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CSU 45/2011: MDG 5 AND FAMILY PLANNING

Monday, 28th of March 2011 Print

Full text is at http://epirev.oxfordjournals.org/content/32/1/152.full#ref-49

Family planning has been cited as essential to the achievement of Millennium Development Goals (5) by former United Nations Secretary General Kofi Annan (6), and, as such, part of the fifth Millennium Development Goal targets universal access to family planning as a key strategy for improving maternal health. . . . Estimates of donor assistance in 2008 for this sector total $10.6 billion, but only $0.25 billion (2.4%) is directed toward supporting family planning (9), or approximately US $0.17 per woman of childbearing age in developing countries.'

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BD

Epidemiologic Reviews, Volume32, Issue1, Pp. 152-174.

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Family Planning and the Burden of Unintended Pregnancies

1.�� Amy O. Tsui*, Raegan McDonald-Mosley and Anne E. Burke

1.��� *Correspondence to Dr. Amy O. Tsui, Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, W4041, Baltimore, MD 21205 (e-mail: atsui@jhsph.edu).

  • Accepted April 29, 2010.

Abstract

Family planning is hailed as one of the great public health achievements of the last century, and worldwide acceptance has risen to three-fifths of exposed couples. In many countries, however, uptake of modern contraception is constrained by limited access and weak service delivery, and the burden of unintended pregnancy is still large. This review focuses on family planning's efficacy in preventing unintended pregnancies and their health burden. The authors first describe an epidemiologic framework for reproductive behavior and pregnancy intendedness and use it to guide the review of 21 recent, individual-level studies of pregnancy intentions, health outcomes, and contraception. They then review population-level studies of family planning's relation to reproductive, maternal, and newborn health benefits. Family planning is documented to prevent mother-child transmission of human immunodeficiency virus, contribute to birth spacing, lower infant mortality risk, and reduce the number of abortions, especially unsafe ones. It is also shown to significantly lower maternal mortality and maternal morbidity associated with unintended pregnancy. Still, a new generation of research is needed to investigate the modest correlation between unintended pregnancy and contraceptive use rates to derive the full health benefits of a proven and cost-effective reproductive technology.

INTRODUCTION

In 1999, the Centers for Disease Control and Prevention identified family planning as one of 10 great public health achievements in the United States during the 20th century (1). Alongside other achievements, such as vaccination and control of infectious diseases, access to family planning and contraceptive services was cited for social, economic, and health benefits conferred through �smaller family size and longer interval between the birth of children; increased opportunities for preconceptional counseling and screening; fewer infant, child, and maternal deaths; and the use of barrier contraceptives to prevent pregnancy and transmission of human immunodeficiency virus and other STDs [sexually transmitted diseases]� (1, p. 241). In the United States, contraceptive use among all women 15�44 years of age in 2002 was 61.9% in 2002 and considerably higher (72.9%) among married women. More than 45 million US women use contraception, relying primarily on the pill, female and male sterilization, and condoms.

The prevalence of contraceptive use is similarly high in European, many Latin American, and east and southeast Asian countries. Contraceptive use among partnered women aged 15�49 years in the developing world rose from 14% in the mid-1960s (2) to 62% in 2008 (3) and from protecting approximately 70 million to more than 600 million couples from unintended pregnancies. Rapid adoption of contraception has been documented in countries as diverse as Thailand, Iran, Egypt, and Colombia between the mid-1980s and mid-2000s (4). In low-income countries in sub-Saharan Africa, south Asia, and Central America, use of modern contraception is more modest and is constrained by limited access to services and weak government programs. While types of contraceptive methods used vary across regions, the health and social benefits of family planning are widely accepted across much of the world. Public sponsorship has launched most national family planning programs targeting low-income users, but modern contraceptive use has risen through sustained individual demand often met by an expansion of care from private providers.

Globally, the strength of government commitment tends to be greater than actual funding levels or program implementation efforts. Family planning has been cited as essential to the achievement of Millennium Development Goals (5) by former United Nations Secretary General Kofi Annan (6), and, as such, part of the fifth Millennium Development Goal targets universal access to family planning as a key strategy for improving maternal health. The proportion of governments in less-developed countries that provide direct or indirect support for contraceptive access grew from 64% in 1976 to 87% in 2009 (7). Global domestic spending on population activities�which includes family planning, reproductive health, sexually transmitted diseases/human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome, and basic research�by governments, nongovernmental organizations, and consumers reached $18.5 billion in 2006, but nearly half (45%) was allocated to sexually transmitted diseases/HIV/acquired immunodeficiency syndrome (8). Estimates of donor assistance in 2008 for this sector total $10.6 billion, but only $0.25 billion (2.4%) is directed toward supporting family planning (9), or approximately US $0.17 per woman of childbearing age in developing countries.

The term �family planning� has been used synonymously with contraceptive practice, although the ability to decide the number and timing of births can be achieved by a range of means, including contraception and assisted-reproductive technologies. Voluntary abstinence�either permanent or intermittent�elective abortion, and artificial insemination are other means commonly used by individuals to achieve reproductive intentions. In this review, we focus on contraception and address unsafe abortion as a preventable outcome of failed contraceptive behavior or methods.

