57. Contraception

Nature, Causes, and Burden of the Conditions That Can Be Addressed

Three rationales—each one involving controversy and touching on deeply held political and cultural perspectives—have underlain policy and programmatic interest in contraception, since the 1960s.

• The demographic rationale, typically framed around lowering the rate of population growth to achieve broad economic, social, and environmental aims, was most prominently applied in the 1960s and 1970s.

• The fertility rationale, which emerged in the 1980s, promoted lower fertility under the assumption that smaller families are better off in terms of economic and health conditions.

• The human rights rationale, which surfaced in 1994 at the International Conference on Population and Development in Cairo, served as a major force in the 1990s to focus attention on women's rights to autonomy and empowerment in childbearing and on female and male reproductive health. The Cairo Programme of Action stressed the political and cultural dimensions of contraception, including gender issues.

Population Growth and Fertility

In part because of the demand for and availability of modern contraception, the worldwide rate of annual population growth has declined from just over 2 percent in the late 1960s to 1.5 percent during 1980-2001. It is projected to decrease to 1 percent during 2001-15. Although the growth rate has slowed, population growth in absolute terms is unprecedented. World population increased from 2.5 billion people in 1950 to 6.3 billion in 2003 and is expected to rise to 7.1 billion by 2015 (UN 2003; World Bank 2003).

Fertility rates in developing countries have declined rapidly in the past 50 years, from more than 6.0 children per woman in the 1950s to about 2.8 children per woman today. Fertility rates remain high, however, in the 49 least developed countries, which had an average total fertility rate of 5.46 children per woman during 1995-2000 (UN 2003).

Fertility levels and trends vary greatly between regions. Fertility rates are lowest in low-and middle-income countries in East Asia and the Pacific, at 2.1 children per woman. Countries in Central Asia and Latin America and the Caribbean also have relatively low total fertility rates, at 2.5 and 2.6 children per woman, respectively. The Middle East and North Africa and South Asia follow, with average total fertility rates of 3.4 and 3.3 children per woman in 2001, respectively. Fertility rates are highest in Sub-Saharan Africa, at 5.2 children per woman (World Bank 2003).¹ Regional averages conceal substantial variation among and within countries.

Because of a legacy of high fertility and corresponding young population structures, population momentum ensures that many developing countries will continue to grow at a relatively high rate for many decades, even as fertility rates continue to decline. Population momentum alone will account for almost three-fourths of the population growth in developing countries in the next quarter-century. The largest growth at present is in Asia and Sub-Saharan Africa. Total population increase in these regions is now twice what it was in 1950. By 2015, population growth is expected to be substantially lower in all regions except Sub-Saharan Africa.

Demand for Contraception

If a woman wishes to postpone or avoid childbearing and is not using contraception (including use by her partners), she is said to have an unmet need for contraception. The most commonly reported reasons for unmet need are lack of knowledge, health concerns, and social disapproval (Casterline and Sinding 2000).

In 2003, an estimated 122.7 million women in developing countries had an unmet need for contraception, including 105.2 million married women, 8.4 million unmarried women, and 9.1 million women of all marital status in the states of the former Soviet Union. This figure represents 17 percent of all married women, a 2 percent decline from the late 1990s that is due to increasing contraceptive use.

Overall, the highest unmet need is in Sub-Saharan Africa, where 19.4 percent of all women have unmet need. About 13 percent of women in Asia, 10.6 percent of women in North Africa and the Middle East, and 8.5 percent of women in Latin America and the Caribbean and Central Asia have unmet need for contraception. Whereas women in the other regions of the world have an equally distributed unmet need for spacing and limiting births, the majority of unmet need in Sub-Saharan Africa is for spacing (Ross and Winfrey 2002). Unmet need is highest in countries where growing numbers of women want to avoid pregnancy but contraceptive prevalence is low. So, for example, among developing countries for which data are available from USAID's Demographic and Health Surveys, unmet need is currently highest in Haiti, where it nears 40 percent of all married women; it is more than 30 percent in Cambodia, Nepal, Pakistan, Rwanda, Senegal, Togo, Uganda, and the Republic of Yemen; and it is lowest, at less than 7 percent, in Brazil, Colombia, and Vietnam.

Total Potential Demand for Contraception

A rough measure of the total potential use of modern contraception in a country can be estimated by combining the measure of unmet need with the current proportion of women using contraception. Brazil, Colombia, and Vietnam all have demand for contraception greater than 80 percent of currently married women. They have satisfied most of this demand, with contraceptive prevalence rates above 75 percent, resulting in both low fertility rates and low unmet need (Westoff 2001). In contrast, in most Sub-Saharan African countries, the unmet need percentage exceeds the percentage of women currently using contraception (see table 57.1).

