With the world's rich-poor gap under increasing scrutiny these days, this is a stark one: the wide divide between women, trapped by circumstance and culture, who have more babies than they want or can support, and women who desperately want a baby they cannot create.
The latter group resides in wealthier nations, where costly fertility treatments are on the rise among affluent, professional women who delayed families and marriage to have a career. But what made those choices possible is what the first group, an estimated 222 million women in developing countries, can't access: proper family planning education and contraception. Providing these programs would prevent 16 million unsafe abortions a year, and significantly reduce maternal and infant deaths.
"The numbers are staggering," says Gary Darmstadt, who heads the family health division at the Bill and Melinda Gates Foundation, which is co-hosting an international summit on family planning in London this week. "This is an extremely important human-rights issue. It comes down to putting the situation in the hands of women."
The UN is using this year's World Population Day – to be commemorated July 11 – to call attention to the dire need for and benefits of contraceptives.
Since the 1980s, both local and foreign-aid resources for reproductive issues shifted to reducing the spread of HIV, especially as family planning initiatives in developing nations have become a political target. In 2009, President Barack Obama rescinded the executive order put in place by his Republican predecessor George Bush, which restricted federal funds for international groups that provided or promoted abortions – a move Bill Clinton also made, to overturn actions by Ronald Reagan. Canada received praise for highlighting maternal health at the 2010 G8 summit. But the Conservative government has also attached restrictions to programs that provide abortions, although, after government statements to the contrary, Prime Minister Stephen Harper clarified that contraception would be included.
According to a new study by the Guttmacher Institute, a U.S.-based organization that researches reproductive health, access to contraception in developing nations has been stalled since 2008 – and single women have an even harder time getting it than their married counterparts. But aside from being an important women's-rights issue, expanding access and increasing education "is one of the most cost-effective investments a country can make," says Dr. Darmstadt, citing research which suggests that for every dollar spent in Sub-Saharan Africa, as much as $6 are recouped in health and economic benefits. (In South Asia, the savings may be as high as $13.)
For women, having more reproductive choice means fewer children, spaced farther apart, and, as a result, a reduction in deaths during childbirth. The health of babies improves because they are breastfed longer and raised in smaller families with more resources since mothers are able to work, or acquire more education. Four out of 10 pregnancies, in developing countries are unplanned. The Guttmacher study estimated unplanned pregnancies in 2012 would result in 21 million abortions, as well as the deaths of nearly 80,000 women and 1.1-million infants.
But family planning requires ongoing and comprehensive programs, points out Jacqueline Darroch, co-author of the study. "This is not something you cure with a vaccine," she says. "It needs to be part of general health care."
Profile of an unwanted pregnancy
In a too-common story in her village of Kisiwa in Tanzania, Maria Mwaya found herself unexpectedly pregnant at the age of 16. When she tried to continue to attend school, she was ordered home: she was seen as a mother, and no longer a student. The father of her son "ran off," and she has no idea where he is. The youngest daughter among five siblings, she expected a life like her mother's trying to cook and care for larger family than she might have wanted.
Today, Ms. Mwaya, now 19, is a peer health educator, instructing other young people in her village about contraception and sexually-transmitted infection. Along with her work collecting and selling wood through a supplier, she visits classrooms and leads gatherings under a tree in the village, as part of a family planning program funded by the African Medical and Research Foundation, partly with Canadian funds. She gives out condoms that young people are reluctant to pick up at the clinic themselves, and speaks to girls about their personal rights about relationships and sex. Discussing reproductive health, and making contraception more easily accessible is necessary to empower young women, especially when getting pregnant forces them to leave school, explains Ms. Mwaya, in Sawhili, on a cellphone from her village. (Her comments were translated by Rita Mbeba, the project manager of the family planning program.) "Girls are also able to make their own decisions in terms of marriage, and able to say no."
The program has been running for just over a year, and for Ms. Mbeba it is too early to know the full impact it is having, although requests for condoms among youth have increased, and there are early signs that births have declined. "Change is happening," she says. Many of the young people who participate will be discussing the topic for the first time, since their parents won't broach the subject with them. Ms. Mbeba says women's advocates are also close to an agreement with the local government to permit girls to return to school after having a baby.
Ms. Mwaya says that if she had received the information she now provides, she would not have become pregnant so soon – there was no discussion of contraception at her village. Now she plans to have three children. But, she says, "I will make the decision myself when to get married and when to have kids."
- Currently, the number of women who have an unmet need for modern contraception in 2012 is 222 million. In the developing world, this number declined slightly between 2008 and 2012, but increased in the 69 poorest countries.
- Use of birth control will prevent 218 million unintended pregnancies in developing countries, averting 55 million unplanned births, 138 million abortions, of which 40 million are unsafe, 25 million miscarriages and 118,000 maternal deaths.
- If every woman seeking modern contraception methods in all developing countries were supplied, an additional 54 million unintended pregnancies would be prevented, including 21 million unplanned births, 26 million abortions, of which 16 million would be unsafe, and seven million miscarriages. This would also prevent 79,000 maternal deaths and 1.1-million infant deaths.
- The Cost Contraceptive care in 2012 will cost $4-billion in the developing world. To meet the need of all women in the developing world would cost $8.1-billion per year.
Four solutions for change
Keep girls in school
The longer young women stay in school, the less likely they are to get pregnant. Schools are also a good location to educate youth about contraception and reproductive rights. In some countries, such an Tanzania, girls are prevented from returning to school once they have had a baby – even if they are lucky to have the resources otherwise to support their child.
Educate about sexual health
In places where on-the-ground education is expanded, particularly by people trained within communities, contraception use rises significantly. In a 2007 study of four African countries, more than one third of the youth surveyed did not know where to get contraception devices. Governments and community leaders are also being called upon to reduce cultural stigma. In countries such as Rwanda, for instance, where the government has expanded family planning funding and promoted education, not only has contraception use increased but the ideal number of desired children has declined.
Ensure a stable supply
Maintaining a reliable stock of condoms and birth control injections, is complicated, especially when they need to travel far inland, or require cold storage. African women often report in surveys that culturally-appropriate or practical contraceptions are not available. Even if they are, some villages will be short of health-care workers trained to administer them. Groups are advocating "task-shifting," which would involve training more people such as midwives to deliver them.
Spend more on R&D
In recent years, pharmaceutical research for contraception has stalled. But more efficient methods of taking them needs to be invented, as well as using generic drugs to reduce cost, says Jennifer Woodside, the London-based head of advocacy and communications at the International Planned Parenting Fund. For instance, one Seattle-based company working with Pfizer is now testing a new version of Depo-Provera, which women would be able to inject themselves.