The Lancet Series Offers Fresh Perspective on the Value of Family Planning
On the eve of the London Summit for Family Planning, The Lancet published a series of articles and commentaries that explores the links between contraception, population growth, and the health and wellbeing of the planet and its current and future inhabitants. The series reviews an array of evidence on the toll that lack of access to family planning takes not only on maternal and child health but also on the social, economic, and environmental health of communities, nations, and the world.
Those who work in family planning are well aware that national political will and international support for contraceptive programs has waned in recent decades. This neglect has perpetuated a continued lack of access, particularly in low-resource settings where the consequences are most dire. The Lancet’s series examines the potential of family planning to advance global health from so many angles that even readers whose careers are devoted to the cause will gain fresh perspective and new insights.
The rebirth of family planning: Herbert Peterson of the UNC Gillings School of Global Public Health, who led the planning, commissioning, and preparation of the series, and Richard Horton of The Lancet identify two central challenges to addressing unmet need: stronger advocacy to policymakers to devote more attention to family planning and translating the scientific evidence presented in this series into innovative programs that are implemented well to achieve universal access to reproductive health.
Making family planning a national development priority: Pierre Damien Habumuremyi, Prime Minster of Rwanda, and Meles Zenawi, Prime Minister of Ethiopia, credit five factors with increased contraceptive use in the successful case studies of Rwanda and Ethiopia over the past decade:
- Policies and programs that ensure access to contraceptives regardless of clients’ ability to pay.
- Use of task sharing and enhancement of local planning and M&E capacity, logistics systems, and training.
- Direct involvement of community members in service provision.
- Use of social marketing and partnerships with private health care providers and religious and traditional leaders.
- Adequate funding to ensure a continuous flow of contraceptives to all parts of the countries.
Giving women the power to plan their families: Bob Carr, Melinda French Gates, Andrew Mitchell, and Rajiv Shah authored this commentary on behalf of the Alliance for Reproductive, Maternal and Newborn Health, which consists of the Australian Agency for International Development (AusAID), The UK’s Department for International Development (DFID), The United States Agency for International Development (USAID), and the Bill & Melinda Gates Foundation. The Alliance calls on developing country governments, the private sector, and others to invest in family planning so that all countries can reap the health and economic benefits that result when women can control their fertility.
Family planning saves lives, yet investments falter: Babatunde Osotimehin of UNFPA contends that while family planning yields many social, economic, and health benefits, above all, it protects the basic human right of individuals to have the information, tools, and ability to make their own decisions about how many children to have and when. He calls on governments of both developing and donor countries, the private sector, and civil society organizations to redouble their efforts to remove the social, geographic, political, and economic barriers to family planning that still prevent many from accessing contraceptive services.
Slowing population growth for wellbeing and development: Based on 2007 population data, the average area of land and water that the global population uses to generate the resources it consumes and absorb its waste (ecological footprint) is 2.7 global hectares per capita, yet the world’s current biocapacity is only 1.8 global hectares per capita. Van Braeckel et al., of the International Centre for Reproductive Health at Ghent University, contend that in order to preserve habitats, biodiversity, and natural resources for future generations, steps must be taken now to slow population growth while respecting democracy, human rights, and cultural integrity.
Getting wet, clean, and healthy: Why households matter: Bartram et al. of the Water Institute at the University of North Carolina at Chapel Hill point out that when it comes to providing access to safe drinking water and basic sanitation, the number of households in a community is more important than population size. While the average number of people per household is declining worldwide, the number of households is growing rapidly, far outpacing population growth. This will present service provision challenges to both developed and developing nations, yet the health, economic, and educational benefits of ensuring access to clean drinking water and sanitation far outweigh the costs.
What will it take to eliminate preventable maternal deaths? The annual number of maternal deaths worldwide has decreased by 47% over the past 20 years. Yet far too many mothers are still dying of pregnancy- and childbirth-related causes, and most countries are far from meeting Millennium Development Goal 5. Kate Gilmore, Deputy Executive Director of UNFPA and Tedros Andhanom Gebreyesus, Minister of Health of Ethiopia, recommend that family planning be made available in every community and facility; that round the clock maternity services, including emergency obstetric and newborn care, be available via one health center per 100,000 population and one district hospital per 500,000 population; that free or affordable contraceptive services are offered to all who need them; that real-time reporting of maternal deaths is used to improve the accuracy of maternal mortality estimates; and that gender equality is promoted, particularly in education.
