Access to family planning is essential for the health and welfare of people and the planet. Family planning includes information and services for contraception and abortion. Family planning improves health, protects human rights, and makes important contributions to social welfare, economic development, and preserving the environment.
The Centers for Disease Control and Prevention cite family planning as one of the top 10 public health achievements of the United States during the 20th century. Some methods of family planning have direct health benefits, including prevention of ovarian and endometrial cancers, and reduction of anemia.1 In countries without advanced emergency care systems, family planning protects women’s health by helping avoid unintended pregnancies, thereby reducing the number of women who die or are injured during childbirth. Use of family planning is also associated with reduced infant mortality and a longer spacing between births that is safer for both mothers and newborns.2
The United Nations’ Universal Declaration of Human Rights states that everyone has the right to health and well-being, and the United Nations Population Fund (UNFPA) considers access to family planning a fundamental human right.3,4 There is an international consensus that individuals and couples have a right to control their reproductive decisions, including family size and the timing of births. But surveys in many developing countries reveal substantial deficiencies in access to family planning. Up to a quarter of women want to either stop childbearing altogether or delay the arrival of their next child, but many lack access to contraception.5
Social and economic development
A majority of U.S. women using family planning report that it has “allowed them to take better care of themselves or their families, support themselves financially, complete their education, or keep or get a job.”6 Economic research in developing countries shows that families who choose to have fewer children can direct more resources towards the health and education of each child.4 Many economists have concluded that slowing population growth improves the economic well-being of individuals and entire countries. We have seen examples of the economic impact of large voluntary family planning programs in Thailand, South Korea, Malaysia, Taiwan, and Singapore. These countries adopted sound economic policies and therefore were well situated to take advantage of the rapid declines in average family size that reduced the dependency ratio—the number of children, youth, and elderly who are not as economically productive compared to workers in the labor force. Fewer nonworking dependents provided a demographic dividend that contributed to the “economic miracle” that occurred in these countries.7
Preserving the environment
The impact of humans on their environment is related to population size, per capita consumption, and the environmental impact of the technology used to produce what is consumed.8 The lifestyle of each person in a rich country has a greater detrimental impact on the environment than each person in a poor country, but as people emerge from poverty, their consumption increases. There are almost five times as many people in the developing countries as live in the developed countries, and some are rapidly improving their economic circumstances and level of consumption. Studies of the status of natural systems make it clear that human over-consumption is depleting the earth’s natural resources and harming life-supporting ecosystems. The UN-sponsored Millennium Ecosystem Assessment concluded that humans have degraded ecosystems more rapidly and extensively over the past 50 years than ever before, primarily to meet increasing demands for food, fresh water, timber, fiber, and fuel.10 Rising population and consumption will likely increase environmental stresses such as the greenhouse effect, rising sea levels, water and cropland scarcity, the collapse of fisheries, deforestation, and chronic undernourishment—all of which can contribute to social unrest and failed states.
Lester Brown has described the interaction between life-supporting ecosystems and population growth as follows: “As land and water become scarce, competition for these vital resources intensifies within societies, particularly between the wealthy and those who are poor and dispossessed. The shrinkage of life-supporting resources per person that comes with population growth is threatening to drop the living standards of millions of people below the survival level, leading to potentially unmanageable social tensions.”9
In 1992, over 1,700 of the world’s leading scientists—including a majority of Nobel laureates in the sciences—warned: “If we do not stabilize population in voluntary, humane ways, it will be done for us by Nature; it will be done brutally, relentlessly and whether we wish it or not.”
Family planning: A progress report
Family planning programs began in the 1960s, and have seen tremendous successes in meeting demand for contraception in some countries. At the outset, these programs provided access to modern methods of contraception via local health educators and trained medical providers. The organization of family planning programs has evolved over time to include social marketing and household distribution of contraceptives. Although programs remain active in most developing countries, the funding for family planning programs is still inadequate.12
National and international policies about family planning
Prior to the 1994 International Conference on Population and Development (ICPD) in Cairo, most population assistance funding was designed to strengthen family planning programs. The ICPD addressed urgent issues relating to human welfare in the developing world, and consequently adopted a broader strategy for population assistance. The new strategy included poverty eradication, women’s empowerment, gender equity, human rights, environmental protection, male responsibility in sexual behavior and family welfare, adolescent reproductive health, and safe abortion—in addition to basic family planning and other reproductive health services.13
The ICPD focus on women’s health, welfare, and reproductive rights had been articulated at the Mexico City population conference a decade earlier. But it was only after the ICPD that the dominant rationale for population work became firmly based on human rights with less attention being given to arguments relating to environmental preservation, economic development, and rapid population growth. In the years following the ICPD, there was not a concomitant increase in development assistance funds for the broader array of activities espoused by the ICPD. There was, however, a rapid increase in funds to address the HIV/AIDS epidemic and modest increases for general reproductive health. Probably in part because of the new emphasis on HIV/AIDS and broad reproductive health goals, notably the reduction of maternal mortality, funds set aside exclusively for family planning actually declined.12
In 2000, the UN adopted the Millennium Development Goals (MDGs) and indicators to measure whether the global community was achieving a substantive reduction in poverty by 2015. In an apparent effort to avoid controversy, the original MDGs addressed maternal health without ever mentioning family planning.14 In 2005, the UN finally included the ICPD goal of universal access to reproductive health, including family planning, as a target under the fifth MDG on improving maternal health.
