The London Summit on Family Planning was the start of something big. If kept, an array of promises made at the groundbreaking July 11 event could have a major impact on the lives of women and girls for years to come.
Impetus for the summit was the fact that family planning had become neglected as a global health priority. Both financially and politically, commitment to this field reached its global high point around the time of the 1994 International Conference on Population and Development (ICPD) in Cairo. Relative neglect since then has stemmed, in part, from "donor fatigue" after years of combating a problem that seemingly has no end: Unlike curing disease, providing women with the information and tools to control their fertility is an ongoing process with each new generation and throughout a woman’s reproductive years. The advent of the HIV/AIDS epidemic was another major factor. That crisis impelled donors to muster substantial resources immediately, which they did more by redirecting funds than by expanding the global health effort more broadly. Finally, the U.S. administration of George W. Bush from 2001–2009 was hostile toward family planning and chilled open discussion about and support for it—both at the global level and among developing country governments that received the message that family planning was not a U.S. priority.
The summit—organized and hosted by the United Kingdom (UK) and the Bill & Melinda Gates Foundation—had a purpose as simple as it was ambitious: to put increased access to contraception for women in the developing world emphatically back on the global health and development agenda. Specifically, the plan was to raise sufficient money to take a giant step toward reducing the existing unmet need for family planning services and to strengthen the political commitment to do so. On both fronts, it was a major success.
Political commitment was demonstrated by the presence of heads of state, notably UK Prime Minister David Cameron and the presidents of four African countries—Malawi, Rwanda, Tanzania and Uganda. The summit also drew more than a dozen ministers of health and development from the developing and developed world, including U.S. Agency for International Development (USAID) Administrator Rajiv Shah; heads of United Nations (UN) agencies, including UN Population Fund (UNFPA) Executive Director Babatunde Osotimehin; Melinda Gates and other philanthropic leaders; representatives of private industry; and a select cadre of invited heads of civil society organizations from around the world. As for the dollars, the organizers exceeded their own expectations by winning specific financial commitments totaling an additional $4.6 billion over the next eight years—including $2 billion from developing countries themselves. The official, stated goal had been $4.2 billion.
The run-up to the event, though, was not without controversy. Notably, the controversy largely was manifest not in the form of political opposition from opponents of contraception, but instead in expressions of deeply felt concern from summit stakeholders firmly committed to sexual and reproductive health and rights. One factor was that the summit’s focus was limited to contraceptive access to the exclusion of promoting greater access to safe abortion services. A more widespread concern, however, was that the summit’s overriding emphasis on quantitative goals—notably, an additional 120 million contraceptive users in the world’s 69 poorest countries by 2020—could open the door to the return of a discredited "population control" mentality and coercive practices on the ground. On this point, the policy statements issued by the organizers by the time of the event itself were much clearer. Indeed, the theme that women’s rights must be at the center of all implementation efforts was repeatedly reinforced during the proceedings. Even so, how this plays out going forward remains a legitimate concern.
Needs and Costs
In preparation for the summit, the Guttmacher Institute and UNFPA produced a new analysis of the total unmet need for contraceptive services in all developing countries. According to Adding It Up: Costs and Benefits of Contraceptive Services—Estimates for 2012, some 645 million women throughout the developing world currently rely on modern contraceptives—male or female sterilization, IUDs, implants, injectables, pills, condoms or spermicides—to prevent or delay pregnancy.1 But 222 million women who are sexually active and do not want a child in the next two years or ever either rely on traditional methods of birth control—withdrawal or periodic abstinence—or use no method at all. The goal of the summit is to reach 120 million of these women in the world’s poorest countries over the next eight years.
The focus on reaching women not using a modern contraceptive method is entirely understandable: Although the 222 million women in this category comprise only about one-quarter of all women wishing to avoid pregnancy, they account for the vast majority of unintended pregnancies (see chart). That said, two in 10 unintended pregnancies occur to women who are using a modern method. Clearly, then, providing mere access to a contraceptive method is not enough. Contraceptive failure results from incorrect or inconsistent use, and from imperfect methods. Meaningful access to family planning, therefore, must include ensuring that women have better information about the advantages and sides effects of the various methods, and that a greater array and reliable supply of method options are available, so that a woman is better able to match her personal needs with the method that works best for her at any given point in her reproductive life. Meaningful access also depends on a woman being unencumbered, by law and custom, so she is able to make those choices on her own.
