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- - - MEETING THE UNMET NEED FOR FAMILY PLANNING

Friday, 17th of May 2013

• MEETING THE UNMET NEED FOR FAMILY PLANNING: NOW IS THE TIME

The Lancet,Volume 381, Issue 9879, Pages 1696 - 1699, 18 May 2013

 

 

Original Text

Herbert B Peterson a b, Gary L Darmstadt c, John Bongaarts d

The rebirth of family planning is well underway and could not be more important or timely, as countries worldwide work towards implementation of international human rights agreements and achievement of the Millennium Development Goals.1, 2 However, as reported in The Lancet by Alkema and colleagues3 and, in this issue, by Jacqueline Darroch and Susheela Singh,4 unmet need for modern contraception in the worlds poorest countries is still unacceptably high. Meeting this need will not only help individuals and couples to gain the right to contraceptive information and services,2 but will also improve the health of women, children, and families.

The Lancet Series on family planning in 2012 provided compelling evidence for these assertions. Ahmed and colleagues5 estimated that contraceptive use averted 272 040 maternal deaths in 2008, and that meeting unmet need for contraception could prevent an additional 104 000 deaths per year. This estimate of an additional 29% reduction in maternal deaths was nearly identical to that made by Cleland and colleagues6 (30%), who also provided evidence for non-contraceptive benefits to womens health and improvements in perinatal outcomes and child survival, mainly by lengthening of interpregnancy intervals. Ezeh and colleagues7 emphasised the effect of meeting the unmet need for contraception on the achievement of global development goals: most of the poorest countries, and particularly those in sub-Saharan Africa, are experiencing rapid population growth (more than 2% per year) with related social, economic, and environmental pressures. Furthermore, the economic consequences of family planning as assessed by Canning and Schultz8 include effects that are associated with positive outcomes for economic growth, such as increases in womens earnings and participation in paid employment, healthier and better educated children, and an increased proportion of people of working age.

How much unmet need for modern contraception is there in developing countries? Alkema and colleagues3 and Darroch and Singh4 provide updated estimates for recent years, but their results seem to differ. For example, the most prominently mentioned unmet need estimates are 26% in Darroch and Singhs study for 2012 and a much lower 12·3% in Alkema and colleagues study for 2010. These variations in estimates are attributable to differences in definitions of unmet need. Alkema and colleagues focused on women who are married (or in union), whereas Darroch and Singh analysed all women irrespective of marital status. Estimates of numbers of women with an unmet need that are limited to married women are lower than are those for all women, because the latter includes unmarried women. A second key difference between the two studies is how users of traditional methods of contraception are treated. Darroch and Singh regard women who rely on a traditional method to have an unmet need for modern contraception. By contrast, Alkema and colleagues assume that the needs of users of traditional methods are met.

These assumptions have a large effect. The assumption that traditional method users have an unmet need increases the number of women with unmet need from 134 million to 196 million for married women, and from 153 million to 222 million for all women in developing countries in 2012 (table).9 The corresponding proportions of women with unmet need are 12·6% for married women (traditional method users not included as having unmet need) and 18·5% (traditional method users included), and 10% and 15%, respectively, for all women. Inclusion of only women who want to avoid pregnancy leads to another set of percentages: Alkema and colleagues estimated the percentage of unmet need for married women in this group as 16·8% (traditional method users not included) and 24·6% (traditional method users included),3 and Darroch and Singh estimated the comparable proportions for all women as 18% and 26%, respectively.9 The table also includes several unpublished estimates provided by Darroch and Singh (Darroch J, Guttmacher Institute, personal communication). These estimates allow a direct comparison of unmet need estimates between the two studies with the same definitions. Once the above definitions are taken into account, the studies yield very similar estimates. Irrespective of the definition used, the unmet need for contraception is too high: placement of this need at the centre of the global public health agenda was the focus of the 2012 London Summit on Family Planning.

TableTable image  

Number in millions (proportion) of women in developing countries with unmet need for contraception in 2012

To achieve the ambitious goal of the London Summit—ie, to enable an additional 120 million women and girls in the worlds poorest countries to access and use lifesaving family planning information, services, and supplies by 2020—innovative approaches and a change in perspective will be needed. Many partners, including developing countries, civil society, the private sector, and donors and foundations, are now taking forward the Summit commitments through Family Planning 2020, a partnership hosted by the UN Foundation. Darroch and Singhs findings are a useful contribution to this work, particularly in the provision of data to inform decision making. As we move forward from the London Summit, six anchor points provide a framework to guide the transformation of family planning efforts, investments, and priorities.

First, the London Summit called for a transformation to how family planning is approached, including political will, respect for rights, quality services, demand creation, funding mechanisms, partnering among stakeholders, available products, supply chains, data collection, monitoring, assessment, accountability, and inclusive policy and programming processes.

Second, womens rights must be at the centre of any effort to increase access to family planning and the summit affirmed the fundamental importance of voluntary family planning, free of coercion and discrimination, and equitable access to a full range of contraceptives for married and unmarried women and adolescent girls. This approach requires development of contraceptive technologies to meet the needs of all women and girls, and involvement of womens input into product design, development, and introduction at each step along the way. Furthermore, women and girls are empowered as active participants in policy making, in the monitoring of policies and budgets, in holding governments to account, and as respected leaders at every level—globally, and at country and village levels.

