Contributions from the U.S. government to voluntary family planning activities in developing countries have generated considerable successes over the last four decades.Yet, the U.S. family planning and reproductive health program, administered primarily through the U.S. Agency for International Development (USAID), has encountered and continues to face many roadblocks to further progress, including policy impediments to sound programming imposed by the government itself. Such self-imposed setbacks include the “Mexico City” policy, also known as the global gag rule, which renders local organizations that engage in privately funded abortion-related activities consistent with their own country’s laws ineligible for U.S. support for contraceptive services. Additional policy constraints involve withdrawal of U.S. assistance to the United Nations Population Fund (UNFPA) on the grounds that UNFPA’s support of voluntary contraceptive services in China is somehow tantamount to support of coercive abortion.While these policy problems have caused serious injury and will require repair, an equally important challenge for policymakers under a new presidential administration will be to remedy the trend of chronic underfunding of international family planning programs.

Needs and Unmet Needs

Over the last 30 years, as women in the developing world increasingly have desired smaller families, contraceptive use has risen and fertility rates have fallen. Still, demographic surveys indicate that the actual family size in most developing countries remains greater than the desired family size. This gap between the real and the ideal persists even in Sub-Saharan Africa, which still retains a preference for larger families and has the highest fertility rates in the world.

According to Adding It Up, a joint report from the Guttmacher Institute and UNFPA, a total of $7.1 billion (in 2003 dollars) is spent annually on family planning services in the developing world. These funds—from both donor countries and recipient developing countries themselves— support contraceptive care for 504 million women, helping them to avoid 187 million unintended pregnancies and 60 million unplanned births. However, approximately 201 million women in developing countries desire to either delay or limit their births, but do not have access to modern contraceptives; 64 million of these women use traditional methods such as periodic abstinence and withdrawal, which have high failure rates. The report concludes that providing family planning services to all of these women would prevent an additional 52 million unintended pregnancies and a wide range of deleterious outcomes from those pregnancies (see box).

Averting an additional 52 million unintended pregnancies annually would prevent:
• 23 million unplanned births
• 22 million abortions
• 7 million miscarriages
• 1.4 million infant deaths
• 142,000 pregnancy-related deaths— 53,000 from unsafe abortion and 89,000 from other causes
• 505,000 children from losing their mothers

Unlike the provision of some types of health care, such as childhood immunizations, meeting the need for contraceptive services is an ongoing imperative. The typical woman who wants only two children (increasingly the worldwide norm) will be pregnant, postpartum or seeking pregnancy for only a few years of her life, but she will need to use contraceptives to avoid additional pregnancies for some three decades. And the challenge only escalates as population growth itself increases, currently driven by 1.2 billion adolescents, the largest cohort of adolescents in history, who are approaching reproductive maturity and will need access to sexual and reproductive health information and services in the coming decades.

A Plethora of Benefits

The United States has long been and remains the single largest donor country for population assistance in the world. Yet, over the last quarter-century, its position as global leader has been compromised by politically motivated programmatic restrictions imposed by successive presidential administrations, restrictions that have themselves been echoed in diminished levels of financial support. The bottom line is that at $461 million, current U.S. funding is only a small fraction of what it should be, according to the formulation derived at the 1994 International Conference on Population and Development in Cairo, Egypt (see box).

As a result, international family planning advocates are embarking on an ambitious goal of more than doubling current funding to $1 billion. This amount—itself less than a third of the $3.2 billion it should be, according to updated estimates—is more than justified, because family planning is the key means to a broad range of critically important individual and societal development goals. First and foremost, of course, family planning enables women and couples to control their own reproductive destinies, an essential human freedom. At the same time, by preventing unintended, often high-risk pregnancies, family planning also saves women's lives and protects their health; improves infant survival rates and bolsters child health; reduces women's recourse to abortion and, especially, unsafe abortion; protects women and their partners against sexually transmitted infections (STIs), including HIV/AIDS; enhances women's status and promotes equality between men and women; fosters social and economic development and security at the family, community and country level; and helps safeguard the environment. These are compelling reasons, individually and collectively, to ramp up financial investment in international family planning programs.