Our review incorporates both population-level and individual-level perspectives in assessing the research evidence of contraceptive practice's relation to the burden of unintended pregnancies. The review has 4 parts. After framing the behavioral epidemiology that links sexual, reproductive, maternal, and newborn health outcomes, we briefly detail the measurement of unintended pregnancy and contraceptive practice. Next, we review findings from recent individual-level studies of 1) fertility intentions and pregnancy and maternal outcomes, 2) fertility intentions and contraceptive behaviors, and 3) contraceptive behaviors and unintended pregnancy outcomes. In the fourth part, we review research on the population-level health implications of family planning need.

A reproductive behavioral epidemiology framework

With broad acceptance of contraception as a modern health technology, why do unintended pregnancies still constitute a health burden for women and their partners? The answers lie in the health risks associated with sexual activity and reproduction. Coition, conception, viable pregnancy, fetal growth, parturition, and the puerperium separately carry health risks or undesirable outcomes, such as sexually transmitted infection, unintended pregnancy, fetal wastage, stillbirth, and maternal and neonatal mortality. Successful progression through these events can be measured by postpartum health and survival of mothers and infants. Many health technologies, including contraception, increase the likelihood that each transition occurs successfully. Table 1 and Figure 1 convey the epidemiologic links among the events and the key interventions, particularly family planning, associated with the pathways.

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Table 1.

Common Measures for Reproductive Epidemiology Outcomes and Range of Values

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Figure 1.

Pathways between sexual, reproductive, maternal, and newborn health outcomes. Motivational pathways are represented by dashed lines, behavioral pathways by solid lines.

Starting with coital activity, the probability of conception during any random act of intercourse is thought to range between 3% and 5% (10). A recent study of conception risk by menstrual cycle day among a small sample of North Carolina women found a likelihood of 3.1% per coition overall (11). In addition to pregnancy, coital activity also carries the risk of sexually transmitted infection. The probability of acquiring an infection will depend on multiple factors, including exposure to a partner infected with an offending organism as well as number of partners and condom use. For example, Wawer et al. (12) found the probability of HIV-1 transmission to be 0.0082 (95% confidence interval (CI): 0.0039, 0.0150) per coital act in Rakai, Uganda. Sex protected by contraception and consistent condom use addresses both pathways a and f in Figure 1 and reduces pregnancies that are unplanned and/or exposed to sexually transmitted infections. Sexually transmitted infection, such as chlamydia, gonorrhea, and syphilis, increases the risk of preterm birth, low birth weight, and stillbirth (i, d). Recurrent infections cause subfecundity (g) and infertility (h).

The probability that conceptions become viable fetuses (b) and progress to term (d) is enhanced by maternal nutritional well-being before pregnancy and nutritional status during gestation (13). The prevalence of spontaneous abortion can range from 5% to 70% of pregnancies, depending on stage of development. Worldwide, 22% of pregnancies, or about 42 million, are electively terminated (c), of which 20 million terminations happen under unsafe conditions, mostly in the developing world (14). Contraception plays a key role in reducing reliance on elective abortions and can avert as many as 13%�15% of the maternal deaths that result from unsafe abortions (a-b-c-m). Figure 1 highlights the significance of protected coitus not only in preventing unintended pregnancy and sexually transmitted infection but also in lowering exposure to subsequent morbidity and mortality risks.

Terminology and definitions in unintended pregnancy research

Fertility-intention measures implicitly require individual cognition of the ability to control the timing and number of pregnancies. This recognition is near, but not completely, universal in the world. Santelli et al. rightly describe pregnancy intendedness as a �complex concept � encompassing affective, cognitive, cultural and contextual dimensions� (15, p. 94). The persistence and stability of individual fertility intentions, and thus their predictive value, have been questioned in a number of studies (1618).

Because population-level measures are primarily assessed through cross-sectional, national household surveys, such as the National Survey of Family Growth, the Demographic and Health Surveys (DHS), and the Reproductive Health Surveys, pregnancy intendedness is based on female respondents� retrospective, potentially biased recall of the planned status of the last or a recent pregnancy: Right before you became pregnant with your (nth, last) pregnancy � , Thinking back to just before you got pregnant with [name of child] � , or At the time you became pregnant with [name of child] � . Prospective studies assess women's future pregnancy intentions and their strength: Are you trying to get (or keep from getting) pregnant now? How important is avoiding a pregnancy to you? Furthermore, in most studies, pregnancy intendedness is dichotomized (intended/unintended, wanted/unwanted), despite recognition that it is a complex and nuanced concept. This dichotomization may be due to the limitations of data collection or measurement instruments, but it does raise questions about what is being missed in current analyses.

The desired timing of the next pregnancy is used to assess unintendedness. Generally, a pregnancy that follows a woman's report of not wanting any additional births is classified as �unwanted,� whereas one that happens before a desired point in time for her is �mistimed.� A pregnancy desired at the time is considered �wanted.� Some pregnancies to women who are unsure of their intendedness are classified as being of �unsure� or �ambivalent� status. Most studies reviewed here adopt a 3-level classification, with �unsure� combined with �wanted� intendedness.

Pregnancy-intention measures provide the denominator for unmet contraceptive-need measures in the developing world (19). The most widely used concept of unmet contraceptive need is a woman exposed to the risk of pregnancy and not currently using contraception who wants to space or limit future childbearing. The standard DHS definition for unmet need means that a woman 1) is married or in a consensual union, 2) is between the ages of 15 of 49 years, 3) is capable of becoming pregnant, 4) wants to have no more children or no children for at least 2 years, and 5) is using neither a traditional nor a modern method of contraception (20, 21). One obvious limitation of this definition is that unmarried women, and especially adolescents, may not be included.

Terminology and definitions in family planning research

Modern contraceptive methods can be categorized in several ways. Hormonal methods include such products as oral contraceptives, patches, vaginal rings, injectables, implants, and levonorgestrel intrauterine contraception. Nonhormonal methods include male and female condoms and other barrier methods, as well as copper intrauterine devices (IUDs). Implants and intrauterine contraception, and sometimes injectables, are also categorized as long-acting, reversible contraceptive methods. Surgical sterilization is a permanent method of family planning.

Contraceptive effectiveness is a measure of the success of typical use of a method. It incorporates efficacy, that is, how well a method works when used consistently and correctly, and a host of other factors, such as ease of compliance. Generally, long-acting, reversible methods and sterilization are the most effective (>99% protection against pregnancy over a year of use), with very low pregnancy rates among typical users that approach perfect-use rates. Once initiated, these methods are relatively user independent. Shorter-acting hormonal contraceptives are generally in the next tier of effectiveness. Included are such methods as pills, patches, and vaginal rings. These methods have high efficacy, but potential problems with compliance (missed doses, unreliable supply) result in higher real-world pregnancy rates. For example, the typical pregnancy rate for the combined oral contraceptive pill is 8% in the first year of use (22). Barrier methods are somewhat less effective (pregnancy rates of 15%�32%), followed by contraception that relies on timed intercourse, such as withdrawal or fertility-awareness methods.

Perhaps one of the best-measured reproductive behaviors, contraceptive practice has been assessed extensively at the population level for more than 4 decades by using the �contraceptive prevalence rate.� Technically, this is not a rate but a proportion�the percentage of exposed women reporting current use of any contraception, including male methods. Exposure involves being of reproductive age (15 years to 44 or 49 years) and sexually active or in a marital or stable union. Contraceptive �method mix� is also a measure of much interest because it is a proxy for method availability and client choice (23). It may reflect preferences of women or couples or it may reflect limits regarding supply or provider bias (24).

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MATERIALS AND METHODS

Guided by the framework in Figure 1, we reviewed the recent research literature on the magnitude and strength of the relation between pregnancy intentions and reproductive, maternal, and newborn health outcomes first (Table 2) and then contraception. Table 3 summarizes studies of pregnancy intentions and contraception behaviors, and Table 4 includes studies of contraceptive behaviors and pregnancy outcomes, specifically the incidence of unintended pregnancy and elective pregnancy termination. Nearly all studies are observational and most cross-sectional, limiting the rigor of the evidence and the reliability of further synthesis.

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Table 2.

Results From Key Studies of Fertility Intentions and Pregnancy and Maternal Outcomes

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Table 3.

Results From Key Studies of Fertility Intentions and Contraceptive Behaviors

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Table 4.

Results From Key Studies of Contraceptive Behaviors and Fertility Outcomes

To investigate the association of pregnancy intentions with birth and maternal outcomes, we conducted an initial search by using the PubMed and Embase databases. The initial search included the terms ((pregnancy intention) OR (unplanned pregnancy) OR (unintended childbearing) OR (unintended fertility) OR (unwanted pregnancy)). Searches for studies on birth outcomes were identified by using the search terms (birth outcome OR neonatal outcome OR prematurity OR preterm birth OR low birth weight) OR (maternal outcome OR maternal health OR maternal morbidity OR maternal mortality). These searches were then combined. Abstracts of retrieved results were then reviewed to identify relevant articles. We also reviewed bibliographies from selected articles to aid with complete review. Given previously published reviews of a related nature (25, 26), we limited searches to articles published in English in 2004 or later. We also limited our review to studies that were prospective or longitudinal, were population based, and included multivariate analyses.

To evaluate recent studies of the relation between pregnancy intentions and contraceptive use, we conducted a second search of the PubMed and Embase databases with the search terms (�pregnancy, unplanned�[MeSH Terms] OR (�pregnancy�[All Fields] AND �unplanned�[All Fields]) OR �unplanned pregnancy�[All Fields] OR (�unintended�[All Fields] AND �pregnancy�[All Fields]) OR �unintended pregnancy�[All Fields]) AND (�contraception�[MeSH Terms] OR �contraception�[All Fields]). Between 2004 and 2009, 256 English-language studies were published. Abstracts of retrieved results were reviewed to identify eligible studies. We again limited our review to studies that were prospective or longitudinal, were population based, and included multivariate analyses.

