CONTROL FERTILITY

CONTRACEPTION AS FREEDOM

The ability to control fertility stands as one of the greatest discoveries of all time with the benefits accruing to all of humanity, but especially to women and girls. Contraceptive use has the potential to directly transform the lives of half of the world’s adult population, indirectly improve the lives of the other half, and dramatically improve the quality of life of the generations of children born in societies where contraception is widely used. Contraception, perhaps more than any other single intervention, gives women the freedom to control their own futures and to reduce and even eliminate one of the greatest threats to the quality of their lives and to the fulfillment of their potentials – unplanned pregnancies.

Contraception is a lifesaving medical intervention which already prevents the deaths of hundreds of thousands of women in pregnancy and childbirth and millions of newborns. If all demand for modern contraception was met for the 214 million married and partnered women who want to use it, and they were provided with quality pregnancy and childbirth care, the deaths of 224,000 women and 2.1 million newborns could be prevented, according to the Guttmacher Institute. The returns are even higher when single women are included. No other single intervention has the power to reduce maternal and newborn deaths to these levels.

Further, the positive impact of contraception on women’s ability to learn and earn is significant. Studies in the USA by Claudia Goldin and Lawrence Katz and Martha Bailey have found that women’s access to the contraceptive pill in the 1960s and 1970s accelerated delays in marriage and childbirth and increased women’s labor force participation, especially in non-traditional, professional jobs. There is now an emerging body of evidence that increasing access to contraception is having the same impact in low and middle income countries, summarized in the 2012 Lancet Series on Family Planning.

When these individual benefits are aggregated at the national and global levels, the returns to investments in contraception are very high,  according to the Copenhagen Consensus. An exhaustive 2014 analysis by Hans-Peter Kohler and Jere Behrman concluded that estimates of the benefit-cost ratios for contraception are in the order of 90:1 to 150:1, meaning benefits exceed costs by a multiple of 90 to 150. Only one other investment measured by the Copenhagen Consensus exceeds these ratios, and that is trade liberalization.

One of the reasons investments in contraception can deliver such potentially massive returns is the role they can play in triggering the “demographic dividend”, which delivers a rise in incomes, if conditions are right, from a higher share of working-age people in the population (and fewer dependent children). Meeting unmet need for modern contraception could increase GDP per capita in Kenya, Nigeria, and Senegal by between 31% and 65%, according to analysis by David Bloom and colleagues.

HUNDREDS OF MILLIONS OF WOMEN ROUTINELY VULNERABLE TO UNPLANNED PREGNANCY

Despite the strong evidence that increasing contraceptive use accelerates development, 570 million (30%) of the 1.9 billion women aged between 15 and 49 in the world may be regularly exposed to the risks of sex without contraception. First there are the 214 million married and partnered women in need of modern contraception, according to the Guttmacher Institute. Second, there are 900 million single women and girls. If we estimate that 360 million (40%) of these single women have an unmet need for modern contraception, the total pool of unprotected women in the world rises to 570 million – 30% of all women aged 15 to 49 years.

Global contraceptive initiatives like Family Planning 2020, studies like the 2012 Lancet Family Planning Series, and databases like World Contraceptive Use all underestimate the size of the population of exposed women because they focus only on married and partnered women. As a result, much less is known about the contraceptive status of single women and girls. It is highly likely that single women face even greater barriers to using contraception and are at a higher risk of unplanned pregnancy compared to their married and partnered peers. A 40% unmet need for modern contraception among single women may be a significant underestimate.

Single women and girls may also be at greater risk of unwanted pregnancy from forced or coerced sex. Rates of sexual violence are high across all regions, but especially in Africa and South Asia where four in 10 women will experience partner violence in their lifetimes, according to the World Health Organisation. In these regions, one third of girls will experience an incident of sexual violence before they reach 18 years of age, according to the Violence Against Children surveys supported by the Together for Girls initiative. We should not underestimate the pregnancy risks to girls and single women in societies with low modern contraceptive use and high rates of sexual violence.

It is of great concern then, that among the ten largest populations of unprotected women and girls, nine are in Asia and Africa. India is home to an estimated 85 million women and girls with an unmet need for modern contraception, China to 25 million, Pakistan to 16 million, Indonesia to 16 million, Nigeria to 15 million, Bangladesh to 10 million, the Philippines to 8 million, Ethiopia to 8 million, and the Democratic Republic of Congo to 7 million. Together, these ten countries are home to 180 million (30%) of the estimated 570 million exposed women and girls. It is important to note that the USA is the only non-Asian or African country in the top ten, with an estimated 18 million women and girls with an unmet need for modern contraception.

Of special concern are the large populations of unprotected women and girls in the countries with extremely low (<20%) modern contraceptive use, high fertility rates (more than 5 children per woman), and high adolescent birth rates (over 100 births per 1,000 15-19 year old girls). In addition to Nigeria and the Democratic Republic of Congo, Niger, Somalia, Mali, Chad, and Angola, fall into this category. Increasing modern contraceptive use in all of these countries could yield major national and regional development returns, including increased economic growth, reductions in poverty and inequality, and improvements in maternal and child health, and education.

