Contraception: evidence brief
Publication date: 2019
Contraception Contraception enables people to make informed choices about their sexual and reproductive health. Evidence brief Key facts ` According to 2017 estimates, 214 million women of reproductive age in developing regions who want to avoid pregnancy are not using a modern contraceptive method. ` Use of modern contraceptives in 2017 prevented an estimated 308 million unintended pregnancies. Meeting all women’s need for modern methods of contraception would avert an additional 67 million unintended pregnancies annually. ` About 15 million adolescents use a modern contraceptive method, while 23 million have an unmet need for modern contraception and are thus at elevated risk of unintended pregnancy. ` Some contraceptive methods help prevent the transmission of HIV and other sexually transmitted infections. ` Contraception offers a range of potential benefits that encompass economic development, maternal and child health, education, and women’s empowerment. ` Family planning, most fundamentally, advances human rights. It reinforces people’s rights to determine the number and spacing of their children. ` Family planning allows people to attain their desired number of children and determine the spacing of pregnancies. It is achieved through information, education and the use of contraceptive methods Benefits of family planning and contraception Family planning is one of the most cost-effective investments a country can make in its future (1). It offers a range of potential benefits that encompass economic development, maternal and child health, education, and women’s empowerment. In almost all regions of the world, contraceptives are used by the majority of women in the reproductive age range (15-49 years) who are married or in a union. Worldwide in 2017, 63 per cent of these women were using some form of contraception. Contraceptive use was above 70 per cent in Europe, Latin America and the Caribbean, and Northern America, while being below 25 per cent in Middle and Western Africa (2). Promotion of family planning – and ensuring access to preferred contraceptive methods for women, girls and couples – is essential to securing the well-being and autonomy of women, while supporting the health and development of communities. The United Nations (UN) estimates that for every US$1 spent on contraception, from US$2 to US$6 can be saved from the reduced numbers of people needing other public services, such as immunizations, health care, education, and sanitation. (3) Preventing maternal morbidity and mortality Family planning has clear health benefits, since the prevention of unintended pregnancies results in a subsequent decrease in maternal morbidity and mortality. Contraception allows spacing of pregnancies, delaying pregnancies in young girls who are at increased risk of health problems from early childbearing, and preventing pregnancies among older women who also face increased risks. Contraception enables women who wish to limit the size of their families to do so. By reducing rates of unintended pregnancies, contraception also reduces the need for unsafe abortion. Contraception is a low- cost and effective way to save lives. Contraceptive supplies cost, on average, about US$1.55 per user annually in developing countries. The global community generally agrees that family planning prevents maternal deaths by: • reducing the number of times a woman is exposed to the risks of pregnancy (4,5); • Helping women avoid unintended and closely spaced pregnancies—a study in Bangladesh found that very short pregnancy intervals are linked with 7 times increased risk of induced abortion (6); • Helping women avoid more than 4 births, or births after 35 years of age (4); Furthermore, if all unmet need for modern contraception were satisfied in developing regions, there would be approximately a three-quarters decline in unintended pregnancies (from the current 89 million to 22 million per year), unplanned births (from 30 million to seven million per year) and induced abortions (from 48 million to 12 million per year). (7) The health benefits of preventing unintended pregnancies would be substantial. Fully meeting the unmet need for modern contraception would result in an estimated 76,000 fewer maternal deaths each year. (7) Reducing unsafe abortion from unintended pregnancies Around the world, unintended and unwanted pregnancies are common challenges that women and couples face. About 44% of all pregnancies worldwide are unintended, and some 56% of unintended pregnancies end in an induced abortion (8). An estimated 56 million induced abortions took place annually in 2010-14, which translates to an annual abortion rate of 35 abortions for every 1000 women aged 15-44 years (9). Contraception can prevent unsafe abortions by reducing the number of unintended