According to the Guttmacher-UNFPA report, the combination of doing better by the women currently receiving family planning services and responding to the needs of the women still left out would cost about double the $4 billion currently being spent. The estimate is comprehensive, including the cost of the contraceptive supplies; personnel for counseling, clinical care, method provision and follow-up; and expenses necessary to maintain and strengthen health service delivery, including staff training and supervision, family planning education and advocacy, construction of facilities, development of logistics systems, and management.
The payoff, however, would far exceed the cost. Each dollar invested in meeting all the need would save $1.40 that otherwise would be spent on maternal and newborn health care for women whose pregnancies were unintended in the first place. This would free up more resources for desperately needed improvements in obstetric and neonatal care, which would benefit many of the same women when they have wanted pregnancies. Globally, the current $4 billion invested in family planning is already saving $5.6 billion in maternal and newborn health services alone; investing the full $8 billion to meet all the need for family planning services would mean averting more than $11 billion in expenditures.
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Even more important than the dollars saved, family planning protects health and saves lives. Effectively meeting all of the need for modern contraception just among the women currently not using a modern method would cause the number of unintended pregnancies to drop by two-thirds. This would lead to dramatic declines in the numbers of abortions (mostly medically unsafe), unplanned births, miscarriages, and maternal and infant deaths (see chart). By far, the largest number of maternal deaths averted would be in Sub-Saharan Africa, the region with the highest levels of maternal deaths and unmet need for modern contraception.
Legitimate Concerns
In announcing plans for the summit, Melinda Gates made clear from the outset that abortion would not be on the agenda. A practicing Catholic whose foundation does not fund abortion, Gates has recently become an impassioned advocate for family planning based on her encounters with local women in the urban slums and remote villages she has visited around the world. The summit’s avoidance of the abortion issue did not quell attacks from a few antiabortion fringe groups, which insist that any discussion of contraception is always code for a desire to promote abortion. More importantly, it sparked strong objections from global reproductive rights activists, who maintained—and some still do—that any high-level gathering relating to any aspect of reproductive health that stops short of grappling with the importance of increasing access to safe abortion services further marginalizes a critically important issue.
Beyond abortion, however, early preparations for the summit alarmed reproductive rights advocates, who feared that the specter of coercion and discrimination might be creeping back into the sexual and reproductive health field. At the landmark Cairo conference, a global consensus emerged explicitly rejecting the concept of "population control" and demographic targets. The core principle of the 1994 ICPD that has guided the global cause since then rests on the premise that it is a basic human right of all individuals to determine for themselves whether and when to have a child, and it is the responsibility of government and society to protect, promote and help women, men and adolescents realize that right. By contrast, most of the early descriptions of plans for the summit emphasized metrics and targets for increasing the number of contraceptive users and included little about safeguarding women’s rights, enhancing informed choice or promoting equity. As International Women’s Health Coalition President Francoise Girard put it several weeks prior to the event, "We welcome more funding for family planning services, but not if it comes with targets and incentives for doctors to pressure women to ‘accept’ contraceptives. That formula leads to coercion of women, plain and simple."2
As the summit approached, it became clear that, on abortion, there would simply have to be an agreement to disagree. Assuredly, advocates from civil society organizations and the donor community—and some country governments—will keep up the pressure in other fora to move forward on the agenda to reduce the number of medically unsafe abortions that still kill about 47,000 women each year and maim millions more.3 Indeed, Gates’ summit cohost, the British government, is one of the world’s leaders in recognizing unsafe abortion as a global public health problem and in supporting efforts to redress it. Even at the summit itself, the Dutch government’s representative, for example, took the opportunity to emphasize that while access to safe abortion was not a topic for this initiative, it would remain a key priority within the Netherlands’ sexual and reproductive health and rights program.
As for the embrace of the broader ICPD approach to family planning, the major speakers and all the materials disseminated at the summit itself could not have been clearer. This initiative firmly rejects population control, coercion and discrimination. It hinges on a rights-based, women-centered approach that promotes greater access to services through enhancing informed choice and equity.
Looking forward to implementation efforts, vigilance will be required to make sure that actions hew to the promises made. An "accountability annex" released just after the summit by the UK development agency and the Gates Foundation, however, is an encouraging sign. It declared that the whole exercise is "about more than new money; it is about changing business as usual." The plan is to increase demand and support for family planning in a way that also removes barriers to access and use. There will be a big push to improve the supply and distribution of contraceptives, as well as develop new and better technologies, toward the goal of expanding real choice of methods. There will be an emphasis on monitoring and evaluation with a special focus on measuring improved quality of services and information to women to promote truly informed and voluntary choice. And there will be a focus on supporting advocacy around sustaining and increasing funding, but also on "protect[ing] and promot[ing] global commitments to family planning within the ICPD framework for sexual and reproductive health and rights."