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RESULTS OF INDIVIDUAL-LEVEL STUDIES

Pregnancy intentions and birth outcomes

Rigorous research on the relation between pregnancy intentions and pregnancy outcomes is limited. What has been published generally focuses on short-term neonatal outcomes, such as prematurity. Many of the studies are older and are methodologically limited. A recent systematic review (27) concluded that unintended pregnancies, compared with intended pregnancies, were associated with higher odds of such neonatal outcomes as low birth weight (odds ratio (OR) = 1.36, 95% CI: 1.25, 1.48) and preterm birth (OR = 1.31, 95% CI: 1.09, 1.58). However, because of heterogeneity among studies�some studies adjusted for potential confounding variables such as race, maternal age, and prior low birth weight, while other studies did not present adjusted results�the authors chose to incorporate only unadjusted odds ratios so as to include as many of these studies as they could. Findings from previously published studies are inconsistent, with some showing a negative influence of intendedness on neonatal outcomes and others showing no difference (25). Much of the available literature is from developed countries.

We identified 3 studies, all in the United States, that included multivariable analyses of population-based data, and one prospective survey. �Birth outcomes� were primarily preterm birth and low birth weight, although the definitions of these outcomes varied somewhat across studies. The results are inconclusive. Two studies found that associations between unintended pregnancy and birth outcomes varied by race or ethnicity, with black women and Latinas having increased odds of negative outcomes if the pregnancy was unintended versus intended (28, 29). A third study (30) found higher odds of low birth weight if the pregnancy was unwanted (vs. wanted; adjusted OR = 1.16, 95% CI: 1.01, 1.33). These 3 studies assessed pregnancy intentions retrospectively, and all used a similar question to do so (Table 2). Results on fertility intentions and birth outcomes for developing countries are more difficult to find. A World Health Organization report analyzed DHS data from 5 developing countries (Bolivia, Egypt, Kenya, Peru, and the Philippines). The authors concluded that the effects of unintendedness on the child's subsequent immunization status and growth were inconsistent across countries (31).

Pregnancy intentions and maternal behaviors and health outcomes

Research findings on fertility intentions� effects on maternal behaviors and health outcomes are even sparser than for pregnancy outcomes. We identified 4 studies that met our search criteria (Table 2). The strength of our review is limited by the different maternal outcomes selected by each group of authors, ranging from antepartum behaviors such as smoking, to pregnancy complications such as hypertension, to postpartum depression and breastfeeding. One study (30) found no association between pregnancy intention and maternal outcomes, while another (32) found unintendedness associated with decreased odds of early prenatal care (vs. intended: adjusted OR = 0.54 for mistimed and OR = 0.34 for unwanted) and significantly increased odds of postpartum depression (adjusted OR = 1.34 and OR = 1.98, respectively). Shapiro-Mendoza et al. (33) found that, compared with intended pregnancies, unwanted and mistimed pregnancies were marginally, but not significantly associated with longer durations of breastfeeding of infants born in the 3 years prior to the 1990 Paraguay and 1994 Bolivia DHSs (adjusted hazard ratio = 0.90, 95% CI: 0.7, 1.2 and adjusted hazard ratio = 0.87, 95% CI: 0.7, 1.0, respectively). What most of these studies have in common is their focus on immediate outcomes. Data on long-term maternal or child outcomes are lacking.

Pregnancy intentions and contraceptive use

Five studies meeting our inclusion criteria were identified (Table 3), all of which were US based. Only one used a prospective cohort design following up adolescent clinic patients, whereas another analyzed survey data on recruits at 2 US Army bases. The remaining 3 relied on data from a nationally representative telephone survey or the 2002 National Survey of Family Growth. Assessed contraceptive behaviors ranged from use at last sex, to consistent use, to resumed use following discontinuation, to type of method used. Fertility intentions were assessed in terms of wanting another pregnancy in the future, number of unintended pregnancies, and importance of avoiding a future pregnancy.

A number of studies reported a high percentage of women who did not intend to become pregnant but did not use contraception (5, 34, 35). On the other hand, adolescent clients committed to not becoming pregnant had higher odds of using contraception 3 months later (adjusted OR = 9.12, 95% CI: 7.75, 12.30), and US Army recruits, irrespective of gender, not intending to have a baby in the next 6 months had higher odds of using an efficacious contraceptive method (adjusted OR = 1.14, 95% CI: 1.09, 1.20). Women who had experienced 1 or more unintended pregnancies had notably higher odds (2.1 times) of using long-acting methods compared with those with no such pregnancies and reduced odds (OR = 0.7) of using the pill or condom (36). Somewhat surprisingly, with 2002 National Survey of Family Growth data, Wu et al. (5) found no association between wanting to avoid a pregnancy in the future and consistent use of contraception during months at risk in the past year. However, Vaughn et al. (37), with the same data, found that the probability of resuming contraceptive use among women who achieved their desired family size was significantly higher than for those discontinuing use when more children were wanted (adjusted hazard ratio = 1.10, 95% CI: 1.04, 1.67). These empirical analyses suggest that intentions to avoid pregnancy are associated with the use of contraception, but far from perfectly.

Contraceptive behaviors and fertility outcomes

Another set of studies examined the association of contraceptive behaviors with subsequent pregnancy outcomes. Nine studies published since 2004 met our inclusion criteria, 7 of which focused on the incidence of unintended pregnancy (3844) and 2 (45, 46) on repeat abortion as outcomes (Table 4). Of the studies, 4 were US-state based (Rhode Island, Colorado, Oregon, and California), while the others were conducted in international settings. Heterogeneity in study design across studies limited our synthesizing the findings in a concise way. Contraceptive behaviors of interest range from general types of methods used, to specific use of symptom-thermal or hormonal methods, to prepregnancy knowledge of emergency contraception.