pregnancies. Reducing newborn and infant mortality Family planning and contraception can prevent closely spaced and ill-timed pregnancies and births, which contribute to some of the world’s highest infant mortality rates. Closely spaced births result in higher infant mortality: international survey data show that babies born less than two years after their next oldest brother or sister are twice as likely to die in the first year, as those born after an interval of three years. Infants of mothers who die as a result of giving birth also have a greater risk of death and poor health. Providing all pregnant women and their infants with the level of maternal and newborn health care recommended by the World Health Organization would reduce maternal deaths by 64%, to 112 000 per year, assuming no change in contraceptive use or in the number of unintended pregnancies. Newborn deaths would drop by 76%, to 655 000. (7) If full care for all pregnant women and newborns were combined with full provision of modern contraception to women who want to avoid pregnancy, maternal deaths would drop from 308 000 to 84 000 per year, and newborn deaths would drop from 2.7 million to 538 000 per year (7). Helping to prevent HIV/AIDS While approximately 1 in 4 women in sub-Saharan Africa has an unmet need for family planning, studies have shown that women living with HIV have higher unmet need for family planning and reproductive health services than the general population, in part due to lack of investment in integrated contraception and HIV services.(10) Another recent study found that if the needs of women with HIV for modern contraceptive methods and antiretroviral medication were both fully met, HIV transmission from mothers to newborns would be nearly eliminated—reduced by 93% annually. (11) Male and female condoms provide dual protection against unintended pregnancies and against STIs including HIV. Empowering people and enhancing education Family planning and contraception enables people to make informed choices about their sexual and reproductive health, and creates an opportunity for women for enhanced education and participation in society, including paid employment. Family planning can help women and girls, especially those who have become mothers, stay in school, become literate, learn a trade, start a business, or otherwise achieve their educational and employment goals. Early and unintended pregnancy can be both a cause and a consequence of dropping out of school. (12) Reducing adolescent pregnancies Preventing unintended pregnancy is essential to improving adolescents’ sexual and reproductive health and their social and economic well-being. (13) Pregnant adolescents are more likely to have preterm and low birth-weight babies. Babies born to adolescents have higher rates of neonatal mortality. Many adolescent girls who become pregnant have to leave school. This has long-term implications for them as individuals, their families and communities .(14) Contributes to Economic Growth Rapid fertility decline, which is linked to increased contraceptive use, lowers the ratio of dependents to income earners. This results in a higher proportion of wage earners and leads to national savings. With supportive socioeconomic policies and attention to equity, countries can then experience a “demographic dividend” of rapid economic growth. Estimates indicate that the demographic dividend effect of contraception is most pronounced in countries with current high fertility, where rates of return on economic productivity and potential lifetime earnings from improved availability and uptake of contraception could exceed 8% of GDP by 2035 .(15) Who provides contraception? It is important that contraceptive methods are widely available and easily accessible to anyone who is sexually active, including adolescents In some countries, midwives are trained and authorized to provide locally-available and culturally-acceptable contraceptive methods. Other trained health workers, for example community health workers, also provide counselling and some methods, such as pills and condoms. For methods such as sterilization, women and men need to be referred to a clinician. WHO has identified which cadre of lower and mid- level health workers can provide contraceptive services safely and effectively, through task shifting and task sharing as part of its Guideline on optimizing the roles of health workers. Global unmet need for contraception As of 2017, 1.6 billion women of reproductive age (15–49) live in developing regions. About half of them (885 million women) want to avoid a pregnancy; of this subset of women, about three-quarters (671 million) are using modern contraceptives. (7) The proportion of women who have an unmet need for modern contraception is highest in Sub-Saharan Africa (21%), while the largest absolute number (70 million women) live