Currently, most developing countries have policies that support access to family planning but many of the poorest and least developed countries commit only meager resources to making these services available. At a July 2012 London Summit on Family Planning, foreign aid donors committed increased funds for international family planning and secured commitments from 22 developing country governments to increase their funding for family planning, but as yet it is unclear whether the developing country commitments will be met.15
Achievements of family planning programs
Since the 1960s, national government and foreign aid financial support for family planning programs has been inconsistent and inadequate to meet the needs of all individuals and couples. Yet, even with this less than optimal support, great progress has been made. In many countries, family planning programs have successfully met much of the demand for modern contraception, brought about smaller families, and slowed population growth.
Thanks in part to family planning programs in less developed countries, between 1960 and 2012:
• Contraceptive use increased from about nine percent of reproductive age women who are married or in a union (30 million women) to 62 percent (638 million women).16,17
• The average number of children per woman or total fertility rate (TFR) declined from 6.2 to 2.7. (Figure 1)
The experiences of Thailand and Iran are examples of how quickly a well-designed publicly supported family planning program can bring the benefits of family planning to individuals and countries.
Thailand: family planning success through innovative methods
Thailand’s government launched its family planning program in 1970. Among the innovative approaches adopted were:
• public messages about the benefits of family planning;
• provision of a broad array of contraceptives, including injectable and oral contraceptive pills, without prescription; and
• distribution by nurses, midwives, and even shopkeepers within communities.19
By the late 1980s, Thailand’s average lifetime number of births per woman had dropped from about seven to below the “replacement-level” of 2.1. Thailand’s current TFR is 1.6.20 A cost-benefit analysis estimated that Thailand’s program will have prevented 16.1 million unintended births between 1972 and 2010, saving the government $11.8 billion in social service costs, or $16 for every dollar invested in the program.21
Iran: improving family planning with political and religious support
Recognizing an impending imbalance between available natural resources and population size, the Iranian government, with the support of Muslim religious leaders, reinvigorated its national family planning program.22 After Iran implemented its family planning program:
• the proportion of married women of reproductive age using contraception increased from 37 percent in 1976 to 73 percent in 199723 and
• the average lifetime number of births per woman declined from 6.8 in 1984, to 5.5 in 1988, to 2.8 in 1996, and finally to 1.9 in 2012.20,24
There is a long list of other countries with successful family planning programs and low fertility rates including Bangladesh, Colombia, Indonesia, Tunisia, Turkey, and Vietnam.20 China, with its one-child policy, is a special case in that its family planning program is not voluntary. The experience of other countries shows that coercion is not necessary.
Well-managed voluntary family planning programs offering high quality services can be highly effective. The experiences of many countries, even those that are very poor such as Bangladesh and Nepal, have taught us the keys to successful family planning programs.27
• high-level political commitment, especially from governments;
• broad support from leadership groups;
• legitimizing smaller families and modern contraception via the mass media;
• a broad choice of contraceptive methods—including the most effective methods, sterilization, and IUDs;
• convenient service sources such as medical facilities, social marketing, and field workers; and
• affordably priced family planning products and services, ensured by adequate program funding.
Family planning: The future
Despite the success of family planning programs, the global population continues to grow, driven by the momentum of the current population. There are more adolescents today than ever before, and even if they choose to have small families, population will grow beyond the replacement rate for decades to come. Although global fertility has declined substantially, the number of people added to the world population each year has increased from 48 million in 1950 to 84 million in 2012 (Table 1).20
Strengthening family planning services is crucial to slowing population growth and limiting world population size to 9.6 billion by 2050—the United Nations’ “medium projection” for population growth. If birth rates and death rates remain unchanged, world population would grow to 11.1 billion (Figure 2).28
Whatever trajectory we follow, nearly 98 percent of growth will occur in developing countries. These countries stand to gain the most by improving access to family planning, and are home to the estimated 222 million who prefer to delay pregnancy or limit their families, but lack access or face other barriers to using contraception. There is room for much improvement in family planning programs where rapid population growth is occurring; Sub-Saharan Africa, Iraq, Afghanistan, Pakistan, and parts of India. (Table 2)
To improve family planning programs in these countries, we will need to address the common challenges outlined below.