Improving maternal health. A woman's ability to control the timing, spacing and total number of her children is critical to preserving her life and health. High-risk pregnancies—those that come too early, too often or too late in life—increase a woman's risk of pregnancy-related death. The impact of birth spacing alone on maternal mortality is dramatic (see chart). According to the World Bank, maternal mortality would drop by 25–35% if the unmet need for family planning were fulfilled for the estimated 137 million women in the developing world who are neither using a traditional nor a modern contraceptive method.

Birth intervals of 27–32 months greatly reduce the risk of maternal deaths.
Spacing Births Saves Mothers' Lives
Note: Birth intervals represent the time between deliveries. Source: Conde-Agudelo and Belizán, British Medical Journal, 2000.

In addition, better timing and spacing of births could reduce the estimated 15 million women each year who face illness or disability from pregnancy-related complications, which in turn result in negative financial, social and health consequences for the women, their families and their communities. Insufficiently spaced pregnancies, along with inadequate prenatal, delivery and postpartum care, can jeopardize a woman's health on a temporary or permanent basis, through such conditions as anemia, obstetric fistula, hemorrhage, hypertension, infection and infertility.

Advancing child survival. Another high-impact public health benefit of family planning is in the area of child health and survival. USAID research shows that infants born closely together are at considerably higher risk of dying before their first birthday than are those with wider birth intervals (see chart, page 16). In fact, if women in developing countries could space their births three years apart, infant and under-five mortality rates would fall by 24% and 35%, respectively. The benefits of these longer birth intervals would also improve other health and nutrition indicators, such as the risk of stunting and underweight children.

Infants born less than two years apart may have twice the risk of dying than those with greater birth intervals.
Reducing Child Mortality
Source: USAID, 2006.

The ability to delay births becomes even more important for the millions of young women who enter marriage at an early age. Adolescents are more vulnerable to complications of pregnancy and maternal death. Similarly, infants born to teen mothers, rather than women in their 20s and 30s, have double the risk of dying during their first year.

Reducing women's recourse to abortion. The undeniable philosophical and political issues associated with abortion, at the individual and country level, are exacerbated in the context of the developing world, where abortions are largely illegal and unsafe. According to a 2007 study conducted by the World Health Organization (WHO) and the Guttmacher Institute, more than half (55%) of abortions in developing countries are unsafe; that proportion reaches as high as 95% in Africa and Latin America. Almost all abortion-related deaths occur in developing countries, accounting for 13% of overall maternal deaths worldwide.

Numerous studies have found that women in countries where abortion is illegal resort to abortion at similar rates as those living in countries where the procedure is legal. The most effective and efficient tool to prevent abortions is to prevent unintended pregnancies in the first place through the use of family planning. In the developing world, two-thirds of unintended pregnancies occur among women who are not using any method of contraception. In these countries, almost one-fifth of all pregnancies end in induced abortion. Satisfying the unmet need for contraception in these countries would further reduce women's recourse to abortion, beyond the substantial progress already made by current contraceptive use (see chart).

Preventing STIs, including HIV/AIDS. Women who are sexually active are exposed to the dual risks of unintended pregnancy and STIs. The WHO cites unsafe sex as the second most important risk factor for disease, disability or death in the poorest countries. STIs, including HIV, are one of the leading causes of loss of healthy life among women. Women in their reproductive years are the fastest growing group of people contracting HIV, comprising more than half of those currently living with the virus.

