1. family and parenting
2. motherhood
3. pregnancy

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 20th 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
% using
The number of couples using contraception in the developing world
has increased ten-fold since the early 1960s.
90
80
70
60
50
40
30 ~70m
20
14 17 11 15
10
2
0
1960-65
Total
East Asia
Latn Amr
85
72
707m
63
54 57
23
5
2008
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
Sub-Saharan Africa
Northern Africa (excluding Sudan)
40.0
Eastern Africa
Middle Africa
Northern Africa
Southern Africa
30.0
Western Africa
20.0
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
% women experiencing unintended
pregnancy in 1st year of use
Method
Combined Pill
Implanon
IUD
Injectable
Implant
Condom
Female Sterilization
Male Sterilization
Withdrawal
No method
Perfect use
Typical use
0.3%
0.2%
0.2-0.6%
0.2%
0.05%
2%
0.5%
0.1%
4.0%
85%
9.0%
0.2%
0.2-0.8%
6.0%
0.05%
18.0%
0.5%
0.15%
22.0%
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.
70
54.7
60
47.7
% using
50
57.4
60.3
61.4
49.7
38.5
40
31.2
30
26.8
18.3
20
10 8.6
0
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
Figure 2. Relationship
between national
rates of unintended
pregnanc
y .
and modern contraceptive prevalence am ong women aged 15-49 across
contraceptive
prevalence
women
aged 15-49
in 158
158 Modern
D em ographic
and Health
Surveys in among
developing
countries,
1991-2007
Demographic and Health Surveys, 1991-2007
% USING MODERN CONTRACEPTION
70
60
50
40
30
20
10
0
0
10
20
30
40
50
60
% OF R ECENT PREGNANCIES U NIN TEN DED (MISTIMED OR UNW AN TED )
Source : MEASU R E D HS StatC o mpiler, http://ww w.statcompile r.co m/, access ed January 11, 2010
Source: Tsui et al., 2010
70
Most unintended pregnancies occur among
women who were not using any contraceptive.
Modern
method
20%
Traditional
method
14%
No method
66%
Unintended pregnancies in developing countries,
by women’s contraceptive use
Source: Guttmacher Institute, 2009
Concentration index
Earlier survey
Later survey
Limiting
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
m
in
ic
an
Re
M p
al
aw
i
P
Ca er
u
m
G bod
ua
te ia
m
al
a
N
ig
er
M
Rw ali
an
d
B a
ol
i
Et via
hi
o
Ni
ca pia
ra
g
C
ol ua
om
bi
a
Br
az
il
K
az Ch
ak ad
Zi hst
a
m
ba n
bw
e
Ha
G iti
ui
ne
a
K
en
Ug ya
an
da
B
en
in
G
ha
na
N
M
oz ige
a m ri
b a
Ca iq
m ue
er
o
Ta on
nz
an
Z a ia
m
bi
a
M
ad To
ag go
as
ca
r
Co Na
m
te
ib
D' ia
Iv
oi
re
Do
Percentage
There is an increasing trend in sexual activity among
unmarried youth.
Earlier survey
Later survey
20
18
16
14
12
10
8
6
4
2
0
Source: Blanc et al., 2010
-0.40
Ca
m
bo
d
Ch ia
Er ad
it r
e
Ni a
Rw g
a er
G nd a
Zi ui
m ne
ba a
b
Ni w e
ge
Ca T ria
m og
er o
o
Do B o n
Ka mi enin
z n
Co a k ica
te hst n
D an
Co 'Ivo
lo ir e
m
bi
Ha a
iti
Et Per
G h u
ua io
te pia
m
G a la
h
M Bu a n
ad rk a
a g in
as a
ca
r
M
Se a
n li
Na eg
m al
ib
Br ia
M az
Ta ala il
nz w i
a
Ke nia
Ug ny
a a
Za nd
Ni m a
ca bi
ra a
g
M
oz Bo ua
am liv
bi ia
qu
e
Annual rate of change
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
0.00
-0.20
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
Relationship betweenprevalence
Contraceptive Prevalence
andclosely
Total Fertility Rates:
Based on
199fertility
Contraceptive
is
linked
to
Demographic and Health Surveys and Reproductive Health Surveys, 1986-2008
levels: A 17-percentage point increase implies a decline
of one birth in the Total Fertility Rate.
Source: StatCompiler http://statcompiler.com/index.cfm; accessed January 11, 2011
9.0
8.0
7.0
Tpta; Fertility Rate
6.0
TFR = 6.72 - 0.06 * CPR
R2 = 0.761
5.0
4.0
3.0
y = -0.0594x + 6.7158
2.0
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
Contraceptive Prevalence % mong Childbearing-Aged Women in Union
Source: StatCompiler, accessed 2010
90.0
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
Mongolia
80
60
40
20
Jordan
0
0
1
2
3
4
5
Total Fertility Rate
6
7
8
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
South-central Asia
2
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
Palestinian Territory
100
80
60
Morocco
40
20
0
0
1
2
3
4
5
6
7
Total Fertility Rate
Source: Population Reference Bureau, Population & Economic
Development Linkages 2007 Data Sheet.
8
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
10
11.8
9.5
9
8.4
8.8
7.5
6.6
5
5.9
5
5.2
2.4
0.4
0
15-19
20-24
25-29
30-34
Women
35-39
40-44
45-49
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.
US Dollars in Millions
$220
$210
$200
$190
$180
$170
$160
$150
$140
$130
$120
$110
$100
$90
$80
$70
$60
$50
$40
$30
$20
$10
$0
Total: $208
Malaria, $10
Maternal Health
$105
$103
Water and
Sanitation
$26
Family
Planning
Immunization
$44
Education
$23
Total Savings
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
% of married women aged 15–49 with unmet need
100
80
19
20
1986–1989
Lack of knowledge
34
25
Health/side effects
24
5
7
10
12
Bolivia
19
21
11
Mali
21
36
27
Ghana
26
25
6
7
Uganda
5
44
Kenya
43
Peru
24
20
Colombia
38
Ghana
13
Peru
Colombia
0
6
11
7
11
16
23
28
Dominican Republic
20
6
Bolivia
18
29
9
Uganda
13
13
10
Mali
12
Kenya
40
7
18
20
Dominican Republic
60
2002–2005
Opposition
Behavioral
Change
Communication
Programs can
efficiently address
awareness and
knowledge gaps.
SIFPSA, India Aao Baatein Karein Spacing Campaign
Over time there has been growing divergence
Percent
of Governments
Reporting
Direct Support
for
between
developing
and
developed
countries’
Contraceptive Access: 1976-2007
support for contraceptive access.
100
Percent
80
60
40
20
0
1976
M
D
C
1986
1996
LDC Access
2001
2007
MDC Access
Source: United Nations Population Policy Inquiry Database
Contraceptive Security and Self-Reliance: A
Priority for the 21st Century
$20,000,000
$18,000,000
$16,000,000
$14,000,000
$12,000,000
Zimbabwe
Sri Lanka
Guatemala
Ghana
$10,000,000
$8,000,000
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