Maternal deaths averted by contraceptive use: Results from a global analysis of 172 countries: Ahmed et al. estimate that 342,203 women around the world died of maternal causes in 2008 but that contraceptive use averted 272,040 maternal deaths. This means that without family planning, the number of maternal deaths would have been 44 percent higher than the actual 2008 total. Rates of unmet need for family planning and unwanted pregnancy are still very high in developing countries where risk of maternal mortality is highest. Satisfying current unmet need for contraception could prevent an additional 104,000 maternal deaths each year.
Global population trends and policy options: Ezeh et al. outline the consequences of varying population growth trends around the world, which range from rapid growth (more than 2 percent per year) in many of the poorest countries, particularly in sub-Saharan Africa, to population decline in Japan and parts of Europe. For countries facing the acute social, economic, and environmental pressures of rapid growth, the authors recommend implementation of voluntary family planning programs to reduce the high unmet need for contraception, unwanted pregnancies, and cultural norms around large family size. More research is needed on the effect of demographic policies on countries with low or negative growth.
Contraception and health: In addition to its impact on maternal mortality described throughout the series, Cleland et al. explain how contraceptive use can improve infant and child health outcomes by making healthy timing and spacing of pregnancies possible. Short birth intervals raise the risk of premature birth and low birth weight. In developing countries, spacing all births by at least two years would lower the risk of infant death by 10 percent and child death by 21 percent. Certain contraceptive methods also yield non-contraceptive health benefits for women, including reduced risk of some cancers.
Demographic change and emissions of carbon dioxide, the main greenhouse gas: O’Neill et al. review the evidence for how demographic factors affect CO2 emissions from the use of fossil fuels and show that changes in CO2 emissions correspond proportionately with changes in population size. Other demographic factors such as aging and urbanization also have significant effects on emissions, though they are less proportional. The authors employed scenario analyses and found that alternative population growth trends can substantially affect global CO2 emissions of future generations. Therefore, policies that slow population growth will likely also help protect the climate.
The economic consequences of reproductive health and family planning: Canning and Schultz write that controlled trials in Bangladesh and Ghana have demonstrated that increased access to family planning reduces fertility and improves birth spacing, yielding better maternal and child health outcomes. Long-term follow-up in Bangladesh revealed substantial improvements in women’s earnings, assets, and body-mass indexes (BMIs) and in children’s educational attainment and BMIs in areas with greater access to family planning than in control sites. On a societal level, when fertility is reduced, fewer youth are in need of services and care and more women can participate in the workforce, resulting in economic growth.
Use of human rights to meet unmet need for family planning: Cottingham et al. contend that the principle of non-discrimination and the right to the highest attainable standard of health, information and education, privacy, and life encompass the right to contraceptive information and services. This assertion lays the foundation for the argument that the demographic definitions of who has unmet need must be expanded to include unmarried people, adolescents, women who are not satisfied with their current contraceptive method, and marginalized populations who experience discrimination in health settings. Other necessities for addressing unmet need include concrete national and district-level plans to provide universal access; removal of legal and policy barriers; commodity security; an appropriately trained and supervised workforce that provides quality care; high-quality health facilities; removal of financial barriers; and effective M&E systems.
Family planning: A political issue: Shiffman and Quissel shed light on past and current political debates around family planning by examining three levels of politics. At the national level, there has been continual debate about the role of government in family planning provision. At the global level, similar questions arise about the role of donors and implementers from high-income countries. Finally, internal politics among family planning proponents include questions about which services to provide and how, as well as whether the aim of family planning programs should be slowing population growth for ecological and economic health versus guaranteeing the rights of women to control their own reproductive health. The paper shares feedback from interviews with a number of leaders in the field.
This series, coupled with the recent Summit, is aimed at galvanizing global commitment to family planning—a simple, cost-effective tool for saving millions and improving billions of lives worldwide. Watch a video interview with Professor Herbert Peterson of the Gillings School of Global Public Health who led preparation of the Lancet series, as he explains the link between family planning and global development and distills key points from the series.