Use of barrier methods of contraception—namely, the male and female condom—reduces the spread of STIs such as HIV from one partner to another—so-called horizontal transmission. Female condoms are particularly important, as they are the only available woman-controlled method that effectively protects against the sexual transmission of HIV. Additionally, by preventing pregnancies and births, all contraceptives play a significant role in prevention of "vertical transmission" of HIV. Although dedicated prevention of mother-to-child transmission (PMTCT) programs in developing countries substantially reduce the transmission of the virus to newborns through application of a short course of antiretroviral drugs, these interventions are not known, accessible or used by the vast majority of affected women in poor countries. Thus, it is extremely important to also supply contraceptives to women living with HIV who themselves desire to limit their childbearing. USAID has found that providing contraceptives to HIV-positive women who wish to avoid pregnancy could help prevent almost twice the number of child infections and almost four times the number of child deaths than stand-alone PMTCT programs.

Raising women's status. Beyond its medical benefits, investment in family planning generates powerful returns in other areas. The ability to control one's fertility is fundamental to raising women's status in society. Women who can decide when and how many children to have will be better positioned to negotiate decision-making in their households and to increase their life choices. Of particular importance is women's increased capacity to take advantage of educational and economic opportunities, and to enhance financial security at the household level. Women who cannot control the timing of their births are often doomed to poverty, as they struggle to raise more children than they would desire.

The impacts of fertility control and the education of young women are interrelated—both are necessary agents in improving women's status and contributing to a country's development. Education delays women's age at marriage and first birth, and contraceptive use decreases the likelihood that young women will drop out of school because of pregnancy. According to an analysis by the Millennium Project, among unmarried, sexually active, 15–17-year-old females, those enrolled in school were more likely than those not in school to use contraceptives. Another report by the POLICY Project estimated that 8–25% of young women in certain Sub-Saharan African countries drop out of school because of unwanted pregnancies. Not only does family planning help women avail themselves of schooling, but educated mothers and smaller families increase the likelihood that children, especially daughters, are also more educated.

Promoting economic growth and social stability. Family planning is essential to building socially and economically stronger families and fighting poverty. Families that can choose the number, timing and spacing of their children are better able to plan their lives, to save resources and to increase their household income. Families with more children have a higher risk of falling into poverty. Having fewer children allows parents to invest in their existing children and provide adequate nutrition, housing and education for the entire family. Moreover, women who control their fertility have more time for their own development and are more able to socially and politically participate in their communities.

Abortion in the developing world is already limited dramatically by women’s access to modern contraceptives—and it could be reduced even further.
Source: Guttmacher Institute, 1999 and 2003.

The relationship between family planning and economic stability at the household level is also reflected at the community and national levels. Reduction of high fertility is a necessary although not sufficient factor in a country's path to economic development. According to a 2007 United Kingdom Parliament report on population, lower fertility accounts for 25–40% of economic growth in developing countries. Family planning decreases morbidity and mortality rates, and thereby produces a healthier and more productive workforce. Lower population growth reduces the burden on countries to make public expenditures for orphan care, family subsidies, food aid, health care, education and other social services.

The relationship between fertility and development has implications for a country's security as well. Expanding populations in poor regions can cause competition for limited resources, such as food, housing, schools and jobs, which in turn, can lead to societal instability. Failure to adopt family planning services has been identified as a key factor in the world's current food crisis. In the Philippines, for example, the government's refusal to support family planning services has been linked to a serious state of food insecurity. Explaining this phenomenon in a recent Washington Post article, a Filipino economics professor noted: "Even when there is widespread corruption, insurgent violence and other powerful reasons for poverty, the evidence from across Asia is that good population policy by itself contributes to significant poverty reduction."

Protecting the environment. In the latter half of the 20th century, the earth's population more than doubled to six billion. It is expected to grow to more than nine billion by 2050, with almost all of the net increase occurring in developing countries that are least able and prepared to absorb this expansion. Unfortunately, millions of women in these countries currently wish to have smaller families—which would curb population growth—but do not have access to modern contraceptive methods that would help them achieve their childbearing goals.