Health Consequences

Excess fertility is responsible for between 12 and 30 percent of the maternal burden of disease (see table 57.2)², although this is clearly an underestimate of the present and future burden of disease that can be prevented through investments in family planning. These estimates include only the direct health benefits of family planning for women by preventing unwanted births, decreasing the number of abortions, and increasing the length of birth intervals. Because of data limitations, these estimates exclude the potential effect of family-planning programs on children's long-term nutritional status and education; women's status and the household economy; and public savings from reduced fertility, AIDS, and other STIs through condom promotion and prevention of mother-to-child transmission (PMTCT). They also exclude the effect of such programs on environmentally related disease owing to population growth. Last, the estimates do not consider the disabling effects of unwanted pregnancies, despite the effect those pregnancies or their termination under unsafe conditions can have on women's welfare and productivity.

Each year, 585,000 women die and more than 54 million women suffer from diseases or complications caused by pregnancy and childbirth (WHO 1997).

Risks Associated with Unwanted Pregnancies

Unwanted pregnancies expose women to additional health risks by increasing the number of lifetime pregnancies and deliveries. Because the lifetime risk of maternal mortality is a function of the number of pregnancies and the quality and utilization of health care, reducing the number of pregnancies can lower maternal mortality rates (Koenig and others 1988). Ambivalence toward pregnancy also is associated with less early and continuous prenatal care and lower use of professional delivery care (Gage 1998; Joyce and Grossman 1990; Weller, Eberstein, and Bailey 1987).

Many women who have unintended pregnancies turn to induced abortion, both in countries where abortion is legal and safe and in those where it is illegal and too often unsafe. Accurate measures of abortion are difficult to obtain in most parts of the world. In countries where abortion is illegal, data are lacking or incomplete, and even where it is legal, abortions may be underreported because of societal attitudes (Bongaarts 1997; Henshaw, Singh, and Haas 1999). It is estimated that about one-fourth of the 210 million pregnancies each year end in abortion.

In 1995, approximately 35.5 million abortions were performed in developing countries. The large majority of legal abortions, 10.6 million, occurred in China. Most of the remaining legal abortions took place in other parts of Asia (5.7 million) and in the Caribbean (0.2 million). Developing countries, which experienced an estimated 19 million illegal abortions in 1995, account for 95 percent of illegal abortions worldwide. Nearly 10 million illegal abortions occurred in Asia, followed by an estimated 5 million in Africa and 4 million in Latin America. These figures mark a particularly large increase for Africa, which was estimated to have only 1.5 million illegal abortions in 1987 (Henshaw, Singh, and Haas 1999).

Unsafe abortion, typically associated with illegality, has large impacts on both maternal mortality and maternal morbidity. Each year, unsafe abortion is believed to account for 80,000 maternal deaths, or 13 percent of the burden of disease in women of reproductive age (WHO 2002a). Deaths related to unsafe abortions are estimated at 100 to 600 death per 100,000 abortions, compared with the mortality rate from legal abortions of 0.6 deaths per 100,000 abortions (Salter, Johnston, and Hengen 1997). Survivors of unsafe abortions also experience consequences; unsafe abortion causes disability in an additional 5 million women (WHO 2002a). Treatment of complications from unsafe abortions constitutes a large proportion of emergency gynecological hospital admissions (Konje, Obisesan, and Ladipo 1992) and requires substantial resources (Kinoti and others 1995; Salter, Johnston, and Hengen 1997).

Legalizing abortion, improving the quality of abortion care, and increasing access to safe abortion can have profound impacts on the health consequences of abortion. When abortion was illegal in Romania in 1988, complications from unsafe abortion caused 86 percent of maternal deaths. After abortion was legalized in 1989, the frequency of abortion persisted because of contraceptive supply shortages, but the number of maternal deaths fell by 50 percent (Hord and others 1991).

Risks Associated with Pregnancy and Birth

All pregnancies and births involve some health risks to women, so preventing any pregnancy reduces women's health risks. Higher mortality and morbidity of women, infants, and children are positively associated with the risk factors of giving birth when a woman is too young or too old, the births are too close together, there are too many births, or a woman has a preexisting health condition. Births in most of these groups—women who are older (over age 35), births that are spaced too closely (24 months or less after the preceding birth), and births that are higher order (fifth or higher)—are also more likely to be reported as unintended, making their prevention doubly important (Tsui, Wasserheit, and Haaga 1997).

An estimated 15 million women under age 20 give birth each year. Women age 15 to 19 are twice as likely to die from childbearing as women in their 20s, and women under age 17 are at even greater risk (Starrs 1997). Adolescent mothers are more likely to suffer from obstetric complications if they lack physical maturity or are malnourished (Aitken and Walls 1986). They are also less likely to receive adequate prenatal or obstetric care, which may cause negative outcomes for them and for their infants (McDevitt and others 1996). In many contexts, negative social consequences are profound, including loss of school and employment opportunities.

Children born to adolescent mothers face a number of risks. Research has demonstrated that infants of teenage mothers are more likely than those born to mothers in their 20s to die before they reach their first birthday (Hobcraft 1992; McDevitt and others 1996; Ross and Frankenberg 1993; Starrs 1997; Sullivan, Rutstein, and Bicego 1994). Children of mothers under age 20 may have a 20 to 30 percent higher risk of death than children of older mothers (Hobcraft 1992; Sullivan, Rutstein, and Bicego 1994). Infants of teenage mothers are also at higher risk of being of low birthweight, small for gestational age, or premature. Finally, adolescent women are less likely to provide adequate care for their infants and children, because they often lack the maturity, education, and resources to do so (Geronimus 1987; Govindasamy and others 1993).

Women over age 35 face an increased risk of maternal mortality. Mothers age 40 to 44, for example, are five times more likely to die during pregnancy or childbirth than mothers in their 20s (Royston and Lopez 1987). Mothers in their late 30s and 40s may also face additional negative consequences, because they may have preexisting health problems owing to age or previous births.

As with children of adolescent mothers, children of women over age 35 also suffer negative consequences. Children born to mothers over age 40 are more likely than those born to younger mothers to die before age 5 (Bicego and Ahad 1996; Sullivan, Rutstein, and Bicego 1994). Older women are also more likely to have stillbirths or to bear children with congenital abnormalities who may not survive childhood (Cnattingius and others 1992; Fretts and Usher 1997).

Longer birth intervals reduce women's risks of death and ill health during pregnancy and childbirth. One study assessed the effects of birth spacing in 450,000 women on the basis of hospital records from 1985 to 1997 in 19 Latin American and Caribbean countries. The study found that women who have their babies 27 to 32 months after a preceding birth are more than two times more likely to survive pregnancy and childbirth than women who have short intervals of 9 to 14 months. Birth intervals of 27 to 32 months are also associated with lower incidence of third trimester bleeding, premature rupture of membranes, anemia, and other negative outcomes (Conde-Agudelo and Belizan 2000).

Recent research suggests that birth intervals of three to five years provide even greater benefits than the two-year intervals that were previously promoted. One study assessed the effect of this longer birth interval in more than 430,000 pregnancies in 18 countries and found that children who are born three to five years after the preceding birth are more likely to survive from the perinatal period through age five. Children born at intervals of three to five years are also 1.2 to 1.4 times less likely to be malnourished or underweight or to experience stunting than those born at intervals shorter than two years (Rutstein 2003).

Putting together a range of patchy data on the effect of family planning on child mortality can yield estimates of the total global impact, but those estimates are highly dependent on assumptions and have varied widely. The World Bank (1993) estimated that family-planning programs could prevent between 20 and 40 percent of all infant deaths by preventing mistimed and underspaced births. In a study of 25 countries, Hobcraft (1994) estimated that if all birth intervals of less than two years were prevented, child mortality levels would be reduced by an average of 17 percent and up to one-third in several countries. Rutstein (2003) found that birth spacing of three to five years alone could prevent up to 46 percent of infant mortality. Muhuri and Menken (1997) found that in rural Bangladesh poor spacing and timing accounted for 25 percent of child mortality. Trussell and Pebley (1984) estimated that spacing could decrease infant mortality by 10 percent and child (age 1 to 5) mortality by 21 percent. Another study found that, even in Latin America, which has lower child mortality rates, spacing could reduce perinatal mortality by 14 percent (Conde-Agudelo and Belizan 2000).

In a study of 19 African countries, Rafalimanana and Westoff (2001) found that median actual birth intervals in every country were shorter than the preferred birth intervals reported by women, reflecting the substantial unmet need for birth spacing. Achieving preferred intervals would decrease neonatal mortality by only 6 percent on average, and infant mortality by a comparable amount, whereas removing all short intervals would decrease both by 13 percent.

Women giving birth for the fourth or higher time are at much higher risk of maternal complications and death. Independent of a woman's age, her risk of dying when giving birth for the fourth or higher time is 1.5 to 3 times greater than during a second or third birth (Winikoff and Sullivan 1987). Women who have had at least three births are also more likely to experience hemorrhage, uterine rupture or prolapse, or kidney disease (Maymon and others 1998).

Children born to mothers who have had many births face risks similar to those of children born to older mothers; they are often the same women. Children born to mothers who have had three or more births are more likely than those born to younger mothers (those under age 20) to die before age 5 (Bicego and Ahad 1996; Sullivan, Rutstein, and Bicego 1994). Women who have had many births are also more likely to have stillbirths or to bear children with congenital abnormalities who may not survive childhood (Cnattingius and others 1992; Fretts and Usher 1997). Children from larger families often receive lower levels of education and health care than children from smaller families because of competition for finite family resources (Blake 1981).

Women with preexisting health conditions often face greater risks in pregnancy and childbirth. Pregnancy can aggravate conditions such as high blood pressure, heart disease, malaria, anemia, tuberculosis, hepatitis, and STIs, including HIV. Indirect causes, including these preexisting conditions, account for an estimated 20 percent of maternal deaths each year (WHO 1997).