Safeguarding the contraceptive supply in Latin America

12th November 2007

(June 2006) Over the past three decades, overall contraceptive use has increased dramatically in Latin America because of strong international donor support and investment by governments to raise awareness of the value of family planning. Throughout the region, the clinical and counseling skills of local service providers were developed to facilitate distribution of contraceptives, giving priority to providing free or low-cost contraceptives to all who wanted them. The swell in demand means that 62 percent of women ages 15-49 are now using modern methods of contraception in Latin America.1 (See table for the increases in use of three modern methods between 1990 and 2003.)

Provider-Based Contraceptive Methods of Choice for Married or In-Union Women Ages 15-49 in Selected Latin American Countries, 1990-2003

Source: P. Taylor et al., Latin America and the Caribbean: Regional Contraceptive Security Report: Findings and Recommendations (2004)

While the family planning method of choice in Latin America remains female sterilization, injectable contraceptives have become increasingly popular, rivaling the pill in some countries. (In two countries- El Salvador and Peru -injectables are the second most-popular modern method after sterilization.)2 Trends throughout the region show increased use of injectables in most countries as well as a concomitant increase in contraceptive costs to governmental budgets, since most injectables are supplied by Ministries of Health.

To a certain degree, this demand for injectables has been driven by international donors eager to increase supplies.3 Moreover, to address unmet need in rural areas, new schemes of community-based distribution of injectables have been piloted with some success. ("Unmet need" for family planning is when women would prefer to avoid a pregnancy, but are not using any form of family planning.) However, international donors, the major suppliers of contraceptives to Latin America, have recently begun to phase out assistance and supplies, producing a gap that Latin American governments have to fill.

This shortfall in funds is a critical problem affecting the region's contraceptive security-the condition when individuals are able to choose, obtain, and use contraceptive whenever they need them.4 For most of Latin America, contraceptive security now requires serious planning and affordbale options so that family planning successes can be maintained.

Trends in Contraceptive Use: The Rise of Depo-Provera

Latin American countries experienced dramatic gains in contraceptive prevalence rates (CPR) in the 1990s.5 During this period, governments made strong investments in public-sector family planning to increase the number of service delivery points, improve quality, and make contraceptives free in government health facilities. Nongovernmental organizations (NGOs) expanded social marketing of contraceptives that facilitated access to contraceptives throughout the population.

Trend in Modern Contraceptive Use from 1990 to 2003, Selected Countries

Source: P. Taylor et al., Latin America and the Caribbean: Regional Contraceptive Security Report: Findings and Recommendations (2004)

And social marketing programs helped disseminate contraceptives widely by adding mobile sales forces and increasing the networks of pharmacies, commercial, and community outlets, as well as community promoters to provide these products.6 The figure shows that the CPR for modern methods increased by 10 to 26 percentage points in four Latin American countries between 1990 and 2004.

Of the modern methods available, injectables have been particularly popular because they are discreet and safe. Among different types of injectables available, Depo-Provera (DMPA) is the most popular one in Latin America. DMPA is an injection of synthetic progesterone hormone that lasts between one to three months (depending on the dose). DMPA is 99.7 percent effective when injected regularly. Its great advantage is that it is private, cannot be seen on the body, and does not require any additional supplies in the home. If a woman chooses to use DMPA, medical monitoring is required.

Use of DMPA increased dramatically when, after 1992 with U.S. Food and Drug Administration approval, the United States Agency for International Development (USAID) began supplying DMPA to its family planning projects throughout the world. In the 1990s, the UNFPA more than tripled its shipments of DMPA to Latin America, from almost 1 million in 1991 to 3.5 million in 2003.7 These strong distribution efforts contributed to the increased overall CPR in Latin America as well as the increased use of injectables. The table shows the trend in injectable usage compared with other service-provider based contraceptives in Latin America.

Unmet Need Remains High in Rural and Poor Latin America

Despite these increases, however, use of modern methods in Latin America continued to be low among certain groups of women-rural, low-income, less educated, adolescents, and certain ethnic groups. Among poor women in the region, the gap between the actual number of children women have and the number they would like to have is widest.

And while unmet need among women in urban Latin America is estimated to be generally under 15 percent, unmet need is at least 60 percent higher in the region's rural areas.8 This pattern is repeated in many countries throughout Latin America, especially among indigenous groups and women of African descent.9

In rural areas, the main contraceptive used is injectables. In the mid-1990s, governments and NGOs began to increase their efforts to distribute injectables to overcome barriers these populations might have in accessing contraceptives. Community-based distribution (CBD) programs were piloted in Guatemala, Peru, Mexico, and Bolivia-particularly among indigenous populations, where health concerns are often localized within the communities and where long travel distances to a health facility may prohibit contraceptive access.