The studies located in developing countries utilized contraceptive calendar data and related respondent use patterns to the subsequent incidence of unintended pregnancy. A Guatemalan study (38) examined the influence of women's contraceptive discontinuation on unintended pregnancy, finding that those who used contraception but discontinued for a reason other than a desired pregnancy had a high relative risk ratio of 14.58 (95% CI: 10.07, 21.12) of having an unwanted (vs. intended) pregnancy. Those who did not use contraception also had a higher relative risk ratio of 3.94 (95% CI: 3.03, 5.10) of having a mistimed pregnancy and a relative risk ratio of 6.17 (95% CI: 4.39, 8.67) of having an unwanted pregnancy.

A Nigerian study (43) found that women who have ever used traditional or modern contraceptives have higher odds of experiencing an unwanted pregnancy than those who never used them. An extensive comparative analysis of 8 countries (39) assessed contraceptive failure rates for different reversible contraceptive methods. Adjusting for potential confounders, the authors found the probability of an accidental pregnancy among contraceptive pill users to range from 0.19 in Zimbabwe to 1.24 in Indonesia, from 0.05 for injectable users in Bangladesh to 0.42 in Colombia, and for IUD users from 0.04 in Egypt to 0.26 in Indonesia. These results, of which most are statistically significant at P < 0.01, are akin to typical-use failure rates found for modern reversible contraceptives.

Three US-state-based studies (41, 42, 44) similarly demonstrated that some contraceptive use or knowledge is advantageous in comparison to nonuse in reducing the incidence of unplanned pregnancy, but the measured protection is not as high as one might expect. For example, in the Colorado study, women having unprotected sex, compared with those using birth control, had an adjusted odds ratio of 1.67 (95% CI: 1.11, 2.52) of having an unintended pregnancy within a 3-year follow-up period. The magnitude of the adjusted odds ratio value, although statistically significant, is not substantial considering what should be a higher efficacy level from contraceptive protection.

Two studies on contraception and repeat abortion incidence (45, 46) showed that reliable contraception is significantly associated with reduced odds of repeat abortion. In Goodman et al.�s study (45), 6.1% of postabortion IUD insertion cases had repeat abortions compared with 15.3% of controls; the adjusted hazard ratio was 0.37 (95% CI: 0.26, 0.52). Although only 60% of participants at risk of unintended pregnancy in the St. Petersburg study (46) used reliable contraception at last sex, the odds of having 2 or more abortions was significantly higher for those using unreliable methods or no protection.

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RESULTS OF POPULATION-LEVEL STUDIES

Contraception benefits for reproductive health

Demographers have long studied the relation between family planning and fertility at the population level and have drawn implications about satisfying contraceptive need on fertility, abortion, and mortality rates in the developing world. In this section, we review study findings from cross-national survey analyses that project the impact of lowering unintended pregnancy on reproductive and child health outcomes. As background, we use the StatCompiler tool (47) to compile DHS-based national estimates of the proportion of pregnancies that are unintended, either mistimed or unwanted, and the proportion of women of reproductive age using modern contraception. Figure 2 shows that the values from 158 DHSs conducted in 68 African, Asian, Latin American, and Caribbean countries between 1991 and 2007 do not closely fit either a linear or curvilinear trend because levels of unintended pregnancy tend to be higher than use of effective contraception. In fact, the relatively flat, curvilinear, and positive trend line suggests that unintended pregnancy levels rise, rather than fall, with modern birth control use. Only a few country data points show high use and low levels of unintendedness.

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Figure 2.

Relation between national rates of unintended pregnancy and modern contraceptive prevalence among women aged 15�49 years across 158 Demographic and Health Surveys in developing countries, 1991�2007 (47).

Reasons for this apparent contradiction may vary from country to country. It is worth recalling that the definition of �contraceptive prevalence� does not presume correct and consistent use. For example, reported prevalence of condoms may not account for the often sporadic nature of their use. Similarly, high rates of contraceptive discontinuation (also not captured in the contraceptive prevalence rate) could counteract the potential impact of contraceptive use on unintended pregnancies. There may also be supply-side determinants of contraceptive use, such as availability of method choice or restricted access, that contribute to high unintended pregnancy rates. Women may be better able to articulate an unintended pregnancy than they are to avail themselves of and practice the means to prevent one with contraception.

Coitus, conception, infection, and contraception

The scale of sexual activity, reproduction, and their potential risks at the population level are challenging to visualize. With a majority of the 1.74 billion reproductive-age females being sexually active and a probability of conception during unprotected coition of 3 in 100 (11), each year as many as 720 million conceptions may occur. The majority of conceptions (60%�70%) will be spontaneously miscarried, leaving approximately 239 million identified pregnancies, of which 136.2 million will progress to livebirths, 33 million being unwanted. Another 46 million pregnancies will be electively terminated.

The Guttmacher Institute (14) estimates a pregnancy rate of 137 per 1,000 women aged 15�44 years in the developing world and an unintended pregnancy rate of 57 per 1,000, or 82.3 million mistimed or unwanted pregnancies. The unintended pregnancy rate has declined since the mid-1990s, largely because of increases in contraceptive use, proportionately faster in the developed than the developing world.

Preventing sexually transmitted infection and HIV transmission, as well as unplanned pregnancies, during coition is a priority in many low-income countries. HIV research has only recently acknowledged the importance of integrating family planning into HIV prevention and care programs. For HIV-positive women who seek to postpone or delay a pregnancy, family planning is a proven and cost-effective method for preventing mother-to-child transmission of HIV (48). A study of 14 developing countries (49) reports that, for 1.342 million HIV-positive women in need of perinatal HIV prevention, a potential 71,945 infant HIV infections and 423,211 births can be averted through increased family planning use. As the client load in need of HIV diagnosis and antiretroviral therapy increases, the financial and service burden for programs to meet that demand elevates the importance of responding to clients interested in spacing and limiting childbearing (50, 51). It is estimated that family planning can avert as many or more vertical pediatric infections and HIV deaths as scaling up antiretroviral efforts to prevent mother-to-child transmission (52).

Contraception, conception, and parturition

While safe, legal induced abortion has few health consequences for the woman, the need for abortion is an indication of unintended pregnancy. Although abortion rates are similar across developed and developing regions, many abortions that take place in the latter areas are unsafe (53, 54). Two-thirds of pregnancies in the developing world occur to women not using contraception (55). If contraception can reduce the incidence of unintended pregnancies, it will lower the risk of death and disability due to unsafe abortions. In Uganda, for example, current use of contraception, compared with no contraceptive use at all, has resulted in 150,000 fewer abortions (56). Meeting the existing level of 41% unmet need there would further reduce this number. In Guatemala, where 32% of pregnancies are unintended and abortion is illegal, 12% of pregnancies end in induced abortion. Eight of 1,000 women of reproductive age were hospitalized in 2003 because of complications of unsafe abortion, a figure that may well underestimate the magnitude of the problem. The relatively low prevalence of modern contraceptives (43%) and high unmet need (28%) are acknowledged to contribute to abortions and related morbidity (57).

Often, however, ineffective contraceptive use, rather than nonuse, contributes to unintended pregnancy: for many eastern European and south Asian countries, as many as two-thirds of abortions are due to contraceptive failure, mostly from traditional method use, and one-third are due to unmet need for contraception (58). In developed countries, it has been reported that most abortions occur as a result of contraceptive failure and a small proportion are due to nonuse of contraception. One study found that 84% of women seeking abortion reported recent contraceptive use about the time they conceived, compared with 16% reporting nonuse (59).

Increased contraceptive uptake is generally associated with reduced numbers of abortions. Since 1995, abortion rates have decreased worldwide. The greatest declines are in eastern Europe, concurrent with an increase in access to modern contraceptive methods (60). Westoff's (58) analysis of contraceptive use and abortion rates for 12 eastern European and south Asian countries shows a strong negative correlation between prevalence of contraceptive methods and abortion rates. That is, with some exceptions, countries with the highest uptake of modern contraceptive methods generally also have the lowest abortion rates. Westoff (58) estimates that, if unmet need in those countries were reduced to zero and traditional contraceptive methods were replaced by modern ones, the number of induced abortions would be lowered by 55%. Satisfying unmet need results in an average 23% reduction in abortions.

Contraception in relation to gestation and birth intervals

Elevated risks of neonatal, infant, and child mortality and of child malnutrition were statistically linked to short birth intervals (less than 30 months) in an analysis of DHS data from 17 developing countries (61). The adjusted odds of neonatal, infant, and under-age-5-years child deaths were 1.67, 1.85, and 1.91 times significantly higher if the birth interval was 18�23 months compared with 36�47 months. Conde-Agudelo et al. (62) found, with Latin American data, greater risk of preterm, low birth weight, and small-for-gestational-age infants associated with short interpregnancy intervals of less than 6 months compared with 18�23 months. In terms of maternal health, 2 studies (63, 64) reported higher risks of premature rupture of membranes, preeclampsia, high blood pressure, and anemia with interpregnancy intervals of less than 6 months in Latin America (in comparison to 18�23�month intervals) and Bangladesh (in comparison to 27�50�month intervals).

The interval between pregnancies is an important window during which contraceptive benefits for maternal health can be experienced. Although the empirical evidence on birth spacing and maternal and newborn outcomes is strong, that for contraceptive use between pregnancies is weak (65). Contraception's benefits need to be empirically differentiated from those of lactation and other protective behaviors in the birth interval. Since breastfeeding can extend over many months, particularly in sub-Saharan African countries, overlap with contraceptive use confounds estimates of the latter's effects. One multicountry analysis of pregnancy outcomes found that 12 months of contraception-only coverage in the preceding birth interval can reduce the mortality risk for the next newborn by 31.2%, while 12 months of contraceptive use overlapping with breastfeeding reduces the risk by 68.4% (66). This same study of DHS data for 19 developing countries found an average of 3�4 months of contraceptive use overlapping with breastfeeding.

Family-planning-averted births and maternal morbidity and mortality

Liu et al. (67) estimated that nearly 230 million births are averted annually by global contraceptive use, or 1.7 times the current number of livebirths. Averted births and pregnancies reduce the size of the denominator of maternal and infant mortality rates. Although it is difficult to attribute change in the maternal mortality ratio to a particular cause, evidence exists that meeting the need for family planning can reduce maternal mortality. An analysis of DHS data indicated a strong negative correlation between maternal mortality ratios and contraceptive prevalence rates (49). Another study (68) estimated that, without contraception, the number of maternal deaths would be 19% higher. A recent Guttmacher Institute study (14) found that fulfilling unmet contraceptive need can prevent an additional 150,000 maternal deaths annually; a study in rural Bangladesh (69) found that, between 1979 and 2005, the fertility decline was responsible for a 30% reduction in maternal deaths. In Uganda, even with substantial unmet need for contraception, current use of contraception has resulted in 490,000 fewer maternal deaths compared with no contraceptive use (56). Similarly, Egypt's maternal mortality ratio was reduced 50% between 1992 and 2000, a development concurrent with increased uptake of family planning and other maternal health improvements (70). Stover and Ross� (71) recent analysis suggested that declines in total fertility rates between 1990 and 2005 in developing countries, attributable to contraceptive use, likely averted 1.2 million maternal deaths.

Contraceptive use in particular may also disproportionately impact women's risk of maternal mortality at either end of the reproductive age span. Adolescence and older reproductive age elevate maternal mortality risk, as does parity greater than 4 births (31). Providing contraceptive services to these groups can reduce the maternal mortality ratio by as much as 58% (55).

For every maternal death, as many as 30 more women may suffer disability or injury due to complications from pregnancy, childbirth, or abortion (72). Levine et al. (73) estimated that unwanted fertility and unsafe abortion account for 12%�30% of maternal disability-adjusted life years across the developing regions of the world. As many as 1.27 million years of life are lost and another 0.76 million years of life with disability are due to this maternal burden of disease in sub-Saharan Africa alone. The global disease burden associated with unmet family planning need among reproductive-aged women is one of the greatest contributors to disability-adjusted life years in the developing world, accounting for 7.4 million disability-adjusted life years among women aged 15�44 years, according to 2006 estimates (74). This issue trumps other risk factors such as anemia (4.7 million disability-adjusted life years) and smoking (1.6 million). Anemia itself is often due to pregnancy, which suggests that the all-cause burden of unmet need is even higher.

Maternal disability is also due to complications of unsafe abortion and childbirth, such as prolonged or obstructed labor resulting in vesicovaginal fistula. A recent prospective study evaluated morbidity in Mombasa, Kenya, among women in the first year postpartum. The authors observed a 50% incidence of anemia, an 11% incidence of HIV, and 39% with an unmet need for family planning (75). The same authors previously found that postpartum morbidity among HIV-positive women was higher in uninfected women (76). In Kenya, where 44% of births are unplanned (77) and contraceptive prevalence is 39%, it is logical to assert that those postpartum women who delivered children from an unintended pregnancy, due to unmet need for family planning, suffered unnecessary and completely preventable disability.

A Mexican study evaluating the impact of family planning on maternal morbidity (78) used historical data and generated comparisons between the current standard of care there and a model in which World Health Organization benchmarks for care would be met (Mother-Baby Package). The study concluded that increasing family planning prevalence from 59% to 74% among women older than age 20 years and from 18% to 33% among women younger than age 20 years (both Mother-Baby Package goals) would avert 1,324 disability events per 100,000 women annually�a 32% reduction compared with the current level of 4,149 disabling events.

Although high-quality published evidence is limited, the conclusions are consistent at the population level. Optimization of family planning can prevent maternal disability. Beyond physical disability, one study suggests that unintended pregnancy can adversely impact women's quality of life, with 94% of those surveyed saying they would experience negative health effects. In the same study, 16% of women also stated they would accept an �immediate risk of death� to avoid an unintended pregnancy (79).

Cost-effectiveness of family planning

International studies confirm that family planning is among the most cost-effective of all health interventions (80, 81). The cost savings stem from a reduction in unintended pregnancy, as well as a reduction in transmission of sexually transmitted infections, including HIV. It has been consistently documented that all contraceptive methods are cost-effective in comparison to no method (82, 83). An analysis of a publicly funded family planning program calculated that long-acting contraceptives (implants and IUDs), in particular, save US $7 in costs from unintended pregnancy for every US $1 spent (84). A recent study examining the cost effectiveness of contraception over 5 years in the United States showed the copper-T IUD, the levonorgestrel-containing IUD, and vasectomy to be the most cost-effective options (83). Although data show differences among individual developing countries, the measured savings are substantial everywhere. One US dollar spent on family planning can avert from US $2 (in Ethiopia) to US $9 (in Bolivia) in health costs, with an average of US $8 annually for all women using all methods of modern contraception (14, 81). The previously cited cost-effectiveness models for Mexico calculate lifetime savings of US $10.5 million with increased contraceptive prevalence (77). However, discontinuation of contraception, which often results from dissatisfaction, negatively impacts cost-effectiveness. Thus, having many contraceptive choices available is likely to increase overall cost-effectiveness (79, 84).

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DISCUSSION

This review has focused on recent empirical studies of associations between pregnancy intentions and pregnancy and maternal outcomes and then examined the intermediate role of contraception as a health intervention. In the pathways of the behavioral epidemiology that link coital activity, conception, viable pregnancy, fetal growth, parturition, and the puerperium, protected sex is an important early juncture for preventing unhealthy sequelae, such as sexually transmitted infection, unintended pregnancy, fetal wastage, stillbirth, and maternal and neonatal morbidity and mortality. Modern contraceptive use and consistent condom use are highly effective means of preventing unplanned pregnancies and sexually transmitted infections.

We located and reviewed 21 eligible studies in the literature between 2004 and 2009, a time frame not covered by recent reviews. All involved individual-level, multivariate analyses; nearly all were observational; and 16 were US based. Three examined the association between pregnancy intentions and birth outcomes and 3 with maternal health behaviors and outcomes. Evidence of the effect of unintended pregnancies was inconclusive. We examined 5 other studies, again all US based, of pregnancy intentions� relation with contraceptive use, one that should have been straightforward and substantial but was not. The bivariate results showed a surprisingly high percentage of study participants not using contraception despite intentions to defer or limit further childbearing. We next reviewed findings of 9 studies, 4 based in the United States, of contraceptive use and pregnancy incidence, particularly unplanned and electively terminated pregnancies. Here, we found more consistent results, generally of the order observed for 1-year contraceptive efficacy under typical use conditions.

The limited number of rigorous studies, particularly outside the United States and beyond individual risk factors, prompted us to look at studies adopting a population or demographic methods approach. Many of these analyses are cross-national, using standardized data and measures from the DHS. The identified studies often applied statistical models or forecasting methods with multiple country surveys to generate aggregate estimates of health benefits, such as averted unplanned pregnancies, pregnancy terminations, and maternal and infant deaths. In contrast to risk ratios from individual-level studies, the population-level studies provide counts of contraception-averted events that affect the pregnancy denominators of maternal and infant morbidity and mortality rates. Reviewing the demographic evidence of the contraceptive use�attributable impact on the burden of unintended pregnancies offers a complementary perspective and a more comprehensive understanding of the underlying structure of behavioral linkages.

By assessing study findings with population-level rates and ratios, we observed the scale and recurring probability of enabling and disabling sexual and reproductive health practices and events. Global contraceptive use prevents more than 200 million unintended births annually, which lowers rates of both unintended pregnancy and abortion. Some studies found that it significantly impacted maternal and infant mortality rates as well. Other studies have measured contraception's benefits in lowering the number of vertical HIV transmission cases among infected mothers interested in postponing or delaying future pregnancies. More research is needed to differentiate contraception's direct effect in reducing the number of (unintended) pregnancies from its indirect effect on the prevalence and incidence of unfavorable outcomes. Rising contraceptive practice in a population can coincide with favorable shifts in the distribution of pregnancy-related risks because of such common influences as gains in female education or household income, but prolonged contraceptive practice in the interpregnancy interval can also confer health benefits of maternal nutrition repletion on fetal growth and newborn survival. A reduction in unintended pregnancies reduces the number of events exposed to poor pregnancy outcomes and can make planned events healthier. An integrated understanding of family planning�attributable change in pregnancy events and change in epidemiologic risk-associated ratios deserves priority in future research efforts.

Understanding the effect of pregnancy intentions on contraceptive and reproductive behaviors is also requisite for strengthening the evidence base that informs maternal and child health policies and programs. Implicitly, it requires improving the measurement of fertility intentions both in the United States and abroad. Santelli et al. (85) identified affective, cognitive, and partner-specific dimensions as promising directions for future improvements. The modest empirical connections observed here among pregnancy intentions, contraceptive use, and health outcomes challenge the assumed reliability of unmet contraceptive need, a widely used measure that depends on a woman's reported desire to time future pregnancies. The gap between intentions and behavior, likely due to a combination of individual preferences and contextual factors of service access and of cultural and personal relationships, demands appropriate research designs to assess the causal relevance of pregnancy intentions to reproductive behavior and more focused research on family planning's health benefits when used before, after, and between pregnancies. The potential of contraception-facilitated birth spacing for preventing preterm and low birth weight infants to avert chronic disease in later adulthood is intriguing and warrants robust investigation with cohort data.

Demographic growth in the developing world will continue to exert upward pressure on the population base of women of reproductive age for several decades. Considerable momentum is built into population age structures as a consequence of past high fertility. At current rates, the number of unintended pregnancies will rise to 92 million globally by 2015. In many countries, where contraceptive prevalence is low and 40% to 50% of the population is under age 15 years, the entry of these cohorts into sexual activity and reproductive age will expose large numbers to the risk of unintended pregnancy. Access to quality contraceptive services will need to be expanded to avoid a rise in the volume of unplanned births and improve preconceptional health. Perhaps even more critical is to mount a substantial research effort that can address the implications of elevated sexual and reproductive health risks among adolescents and youth and the demographic import for future generations� health and well-being.

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Acknowledgments

Author affiliations: Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Amy O. Tsui); and Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland (Raegan McDonald-Mosley, Anne E. Burke).

This review was supported in part by funding from the Bill and Melinda Gates Foundation to the Bill and Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.

Conflict of interest: none declared.

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Footnotes

  • Abbreviations

CI

confidence interval

DHS

Demographic and Health Surveys

HIV

human immunodeficiency virus

IUD

intrauterine device

OR

odds ratio

Previous Section

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