Breaking Through
Because political commitment is as essential as financial commitment to any cause, the mere presence of so many dignitaries from around the globe at the summit made a powerful statement. But the financial commitment was surprisingly strong, too.
Among developing countries, Nigeria pledged to triple its budget support for family planning, enhance the manufacturing of contraceptive supplies domestically and focus on education of girls. Senegal promised to double its existing investment, focusing on increasing contraceptive supplies, mass media campaigns, community-based distribution efforts and mobile clinics—critical steps in this country that has one of the world’s lowest rates of contraceptive use. Important commitments were made by nine other countries in Africa, as well as India, Indonesia and the Philippines. Together, these developing countries pledged $2 billion in new funding by 2020 for the wide array of activities that will be necessary to improve services to their own people.
The donors, including governments, philanthropies and pharmaceutical companies, brought $2.6 billion in new pledges to the table. The single largest pledge came from the British government, which will double its contribution over the next eight years with an additional $800 million. The Gates Foundation will double its commitment with an additional $560 million over the same period, bringing its support for family planning into line with its other major global health initiatives. And pharmaceutical companies made important pledges toward increased availability of low-or no-cost contraceptives, including injectables, implants and female condoms.
The United States—which remains the single largest family planning donor at $610 million this year—was not in a position to commit new funds. USAID Administrator Shah did assert, however, that family planning will continue to be a high priority under the Obama administration. In particular, the United States will step up its efforts in the area of contraceptive research and development, especially highly effective methods that can be used in low-resource settings. The United States is leading a drive to develop an effective "multipurpose" technology, besides condoms, that will help women simultaneously prevent unintended pregnancy and STIs, including HIV.
Amidst the pledges, there were many rousing speeches. It was UK Prime Minister Cameron, though, who brought down the house. Helping women to have the information and services necessary to decide freely whether, when and how many children to have, he proclaimed, is not just nice, "it’s absolutely fundamental to any hope of tackling poverty in our world."4 When a woman has "opportunity, resources and a voice," he said, "the benefits cascade to her children, her community and her country. So family planning is just the first step on a long journey towards growth, equality and development."
Cameron took on some of the well-entrenched canards about family planning programs as well. He chided "those who say we shouldn’t interfere….We’re not talking about some kind of Western imposed population control, forced abortion or sterilization. What we’re saying today is quite the opposite….We’re giving women and girls the power to decide…. And to those who try to say it is wrong to interfere by giving a woman that power to decide, I say they are the ones who are interfering, not me….Because there are no valid excuses for the denial of basic rights and freedoms for women around the world."
But it is perhaps Melinda Gates who makes the case most simply for the goals of the summit and for what she terms "a totally uncontroversial idea."5 That is: All women should be free to decide whether and when to have a child and should have access to modern contraception to help them act on those decisions.
REFERENCES
1. Singh S and Darroch JE, Adding It Up: Costs and Benefits of Contraceptive Services—Estimates for 2012, New York: Guttmacher Institute and United Nations Population Fund (UNFPA), 2012, <http://www.guttmacher.org/pubs/AIU-2012-estimates.pdf>, accessed July 20, 2012.
2. Center for Reproductive Rights, Global advocates: family planning summit must put women’s human rights first, June 20, 2012, <http://reproductiverights.org/en/press-room/global-advocates-family-planning-summit-must-put-womens-human-rights-first>, accessed July 20, 2012.
3. Guttmacher Institute, Facts on induced abortion worldwide, In Brief, New York: Guttmacher Institute; and Geneva: World Health Organization, 2010, <http://www.guttmacher.org/pubs/fb_IAW.pdf>, accessed July 20, 2012.
4. David Cameron’s speech on family planning in full, July 11, 2012, <http://www.politics.co.uk/comment-analysis/2012/07/11/david-cameron-s-speech-on-family-planning-in-full>, accessed July 20, 2012.
5. TED, Melinda Gates: Let’s put birth control back on the agenda, April 2012, <http://www.ted.com/talks/lang/en/melinda_gates_let_s_put_birth_control_back_on_the_agenda.html>, accessed July 20, 2012.
