U.S. support for family planning assistance in developing countries peaked in 1994, coinciding with the United Nations International Conference on Population and Development in Cairo. When social conservatives took control of Congress only a few months after the conference, however, the U.S. Agency for International Development's (USAID's) population assistance program immediately became a target of both policy assaults and funding cuts. And while the battle over the "global gag rule" has raged over these last six years, conservatives largely won on the funding front right at the outset.

In 1995 (for FY 1996), the appropriation for the program was slashed almost $200 million—from $542 to $356 million; moreover, funding was delayed until well into the fiscal year, and when released, it was doled out in monthly installments. These actions were intended to punish the program and to pressure its advocates and the administration to accept the gag rule, restricting what overseas organizations can do with their own funds relating to abortion services and advocacy. For FY 1997, funding was allowed to rise slightly to $385 million, the level at which it has remained ever since, although the delays and the monthly "metering" did not end completely until FY 2000 (see chart). The program has been further penalized in FY 2000, however: Congress insisted that its funding be reduced to $372.5 million if the president exercised his authority to partially waive imposition of the global gag rule, which he did ("Global Gag Rule Threatens International Family Planning Programs," TGR, February 2000, page 1).

Population assistance funding has remained steady since it was slashed by 35% for FY 1996

With appropriations still at only two-thirds the level attained at the time of the Cairo conference, the administration has made fully restoring financial support for international population assistance a priority for its final year in office. Yet the prospects for any funding increase are tied to the politics over the fate of the gag rule policy language, and, as has been the case every year since 1995, the outcome on both likely will not be known until the final days of this congressional session.

More Funds, Fewer Abortions

In light of the administration's request that Congress "go back to the future," as Rep. Carolyn B. Maloney (D-NY) recently put it, a consortium of leading researchers and demographers from The Alan Guttmacher Institute, The Futures Group International, Population Action International and the Population Reference Bureau, in consultation with the Population Council, conduced a special analysis to quantify the benefits that would accrue if Congress actually were to agree to increase the program's funding by $169 million to $542 million. What is clear is that restoring the program to its FY 1995 funding level would have a measurable positive impact on the health and well-being of women and their families in countries receiving population aid from the United States.

The analysis takes into account information from a wide variety of sources, including United Nations estimates of annual births, USAID population funding trends, country-specific surveys of women of reproductive age and special studies of contraceptive use and of pregnancy outcomes (see box). It assumes that the additional $169 million would be allocated in the same manner in which current funds are distributed and that the public-sector costs per each individual using family planning services will remain constant. It concludes, conservatively, that as a result of the funding increase:

• 11.7 million more couples in developing countries receiving USAID population assistance would have access to and use a modern method of contraception, which would enable 4.3 million more women to avoid an unintended pregnancy each year;

  • there would be 1.5 million fewer unintended births, 2.2 million fewer abortions and 500,000 fewer miscarriages each year as a result of the number of unintended pregnancies averted; and

    • 15,000 fewer women (7,000 fewer from pregnancy-related causes other than induced abortion and 8,000 fewer from unsafe abortions) and 92,000 fewer infants would die each year as a result of preventing the additional high-risk pregnancies.

    The impact of increased expenditures on abortion rates could be significant politically, as well as from a public health standpoint, since lawmakers who have insisted on the funding cuts continue to blame the program for increasing, rather than decreasing, the number of abortions worldwide. Moreover, the fact that greater access to family planning is a key to saving the lives of women and children also has been obscured in the political debate. And these estimates do not begin to consider the less quantifiable benefits of improved access to family planning services, such as protecting women's overall health, promoting their autonomy and social well-being, and enhancing their educational and economic opportunities.

    Demand for Services Is High

    Worldwide, 150 million couples say they would like to decide on the timing and spacing of their children but do not use family planning. While many factors contribute to this gap, in many countries a fundamental issue is lack of access to high quality information and services. And with one billion adolescents about to enter their childbearing years, the largest cohort in history, the need for services can only intensify.

    A study by demographers Charles F. Westoff and Akinrinola Bankole, published in the June 2000 issue of International Family Planning Perspectives, found that the demand for contraceptive services for the purpose of limiting births is increasing worldwide, reflecting the universal desire for smaller families. In Asia and Latin America—where this smaller family norm took hold earliest and where the proportion of women who want no more children but are not using a method of contraception (the so-called unmet need) is falling or leveling off—it remains necessary to continue support for family planning programs in order to meet the existing demand and to improve the quality of services. By contrast, the authors found that in Sub-Saharan Africa, the unmet need is on the rise, highlighting the importance of family planning assistance in this region, where the focus is on removing geographic, economic, informational and cultural obstacles to quality services.

