Percentage of women using modern birth control as of 2010.
6%
12%
18%
24%
36%
48%
54%
60%
66%
78%
86%
No data
Access to safe and adequate sexual and reproductive healthcare
constitutes part of the Universal Declaration of Human Rights, as upheld
by the United Nations.
Most of the countries in Africa have some of the lowest rates of
contraceptive use; highest maternal, infant, and child mortality rates;
and highest fertility rates.
Approximately 30% of all women use birth control, although over half of all African women would use birth control if it were available.
The main problems that prevent the use of birth control are limited
availability (especially among young people, unmarried people, and the
poor), high cost, limited choice of birth control methods, lack of
knowledge on side-effects, spousal disapproval or other gender-based
barriers, religious concerns, and bias from healthcare providers.
45% of pregnancies that occur among adolescents in Africa are unplanned. It is estimated that 1 in 3 pregnancies that are unintended in Africa, occur among girls between the ages of 15 and 19.
There is evidence that increased use of family planning methods
decreases maternal and infant mortality rates, improves quality of life
for mothers, and stimulates economic development.However, according to CHASE AFRICA, a charitable organisation that
promotes healthcare and education for women in Kenya and Uganda,
approximately 1 in 5 women who want family planning cannot access it.
Public policies and cultural attitudes play a role in birth control prevalence.
Prevalence
Notes:
Estimates are based on the data available between 1998 and 2007. These
percentages refer to women who are married or in a union. Northern
Africa: Algeria, Egypt, Libya, Morocco, Sudan, Tunisia. Western Africa:
Benin, Burkina Faso, Cape Verde, Côte d'Ivoire, Gambia, Ghana, Guinea,
Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal,
Sierra Leone, Togo. Eastern Africa: Burundi, Comoros, Djibouti, Eritrea,
Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mozambique, Rwanda,
Somalia, Tanzania, Uganda, Zambia, Zimbabwe. Middle Africa: Angola,
Cameroon, Central African Republic, Chad, Congo, Democratic Republic of
Congo, Gabon, São Tomé and Príncipe. Southern Africa: Botswana, Lesotho,
Namibia, South Africa, Swaziland
In Africa, 24% of women of reproductive age have an unmet need for modern contraception. Low rates of contraceptive use are most prevalent in Sub-Saharan African countries.
Research undertaken in 2007 led by Akinrinola Bankole, found that
correct and consistent condom use by those aged 14-19 was found to be
38% in Burkina Faso, 47% in Ghana, 20% in Malawi and 36% in Uganda.
In Uganda, NGOs are trying to make contraceptives more available in rural areas.
According to a 2008 study done by Ike Nwachukwu and Obasi in Nigeria,
modern birth control methods were used by 30% of respondents.
The Demographic Health Survey (DHS) of 2013 revealed that a mere
2% of sexually-active girls, between the ages of 15 and 19, use
contraceptives. 23% of the girls in this age group have children.
In 2022, BMC Public Health conducted a study that examined
contraceptive-use among school-going adolescents across nine Sub-Saharan
African countries.
Not using condoms during sex was most notably associated with being
younger, having limited to no parental support, being sexually
inexperienced, or having multiple sexual partners at once. Although,
across the nine countries, more than 50% of sexually-active participants
had used a condom at their last sexual encounter. Over a third used
other methods of contraceptive for their last sexual intercourse. The
highest rate of contraceptive-use was found in those from Namibia, and the lowest prevalence was found to be in Tanzania. The study concluded that there remains a great need for substantial intervention into contraceptive-use.
Use of contraception is also reported to decline each year a young woman ages.
Namibia, with a contraception-use rate of 46% in 2006–07, has one of the highest rates of contraceptive-use in Africa. Senegal, with an overall rate of 8.7% in 2005, has one of the lowest.
Limited contraceptive-use contributes to an exponential rise in population across the continent. The United Nations has predicted that by 2050 the population will more than double.
Factors contributing to prevalence
A
growing population, limited access to contraception, limited
availability in different contraceptive methods, perceived or actual
cultural stigma and religious judgement, poor quality of sexual and
reproductive healthcare, and gender-based barriers, each contribute to
the high "unmet need" for contraception in Africa. There needs to be consistent and effective provisions of modern contraceptives for the improvement of family planning.
There is a correlation between parental support and guidance, and the sexual health and use of contraception in young women.
In Eastern Africa, the unmet need is attributed to socioeconomic variables, including the family planning program environment and reproductive behaviour models. Data collected in the late twentieth century, suggests that high fertility rates
in Sub-Saharan African countries, compared to other developing
countries, is due to "the inter-related factors of early childbearing,
high-infant mortality, low education and contraceptive use, and
persistence of high fertility-sustaining social customs."
Referring to family projects that are underway in the Democratic Republic of Congo, an advisor to the United Nations Population Fund, Frederick Okwayo, stated that "the logistics of providing care is difficult because of the bad infrastructure." A lack of infrastructure, resulting from minimal governmental funding
and a limited number of health clinics in some areas, create prominent
barriers to accessing birth control.
An analysis of birth rates and fertility in Ghana,
found that without effective contraception, "the total number of
children a woman bears is principally a function of the age at which
childbearing begins." The study finds that pregnancies which occur in childhood and adolescence can be prevented by contraceptive-use.
Some of the factors identified that prevented use of modern birth control methods in a 2008 study in Nigeria
were "perceived negative health reaction, fear of unknown effects,
cost, spouse's disapproval, religious belief and inadequate
information."
According to a study titled, 'Equity Analysis: Identifying Who Benefits
from Family Planning Programs', the main factors that contribute to the
unavailability of family planning information and modern birth control
methods are low education level, young age, and living in a rural area. A 1996 study that included couples in both urban and rural Kenya
who did not want have a child, yet were not using birth control, found
additional factors that limited birth control use to be traditional
practices, such as "naming relatives" and a preference for sons who can
provide more financial security to parents as they age.
Until the 1990s, contraception and family planning were associated with fears of eugenic ideology and population control, which narrowed the scope of behavior-change communication and distribution of contraceptive devices.
Patriarchal ideologies that are fostered by traditional cultural
and religious beliefs, and primarily undermine the worth of female
autonomy and the validity of female agency, greatly contribute to a
reduction of contraceptive-use.
Fatimata Sy, who directed the Ouagadougou Partnership that
launched in 2011 to increase the use of modern contraception across
Africa, explained that the biggest hindrances to the movement were
religion, social and gender norms and cultural taboos.
Men are frequently cited as a major factor preventing adequate
birth control access in Africa. They reinforce many societal and
cultural ideologies that block women from choosing and accessing sexual
and reproductive healthcare. Male adolescents were also among the highest of those who used no contraception during sexual intercourse.
John Magufuli, who was president of Tanzania
from 2015 to 2021, strongly advised women to not use birth control or
any other family planning method. He stated that those who do are "lazy"
and "do not want to work hard to feed a large family".
He also declared that women were not allowed to return to education
after they had become pregnant, reinforcing a 1960s law that banned
young mothers from attending state school education.
In the cities of Nairobi and Bungoma in Kenya,
major barriers to contraceptive use revolve around sexual partners
unable to agree on the contraceptive method and their reproductive
intentions. Approximately 33% of wives in Nairobi and 50% of wives in
Bungoma desired no more children, compared to 70% of husbands wanting
around four or more children than their wives wanted.
A 2013 study in Kenya and Zambia
shows a correlation between ante-natal care use and post-partum
contraceptive use which suggests that contraceptive use could be
increased by promoting ante-natal care services.
A 1996 study in Zambia again cites the importance of educating both men
and women and states that single mothers and teenagers should be the
primary focus of birth control education. Of the 376 women recruited
after giving birth at a hospital, 34% had previously used family
planning, and 64% had used family planning a year after giving birth. Of
the women who did not use family planning, 39% cited spousal
disapproval as the reason. 84% of single mothers had never used family
planning before and 56% of teenagers did not know anything about family
planning.
A 1996 Kenyan study suggests the need for modern contraception
education that promotes quality of life over "traditional reproductive
practices."