in Southern Asia. Together, Sub-Saharan Africa and Southern Asia account for 39% of all women in developing regions who want to avoid pregnancy and 57% of women with an unmet need for modern contraception. (7) Reasons for this include: • limited access to contraception, particularly among young people, poorer segments of populations, people living in rural areas and in humanitarian crises situations or unmarried people; • limited choice of methods; • fear or experience of side-effects; • cultural or religious opposition; • poor quality of available services; • gender-based barriers. The unmet need for contraception remains too high. This inequality is fueled by both a growing population, and a shortage of services. WHO response Achieving universal access and the realization of sexual and reproductive health services will be essential to fulfil the pledge of the 2030 Agenda for Sustainable Development that “no one will be left behind”. (2) It will require intensified support for contraceptive services, including through the implementation of effective government policies and programmes. For more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland E-mail: email@example.com www.who.int/reproductivehealth WHO is working to promote contraception by producing evidence-based guidelines on safety and service delivery of contraceptive methods and on ensuring human rights in contraceptive programmes. It is also developing quality standards and providing pre-qualification of contraceptive commodities. WHO further assists countries to adapt and implement these tools to strengthen contraceptive policies and programmes. Additionally, WHO participates in developing new contraceptive technologies to and leads and conducts implementation research for expanding access to and strengthening delivery contraceptive information and services. References 1. Starbird E, Norton M, Marcus R. Investing in family planning: key to achieving the sustainable development goals. Glob Health Sci Pract. 2016;4(2):191-210. http:// dx.doi.org/10.9745/GHSP-D-15-00374 2. United Nations, Department of Economic and Social Affairs, Population Division (2017). World Family Planning 2017 - Highlights (ST/ESA/SER.A/414). 3. UN Population Division. 2009. “What Would It Take to Accelerate Fertility Decline in the Least Developed Countries?” Policy Brief 2009/1, United Nations, New York. 4. Stover J, Ross J. How increased contraceptive use has reduced maternal mortality Matern Child Health J. 2010;14(5):687–695. doi:10.1007/s10995-009-0505-y. pmid:19644742 5. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet. 2012;380(9837):149– 156. doi:10.1016/S0140-6736(12)60609-6. pmid:22784533 6. DaVanzo J, Hale L, Razzaque A, Rahman M. Effects of interpregnancy interval and outcome of the preceding pregnancy on pregnancy outcomes in Matlab, Bangladesh. BJOG. 2007;114(9):1079–1087. doi:10.1111/j.1471- 0528.2007.01338.x. 7. Darroch JE, Sully E. Adding It Up: Investing in Contraception and Maternal and Newborn Health, 2017. New York. Guttmacher Institute, 2017. 8. Bearak J Popinchalk A Alema A Sedgh G. Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: estimates from a Bayesian hierarchical model. Lancet. 2018; 6: e380-e389 9. Sedgh G Bearak J Singh S et al. Special tabulations of updated data from Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet. 2016; 388: 258-267 10. Petruny T, Minichiello SN, McDowell M, Wilcher R. Meeting the contraceptive needs of key populations affected by HIV in Asia: an unfinished agenda. AIDS Res Treat. 2012;2012:792649. doi:10.1155/2012/792649. pmid:22991656 11. Singh S, Darroch J, Ashford L. Adding it up: the costs and benefits of investing in sexual and reproductive health 2014. New York: Guttmacher Institute; 2014. 12. United Nations Educational, Scientific and Cultural Organization (UNESCO). Developing an education sector response to early and unintended pregnancy. Paris (France): UNESCO; 2014. Available from: http://unesdoc. unesco.org/images/0023/002305/230510E.pdf 13. Jacqueline E. Darroch, Vanessa Woog, Akinrinola Bankoleand, Lori S. Ashford. Adding It Up: Costs and Benefits of Meeting the Contraceptive Needs of Adolescents, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/adding-it-meeting- contraceptive-needs-of-adolescents. 14. United Nations Population Fund (UNFPA) [Internet]. New York: UNFPA. Population and poverty; 2014. Available from: http://www.unfpa.org/resources/population-and- poverty 15. Stenberg K, Axelson H, Sheehan P, Anderson I, Gülmezoglu AM, Temmerman M, et al. Study Group for the Global Investment Framework for Women’s Children’s Health. Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework. Lancet. 2014;383(9925):1333–1354. doi:10.1016/S0140-6736(13)62231-X. pmid:24263249 WHO/RHR/19.18 © World Health Organization 2019. Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence.