Family planning is to maternal health what immunization is to child health,” wrote Uganda’s First Lady Janet Museveni in an opinion piece for The Kampala Monitor in March. “It is a low-cost yet effective way of preventing maternal deaths whereby risky pregnancies are avoided.” This statement is remarkable not only because of its clarity in expressing the simple truth that family planning actually saves lives, but especially because it comes from Museveni, previously known on the world stage for her strong advocacy of abstinence until marriage programs to prevent HIV/AIDS.

Global leaders and government officials in developing and donor countries alike increasingly are committing themselves to further reduce the inexcusably high number of pregnancy-related deaths that occur worldwide each year—99% of them in developing countries. Providing women with high-quality care during pregnancy, delivery and the immediate postpartum period is obviously essential; however, less obvious—if not, in fact, counterintuitive for some policymakers—is the central role that family planning plays in improving maternal health and birth outcomes. Contraceptive use helps women prevent unintended and often high-risk pregnancies, as well as reduce the likelihood of abortion, which is critically important because so many women who have unintended pregnancies are maimed by or even die from septic, clandestine abortion.

Although the roles of family planning and maternal and newborn care in reducing maternal mortality have been documented separately, powerful new evidence produced by the Guttmacher Institute and the United Nations Population Fund (UNFPA) establishes for the first time the large synergistic benefits of investing simultaneously in both. Doubling the modest, current global investment in family planning and maternal and newborn care—to just over $24 billion combined annually—would reduce maternal mortality by at least 70%, halve the number of newborn deaths and do so at a lower total cost than investing in maternal and newborn care alone.

Where We Are

According to the Guttmacher-UNFPA report, Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health, the current $3.1 billion global investment in contraceptive services enables 603 million women to prevent 188 million unintended pregnancies each year. Preventing these pregnancies in turn results in 112 million fewer annual abortions and 54 million fewer unplanned births than would otherwise occur. It also means that some 200,000 mothers do not die from pregnancy-related causes, and more than a million more newborns survive, at least in part because babies whose mothers die in childbirth are 10 times more likely than those whose mothers survive childbirth to die before age two.

However, 215 million women living in the developing world want to avoid pregnancy, but either are not practicing contraception or are using a low-efficacy traditional method. If all such women used a modern method, unintended pregnancies in the developing world would plummet and the lives of hundreds of thousands more women and newborns would be saved each year. (Unintended pregnancy would not be eliminated entirely, of course, because various social, cultural and other practical issues interfere with women’s ability to practice contraception consistently and effectively, especially over long periods.)

Furthermore, of the 123 million women living in developing countries who give birth each year, only about half receive the maternal and newborn care they need, for which the current global expenditure is $8.7 billion. According to the World Health Organization (WHO), high-quality maternal and newborn care entails routine prenatal and delivery care provided by trained professionals, care for complications that arise during pregnancy and delivery (including emergency obstetric and newborn care and care for abortion complications), and timely postpartum care for mothers and newborns. About 60 million women make fewer than the minimally recommended four prenatal visits before giving birth, 55 million do not deliver in a health facility and 22 million have obstetric complications that go untreated. In addition, 20 million women have unsafe abortions each year, three million of whom experience serious complications for which they receive no treatment.

As with family planning, the current level of pregnancy and delivery care for the millions who do receive it is literally lifesaving. But because the current levels for neither intervention fully meet the demonstrated need, maternal mortality remains unacceptably and unnecessarily high. (Maternal mortality is defined as a death related to pregnancy or its management that occurs during pregnancy or childbirth, or within 42 days of the termination of pregnancy.) According to Adding It Up, maternal mortality in 2008 totaled 550,000—which was derived from a joint estimate (2005) from WHO, the World Bank, UNICEF and UNFPA. Using a methodology that is different from the joint estimate, a study conducted by Margaret Hogan and colleagues from the Institute on Health Metrics and Evaluation and published in The Lancet in April 2010 put that number at 340,000. Meanwhile, for each woman who dies, approximately 20 more suffer from injury, infection or disease. And nearly four million newborns die within four weeks of birth, from mostly preventable conditions.

Where We Could Be

Adding It Up projects the costs and benefits of making significant, independent investments in family planning and in maternal and newborn care, but the major finding points to the synergistic effects of simultaneously investing in both. It concludes that fully meeting the global need for maternal and newborn care—without increasing support for family planning services to further reduce current levels of unintended pregnancy— would require increased spending from the current almost $9 billion to about $23 billion. Nearly one-third of the total amount, however, would be spent on pregnancy and delivery care for women who did not intend to become pregnant in the first place. If the amount that is currently invested in family planning is roughly doubled to $6.7 billion, the amount that would need to be spent on pregnancy and delivery care would be substantially reduced because far fewer unintended pregnancies would occur (see chart).

Dual investment to fully meet the need for both maternal and newborn health care and family planning in the developing world yields the same dramatic results for less than investing in maternal and newborn health care alone.
Bang for the Buck
Source: Guttmacher Institute and United Nations Population Fund (UNFPA), 2009.

Every dollar spent on contraceptive services to help women prevent unintended pregnancies saves $1.40 in maternal and newborn health care costs. And the synergistic effect of simultaneous investment in family planning as well as maternal and newborn care is considerable: Fully meeting the global need for maternal and newborn care can be achieved more efficiently—and for $1.5 billion less—if the global need for family planning is met at the same time.

The impact of this simultaneous dual investment on the lives of women and infants would be staggering: Maternal mortality would be reduced by some 70%, and newborn deaths would be cut in half. In terms of numbers, meeting the need for both family planning and maternal and newborn health care would annually prevent:

• 53 million unintended pregnancies that otherwise would result in 22 million unplanned births, 25 million abortions and seven million miscarriages;

• at least 240,000 maternal deaths (The Lancet) and as many as 390,000 (Adding It Up); and,

• 1.6 million newborn deaths.

The dramatic decline in maternal deaths in particular is far greater than what could be expected by investing solely in more family planning or solely in more maternal and newborn care. Enabling women to avoid pregnancies they do not intend means more and better pregnancy and delivery care for the women who do need it, and fewer high-risk pregnancies and unsafe abortions.The result would be the survival of hundreds of thousands more women (see chart).

The most maternal deaths can be prevented by fully investing simultaneously in family planning and maternal and newborn care throughout the developing world.
Saving Women's Lives
Source: Guttmacher Institute and United Nations Population Fund (UNFPA), 2009.

Other benefits from the dual approach may be less quantifiable, but are no less important. A significant portion of the costs associated with ramping up both family planning and maternal and newborn care services would go toward program and system costs, which would strengthen the health system overall. Additional benefits would include:

• providing an entry point into the health system for many women, increasing the chances that they will use it later to address pregnancy-related and other health concerns;

• improving the capacity of facilities to respond to obstetric emergencies, which can enhance their response to other health emergencies;

• increasing referrals to other related care (e.g., well-baby programs), gynecologic care and nonmedical services (e.g., counseling regarding domestic violence);

• reducing the risk of STIs including HIV (through increased condom use), thereby providing greater individual protection and improved pregnancy outcomes; and,

• decreasing the incidence of mother-to-child transmission of HIV, by reducing unintended pregnancies among women living with HIV.

In addition, increasing the proportion of pregnancies that are planned and healthy contributes to social and economic gains beyond the health sector. Families in these circumstances are better able and more likely to provide their children (especially girls) with an education, and young women who delay pregnancy have a better chance of staying in school and becoming economically productive. In turn, these factors are integral to increasing the status of women overall, which is strongly associated with poverty reduction and sustainable economic development more broadly.

Aligning the Stars

The good news is that maternal health seems to have arrived as a high priority. United Nations (UN) Secretary General Ban Kimoon has termed it “the mother of all challenges,” not because it is so hard to address, but because of the imperative to solve it. Later this year, the world’s leaders will gather at the UN to assess progress toward the eight Millennium Development Goals (MDGs), established under the auspices of the UN in 2000 to achieve specific development targets by 2015. With five years to go, it is clear that attaining MDG 5—which calls for reducing maternal mortality by three-fourths from its 1990 level and achieving universal access to reproductive health services—is an attainable if still highly ambitious goal.

Indeed, the solutions are straightforward and relatively cheap. Richard Horton, editor of The Lancet, concluded from the new findings from Hogan and colleagues that “programmes to reduce fertility rates, increase individual incomes, expand maternal education, and widen access to skilled birth attendants are having a measurable effect—saving the lives of women during pregnancy.Two decades of concerted campaigning by those dedicated to maternal health is working. Even greater investment in that work is likely to deliver even greater benefits.”

The Obama administration is firmly committed to putting resources and policy support behind maternal health and family planning and reproductive health programs. In January, the administration articulated its plans for a Global Health Initiative, which aims to have allocated $63 billion altogether for global health programs between 2009 and 2014.Two of its four primary targets are decreasing maternal mortality and preventing unintended pregnancy.To that end, the administration is urging Congress to further increase funding for maternal and child health programs by 28% to $700 million next year and for family planning and reproductive health programs by 10% to $716 million. If Congress approves or exceeds the administration’s requests, it would result in historic highs for both programs.