Birth control methods
In most African countries, only a few types of birth control are offered, which makes finding a method that fits the reproductive needs, of a couple or an individual, difficult. Many African countries had low access scores on almost every method. In the 1999 ratings for 88 countries, 73% of countries offered condoms to at least half their population, 65% of countries offered the pill, 54% offered IUDs, 42% offered female sterilization, and 26% offered male sterilization. Low levels of condom use are cause for concern, particularly in the context of generalized epidemics in Sub-Saharan Africa. The use rate for injectable contraceptives increased from 2% to 8%, and from 8% to 26% in Sub-Saharan Africa, while the rate for condoms was 5%–7%. The least used method of contraception is male sterilization, with a rate of less than 3%. 6%–20% of women in Sub-Saharan Africa used injectable contraceptives covertly, a practice more common in areas where contraceptive prevalence was low, particularly rural areas.
Cultural attitudes toward family planning
In Northern Ghana, payment of bridewealth
in cows and sheep signifies the wife's obligation to bear children,
which results in an ingrained expectation toward a woman's duty to
reproduce. As a result, men often perceive contraceptive-use as an
indicator of their wife's infidelity or promiscuity.
Child and forced marriages, a human rights breach that remains
particularly high in Sub-Saharan African countries, limit female
autonomy and often result in a culture that prevents women and young
girls from feeling in control of their reproductive health.
The possibility that women may act independently, either toward
healthcare or socially, is also regarded as a threat to the strong
patriarchal tradition.
Recently however, attitudes toward child marriages have improved, particularly in Nigeria, with many discussing the social and emotional disadvantages this can cause.
According to a 1987 study by John Caldwell, large families are seen as socially favourable and infertility is viewed negatively.
This can cause a paradoxical use in birth control, where it is used to
increase birth intervals, rather than to limit family size.
Physical abuse and reprisals from the extended family pose
substantial threats to women. If the wife used a contraceptive method
without the husband's knowledge, violence against women was considered
justified by 51% of female and 43% of male respondents. Women feared that their husband's disapproval of family planning could lead to the withholding of affection or sex, and even lead to divorce.
In areas that have communal grazing areas or "tribal tenure,"
Danish economist Ester Boserup, found that large families are desirable
because more children means more productive capability. This would result in higher social status and increased wealth for the father.
Pragmatically, having more children decreases the mother's
workload, and is deemed as an additional benefit for the urban African
home. Boserup suggests that large families are regarded as indicators of
a man's wealth and high social status.
This is the opposite for the large majority in African countries,
who live in rural areas or agricultural communities that have
private-land ownership. For these communities, having a larger family
can in fact be viewed negatively. Private landowners do not need to rely
on financial support from children in old age or in crises because of
the high-profitability of their land. As such, opting for family
planning can be less stigmatised.
In other Sub-Saharan African
cultures, spousal discussion of sexual matters is discouraged. Friends
of family and in-laws are used by proxy for spouses to exchange ideas or
issues relating to reproduction. Other forms of communication to convey sex-related messages, include music, wearing specific waist beads, acting in a certain way, and preparing desired meals. A man may also use contraception as a nonverbal indicator of his feelings.
Therefore, effective communication and reduced stigma between partners
may improve family planning attitudes only when it is more efficient
than, or augments the effectiveness of, other forms of communication.
Effects
Tracking the change in contraception use of African women from 2008 to 2012
In 1992, the executive director of the United Nations International Children's Emergency Fund (UNICEF),
James Grant, stated that "Family Planning could bring more benefits to
more people at less cost than any other single technology now available
to the human race."
Use of modern birth control methods has been shown to decrease the female fertility rate in Sub-Saharan Africa.
Health
Africa has the highest maternal death rate, which measures the death rate of women from pregnancy and childbirth. The maternal mortality ratio in Sub Saharan Africa is 1,006 maternal deaths per 100,000 live births. A study by Rebecca Baggaley et al. suggests that increasing access to safe abortion would reduce maternal mortality due to unsafe abortions in Ethiopia and Tanzania.
Alexandra Alvergne et al. argue in their study, 'Fertility, parental
investment, and the early adoption of modern contraception in rural
Ethiopia', that an increase in usage of family planning increases birth
spacing which consequently decreases infant mortality. Although, there was no observed effect on overall child mortality, possibly due to a recent overall decrease in childhood death rates among both contraceptive users and non-users.
Having unprotected sex in nearly all countries of Africa,
especially at an early age, is associated with an increased risk of
acquiring sexually transmitted diseases, most prolifically being HIV and AIDS.
In Eastern and Southern parts of Africa, 1 in 4 adolescent girls and 1
in 5 adolescent boys between the ages of 15 and 19 tested positive for HIV in 2021-2022. Increasing condom use in Africa would decrease rates of HIV transmission.
Social
According
to Stephen Gyimah, women who have their first child at a younger age
are less likely to finish school and will be likely limited to
low-paying career options.
Research suggests that a desire to continue with their education is one
of the largest reasons that women use birth control and terminate
pregnancies.
Since birth control is not widely available, beginning a family at a young age is additionally correlated with a higher overall fertility rate.
Alexandra Alvergne states that another benefit of longer birth
intervals due to contraception use is an increase in parental investment
and proportion of resources dedicated to each child.
Two notable reasons for married women opting to use birth control
are: to plan birth spacing and postpone pregnancies in order to achieve
their desired family size.
Economic
An increase in the use of family planning
results in economic improvements; women are more likely to stay in work
and have the socio-economic foundations to support the development of
their children.
Family planning results in an estimated 140-600% return on investment
due to a reduction in health care spending and the fostering of
financial agency.
A study titled, 'The Economic Case for Birth Control in Underdeveloped
Nations', published in 1967, argues that decreasing the birth rate in
countries with high fertility levels is crucial to economic growth and
that "one dollar used to slow population growth can be 100 times more
effective in raising income per head than one dollar to expand output."
Since the majority of African countries have high fertility rates
relative to the rest of the world, it is clear that most African
countries have not undergone a demographic transition.
In other parts of the world, there is evidence that economic growth
increases after a country undergoes demographic transition.
This is due to more women working, greater parental investment in
children in terms of education and attention, and longer, more
productive working life due to health improvements. Although other
improvements in public health are necessary to fully undergo a
demographic transition, it cannot occur without family planning. It is
unclear, however, how exactly the demographic transition will affect
society in Sub-Saharan Africa.
Some believe that one economic downside to using birth control
and preventing pregnancy, is the possibility that parents will not have
enough successful, living offspring who can support them in old age.
This is a prominent concern among parents in Sub-Saharan African
countries.
South Africa, Botswana, and Zimbabwe have successful family planning
programs, but other central and southern African countries continue to
encounter difficulties in achieving higher contraceptive prevalence and
lower fertility rates. Socioeconomic class can be defined as an inequity in relation to mortality and morbidity.
The disparity in the use of contraception between the upper and lower
classes has remained the same despite overall improvements in
socioeconomic status and expansion of family planning services.
Change
Public policy
The BMC Public Health
inquiry into the use of birth control methods among sexually-active
adolescents, surmised that to improve on overall contraceptive-use, "the
development of country-specific sexual health education and
youth-friendly sexual and reproductive health interventions that target
risky adolescents and promote adolescent-parent effective communication"
would be needed.
Recently, a new approach that promotes spousal discussion of
contraception has been proposed as a policy strategy to narrow the
gender gap in wanting to have children.
Men are usually the decision makers on birth control use, and therefore
should be the targeted audience of educational campaigns.
Discussion between spouses is expected to increase contraceptive use.
This is because a reason women cite for not using contraception, is an
expected concern of their husband's disapproval.
At the 1994 Cairo International Conference on Population and
Development, an emphasis was made on human lives rather than statistics
when considering the impacts of population increase, with a particular
emphasis on improving healthcare and reproductive rights in Sub-Saharan Africa.
Recommendations were made to governments in countries throughout
Africa, to prioritise sexual and reproductive health services and make
family planning universally accessible.
In 2000, the London Summit on Family Planning attempted to make
modern contraceptive services accessible to an additional 120 million
women in 69 of the world's poorest countries by the year 2020. The summit hoped to eradicate discrimination or coercion against girls who seek contraceptives.
The United Nations
created the 'Every Woman Every Child' initiative in 2010 to assess the
progress toward meeting women's contraceptive needs and modern family
planning services.
Setting their initiative through goals of expected increases in usage
of modern contraceptive methods, acts as an indicator of the
effectiveness of these interventions.
The World Health Organisation
actively encourages sexual and reproductive health rights for all women
and girls, and recognises a need for effective, and sustainable
policies or interventions which can produce this.
Sustainable and Development Goals (SDG), run by the United Nations, has
set a target to ensure universal access to sexual and reproductive
health care services (particularly in the form of family planning and
birth control) and strives to implement these within the health policies
and programmes of members states. 54 African countries are part of the United Nations, including Burkina Faso, Ghana and Rwanda.
One of the Millennium Development Goals is improving maternal health. In developing countries, the maternal mortality rate is fifteen-times higher than in the developed regions. The Maternal Health Initiative called for countries to reduce their maternal mortality rate by three quarters by 2015. Eritrea is one of the four African countries to successfully achieve some or most of the Millennium Development Goals, resulting in a rate of less than 350 deaths per 100,000 births.
Ethiopia
In recent years, the Government of Ethiopia has worked hard to improve healthcare in line with the United Nations' Sustainable Development Goals.
It has been reported that by prioritising the health, education and
socio-economic prospects of their citizens, there has been a significant
reduction in the country's birth rate. The United States government, through the form of USAID,
has helped strengthen family health in the country, in the form of
"quality reproductive, maternal, newborn, child, and adolescent health
services".
Rwanda
After the 1994 Rwandan Genocide, the country's healthcare system underwent major changes that led to a 60% increase in contraceptive-use.
A start-up called Kasha, allows citizens in Rwandan villages to order condoms and contraceptives via text message and delivers them with a moped.
Niger
There has been wide media support in the promotion of contraceptive-use in Niger, a country in West Africa.
Athletes, celebrities, and prominent political figures have used
their status to speak out on, and encourage the use of, contraception in
the country.
L'Association des Jeunes Filles pour la Santé de la Reproduction
(AJFSR) (The Girls' Association for Reproductive Health), was
established in 2020 to create campaigns and workshops raising awareness
and education for girls and women in Niger.
Kadiatou Idani, the president of the group believes "[r]eproductive
health is a taboo subject. But girls have sexual and reproductive
rights, [and] they need to know about them".
Burkina Faso
Burkina Faso implemented a national free healthcare policy in 2016, for women and children under 5. This involved the free distribution of contraceptives.
Between 2013 and 2018 government expenditure on healthcare, particularly sexual and reproductive, increased by 30%.
Tanzania
The first female president of Tanzania, Samia Suluhi Hassan, has made a pledge to improve access to birth control in the country.
Hassan believes that birth control access will help improve Tanzania's
economic prospects, and urges women to want and to have less children.
Improvements
Contraceptive use among women in Sub-Saharan Africa has risen from approximately 5% in 1991 to approximately 30% in 2006.
In the 2020 Family Planning report (FP2020), written by the United Nations, it stated that between 2012-2020 there was a 66% increase in the number of women and girls who used modern contraception.
The report also informed that in Central and West Africa women who use
birth control as much as doubled, and in Eastern and Southern Africa,
the increase was up to 70%.
Gyimah reports that fertility rates are declining in some African countries, particularly Kenya, Botswana, Zimbabwe, and Ghana. The decrease in fertility rates in Ghana
is largely attributed to investment in education that has caused an
increase in age at first birth and improved job opportunities for women.
Combined oral contraceptives. Introduced in 1960, "the Pill" has played an instrumental role in family planning for decades.A community health worker explains to a woman in Madagascar different methods for family planning.
Family planning is the consideration of the number of children
a person wishes to have, including the choice to have no children, and
the age at which they wish to have them. Things that may play a role on
family planning decisions include marital situation, career or work
considerations, financial situations. If sexually active, family
planning may involve the use of contraception (birth control) and other techniques to control the timing of reproduction.
Family planning is sometimes used as a synonym or euphemism
for access to and the use of contraception. However, it often involves
methods and practices in addition to contraception. Additionally, many
might wish to use contraception but are not necessarily planning a
family (e.g., unmarried adolescents, young married couples delaying
childbearing while building a career). Family planning has become a
catch-all phrase for much of the work undertaken in this realm. However,
contemporary notions of family planning tend to place a woman and her
childbearing decisions at the center of the discussion, as notions of
women's empowerment and reproductive autonomy have gained traction in
many parts of the world. It is usually applied to a female-male couple who wish to limit the number of children they have or control pregnancy timing (also known as spacing children).
Family planning has been shown to reduce teenage birth rates and birth rates for unmarried women.
Purposes
In 2006, the US Centers for Disease Control (CDC) issued a recommendation, encouraging men and women to formulate a reproductive life plan, to help them in avoiding unintended pregnancies and to improve the health of women and reduce adverse pregnancy outcomes.
There are multiple benefits to family planning including spacing
births for healthier pregnancies, thus decreasing risks of maternal
morbidity, fetal prematurity and low birth. There is also a potential
positive impact on the individual's social and economic advancement, as
raising a child requires significant amounts of resources: time, social, financial, and environmental. Planning can help assure that resources are available.
For many, the purpose of family planning is to make sure that any
couple, man, or woman who has a child has the resources that are needed
in order to complete this goal. With these resources a couple, man or woman can explore the options of natural birth, surrogacy, artificial insemination, or adoption.
In the other case, if the person does not wish to have a child at the
specific time, they can investigate the resources that are needed to
prevent pregnancy, such as birth control, contraceptives, or physical protection and prevention.
There is no clear social impact case for or against conceiving a child. Individually, for most people,
bearing a child or not has no measurable impact on personal well-being.
A review of the economic literature on life satisfaction shows that
certain groups of people are much happier without children:
Single parents
Fathers who both work and raise the children equally
Singles
The divorced
The poor
Those whose children are older than three
Those whose children are sick
However, both adoptees and the adopters report that they are happier after adoption.
Resources
When
women can pursue additional education and paid employment, families can
invest more in each child. Children with fewer siblings tend to stay in
school longer than those with many siblings. Leaving school in order to
have children has long-term implications for the future of these girls,
as well as the human capital of their families and communities. Family planning slows unsustainable population growth which drains resources from the environment, and national and regional development efforts.
Global maternal mortality rate per 100,000 live births (2010)
The WHO states about maternal health that:
"Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period.
While motherhood is often a positive and fulfilling experience, for too
many women it is associated with suffering, ill-health and even death."
About 99% of maternal deaths occur in less developed countries; less than one half occur in sub-Saharan Africa and almost a third in South Asia.
Maternal health also faces racial disparity in maternal health outcomes
as per CDC 2021 report, where maternal mortality is higher among
Hispanics compared to their counterparts.
Both early and late motherhood have increased risks. Young
teenagers face a higher risk of complications and death as a result of
pregnancy.
Waiting until the mother is at least 18 years old before trying to have
children improves maternal and child health. To prevent complications,
access to quality health care is imperative, including contraception,
skilled medical professionals, and abortion services and care.
Also, if additional children are desired after a child is born,
it is healthier for the mother and the child to wait at least two years
(but not more than five years) after the previous birth before
attempting to conceive. After a miscarriage or abortion, it is healthier to wait at least six months.
When planning a family, women should be aware that reproductive
risks increase with age. Like older men, older women have a higher
chance of having a child with autism or Down syndrome; the chances of having multiple births increases, which cause further late-pregnancy risk; they have an increased chance of developing gestational diabetes; the need for a Caesarian section is greater; and the risk of prolonged labor is higher, putting the baby in distress.
Placard showing negative effects of lack of family planning and having too many children and infants (Ethiopia)
Family planning is among the most cost-effective of all health interventions.
"The cost savings stem from a reduction in unintended pregnancy, as
well as a reduction in transmission of sexually transmitted infections,
including HIV".
Childbirth and prenatal health care cost averaged $7,090 for normal delivery in the United States in 1996. U.S. Department of Agriculture
estimates that for a child born in 2007, a U.S. family will spend an
average of $11,000 to $23,000 per year for the first 17 years of child's
life. (Total inflation-adjusted estimated expenditure: $196,000 to $393,000, depending on household income.)
Investing in family planning has clear economic benefits and can
also help countries to achieve their "demographic dividend", which means
that countries productivity is able to increase when there are more
people in the workforce and less dependents. UNFPA says that "For every dollar invested in contraception, the cost of pregnancy-related care is reduced by $1.47."