There is a complex relationship among the effects of consumption and population growth on global environmental sustainability. One aspect of that relationship is that the rapid depletion of environmental resources in many poor countries is occurring to meet the needs of growing, migrating, urbanizing, and aging populations. These population pressures are straining the world's resources by diminishing safe water supplies, increasing carbon emissions, deforesting lands, and polluting the air and oceans. For example, the United Nations (UN) estimates that by 2025, more than three billion people will live in water-stressed countries, where basic water requirements for cooking, drinking and hygiene will be at risk. Climate change will contribute to less rainfall in regions such as North Africa, while demand for water in these areas will rise (see chart). Lack of adequate and safe water will endanger staple food production, exacerbate malnutrition and spread disease from lack of adequate sanitation.

As the population grows in the Middle East and North Africa, the availability of water for the region’s residents is rapidly depleting.
Growth Outpaces Supply
* Projected. Source: Population Reference Bureau, 2002.

Stepping Up

At a recent conference of the UN Commission on Population and Development, UN Secretary-General Ban Ki-moon and UNFPA Executive Director Thoraya Ahmed Obaid singled out the downward trend in international funding for family planning as endangering the realization of the Millennium Development Goals, established in 2000 to set objectives for addressing poverty, health and women's empowerment in developing countries. A UN report released at the meeting noted that global funding for family planning services plummeted between 1995 and 2006. The Secretary-General warned that this pattern of shrinking funding for family planning poses "serious implications for the ability of countries to address the unmet need for such services, and could undermine efforts to prevent unintended pregnancies and reduce maternal and infant mortality."

Against this backdrop, the United States has a financial and moral obligation to reduce the deficiencies in services, in funding, in policy formulation and in direction for global family planning efforts. Reasserting this leadership begins with overturning the global gag rule and releasing UNFPA funds. It continues with reprioritizing and reinvigorating financial assistance for international family planning activities—assistance that must be sustained over the long haul, since using family planning services is not a one-time event for individuals and couples, but a need that lasts throughout an individual's reproductive life, and will rise globally with increased population growth. Finally, U.S. leadership should serve as a call to action for all countries to step up and put family planning back on the agenda as an important foreign assistance and development issue. Millions of women and families in the developing world are depending on this leadership.

Broken Policies and Promises

Although the United States has maintained its relative position as the top donor country for population assistance because of significant support from Congress in recent years, it has been trailing in its historical role of policy and programmatic leadership. Beginning in the early 1980s, the government’s international family planning activities became embroiled in abortion politics, ever since crippling effective implementation of these programs. It was in 1984 that the Reagan administration initiated the Mexico City policy, or global gag rule. The policy prohibits U.S. funding to foreign nongovernmental organizations that—even with other, non-U.S. funds—“perform or promote abortion as a method of family planning,” which has been defined to include provision of direct abortion services, as well as counseling, referrals or advocacy activities for abortion. The executive order was rescinded in 1993 by President Clinton, but was reinstated in 2001 during President Bush’s first week in office and has remained in effect despite efforts by Congress to overturn it. Similarly, UNFPA suffered under President Reagan, who suspended the agency’s funding in 1986, alleging that UNFPA indirectly supported coercive abortion and sterilization practices in China through its presence in the country. Funding was restored to UNFPA by Clinton in 1993, but subsequently cut off again by Bush.

This pattern of restriction and relief by successive administrations has not been limited to policy issues. Funding levels reached a high in 1995 under Clinton at $542 million, with an additional $35 million to UNFPA. At the 1994 landmark International Conference on Population and Development in Cairo, the United States pledged along with other donor nations to provide one-third of the agreed-upon $18.5 billion—a sum now widely regarded as substantially underestimated—to help developing countries reach benchmarks on reproductive health and sustainable development by 2015. These commitments to international family planning have been significantly eroded under the Bush administration, which has repeatedly requested cuts in the program. Although Congress has largely rebuffed these requests, the fact remains that since its apex in 1995, U.S. government support for family planning assistance has dropped in inflation-adjusted terms by 39% to $461 million in FY 2008. In his final budget to Congress, President Bush requested yet another deep cut—to $327 million.

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