Further, due to the “youth bulge” in many of these countries, increasing modern contraceptive use could also deliver a long-term “peace and security dividend”. By 2030 the number of young men (15 to 29 years) will have increased by more than 50% in most of the central and west African countries. The rising numbers of young men, many of whom will come of age during period of high unemployment and rapid urbanization, could become a potent force for conflict and insecurity.

THE CHILD DEPENDENCY RATIO: A NEW DEVELOPMENT CONCEPT

In recognition of the economic and social costs of high fertility to individual women, their families and nations, and of the tendency for current measures of modern contraceptive use to underestimate the need, countries should adopt a new measure called the Child Dependency Ratio. This ratio expresses the number of dependent children (less than 14 years) as a proportion of the number of women of working age (15 to 49 years) in the total population. It is a measure of the relative burden of child bearing and rearing that falls disproportionately on women of working age. This burden acts as a barrier to women’s and girls’ education and labor force participation in almost all countries.

For example, countries with Child Dependency Ratios greater than 1 have on average more than one dependent child per woman of working age, a level which can restrict women’s and girls’ freedom to pursue education and earnings and to contribute to economic growth and development, especially in societies lacking policies and programs to support mothers to learn and earn.  In contrast, countries with ratios less than 1 have fewer than one child per woman of working age, a level at which women have greater freedom to pursue improvements in their quality of life and contribute to national development.

In 2018, the global Child Dependency Ratio was 1.04. For every single woman aged 15 to 49 in the world, there were 1.04 children aged under 14 years. The ratio varied widely across regions, from a high of 1.68 in Africa, to .71 in Europe. In all regions except Africa there were more women aged 15 to 49 than children under 14 years.

Among the ten countries with the largest populations of girls and women exposed to the risks of unplanned pregnancy six have Child Dependency Ratios above 1. The Democratic Republic of Congo recorded the highest ratio (2.08), followed by Nigeria (1.91), Ethiopia (1.61), Pakistan (1.38), the Philippines (1.22), and India (1.06). Four of the countries recorded rates below 1, including Bangladesh (0.99), Brazil (0.78), China (0.72), and the USA (0.83).

Among the additional countries with very low modern contraceptive prevalence, high fertility, and high teen pregnancy, all had Child Dependency Ratios above 2. For every woman aged 15 to 49 in Niger, there are 2.39 children under 14 years. The ratio in Mali is 2.14, in Somalia 2.05, in Chad 2.08, and in Angola 2.03. Women in these countries are spending so much time having and raising children in such challenging circumstances that it is undermining the quality of their own lives, their children’s, and the nation’s.

Child dependency is correlated with human development. The countries with the highest child dependency ratios score the lowest on the Human Development Index, all of them in Sub-Saharan Africa, while the countries with the lowest child dependency ratios score the highest in measures of human development, all in Europe, except Australia, Hong Kong, and Singapore.

NEW APPROACHES NEEDED TO ACCELERATE FERTILITY RATE DECLINES

In recent decades, progress in increasing the use of modern contraception and reducing fertility rates has been disappointing. Between 1990 and 2017 modern contraceptive prevalence increased from 53% to 58%, according to the United Nations. Rates vary widely across regions, from 70% in Latin America and the Caribbean to 32% in Africa. Of special concern, 15 countries, all of them in west and central Africa, currently have modern contraceptive prevalence rates below 20%, according to Family Planning 2020.

New approaches are needed to accelerate fertility rate declines and trigger the demographic dividend under the Sustainable Development Goals. This is especially important in those Sub-Saharan African countries where continued high fertility and low modern contraceptive use threatens not only national economic and social development, but also peace and security. The ultimate goal of the new Child Dependency Ratio is to accelerate the rate of progress in reducing the fertility rate to the levels required for achievement of the new Sustainable Development goals relating to health and gender equality.

Accordingly, the United Nations, its agencies, and development partners should support a new focus on reducing the Child Dependency Ratio by ensuring that all governments and UN agencies understand that reducing the burden of child bearing and rearing on women of working age will contribute to gender equality as well as national economic and social development. The UN should publish an annual Child Dependency Ratio for every country and also examine sub-national trends among certain populations of women, especially those on the lowest incomes who face both higher risks and costs associated with unplanned pregnancy.

A final note. Throughout this analysis the term “contraception” rather than “family planning” has been used because not all women and girls who use contraception are planning families. Many are seeking instead to prevent pregnancy and still others are using contraception for other purposes (e.g. to minimize complications from menstrual and other painful conditions). In this context, contraception is a simple and highly effective medicine that women take to prevent pregnancy, but also for other reasons, no different to a vaccine given to children to prevent polio or an antibiotic to treat pneumonia. Having already transformed the quality of life for hundreds of millions of the world’s women and girls and with the potential to transform the lives of many millions more, and responsible for preventing the deaths of hundreds of thousands of women and many millions of babies, contraception may well be the world’s most life-affirming medical discovery.