UNFPA states,
The lifetime opportunity cost
related to adolescent pregnancy – a measure of the annual income a young
mother misses out on over her lifetime – ranges from 1 per cent of
annual gross domestic product in a large country such as China to 30 per
cent of annual GDP in a small economy such as Uganda. If adolescent
girls in Brazil and India were able to wait until their early twenties
to have children, the increased economic productivity would equal more
than $3.5 billion and $7.7 billion, respectively.
In the Copenhagen Consensus
produced by Nobel laureates in collaboration with the UN, universal
access to contraception ranks as the third-highest policy initiative in
social, economic, and environmental benefits for every dollar spent.
Providing universal access to sexual and reproductive health services
and eliminating the unmet need for contraception will result in 640,000
fewer newborn deaths, 150,000 fewer maternal deaths and 600,000 fewer
children who lose their mother. At the same time, societies will
experience fewer dependents and more women in the workforce, driving
faster economic growth. The costs of universal access to contraceptives
will be about $3.6 billion/year, but the benefits will be more than $400
billion annually and maternal deaths will be reduced by 150,000.
In regard to the use of modern methods of contraception, The United Nations Population Fund
(UNFPA) says, "Contraceptives prevent unintended pregnancies, reduce
the number of abortions, and lower the incidence of death and disability
related to complications of pregnancy and childbirth."
UNFPA states, "If all women with an unmet need for contraceptives were
able to use modern methods, an additional 24 million abortions (14
million of which would be unsafe), 6 million miscarriages, 70,000 maternal deaths and 500,000 infant deaths would be prevented."
In cases where couples may not want to have children just yet,
family planning programs help a lot. Federal family planning programs
reduced childbearing among poor women by as much as 29 percent,
according to a University of Michigan study.
Adoption
is another option used to build a family. There are seven steps that
one must make towards adoption. One must decide to pursue an adoption,
apply to adopt, complete an adoption home study, get approved to adopt,
be matched with a child, receive an adoptive placement, and then
legalize the adoption.
Placard showing positive effects of family planning (Ethiopia)
A number of contraceptive methods are available to prevent unwanted pregnancy. There are natural methods and various chemical-based methods, each with particular advantages and disadvantages. Behavioral methods to avoid pregnancy that involve vaginal intercourse include the withdrawal and calendar-based methods, which have little upfront cost and are readily available. Long-acting reversible contraceptive methods, such as intrauterine device
(IUD) and implant are highly effective and convenient, requiring little
user action, but do come with risks. When cost of failure is included,
IUDs and vasectomy are much less costly than other methods. In addition to providing birth control, male and/or female condoms protect against sexually transmitted infections (STI). Condoms may be used alone, or in addition to other methods, as backup or to prevent STIs. Surgical methods (tubal ligation, vasectomy) provide long-term contraception for those who have completed their families.
When, for any reason, a woman is unable to conceive by natural means,
she may seek assisted conception. It is recommended to the couple to
ask for reproductive counseling after one year of trying to conceive, or
after six months of trying if the woman is more than 35 years old, if
she has irregular or infrequent menses, if she has a history of endometriosis or pelvic inflammatory disease, or if a problem related to the male is present.
Some families or women seek assistance through surrogacy,
in which a woman agrees to become pregnant and deliver a child for
another couple or person (this is not allowed in all countries). There
are two types of surrogacy: traditional and gestational. In traditional
surrogacy, the surrogate uses her own eggs and carries the child for her intended parents. This procedure is done in a doctor's office through intrauterine insemination
(IUI). This type of surrogacy obviously includes a genetic connection
between the surrogate and the child. Legally, the surrogate will have to
disclaim any interest in the child to complete the transfer to the
intended parents. A gestational surrogacy occurs when the intended
mother's or a donor egg is fertilized outside the body and then the
embryos are transferred into the uterus. The woman who carries the child
is often referred to as a gestational carrier. The legal steps to
confirm parentage with the intended parents are generally easier than in
a traditional because there is no genetic connection between child and
carrier.
Sperm donation is another form of assisted conception. It involves donated sperm being used to fertilise a woman's ova by artificial insemination (either by intracervical insemination or IUI) and less commonly by in vitro fertilization (IVF), but insemination may also be achieved by a donor having sexual intercourse with a woman for the purpose of achieving conception. This method is known as natural insemination (NI).
Mapping of a woman's ovarian reserve, follicular dynamics and associated biomarkers can give an individual prognosis about future chances of pregnancy, facilitating an informed choice of when to have children.
Fertility awareness refers to a set of practices used to determine the fertile and infertile phases of a woman's menstrual cycle. These methods may be used to avoid pregnancy, to achieve pregnancy, or as a way to monitor gynecological
health. Methods of identifying infertile days have been known since
antiquity, but scientific knowledge gained during the past century has
increased the number and variety of methods. Various methods can be used
and the Symptothermal method has achieved success rates over 99% if
used properly.
These methods are used for various reasons: There are no drug-related side effects,
they are free to use and only have a small upfront cost, they work for
both achieving and preventing pregnancy, and they may be used for
religious reasons. (The Catholic Church promotes this as the only acceptable form of family planning, calling it Natural Family Planning.)
Their disadvantages are that either abstinence or a backup
contraception method is required on fertile days, typical use is often
less effective than other methods, and they do not protect against sexually transmitted infection.
Media campaign
Recent
research based on nationally representative surveys supports a strong
association between family planning mass media campaigns and
contraceptive use, even after controlling for social and demographic
variables. The 1989 Kenya Demographic and Health Survey found half of
the women who recalled hearing or seeing family planning messages in
radio, print, and television consequently used contraception, compared
with 14% who did not recall family planning messages in the media, even
after age, residence and socioeconomic status were taken into account.
The Health Education Division of the Ministry of Health conducted
the Tanzanian Family Planning Communication Project from January 1991
through December 1994, a project funded by the U.S. Agency for
International Development (USAID).
The program intended to educate both men and men of reproductive age
about modern contraception methods. The major media channels and
products included radio spots, radio series drama, Green Star logo
promotional activities (identifies sites where family planning services
are available), posters, leaflets, newspapers, and audio cassettes. In
conjunction with other non-project interventions sponsored by other
Tanzanian and international agencies from 1992 to 1994, contraception
use among women ages 15–49 increased from 5.9% to 11.3%. The total
fertility rate dropped from 6.3 lifetime births per individual in
1991–1992 to 5.8 in 1994.
Providers
Direct government support
Direct
government support for family planning includes providing family
planning education and supplies through government-run facilities such
as hospitals, clinics, health posts and health centers and through
government fieldworkers.
In 2013, 160 out of 197 governments provided direct support for
family planning. Twenty countries only provided indirect support through
private sector or NGOs. Seventeen governments did not support family
planning. Direct government support has continued to increase in
developing countries from 82% in 1996 to 93% in 2013, but is declining
in developed countries from 58% in 1976 to 45% in 2013. Ninety-seven
percent of Latin America and the Caribbean, 96% of Africa, and 94% of
Oceania governments provided direct support for family planning. In
Europe, only 45% of governments directly support family planning. Out of
172 countries with available data in 2012, 152 countries had
implemented realistic measures to increase women's access to family
planning methods from 2009 to 2014. This data included 95% of developing
nations and 65% of developed nations.
Private sector
The
private sector includes nongovernmental and faith-based organizations
that typically provide free or subsidized services to for-profit medical
providers, pharmacies and drug shops. The private sector accounts for
approximately two-fifths of contraceptive suppliers worldwide. Private
organizations are able to provide sustainable markets for contraceptive
services through social marketing, social franchising, and pharmacies.
Social marketing employs marketing techniques to achieve
behavioral change while making contraceptives available. By utilizing
private providers, social marketing reduces geographic and socioeconomic
disparities and reaches men and boys.
Social franchising designs a brand for contraceptives in order to expand the market for contraceptives.
Drug shops and pharmacies provide health care in rural areas and
urban slums where there are few public clinics. They account for most of
the private sector provided contraception in sub-Saharan Africa,
especially for condoms, pills, injectables and emergency contraception.
Pharmacy supply and low-cost emergency contraception in South Africa and
many low-income countries increased access to contraception.
Workplace policies and programs help expand access to family
planning information. The Family Guidance Association of Ethiopia, which
works with more than 150 enterprises to improve health services,
analyzed health outcomes in one factory over 10 years and found
reductions in unintended pregnancies and STIs as well as sick leave.
Contraception use rose from 11% to 90% between 1997 and 2000. In 2016,
the Bangladesh Garment Manufacturers Export Association partnered with
family planning organizations to provide training and free
contraceptives to factory clinics, creating the potential to reach
thousands of factory employees.
Non-governmental organizations
Non-governmental
organizations (NGOs) may meet the needs of local poor by encouraging
self-help and participation, understanding social and cultural
subtleties, and working around red tape when governments do not
adequately meet the needs of their constituents. A successful NGO can
uphold family planning services even when a national program is
threatened by political forces. NGOs can contribute to informing
government policy, developing programs, or carry out programs that the
government will not or can not implement.
Family planning programs are now considered a key part of a
comprehensive development strategy. The United Nations Millennium
Development Goals (now superseded by the Sustainable Development Goals)
reflects this international consensus. The 2012 London Summit on Family
Planning, hosted by the UK government and the Bill and Melinda Gates
Foundation, affirmed political commitments and increased funds for the
project, strengthening the role of family planning in global
development.
Family Planning 2020 (FP2020) is the result of the 2012 London Summit
on Family Planning where more than 20 governments made commitments to
address the policy, financing, delivery, and socio-cultural barriers to
women accessing contraception formation and services. FP2020 is a global
movement that supports the rights of women to decide for themselves
whether, when and how many children they want to have.
The commitments of the program are specific to each country, as
compared to the generalized main goals of the 1995 conference program of
action. FP2020 is hosted by the United Nations Foundation and operates
in support of the UN Secretary-General's Global Strategy for Women's,
Children's and Adolescent's Health.
Reducing HIV infection rates in persons aged 15–24 years by 25% in the most-affected countries by 2005, and by 25% globally by 2010
The World Health Organization (WHO) and World Bank
estimate that $3 per person per year would provide basic family
planning, maternal and neonatal health care to women in developing
countries. This would include contraception, prenatal, delivery, and post-natal care in addition to postpartum family planning and the promotion of condoms to prevent sexually transmitted infections.
Injustices and coercive interference with family planning
Inequities in family planning within the United States
Historically,
the capacity to control one's reproductive abilities has been unequally
distributed across society. Long-acting reversible contraception
(LARCs), including intrauterine devices and progestin implants, and
permanent sterilization have been implemented to limit reproduction in
communities of color, the lower socioeconomic class, and among
individuals with intellectual disabilities.
Multiple studies have reported disproportionate recommendations of
LARCs to individuals from marginalized communities compared to white,
high-income individuals. With the eugenics
movement of the 20th century, 60,000 people were sterilized in 32
states across the US with state-sanctioned sterilizations peaking in
1930-40's.
More recently, unwanted sterilizations have been performed on over a
thousand women in California prisons between 1997 and 2010.
Protocols have been established to protect against unwanted permanent
contraception through Medicaid Laws, but there has not been a widespread
declaration by the Supreme Court ruling forced sterilization
unconstitutional.
Compulsory or forced sterilization programs or government policy
attempt to force people to undergo surgical sterilization without their
freely given consent. People from marginalized communities are at most
risk of forced sterilization. Forced sterilization has occurred in recent years in Eastern Europe (against Roma women), and in Peru (during the 1990s against indigenous women). China's one-child policy was intended to limit the rise in population numbers, but in some situations involved forced sterilisation.
In Rwanda,
the National Population Office has estimated that between 2,000 and
5,000 children were born as a result of sexual violence perpetrated
during the genocide, but victims' groups gave a higher estimated number of over 10,000 children.
Some consider access to safe, voluntary family planning to be a human
right and to be central to gender equality, women's empowerment and poverty reduction.
Over the past 50 years, right-based family planning has enabled the
cycle of poverty to be broken resulting in millions of women and
children's lives being saved.
The United Nations Population Fund
(UNFPA) says that "Some 225 million women who want to avoid pregnancy
are not using safe and effective family planning methods, for reasons
ranging from lack of access to information or services to lack of
support from their partners or communities." The UNFPA says that "Most of these women with an unmet need for contraceptives live in 69 of the poorest countries on earth."
The UNFPA says,
Global consensus that family
planning is a human right was secured at the 1994 International
Conference on Population and Development, in Principle 8 of the
Programme of Action: All couples and individuals have the basic right to
decide freely and responsibly the number and spacing of their children
and to have the information, education, and means to do so.
As part of the United Nations Millennium Development Goals
(MDGs) universal access to family planning is one of the key factors
contributing to development and reducing poverty. Family planning
creates benefits in areas such as, gender quality and women's health,
access to sexual education and higher education, and improvements in
maternal and child health. Note that the Millennium Development Goals have been superseded by the Sustainable Development Goals.
UNFPA and the Guttmacher Institute say,
Serving all women in developing
countries that currently have an unmet need for modern contraceptives
would prevent an additional 54 million unintended pregnancies, including
21 million unplanned births, 26 million abortions and seven million
miscarriages; this would also prevent 79,000 maternal deaths and 1.1
million infant deaths.
Since climate change is directly proportional to the number of humans, family planning has a significant impact on climate change. The research project Drawdown estimates that family planning is the seventh most efficient action against climate change (ahead of solar farms, nuclear power, afforestation and many other actions).
In a 2021 paper for Sustainability Science, William J. Ripple, Christopher Wolf and Eileen Crist argue that population policies can both advance social justice,
while at the same time mitigating the human impact on the climate and
the earth system. They note that the richer half of the world's
population is responsible for 90% of the CO2 emissions.
Quality-quantity trade-off
Having
children produces a quality-quantity trade-off: parents need to decide
how many children to have and how much to invest in the future of each
child.
The increasing marginal cost of quality (child outcome) with respect to
quantity (number of children) creates a trade-off between quantity and
quality.
The quantity-quality trade-off means that policies that raise benefits
of investing in child quality will generate higher levels of human
capital, and policies that lower the costs of having children may have
unintended adverse consequences on long-run economic growth. When
deciding how many children, parents are influenced by their income
level, perceived return to human capital investment, and cultural norms
related to gender equality. Controlling birth rates allows families to
raise the future earnings power of the next generation. Many empirical
studies have tested the quantity-quality trade-off and either observed a
negative correlation between family size and child quality or did not
find a correlation.
Most studies treat family size as an exogenous variable because parents
choose childbearing and child outcome and therefore cannot establish
causality. They are both influenced by typically non-observable parental
preferences and household characteristics, but some studies observe
proxy variables such as investment in education.
High fertility countries have 18% of the world's population but contribute 38% of the population growth.
In order to become rich, resources must be re-appropriated to increase
income per person rather than supporting larger populations. As
populations increase, governments must accommodate increasing
investments in health and human capital and institutional reforms to
address demographic divides. Reducing the cost of human capital can be
implemented by subsidizing education, which raises the earning power of
women and the opportunity cost of having children, consequently lowering fertility.
Access to contraceptives may also yield lower fertility rates: having
more children than expected constrains the individual from attaining
their desired level of investment in child quantity and quality.
In high fertility contexts, reduced fertility may contribute to
economic development by improving child outcomes, reducing maternal
mortality and increasing female human capital.
Dang and Rogers (2015) show that in Vietnam, family planning
services increased investment in education by lowering the relative cost
of child quality and encouraging families to invest in quality.
By observing the distance to the nearest family planning center and the
general education expenditure on each child, Dang and Rogers provide
evidence that parents in Vietnam are making a child quality-quantity
trade-off.
Demand for Private Tutoring with and without access to family planning
Developed countries
Currently,
developed countries have experienced rising economic growth and falling
fertility. As a result of the demographic transition that takes place
when countries become rich, developed countries have an increasing
proportion of retired people which raises the burden on the workforce
population to support pensions and social programs. Encouraging higher
fertility as a solution may risk reversing the benefits for increased
child investment and female labor force participation have had on
economic growth. Increasing high skill migration may be an effective way
to increase the return to education leading to lower fertility and a
greater supply of highly skilled individuals.
Demand for family planning
Demand for family planning satisfied by modern methods as of 2017United
Nations Department of Economic and Social Affairs, Population Division,
"Trends in Contraceptive Use Worldwide 2015", New York: United Nations,
2015
214 million women of reproductive age in developing countries who do
not want to become pregnant are not using a modern contraceptive method.
This could be a result of a limited choice of methods, limited access
to contraception, fear of side-effects, cultural or religious
opposition, poor quality of available services, user or provider bias,
or gender-based barriers. In Africa, 24.2% of women of reproductive age
do not have access to modern contraception. In Asia, Latin America, and
the Caribbean, the unmet need is 10–11%. Meeting the unmet need for
contraception could prevent 104,000 maternal deaths per year, a 29%
reduction of women dying from postpartum hemorrhage or unsafe abortions.
According to the United Nations Department of Economic and Social
Affairs: Population Division, 64% of the world uses contraceptives, and
12% of the world population's need for contraceptives is unmet. In the
least developed countries, 22% of the population do not have access to
contraceptives, and 40% use contraceptives.
The unmet need for modern contraceptives is very high in sub-Saharan
Africa, south Asia, and western Asia. Africa has the lowest rate of
contraceptive use (33%) and highest rate of unmet need (22%). Northern
America has the highest rate of contraceptive use (73%) and the lowest
unmet need (7%). Latin America and the Caribbean follows closely behind
with 73% contraceptive use and 11% unmet need. Europe and Asia are on
par: Europe has a 69% contraceptive use rate and 10% unmet need, Asia
has a 68% contraceptive use and 10% unmet need. Although unmet need is
lower in Asia because of the large population in this region, the number
of women with unmet need is 443 million, compared to 74 million in
Europe Oceania has a 59% contraceptive use rate and 15% unmet need. When
comparing the regions within these continents, Eastern Asia ranks the
highest rate of contraceptive use (82%) and lowest unmet need (5%).
Western Africa ranks the lowest rate of contraceptive use (17%). Middle
Africa ranks the highest unmet need (26%). Unmet need is higher among
poorer women; in Bolivia and Ethiopia unmet need is tripled and doubled
among poor populations. However, in the Democratic Republic of Congo and Liberia the rates of unmet need are different by 1–2 percentage points. This suggests that as wealthier women begin to want smaller families, they will increasingly seek out family planning methods.
Substantial unmet need has provoked family planning programs by
governments and donors, but the impact of family planning programs on
fertility and contraceptive use remains somewhat unsettled. "Demand
theory" argues that in traditional agricultural societies, fertility
rates are driven by the desire to offset high mortality, thus as society
modernizes, the costs of raising children increases, reducing their
economic value, and resulting in a decline in desired number of
children. Under this theory, family planning programs will have a
marginal impact. Bongaarts (2014) shows that using a country case study
approach, both stronger and weaker family programs reduce the unmet need
for contraceptives and increases use by making modern contraceptives
more widely available and removing obstacles to use.
Also, the demand that is satisfied and the proportion of women using
modern methods increased. The programs may have an additional effect of
diffusing the ideas related to family planning and thus raising the
demand for contraception. As a result, a small decrease in unmet need
may be offset by a rise in demand. Nonetheless, even in countries where
it is assumed that family programs will make a marginal impact,
Bongaarts shows that family planning programs can potentially increase
contraceptive use and increase/decrease demand depending on the
preexisting attitudes of the community.
Regional variations
A family planning facility in Kuala Terengganu, Malaysia
Most of the countries with lowest rates of contraceptive use, highest
maternal, infant, and child mortality rates, and highest fertility
rates are in Africa.
Only about 30% of all women use birth control, although over half of
all African women would like to use birth control if it was available to
them.
The main problems that preventing access to and use of birth control
are unavailability, poor health care services, spousal disapproval,
religious concerns, and misinformation about the effects of birth
control. The most available type of birth control is condoms.
A rapidly growing population coupled with an increase in preventable
diseases means countries in Sub-Saharan Africa face an increasingly
younger population.
China's Family planning policy forced couples to have no more than one child. Beginning in 1979 and being officially phased out in 2015,
the policy was instated to control the rapid population growth that was
occurring in the nation at that time. With the rapid change in
population, China was facing many impacts, including poverty and
homelessness. As a developing nation, the Chinese government was
concerned that a continuation of the rapid population growth that had
been occurring would hinder their development as a nation. The process
of family planning varied throughout China, as people differed in their
responsiveness to the one-child policy, based on location and
socioeconomic status. For example, many families in the cities accepted
the policy more readily based on the lack of space, money, and resources
that often occurs in the cities. Another example can be found in the
enforcement of this rule; people living in rural areas of China were, in
some cases, permitted to have more than one child, but had to wait
several years after the birth of the first one.
However, the people in rural areas of China were more hesitant in
accepting this policy. China's population policy has been credited with a
very significant slowing of China's population growth which had been
higher before the policy was implemented. However, the policy has come
under criticism that it has resulted in abuse of women and girls. Often
implementation of the policy has involved forced abortions, forced sterilization,
and infanticides. In areas where family-planning regulations were
strictly enforced like Guangxi Province, 80% of trafficked babies were
girls as parents were more likely to sell their baby girls on the black
market than baby boys. The number of girls that die within their first
year of birth is twice that of boys. Another drawback of the policy is that China's elderly population is now increasing rapidly.
However, while the punishment of "unplanned" pregnancy is a large fine,
both forced abortion and forced sterilization can be charged with
intentional assault, which is punished with up to ten years'
imprisonment.
Family planning in China had its benefits, and its drawbacks. For
example, it helped reduce the population by about 300 million people in
its first 20 years.
A drawback is that there are now millions of sibling-less people, and
in China siblings are very important. Once the parent generation gets
older, the children help take care of them, and the work is usually
equally split among the siblings.
Another benefit of the implementation of the one-child law is that it
reduced the fertility rate from about 2.75 children born per woman, to
about 1.8 children born per woman in the 1979.
In 2015, China ended the one-child policy, announcing that all married
couples will be allowed to have two children, in a bid to reverse the
rapid aging of the labor force. The one-child policy was replaced with a two-child policy.
Map of population density by country, per square kilometer
In 2020, Chinese academics warn the country's leaders that the
country's history of family planning have led to a decline in population
growth. The decline in birthrate along with the increase in life
expectancy could potentially mean that there will be too few workers to
support the large aging population.
In 2021, Chinese officials announced that a Chinese couple can
now have three children, as the two-child policy failed to increase the
country's declining birthrate.
Xinjiang and the genocide of the Uyghur people
According
to an investigative report by The Associated Press published 28 June
2020, the Chinese government is taking draconian measures to slash birth
rates among Uyghurs
and other minorities as part of a sweeping campaign to curb its Muslim
population, even as it encourages some of the country's Han majority to
have more children.
While individual women have spoken out before about forced birth
control, the practice is far more widespread and systematic than
previously known, according to an AP investigation based on government
statistics, state documents and interviews with 30 ex-detainees, family
members and a former detention camp instructor.
The ongoing oppression of the Uyghur people and the violence
against their reproductive rights started in 2017 in the far west region
of Xinjiang, and is leading to what some experts are calling a form of
"demographic genocide".
In 2021, the Uyghur Tribunal in London concluded that China has
subjected the Muslim minority to forced sterilizations and abortion
approved by the highest level in Beijing.
Through their investigation they also found evidence that pregnant
women were forced to have abortions even at the last stage of pregnancy.
Since 2017, births in China's Xinjiang regions have dropped sharply.
Between 2015 and 2018, population growth in largely Uyghur areas fell by
84%.
This decline is not only attributed to the splitting of couples, but
also mass sterilization policies and forced IUD implantation. Between
2014 and 2018, the rate of IUD placements increased by more than 60% in
Xinjiang, while it dropped in other areas of China.
Uyghur survivors who have made it out of the concentration camps have
reported and testified regarding the violence against reproductive
rights in the camps. One survivor shares that she was given injections
and kicked repeatedly in the stomach, and is no longer able to have
children.
This is one of countless examples of the violence against women and
their rights to family planning within the Uyghur concentration camps.
In Hong Kong, the Eugenics League was founded in 1936, which became The Family Planning Association of Hong Kong in 1950. The organisation provides family planning advice, sex education, birth control services to the general public of Hong Kong.
In the 1970s, due to the rapidly rising population, it launched the
"Two Is Enough" campaign, which reduced the general birth rate through
educational means.
The Family Planning Association of Hong Kong, Hong Kong's national family planning association, founded the International Planned Parenthood Federation with its counterparts in seven other countries.
Family planning in India is based on efforts largely sponsored by the Indian government.
In the 1965–2009 period, contraceptive usage has more than tripled
(from 13% of married women in 1970 to 48% in 2009) and the fertility
rate has more than halved (from 5.7 in 1966 to 2.6 in 2009), but the
national fertility rate is still high enough to cause long-term
population growth. India adds up to 1,000,000 people to its population
every 15 days.
However, forecasted growth rate may be inaccurate due to high
disparities in education among Indian females and Indian states. An
increase in education rates has been associated with a decline in the
national fertility rate of India. As of 2015, the national fertility
rate among Indian females is 2.2 children per female, which is
approximately 3 times less than India's national fertility rate in the
1960s. This shift in national fertility rate may also reflect a marked change in family planning practices within India.
India's Ministry of Health and Family Welfare
states that if adequate family planning access resources become
available and accessible, India would reduce the number of infant deaths
by 1,200,000.
Some of the most prevalent forms of contraception used in India today
include sterilization, which is the most common method, followed by use
of condoms and oral contraceptive pills. However, the use of intrauterine devices (IUD's) remains markedly lower.
There is also a wide variation in the demand for family planning services and methods in different Indian states, with Manipur having the lowest demand (23.6%) while Andhra Pradesh has the highest (93.6%). Levels of social independence and attitudes towards domestic violence
have been shown to influence demand for family planning services and
resources. However, more research is necessary to determine other
predictive factors to gauge demand for family planning. Economic and cultural barriers also impede the delivery of family planning resources to all women on a national level. A lack of cohesive infrastructure in developing countries poses one great hurdle to physically delivering oral contraceptives
and medications to woman residing in non-urban areas. Additionally, the
expensiveness of modern contraceptives limits women from regularly
accessing these resources. Culturally, the use of contraceptives is
discouraged and antagonized. However, it is important to note that this sentiment varies greatly among castes, social classes, education status, and geographic location.
Debate exists regarding the widespread acceptance of family
planning practices within India. Some parties argue that longer life
expectancy, coupled with lower birth rates, allow working-age
individuals to accumulate more wealth since they need to support fewer
dependents.
Conversely, other studies indicate that family planning can reduce the
birth rate and cause the country's population to shrink. This debate has
garnered national attention, and legislation has been passed and is
being considered in the Indian Parliament to resolve these issues.
While Iran's population grew at a rate of more than 3% per year
between 1956 and 1986, the growth rate began to decline in the late
1980s and early 1990s after the government initiated a major population
control program. By 2007 the growth rate had declined to 0.7 percent per
year, with a birth rate of 17 per 1,000 persons and a death rate of 6
per 1,000.
Reports by the UN show birth control policies in Iran to be effective
with the country topping the list of greatest fertility decreases. UN's
Population Division of the Department of Economic and Social Affairs
says that between 1975 and 1980, the total fertility number was 6.5. The
projected level for Iran's 2005 to 2010 birth rate is fewer than two.
In late July 2012, Supreme LeaderAli Khamenei
described Iran's contraceptive services as "wrong", and Iranian
authorities are slashing birth-control programs in what one Western
newspaper (USA Today)
describes as a "major reversal" of its long standing policy. Whether
program cuts and high-level appeals for bigger families will be
successful is still unclear.
The sale of contraceptives was illegal in Ireland from 1935 until
1980, when it was legalized with strong restrictions, later loosened. It
has been argued that the resulting demographic dividend played a role in the economic boom in Ireland that began in the 1990s and ended abruptly in 2008 (the Celtic tiger) was in part due to the legalisation of contraception in 1979 and subsequent decline in the fertility rate. In Ireland, the ratio of workers to dependents increased due to lower fertility—the reality of which has been questioned—but was raised further by increased female labor market participation.
In agreement with the 1994 International Conference on Population and Development in Cairo, Pakistan
pledged that by 2010 it would provide universal access to family
planning. Additionally, Pakistan's Poverty Reduction Strategy Paper has
set specific national goals for increases in family planning and contraceptive use. In 2011 just one in five Pakistani women ages 15 to 49 uses modern birth control. Contraception is shunned under traditional social mores that are fiercely defended as fundamentalist Islam gains strength.
Philippines
In the Philippines, the Responsible Parenthood and Reproductive Health Act of 2012 guarantees universal access to methods on contraception, fertility control, sexual education,
and maternal care. While there is general agreement about its
provisions on maternal and child health, there is great debate on its
mandate that the Philippine government and the private sector will fund
and undertake widespread distribution of family planning devices such as
condoms, birth control pills, and IUDs, as the government continues to disseminate information on their use through all health care centers.
According to a 2004 study, current pregnancies were termed "desired
and timely" by 58% of respondents, while 23% described them as "desired,
but untimely", and 19% said they were "undesired". As of 2004, the
share of women of reproductive age using hormonal or intrauterine birth
control methods was about 46% (29% intrauterine, 17% hormonal).
During the Soviet era high quality contraceptives were difficult to
obtain, and abortion became the most common way of preventing unwanted
births. Since the dissolution of the Soviet Union abortion rates have
fallen considerably, but they are still higher than rates in many
developed countries.
Population control in Singapore spans two distinct phases: first to slow and reverse the boom in births that started after World War II; and then, from the 1980s onwards, to encourage parents to have more children because birth numbers had fallen below replacement levels.
Thailand
In
1970, Thailand's government declared a population policy that would
battle the country's rapid population growth rate. This policy set a
five-year goal to reduce Thailand's population growth rate from 3
percent to 2.5 percent through methods such as spreading family planning
awareness to rural families, or integrating family planning activities
into maternal and child healthcare education. Public figures such as Mechai Viravaidya helped spread family planning awareness through public speakings and charitable activities.
United Kingdom
Contraception has been available for free under the National Health Service since 1974, and 74% of reproductive-age women use some form of contraception. The levonorgestrel intrauterine system has been massively popular. Sterilization is popular in older age groups, among those 45–49, 29% of men and 21% of women have been sterilized. Female sterilization has been declining since 1996, when the intrauterine system was introduced. Emergency contraception
has been available since the 1970s, a product was specifically licensed
for emergency contraception in 1984, and emergency contraceptives
became available over the counter in 2001.
Since becoming available over the counter it has not reduced the use of
other forms of contraception, as some moralists feared it might. In any year only 5% of women of childbearing age use emergency hormonal contraception.
Despite widespread availability of contraceptives, almost half of pregnancies were unintended in 2005. Abortion was legalized in 1967.
In the US, family planning is more expiclitly associated with
contraception. It is defined as "the ability of individuals and couples
to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility."
Despite the availability of highly effective contraceptives, about half of U.S. pregnancies are unintended. Highly effective contraceptives, such as IUD, are underused in the United States. Increasing use of highly effective contraceptives could help meet the goal set forward in Healthy People 2020 to decrease unintended pregnancy by 10%. Cost to the user is one factor preventing many American women from using more effective contraceptives.
Making contraceptives available without a copay increases use of highly
effective methods, reduces unintended pregnancies, and may be
instrumental in achieving the Healthy People 2020 goal.
In the United States, contraceptive use saves about $19 billion in direct medical costs each year. Title X of the Public Health Service Act,
is a U.S. government program dedicated to providing family planning
services for those in need. But funding for Title X as a percentage of
total public funding to family planning client services has steadily
declined from 44% of total expenditures in 1980 to 12% in 2006. Current
funding for Title X is less than 40% of what is needed to meet the need
for publicly funded family planning. Title X would need $737 million annually to meet the need for family planning services.
Only 6.2 million women accessed publicly funded services from 10,700
clinics in 2015, despite an estimated 20 million women who could
benefit.
Clinics funded by Title X served 3.8 million of these women with
access to services.In 2015, publicly funded contraceptive services
helped women prevent 1.9 million unintended pregnancies; 876,100 of
these would have resulted in unplanned births and 628,000 abortions.
Without publicly funded contraceptive services, the rates of unintended
pregnancies, unplanned births and abortions would have been 67% higher. The rates for teens would have been 102% higher. Title X funded programs saw 1.2 million fewer patients in 2015 compared to 2010 as funding decreased by $31 million. In 2015, an estimated 2.4 million additional women received Medicaid-funded contraceptive services from private doctors.
Medicaid has increased from 20% to 71% from 1980 to 2006. In 2006, Medicaid contributed $1.3 billion to public family planning. The $1.9 billion spent on publicly funded family planning in 2008 saved an estimated $7 billion in short-term Medicaid costs. Such services helped women prevent an estimated 1.94 million unintended pregnancies and 810,000 abortions.
