda Bolivia Ethiopia Nicaragua Colombia Brazil Chad Kazakhstan Zimbabwe Haiti Guinea Kenya Uganda Benin Ghana Nigeria Mozambique Cameroon Tanzania Zambia Togo Madagascar Namibia Cote D'Ivoire 0 Source: Blanc et al., 2010
Contraceptive use among sexually active youth has also been rising: 34 DHS countries 1996-2006 Annual rate of change in contraceptive prevalence among 15-19 year old sexually active unmarried females 1.00 0.80 0.60 0.40 0.20 Cambodia Chad Eritrea Niger Rwanda Guinea Zimbabwe Nigeria Togo Cameroon Benin Dominican Kazakhstan Cote D'Ivoire Colombia Haiti Peru Ethiopia Guatemala Ghana Burkina Madagascar Mali Senegal Namibia Brazil 0.00 Annual rate of change Malawi Tanzania Kenya Uganda Zambia Nicaragua Bolivia Mozambique -0.20-0.40 Source: Blanc et al., 2010
Family Planning Patterns among Youth Are Unique Use often exceeds that of older married counterparts Reflects efforts to prevent unplanned pregnancies Experimentation and inconsistent use, leading to method failure Significant implications for contraceptive demand with expansion in youth cohort size Source: Blanc et al., 2010
Consequences Health and economic benefits of preventing unwanted childbearing
Contraceptive prevalence is closely linked to fertility Relationship between Contraceptive Prevalence and Total Fertility Rates: Based on 199 Demographic and Health Surveys and Reproductive Health Surveys, 1986-2008 levels: A 17-percentage Source: StatCompiler http://statcompiler.com/index.cfm; point increase accessed January implies 11, 2011 a decline 9.0 8.0 of one birth in the Total Fertility Rate. 7.0 6.0 Tpta; Fertility Rate 5.0 4.0 3.0 TFR = 6.72-0.06 * CPR R 2 = 0.761 2.0 y = -0.0594x + 6.7158 R 2 = 0.7606 1.0 0.0 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 Contraceptive Prevalence % mong Childbearing-Aged Women in Union Source: StatCompiler, accessed 2010
Association Between Fertility and Poverty Countries with a higher percentage of people living in poverty often have higher fertility rates. Percent of Population Living on <$2 per Day 100 Niger 80 Mongolia 60 40 20 Jordan 0 0 1 2 3 4 5 6 7 8 Total Fertility Rate Source: Population Reference Bureau, Population & Economic Development Linkages 2007 Data Sheet.
Trends in Number of Working-Age Adults per Dependent Number of Working-Age Adults (Ages 15-64) per Dependent (Under Age 15 and Ages 65 and Over) 3 Eastern Europe South-eastern Asia 2 South-central Asia Latin America and the Caribbean Sub-Saharan Africa 1 0 1980 1990 2000 2010 2020 2030 2040 2050 Source: United Nations, World Population Prospects: The 2004 Revision, 2005.
Age Pattern of Labor Income and Consumption for 4 Low-Income and 4 High-Income Countries LDC: Kenya, Nigeria, Costa Rica, Brazil MDC: US, Sweden, Finland, Austria Source: R Lee and A Mason, 2010
Total human capital investment is higher where fertility is lower. Source: R Lee and A Mason, 2010
Association Between Fertility and Female Education Countries with higher fertility typically have fewer girls enrolled in school Percent of Girls Enrolled in Secondary School Uruguay 120 100 Palestinian Territory 80 60 40 Morocco 20 0 0 1 2 3 4 5 6 7 8 Total Fertility Rate Source: Population Reference Bureau, Population & Economic Development Linkages 2007 Data Sheet.
The lifetime risk of dying at birth rises with childbearing. Recent declines in fertility are estimated to have prevented 3.6 million deaths between 1990-2008. Source: Marston and Cleland, 2004; Ross and Blanc, 2011
Women of reproductive age are disproportionately affected by HIV Percentage of population HIV+ by sex and age 15 12.9 11.7 11.8 10 5 5 9 7.5 6.6 9.5 8.4 8.8 5.9 5.2 2.4 0 0.4 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Women Men Family Planning and HIV Special supplement 2009 Source: Kenya DHS, 2003.
Efforts to integrate family planning, maternal, newborn and child and sexual health care are improving. Adapted from K.J. Kerber, et al., Continuum of Care for Maternal, Newborn, and Child Health: From Slogan to Service Delivery, 370 Lancet 1358 (2007). 1
Fulfilling unmet need for modern FP methods would cost $3.6 billion (2008 $) on top of $3.1 billion for current FP users For $4.50 per capita ($24.6b) existing FP and maternal and newborn needs can be met. Source: Guttmacher Institute, 2010
$103m spent on family planning can generate $208m in social sector savings by 2015 in Ethiopia. $220 $210 $200 $190 $180 $170 $160 $150 $140 $130 $120 $110 $100 $90 $80 $70 $60 $50 $40 $30 $20 $10 $0 US Dollars in Millions Total: $208 Malaria, $10 Maternal Health $105 Immunization $44 Total Savings Water and Sanitation $26 Education $23 $103 Family Planning Total Costs Source: USAID. Healthy Policy Initiative, Achieving the MDGs: The Contribution of Family Planning, Ethiopia. 2009.
Securing family planning s successes 1. Ideation and knowledge 2. Self-reliance in contraceptive financing
The importance of some reasons for non-use has changed over time: Greater concern over health and side effects 100 % of married women aged 15 49 with unmet need 80 60 40 13 29 12 20 13 18 16 10 9 18 7 11 6 20 20 19 7 27 11 20 0 28 11 6 7 23 13 24 25 38 43 44 26 5 6 21 19 36 34 24 21 25 5 7 10 12 Dominican Republic Colombia Peru Kenya Ghana Uganda Mali Bolivia Dominican Republic Colombia Peru Kenya Uganda Ghana 1986 1989 2002 2005 Mali Bolivia Lack of knowledge Health/side effects Opposition
SIFPSA, India Aao Baatein Karein Spacing Campaign Behavioral Change Communication Programs can efficiently address awareness and knowledge gaps.
Over time there has been growing divergence between Percent developing of Governments and Reporting developed Direct Support countries for Contraceptive Access: 1976-2007 support for contraceptive access. 100 80 Percent 60 40 20 0 1976 1986 1996 2001 2007 M D LDC Access MDC Access Source: United Nations Population Policy Inquiry Database
Contraceptive Security and Self-Reliance: A Priority for the 21 st Century $20,000,000 $18,000,000 $16,000,000 $14,000,000 $12,000,000 $10,000,000 $8,000,000 Zimbabwe Sri Lanka Guatemala Ghana Donor support for contraceptive procurement has been enduring but will not be indefinite. $6,000,000 $4,000,000 $2,000,000 $0 1989 1991 1993 1995 1997 1999 2001 2003 2005 Source: http://www.rhsupplies.org/nc/resources-tools/supplies-information-database-sid/sid-search-results.html
Family planning is to maternal survival what a vaccination is to child survival. Khama Rogo World Bank
Thank you