CONTRACEPTION AS FREEDOM

The ability to control fertility stands as one of the greatest discoveries of all time with the benefits accruing to all 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 an estimated 100,000 deaths relating to pregnancy and childbirth and 2.7 million newborn deaths and stillbirths. If all demand for contraception was met for the 225 million married and partnered women who want to use it, an extra 70,000 deaths of women and 1.1 million newborn deaths and stillbirths could be prevented, according to the Guttmacher Institute. No other single intervention has the power to reduce maternal and newborn deaths and stillbirths at 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, making contraception one of the development priorities with the highest cost-benefit ratios according to the Copenhagen Consensus Center.  An exhaustive 2014 paper 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). Recent analysis by David Bloom and colleagues concludes that meeting unmet need for modern contraception could increase GDP per capita in Kenya, Nigeria, and Senegal by between 31% and 65%.

HUNDREDS OF MILLIONS OF WOMEN ROUTINELY VULNERABLE TO UNPLANNED PREGNANCY

Despite the strong evidence that increasing contraceptive use accelerates development, an analysis of United Nations data reveals that as many as 40% of the 1.8 billion women aged between 15 and 49 in the world today may be regularly exposed to the risks of unprotected sex, including pregnancy. Currently an estimated 800 million married and partnered women aged between 15 and 49 use contraception.  Of the remaining 1 billion, 225 million are married and partnered and in need of contraception.  The remaining 775 million are single women and girls, the majority of whom are likely to be sexually active but who are not currently counted in official measures of demand for contraception. If we estimate that contraceptive use among these women and girls is 27% (half the global average of 55%), 570 million would be exposed increasing the total pool of unprotected women in the world to an estimated 791 million, or more than 40% of all women aged 15 to 49 years.

Because the focus of global contraceptive initiatives (e.g. Family Planning 2020), studies (e.g. 2012 Lancet Family Planning Series) and databases (e.g. World Contraceptive Use) is on married and cohabiting women, the official measures of contraceptive coverage overestimate prevalence and underestimate demand because they exclude a very large group of single women and girls from measurement. Much less is known about the contraceptive status of single women and girls but it is highly likely that in lower and middle income countries they face even greater barriers to using contraception and are at a higher risk of unplanned pregnancy compared to their married and partnered peers.

Further, single women and girls may be at greater risk of unwanted pregnancy from forced or coerced sex as rates of sexual violence are high in many low and middle income countries.  According to the WHO, almost 4 in 10 women in Africa and South Asia will experience partner violence in their lifetimes, and a Lancet study from Swaziland found that 33% of girls experienced an incident of sexual violence before they reached 18 years of age. The US Centers for Disease Control and Prevention has found similarly high rates of forced sexual activity for girls in Kenya, Tanzania and Zimbabwe. We should not underestimate the pregnancy risks to women and girls in societies with low contraceptive use and high rates of sexual violence.

It is of great concern then, that the largest populations of unprotected women and girls live in lower and middle income countries, especially India, China, Pakistan, Nigeria, Indonesia, Brazil, Bangladesh, Mexico, and Ethiopia, home to an estimated 400 million exposed women and girls or half the global total. Of particular concern are the unprotected populations of women and girls in the countries with extremely low (<20%) modern contraceptive use, high fertility rates (more than 5 children per woman), high adolescent birth rates and low high school attendance rates for girls. Niger, Mali, Somalia, Chad, Burundi, Nigeria, Angola, the Democratic Republic of Congo, Uganda and Burkina Faso top the list and increasing modern contraceptive use in 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 contraceptive use could also deliver a long-term “peace and security dividend”.  By 2030 the number of young men (15 to 29 years) in many fragile countries will have increased dramatically including in Niger (99%), Mali (70%), Somalia (59%), Chad (61%), Burundi (55%), Nigeria (58%), Democratic Republic of Congo (50%), and Uganda (65%).  The rising numbers of young men many of whom will come of age during period of rising unemployment and rapid urbanization, could become a potent force for conflict and insecurity.

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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 and is a measure of the relative burden of child bearing and rearing that falls on  women of working age – a burden that acts as a barrier to women’s and girls’s education and labor force participation in almost all countries.

For example, countries with Child Dependency Ratios >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 contribute to economic growth and development, especially in societies lacking policies and programs to support mothers to learn and earn.  In contrast, countries with rates <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 2015, the global Child Dependency Ratio was 1.03. Interestingly, countries scoring the highest in measures of human development recorded among the lowest ratios of dependent children to working age women including Norway, Australia, Switzerland, the Netherlands, USA, Germany, New Zealand, Canada, Singapore and Denmark.  In contrast, the countries scoring the lowest on the Human Development Index had Child Dependency Ratios well above the global average. Of the countries with the largest populations of women and girls exposed to the risk of unplanned pregnancy, India, Pakistan, Nigeria, Indonesia, Bangladesh and Ethiopia all scored above the global average, while the USA, China, Brazil and Mexico all fell below.  All of the ten countries deserving special attention to accelerate contraceptive access scored well below the global Child Dependency Ratio average.

NEW APPROACHES NEEDED TO ACCELERATE FERTILITY RATE DECLINES

Over the period of the Millennium Development Goals (MDGs), progress in increasing the use of modern contraception and reducing fertility rates has been disappointing. Between 1990 and 2015 modern contraceptive prevalence increased from 55% to 63%, and unmet need fell from 15% to 12%.  In 23 countries, all of them in Africa, modern contraceptive prevalence was below 20% and in 15 countries (12 of them in Africa) unmet need was higher than 30%.  In the six African countries with the highest fertility rates (6 and above), only Burundi ended the MDG era with modern contraceptive use above 15%.

New approaches are needed to accelerate fertility rate declines and trigger the demographic dividend under the Sustainable Development Goals (2015-2030). 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 UN, its agencies and development partners should support this new focus on reducing the Child Dependency Ratio by including it as a specific indicator in the Sustainable Development Goals and by ensuring that all agencies understand the significance of reducing the burden of child bearing and rearing on populations of women of working age to women’s freedom to pursue improvements in their own quality of life and national economic and social development. The UN should encourage the annual publication of Child Dependency Ratios by country and by certain sub-populations of women, especially those in the lowest income quintiles 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 the 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.