About 3 out of 10 women in the United States have an abortion by the time they are 45 years old.
A 2017 paper found that parents' access to family planning
programs had a positive economic impact on their subsequent children:
"Using the county-level introduction of U.S. family planning programs
between 1964 and 1973, we find that children born after programs began
had 2.8% higher household incomes. They were also 7% less likely to live
in poverty and 12% less likely to live in households receiving public
assistance. After accounting for selection, the direct effects of family
planning programs on parents' incomes account for roughly two thirds of
these gains."
A 2021 study found disparity among racial groups in the perceived
quality of family planning care received, with white women (72%) more
likely to rate their experience with their providers as excellent than
Black (60%) and Hispanic women (67%).
In Uzbekistan, the government has pushed for uteruses to be removed from women in order to forcibly sterilize them.
LGBT family planning
For
individuals who plan on building a family in the near or distant
future, some options available are oocyte cryopreservation, IVF with
cryopreservation of embryos using donor gametes, or ovarian tissue
cryopreservation (OTC). The method with the highest likelihood of future
pregnancies is oocyte freezing and embryo freezing. For individuals
wanting to conceive very soon, they will need to use donor gametes. The
donor gametes can be anonymous or known directed donors. These donors
must undergo a mandated Food and Drug Administration (FDA) screenings
which include questionnaires, physical examination, and sexually
transmitted infection.
Lesbian couples
Lesbian
couples need donor sperm to conceive through several options, including
therapeutic donor insemination (TDI) with or without ovarian
stimulation, autologous IVF, and reciprocal or co-IVF.
Reciprocal or co-IVF is an option where one partner undergoes
controlled ovarian hyper-stimulation and oocyte retrieval followed by
transfer of a fertilized embryo into the other's uterus. Co-IVF is not
considered oocyte donation because the oocyte is considered shared (just
as the sperm is "shared" between heterosexual couples). Studies suggest
that co-IVF can lessen emotional insecurities in lesbian households.
Gay male couples
Options
for male couples involve both an oocyte donor and gestational carrier.
Oocyte donors undergo FDA screening processes and testing. Gestational
carriers are individuals who birth a genetically unrelated child for
another individual/couple.
The American Society for Reproductive Medicine (ASRM) recommends
psychosocial evaluation of both the gestational carrier and the intended
parents because of the complex stressful process for all parties
involved.
Transgender individuals
Overall, transgender
and gender diverse individuals face multiple barriers to achieving
family planning goals. This community experiences lack of access to
reproductive health care settings where they feel accepted, safe, and
understood; reproduction help; pregnancy care; and contraception.
A barrier that gets in the way of becoming parents is the cost
involved with fertility preservation options. For example, the use of
sperm cryopreservation
in the United States is less than 5% while countries such as the
Netherlands, Australia and Israel have higher rates; this may be the
result of challenges navigating health insurance coverage.
According to a study, in the United States the national median initial
bank fee and annual price of storage are $350 and $385 respectively.
For those looking for egg preservation, a study calculated that the
median total cost (which includes egg freezing, egg thawing, and annual
preservation fee) in United States was around $7,444, and the
cumulative costs for one live birth of US$11,704 for an individual in
the age groups ≤ 35 years. Other common concerns that arise when seeking pregnancy include having to stop or delay of hormonal therapy, worsening of gender dysphoria with treatment related to pregnancy.
Interventions used to facilitate gender transition such as hormone therapy
and gender affirming surgeries (e.g., genital surgery, and chest
surgery) can temporarily or permanently impact the chance of becoming
pregnant.
The World Professional Organization for Transgender Health (WPATH) and
American Society for Reproductive Medicine (ASRMA) recommend offering
counseling on the impact on family planning and transitioning to all
transgender individuals
Even though many transgender and gender-nonbinary youth express desire
to receive fertility counseling and recommendations from professional
organization, studies indicate that only a small portion have these
conversations with their health care team.
Health care professionals attribute lack of knowledge of reproductive
health in this community, knowledge limitation due to lack of data on
long term effects of hormonal intervention to the inconsistency in
discussion around family building.
Studies have shown that transgender men can still become pregnant
even in the absence of menstruation caused by gendered affirming
therapy in the form of testosterone.
Inconsistent hormonal therapy such as missed doses, incomplete dosing,
or switching therapy regimen, mostly due to barriers noted earlier, may
also lead to breakthrough ovulation which can contribute to increase chances of unintended pregnant,
highlighting the need of contraception on transgender men (who have
conserved reproductive organs) on testosterone if pregnancy is not
desired.
Furthermore, testosterone can cause abnormal vaginal development in
female fetuses (especially in the first trimester of pregnancy),
becoming a concern for transgender men who conceived while on hormone
therapy. Moreover, condoms are one of the most common contraceptive
methods in transgender men, while another subset report no contraception
use which can lead to unintended pregnancies. Some challenges to
adopting a form of family planning method among this population varies
depending on the method. For instance, fear of prevention of
masculinization with use of estrogen-based contraceptives, and gender dysphoria with the use of contraceptive devises inside cervical/pelvic cavity.
Additionally, negative experiences in the health care system related to
gender identity, and denial of health care based on gender identity
makes it difficult for this community to access health care and family
planning resources.
Obstacles to family planning
There are many reasons as to why women do not use contraceptives.
These reasons include logistical problems, scientific and religious
concerns, limited access to transportation in order to access health
clinics, lack of education and knowledge, and opposition by partners,
families or communities.
The UNFPA states, "Poorer women and those in rural areas often
have less access to family planning services. Certain groups — including
adolescents, unmarried people, the urban poor, rural populations, sex
workers and people living with HIV also face a variety of barriers to
family planning. This can lead to higher rates of unintended pregnancy,
increased risk of HIV and other STIs, limited choice of contraceptive
methods, and higher levels of unmet need for family planning."
For national, international, or local health programs involved in family planning, the use of standard indicators
is increasingly encouraged, to track barriers to effective family
planning along with the efficacy, uptake, and provision of family
planning services.
Social conservativism
Family
planning has reduced the burden of childbearing from women. Now having
to raise fewer children than before, women are no longer as economically
dependant on their partners. As such, they are not necessitated to stay
in marriages, due to the confidence that they can raise children with
less financial difficulty that if they had several children. In order to
preserve traditional gender roles, social conservatives seek to reverse
the social changes brought by family planning and declining birth rate.
They are opposed to most forms of family planning and advocate for
larger families with many children. To this end, they sometimes cite the
decline of religion or "the family", but as Hans Rosling notes in his
book "Factfulness", this has little to do with religious or famiy
values, and are merely "patriarchal values".
COVID-19
As of
March 2020, there were an estimated 450 million women using modern
contraceptives across 114 priority low- and middle-income countries. The
COVID-19 pandemic as well as social distancing and other strategies to
reduce transmission are anticipated to impact the ability of these women
to continue using contraception. The number of unintended pregnancies
will increase as the lockdown continues and services disruptions are
extended.
Some 47 million women in 114 low- and middle-income countries are
projected to be unable to use modern contraceptives if the average
lockdown, or COVID-19-related disruption, continues for six months with
major disruptions to services. For every three months the lockdown
continues, assuming high levels of disruption, up to 2 million
additional women may be unable to use modern contraceptives. If the
lockdown continues for six months and there are major service
disruptions due to COVID-19, an additional 7 million unintended
pregnancies are expected to occur.
World Contraception Day
September
26 is designated as World Contraception Day, devoted to raising
awareness of contraception and improving education about sexual and
reproductive health, with a vision of "a world where every pregnancy is
wanted". It is supported by a group of international NGOs, including:
The United Nations Population Fund explicitly states it "never promotes abortion as a form of family planning".
The World Health Organization states that "Family
planning/contraception reduces the need for abortion, especially unsafe
abortion."
The campaign to conflate contraception and abortion is rooted on
the assertion that contraception ends, rather than prevents, pregnancy.
This is due to the notion that preventing implantation implies an
abortion, when considering fertilization as the initial moment of
pregnancy. According to an amicus brief submitted to the U.S. Supreme
Court in October 2013 led by Physicians for Reproductive Health and the American College of Obstetricians and Gynecologists,
a contraceptive method prevents pregnancy by interfering with
fertilization, or implantation. Abortion, separate from contraceptives,
ends an established pregnancy.
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