Third, country leaders are showing their commitments to increasing access to family planning by guiding policies into action and coordinating efforts to reach national-level goals. These leaders have acknowledged that the goals cannot be achieved without effective collaboration to share knowledge, technical expertise, and best practices. The global community is committed to working with these leaders and providing support for transformations on the basis of their own national health strategies and plans for increasing access. Country leaders can show strong political will by mobilising financial and health system resources for service delivery at the country level and increasing those resource contributions over time. Civil society plays an important part in articulating the voice of affected populations and holding country-level leadership accountable.

Fourth, innovative solutions with a focus on gender are an important part of improvements in access to and use of family planning. Sharing of practical knowledge and best practices, including successes and lessons learned from failures, is crucial for progress. Innovation should happen at all levels, including not only the development of new technologies, but also the use of new implementation processes to increase availability and access to family planning.

Fifth, market interventions can be a driver for innovation to increase the range of affordable methods from which women can choose. These interventions should be input in conjunction with strengthening of weak supply chains and service delivery, and alongside demand-side activities to empower women to learn about and freely access and use their method of choice. Worldwide, efforts will aim to improve commodity quality and affordability, particularly for long-acting methods. The availability of products should also be increased through improved forecasting and enhanced delivery systems, both at the global and country levels. Efforts will be made to work with the private sector, including developing-country and generic manufacturers, for the development of quality, affordable family planning products that meet the needs of all women. Available approaches include guarantees for manufacturers and distributors when markets for new or niche commodities are fragile, to ensure less risk to the manufacturer for introduction of methods into a new market, and improvement of the ability of suppliers to navigate regulatory pathways and processes.

Finally, establishment of a robust performance measurement and accountability framework is crucial to allow progress to be tracked and barriers to be identified and addressed to improve programme performance and hold providers and policy makers accountable. Metrics should include measures of quality of care and equitable access to a broad mix of methods, thus ensuring freedom from coercion and discrimination. The goal is to transform the way in which progress and results are monitored and used to drive political accountability. This goal will be achieved by development and rolling out of innovative approaches to data collection and reporting, and working with civil society at local and national levels to ensure that womens rights are respected and promoted. These efforts will complement, align with, and contribute to government, civil society, and donor commitments for the UN Secretary-Generals Global Strategy, Every Woman Every Child.

Realisation of the vision of the London Summit will need great effort, but as William Foege said in characterising the triumph of smallpox eradication, This is a cause-and-effect world, and smallpox disappeared because of a plan, conceived and implemented on purpose, by people. Humanity does not have to live in a world of plagues, disastrous governments, conflict and uncontrolled health risks. The coordinated action of a group of dedicated people can plan for and bring about a better future.10 We need that mindset and level of commitment to meet the unmet need for contraceptive information and services. International human rights agreements and development goals are calling and now is the time to answer.

For more on the London Family Planning Summit and Family Planning 2020 see http://www.londonfamilyplanningsummit.co.uk/

We acknowledge the contributions of the London Summit on Family Planning and the FP2020 initiative. The London Summit on Family Planning was an initiative led by the UK Government and the Bill & Melinda Gates Foundation, with UNFPA and USAID. The FP2020 initiative is being developed by a Reference Group and Task Team hosted by the UN Foundation. We declare that we have no conflicts of interest.

1 Horton R, Peterson HB. The rebirth of family planning. Lancet 2012; 380: 77. Full Text | PDF(64KB) | CrossRef | PubMed

2 Cottingham J, Germain A, Hunt P. Use of human rights to meet the unmet need for family planning. Lancet 2012; 380: 172-180. Summary | Full Text | PDF(102KB) | CrossRef | PubMed

3 Alkema L, Kantorova V, Menozzi C, Biddlecom A. National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis. Lancet 2013; 381: 1642-1652. Summary | Full Text | PDF(322KB) | CrossRef | PubMed

4 Darroch JE, Singh S. Trends in contraceptive need and use in developing countries in 2003, 2008, and 2012: an analysis of national surveys. Lancet 2013; 381: 1756-1762. Summary | Full Text | PDF(90KB) | PubMed

5 Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet 2012; 380: 111-125. Summary | Full Text | PDF(1049KB) | CrossRef | PubMed

6 Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet 2012; 380: 149-156. Summary | Full Text | PDF(311KB) | CrossRef | PubMed

7 Ezeh AC, Bongaarts J, Mberu B. Global population trends and policy options. Lancet 2012; 380: 142-148. Summary | Full Text | PDF(613KB) | CrossRef | PubMed

8 Canning D, Schultz TP. The economic consequences of reproductive health and family planning. Lancet 2012; 380: 165-171. Summary | Full Text | PDF(187KB) | CrossRef | PubMed

9 UN Department of Economic and Social Affairs Population Division, Fertility and Family Planning Section. World contraceptive use 2012. http://www.un.org/esa/population/publications/WCU2012/MainFrame.html. (accessed May 1, 2013).

10 Foege WH. House on fire: the fight to eradicate smallpox. Berkeley, CA: University of California Press, 2011.

a Department of Maternal and Child Health, Gillings School of Global Public Health, Chapel Hill, NC 27599, USA

b Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA

c Family Health Program, The Bill & Melinda Gates Foundation, Seattle, WA, USA

d Population Council, New York, NY, USA