    The consequences of inadequate access to primary health care, including preventive reproductive health care, are particularly harsh in developing countries. Of the 600,000 maternal deaths that occur each year, virtually all take place in the developing world; 72,000 of them result from unsafe abortion. Meeting only the existing demand for contraceptive services could prevent 20% of high-risk pregnancies, leading to an equivalent reduction in maternal deaths and injuries. Further, family planning programs provide services and information aimed at preventing sexually transmitted diseases, including HIV, which themselves can lead to death, disability or infertility.

    A Key Foreign Policy Issue

    Secretary of State Madeleine K. Albright has defended and supported U.S. involvement in international family planning assistance throughout her tenure with the Clinton administration. For most of that time, she has spoken of family planning primarily as a matter of promoting women's health and advancing their status. Recently, however, Albright has been enunciating the view that family planing assistance is also "among the most important aspects of our foreign policy." According to Albright, "when women have the knowledge and power to make our decisions, whole societies benefit. And this is how the cycle of poverty is broken and socially constructive values are most readily passed on to the young. Access to family planning is not just a health issue, it's a necessary part of our support for economic and political reform in developing countries around the world."

    Albright has made this case before numerous congressional committees in the course of defending the administration's FY 2001 foreign aid budget request. And this case has been taken up by the president himself, who, at the White House earlier this year during a special event commemorating World Health Day, said:

    "America has a profound interest in safe, voluntary family planning; a moral interest in saving human lives, a practical interest in building a world of healthy children and strong societies. And because we are a nation that believes in individual freedom and responsibility, we have every interest in supporting others around the world who seek the same rights and responsibilities we ourselves enjoy."

    In legislative action so far this year, the Senate has passed its version of a FY 2001 foreign aid appropriations bill, which would increase population assistance funding to $425 million and prevent implementation of the gag rule. The House-passed bill would continue funding as provided in current law, an effective level of $372.5 million with the current gag rule intact. The final decision, on both the funding level and the gag rule, likely will not come until this year's "endgame" in the final days of the legislative session. Conservatives in Congress will no doubt persist in accusing the international family planning program of causing more abortions and of detracting from efforts to promote healthy birth outcomes. The program's proponents, however, can now provide the evidence that more investment in family planning yields fewer abortions, as well as a greater likelihood that more women will survive pregnancy and childbirth and give birth to healthy infants.

    How The Analysis Was Conducted

    While there are multiple indirect health benefits of family planning, the collaborative effort of researchers at The Alan Guttmacher Institute, The Futures Group International, Population Action International and the Population Reference Bureau, in consultation with the Population Council, calculated only the direct effects of increased contraceptive use.

    First, the researchers estimated the number of new contraceptive users by assuming that the new funds would be distributed among the existing 68 USAID-supported countries in the same proportion as they are currently. Relying on current estimates of country-level, public-sector costs per individual public-sector user, they calculated the total number of new users who could be served with the additional funds.

    The researchers then estimated the number of unplanned pregnancies that these new contraceptive users would be able to prevent. They assumed that all of the new users would be switching to a modern method of contraception. The pregnancies averted would be associated with that subset of the 11.7 million new users who had previously used no contraception or used a traditional method; there would be no net change in pregnancy rates associated with those women already using a modern method previously obtained through the private sector. The annual pregnancy rates used in the analysis were 13% for modern-method users, 30% for traditional-method users and 68% for no-method users. Accordingly, for those who switch from no method to a modern one, the unplanned pregnancy rate is assumed to decline from 68% to 13%; for those who switch from a traditional method, the rate is assumed to drop from 30% to 13%.

    The numbers of unplanned births and abortions averted were calculated using regional estimates of the current proportions of unintended pregnancies that end in births or abortions.

    Finally, using data from the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), the researchers were able to estimate the number of maternal and infant deaths averted. Reducing high-risk pregnancies and recourse to unsafe abortion lowers the likelihood of pregnancy-related maternal mortality. Similarly, unplanned births, especially those occurring soon after the previous birth or when the mother is very young, are associated with higher rates of infant mortality. Accordingly, the researchers applied the WHO and UNICEF estimates of maternal and infant mortality at the country level to the number of unplanned births and abortions averted.

    A detailed description of these calculations and the conclusions drawn by the researchers may be found here.