Ironically, it was a misstep earlier this year by Canada that perhaps helped elevate not only the importance of the maternal health agenda, but the essential role played by family planning in that agenda. While rhetorically stepping up to the challenge on maternal health, the conservative Canadian government stumbled badly on family planning. Foreign Minister Lawrence Cannon tried explaining to Parliament the initial thinking about the maternal health proposal that the prime minister was preparing for the G8 summit hosted in Ottawa this year. “It does not deal in any way, shape or form with family planning,” he said. “Indeed the purpose is to save lives.”

This non sequitur led to a firestorm throughout Canada and around the world. And the response, including from Secretary of State Hillary Rodham Clinton, was unequivocal: A maternal health initiative that does not include family planning is self-defeating. The Canadian government seemed taken aback by the fierce reaction at home and abroad and quickly started backtracking, at least on the subject of family planning. Moreover, the process provided another opportunity to raise public awareness and secure recognition for the vital role that family planning plays in saving women’s lives and for the cost-effective way in which it does so. Bowing to domestic political concerns, the conservative Canadian government drew the line at abortion, however. This head-in-the-sand approach to the abortion issue—unfortunately shared by the U.S. government, which has a decades-old law that prohibits U.S. funds from being used to provide abortion services overseas—only perpetuates the public health tragedy of unsafe abortion that claims the lives of 50,000 to 70,000 women each year, many of whom could survive if they had access to safe abortion services (see box).

As for family planning, the case is substantively closed, the global consensus has only been strengthened by recent developments and the time for action is now. Even so, there may be some politicians who refuse to face the facts or who cannot or will not separate family planning from abortion. For all of them, Bill Gates may have summed it up best when he testified in March before the Senate Foreign Relations Committee on the subject of global health: “The question of whether and how [governments] should help increase access to voluntary family planning for those who seek it remains difficult for many lawmakers. As you wrestle with this question, I urge you to remember that voluntary family planning is a proven and cost-effective way to save lives.”

Safe Abortion Saves Lives

Almost all of the approximately 20 million unsafe abortions taking place each year occur in developing countries, and those abortions account for at least 13% of all maternal deaths. Many millions more women who survive an unsafe abortion—one that is self-induced or performed by an unskilled practitioner or in an unhygienic setting—experience severe complications that may result from incomplete abortion, excessive bleeding and infection. Roughly five million women suffering from the complications of unsafe abortion are able to obtain treatment in time to avert long-term health consequences, such as anemia, pelvic inflammatory disease and secondary infertility; however, three million women receive no treatment at all.

There are three ways to prevent unsafe abortion or its consequences. The least controversial is to facilitate access to treatment for the complications of unsafe and incomplete abortion, to mitigate the immediate and longer-term harms suffered by millions of women. This is something even staunch foes of abortion are willing to support.

Although much more controversial, one straightforward way to reduce the incidence of unsafe abortion itself is to enable a woman who is going to have an abortion to have a safe one rather than an unsafe one. Safe abortion services are those provided openly in hygienic settings by trained professionals. By and large, this can only happen where abortion is legal, because where it is severely restricted, abortions must be clandestine. Clandestine (usually illegal) abortion is almost always unsafe, and it is in these settings where the costs in terms of women’s health and lives are the highest. By contrast, abortion-related deaths are virtually unknown where abortion is safe and legal.

Some fear or assert that legalizing abortion leads to more abortions. The evidence is clear, however, that legality is most strongly associated with safety, not incidence, especially over the long term. Abortion rates are the lowest and decline the fastest where unintended pregnancy is lowest and contraceptive use is increasing. The Netherlands, for example, has one of the lowest abortion rates in the world, but abortion is legal and widely available. The most dramatic declines in abortion rates continue to take place throughout Eastern Europe, where abortion has long been legal and heavily relied upon. With the relatively recent advent of modern contraception in this region, however, use of modern birth control methods is escalating rapidly, corresponding closely with the steep drop in abortion rates.

Ultimately, then, the most effective way to reduce the incidence of abortion overall, including unsafe abortions, is to increase use of modern contraception—making it easier for women to avoid unintended pregnancy in the first place. This is probably the most widely acceptable intervention to reduce unsafe abortion, and it is not controversial, except among the most extreme anti–birth control factions. Nonetheless, no contraceptive method is 100% effective at preventing pregnancy, and users do not always use methods consistently or correctly, so safe abortion services also must remain available. Abortion opponents should take some comfort in knowing that the availability of safe abortion services has little to do with whether or not abortions happen. But they should take heed that it has almost everything to do with whether or not women have to risk their lives when they terminate a pregnancy.