Maintaining a contraceptive method mix is generally important so that women and their partners have options to help them implement their preferences for smaller families and avoid unwanted pregnancies.10 To some degree, the preference for injectables in Latin America has been fueled by the willingness of donors to supply these commodities, making widespread distribution appealing throughout the region. Unfortunately, this high demand now translates into high contraceptive costs for national governments in this new era of donor phase-out.11

Challenges to Contraceptive Security

Despite the major successes in increasing contraceptive use throughout Latin America, international donors are now taking a step back. Although the timeline varies by country, USAID (currently the region's major supplier) will stop supplying contraceptives to all Latin American countries by 2008, although other donors will remain and phase out more gradually. As public-sector health budgets shrink throughout the region, donor pull-out will have a strong impact on the provision of the free family planning methods that are fairly widespread in the majority of countries in Latin America.12

The most urgent requirement for Latin American countries is to identify alternative sources for financing and procuring contraceptives.13 Yet many countries-Peru, Paraguay, El Salvador, Guatemala, Honduras, Ecuador, and the Dominican Republic-still have not begun purchasing on the international market, and instead rely on the distribution and support offered by UNFPA.

For most of Latin America, achieving contraceptive security means building local and regional capacities for manufacturing and production so that a continued supply and mix of contraceptives are available to meet the demand that has been built. Two countries-Paraguay and Peru-have line items within their national budgets for the purchase of contraceptives.

But even with these efforts, there remain overall costs for any contraceptive and the higher cost of injectables. Careful contraceptive-security planning by Latin American governments can meet the challenge of donor phase-out, but free family planning services will no longer be widely available.14

The Outlook

Local capacity building and distribution of low-cost, high-quality products is the new imperative for contraceptive security in Latin America. But so far, only Peru is making its own injectable contraceptive-known as Soluna. Contraceptive demand has been built for certain products (namely, injectables), resulting in increased contraceptive costs in most countries because these products are more expensive than other modern methods.15 A key question for Latin America will be how to keep the overall demand for contraceptives high, while focusing the demand for injectables into lower-cost products that women will use and whose supplies can be secured.

Thaís Aguilar Z. is editorial coordinator of Perfil magazine in Costa Rica.

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November 12 2007, Thaís Aguilar Z, Population Reference Bureau

References for article

1.   Carl Haub, 2005 World Population Datasheet (Washington, DC: Population Reference Bureau, 2005). 2.   United Nations Department of Economic and Social Affairs, World Contraceptive Report 2003, accessed online at, on May 19, 2006. 3.   P. Taylor et al., Latin America and the Caribbean: Regional Contraceptive Security Report: Findings and Recommendations (Arlington, VA: DELIVER/John Snow, Inc., and Washington, DC: POLICY II Project/The Futures Group, for the U.S. Agency for International Development, 2004). 4.   Suneeta Sharma, James N. Gribble, and Elaine P. Menotti, "Creating Options in Family Planning for the Private Sector in Latin America," Pan American Journal of Public Health 18, no. 1 (2005): 37-44. 5.   The contraceptive prevalence rate (CPR) is the percentage of married women (including women in union) ages 15 to 49 who are using, or whose partners are using, any form of contraceptive, whether modern or traditional. 6.   Taylor, et al., Latin America and the Caribbean. 7.   UNFPA, "Donor Support Report, 1991," and "Donor Support Report, 2003," personal communication with Jagdish Upadhyaya, Chief, Commodity Management Branch, TSD/UNFPA on June 6, 2006. 8.   United Nations Population Fund (UNFPA), State of the World Population 2006, accessed online at, on May 22, 2006. 9.   UNFPA, Latin America and the Carribblean: Overview, accessed online at on May 17, 2006. 10.   John Bongaarts and Elof Johansson, "Future Trends in Contraceptive Prevalence and Methods Mix in the Developing World," Studies in Family Planning 33, no. 1 (2002): 24-36. 11.   Taylor et al., Latin America and the Caribbean. 12.   Taylor et al., Latin America and the Caribbean. 13.   Taylor, et al., Latin America and the Caribbean. 14.   Taylor et al., Latin America and the Caribbean. 15.   Taylor et al., Latin America and the Caribbean.

Categories: Guatemala, Mexico, Peru, Market Development Approaches Working Group, Systems Strengthening Working Group

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