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FAMILY PLANNING AND THE BURDEN OF UNINTENDED PREGNANCIES

Sunday, 3rd of July 2011

'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.'

FAMILY PLANNING AND THE BURDEN OF UNINTENDED PREGNANCIES

1. 1.      Amy O. Tsui^*,
2. 2.      Raegan McDonald-Mosley and
3. 3.      Anne E. Burke
4. *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).

Abstract and introduction below; full text is at http://epirev.oxfordjournals.org/content/32/1/152.full

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.