United States political scene
Family planning remains a political football in the United States, with constant changes in policies and static funding levels for bilateral and multilateral family planning programs. Fortunately, there are other major donors to international family planning programs, including the United Kingdom, Norway, Sweden, Germany, and the Netherlands. And recently, some philanthropies have increased their level of commitment to this area.
An estimated $8.1 billion per year is needed for family planning programs in developing countries. Current funding from foreign aid donors and from consumers and governments within developing countries is $4 billion annually—half of what is needed (Table 3).18 In many developing countries, especially in Latin America, consumers pay most of the costs for contraceptives. But in other countries, especially those in Sub-Saharan Africa, family planning services are dependent on government and donor funds.12
Even though political support for family planning remains problematic, there have been some gains in family planning funding. The ICPD recommended that donors pay one-third of the needed $8.1 billion or $2.7 billion. In 2008, donor funding was $572 million. In 2010, funding had increased to $882 million, and could reach $1.3 billion by 2014 thanks to the London Summit on Family Planning. Led by Melinda Gates of the Bill and Melinda Gates Foundation and British Prime Minister David Cameron, the Summit set a goal of providing family planning to 120 million additional women in the 69 poorest countries by 2020. Over the next eight years, donors pledged to provide an additional $2.3 billion, and developing country governments made a less firm commitment of an additional $2 billion. The additional $538 million a year amounts to about 13 percent of the increase in funds needed.15
Access to safe abortion
Although the accomplishments of family planning programs are significant, approximately 40 percent of pregnancies in developing countries continue to be unintended—more than 80 million each year.18 While addressing the unmet need for modern contraceptives on the part of an estimated 222 million women in developing countries would substantially decrease the need for abortion, it can not eliminate this need because no contraceptive method is 100 percent effective for pregnancy prevention—annual failure rates range from 30 percent to less than 1 percent.25 International research shows that women with unintended pregnancies turn to abortion to attain their childbearing goals, regardless of its legal status. In 2008, of all unsafe abortions worldwide, 97 percent, or an estimated 21.2 million, occurred in developing countries, placing a hugely disproportionate burden on women in these countries.26 Unsafe abortion remains a major threat to women’s health, contributing one in eight maternal deaths in developing countries.
Family planning benefits
The role of family planning in the solution of world problems is easily underestimated because it is largely a preventive measure. Family planning facilitates and makes it easier to progress on other important issues. Since the 1960s, the world has made impressive progress in bringing the benefits of family planning to the poor in developing countries. But our work is not done: an estimated 222 million women still need services.5 The least developed countries present the greatest challenge and need the greatest assistance in training personnel and establishing services. Because desired fertility remains high in many countries in Sub-Saharan Africa, communication about the individual and family benefits of family planning is of particular importance.27
Cost-effectiveness for governments and families
Investing in family planning in the U.S. saves money for individuals and the public. In 2010, nine million women received publicly funded contraceptive services. These services cost $2.4 billion, prevented an estimated 2.2 million unintended pregnancies, and resulted in net public savings of $10.5 billion. Every dollar invested in publicly funded contraceptive services in the U.S. saved $5.68 in public costs for pregnancy and infant care.28,29 A return on investment of similar magnitude occurs in developing countries.27
Beyond family planning’s financial benefits to governments, its financial benefits to individuals and families can be substantial. Well-timed and wanted pregnancies allow women to complete their desired education, and obtain paid work.6 U.S. women who become mothers by age 18 are unlikely to prosper, with fewer than 2 percent attaining a college degree by age 30.30
The current underfunding of family planning for developing countries is short-sighted. With an expenditure of just a little over a dollar per year for each of the seven billion of us now alive on the planet, we could meet the expressed needs for family planning in developing countries.18 That is a low price to pay for the benefits of universal access to family planning.
Family planning can make critical contributions to the solution of multiple world problems relating to reproductive health, human rights, social welfare, poverty, food security, preservation of the environment, climate change, and social unrest. We have limited ability to prevent war and cure cancer, but we have repeatedly demonstrated that we can help couples attain their fertility goals at a very low cost. Given access to quality family planning services, people from all walks of life almost invariably choose small families and the attendant economic benefits.
The stakes are high, and our best scientists have warned us that providing for an additional 1.6 million people every week is not sustainable: “Earth is finite… Its ability to provide for growing numbers of people is finite. And we are fast approaching many of the earth’s limits.”11 Fortunately, we have reason for optimism: “The family planning movement has been one of the most successful examples of development cooperation in history. For all the underlying cultural and political conflict that attended it, the movement …[is] a demonstration of what collective political will and strong international cooperation can achieve.”31 And as Jared Diamond has observed: “To save ourselves we don’t need new technology: we just need the political will to face up to our problems of population and the environment.”32