Over the last three years, the international community of civil society advocates, policymakers, donors and multilateral agencies has devoted enormous resources to negotiate and shape a new global development agenda for adoption at the United Nations (UN) General Assembly in September 2015. This post-2015 development framework will build on the Millennium Development Goals, the current UN roadmap for tackling the world’s problems related to poverty, development and sustainability set to expire later this year. In particular, the post-2015 framework will set forth a series of goals and targets on a range of issues critical to global development and environmental sustainability, likely including health, education, gender equality, protection and management of environmental resources, poverty, hunger and others. As such, its impact will be felt on development funding and programming for the next 15 years through its influence on national and donor priorities for the allocation of resources.


Delegates participating in the intergovernmental negotiations thus far have identified universal access to sexual and reproductive health care services and the fulfillment of reproductive rights as interventions integral to overall development goals related to ensuring healthy lives and achieving gender equality. This political support for sexual and reproductive health and rights is both sensible and strategic, given that the evidence shows that these investments are among the most effective in development.


Indeed, a new global analysis from the Guttmacher Institute, released jointly with the United Nations Population Fund (UNFPA), documents the substantial benefits that accrue from investing in a constellation of sexual and reproductive health services in several key areas: contraceptive services; pregnancy, delivery and newborn care; services and medicines for pregnant women living with HIV; and treatment for four other common STIs.1 The research updates and quantifies the immediate and direct impact of these investments in terms of lives protected and dollars saved, as well as the synergies that can result from fully meeting a range of needs simultaneously. At the same time, there is a host of additional—but no less important—social and economic benefits for women, families and communities that flow from such investments. 


Falling Far Short of the Need


In the last decade, the developing world as a whole has witnessed declines in maternal and infant deaths and rates of new HIV infection, which reflects increased international efforts in these health areas. Yet, progress has been uneven, and widespread disparities endure among and within countries. Guttmacher’s new report, Adding It Up: The Costs and Benefits of Investing in Sexual and Reproductive Health 2014, finds that throughout the developing world, fulfillment of women’s sexual and reproductive health needs is lacking.1 The report builds on previous analyses and calculates the costs and benefits of meeting the developing world’s needs for contraceptive, maternal and newborn care. Moreover, for the first time, this analysis also includes services for pregnant women living with HIV and their newborns, and treatment for women with common STIs. 


Contraception


Adding It Up 2014 documents that more than half of all women of reproductive age in developing regions are at risk of pregnancy and want to avoid a pregnancy in the next two years or longer.1 Yet, one-fourth of these women—225 million in 2014—are not practicing contraception or are using traditional methods such as withdrawal or common methods of periodic abstinence. These women have an unmet need for modern contraception. Accordingly, they are at high risk for a number of negative health consequences due to unintended pregnancy. Every year, 74 million unintended pregnancies occur in developing countries, which lead to an estimated 28 million unplanned births and 36 million abortions (20 million of which are unsafe). The vast majority of these unintended pregnancies—81%—occur among women with an unmet need for contraception. The reasons for this unmet need are many and varied (see box). 


Reasons for Unmet Need for Contraception

An updated 2014 study from Guttmacher analyzed the reasons why many married women in developing countries who are fertile and do not want a child in the next two years or at all are not practicing contraception.2 Although the reasons vary across country and region, the most widespread have less to do with barriers to access to methods (as commonly viewed) than with women’s concerns about side effects and health risks (both real and perceived), their perceived low risk of pregnancy due to infrequent sexual activity, and opposition from partners or others. Such findings point to the importance not only of expanding the reach of family planning programs, but also of improving the quality of services (with better information and counseling about method effectiveness and possible side effects) and of providing a broad range of methods (so that women can make informed choices). In the long run, however, policymakers and donors seeking to reduce unmet need for contraception cannot focus on access or quality improvements alone. Rather, they will need to revive investments in new contraceptive technologies that address women’s needs and concerns, such as methods with fewer side effects or those that can be used at the time of sex for women who engage in infrequent sexual activity.

Although more women are using modern contraceptives now than a decade ago, unmet need remains high worldwide. In fact, it has increased slightly since 2008, largely because levels of contraceptive use have not quite kept up with global population growth and the growing desire for smaller families. The problem of unmet need for modern contraception is not only persistent, but is concentrated among women wanting to avoid pregnancy who live in the poorest households, those with low education, teenage women and those living in rural areas. Within developing regions, this disparity plays out between poorer and wealthier areas. For example, Sub-Saharan Africa and South Asia together account for 40% of women wanting to avoid pregnancy, but for 61% of women with unmet need for modern contraception. 


Maternal and Newborn Health


Because the health of a mother and her newborn are closely intertwined, their care must also be linked. The World Health Organization (WHO) has established standards to define a minimum level of care for all reproductive-age women and their infants—before and during pregnancy, during childbirth and after birth—to promote safe and healthy outcomes. 


Adding It Up 2014 documents that among the 125 million women who give birth annually in developing regions, more than four in 10 do not obtain the minimum of four antenatal visits recommended by WHO.1 Even when they do make those visits, they do not receive all of the services that they need. About one-third of women across developing countries do not deliver their babies in a health facility, and this problem is particularly common in Eastern Africa. Among women who experience an obstetric complication during pregnancy or delivery, such as hypertension, hemorrhage or obstructed labor, more than two-thirds do not receive the care that they need—either because they do not deliver in a health facility or that facility does not provide the necessary care. Moreover, more than two-thirds of newborns who need medical care for major complications do not receive it. 


Women whose pregnancies do not result in a live birth—because of miscarriage, stillbirth or abortion—also need care, but a substantial portion does not receive it. For example, five million women in developing countries do not get facility-based care for a miscarriage or stillbirth, and just over three million women with complications from unsafe abortion do not receive postabortion care. 


Failing to meet women’s contraceptive and maternal health care needs leads to an estimated 290,000 pregnancy-related deaths each year among women in developing countries, including 22,000 from unsafe abortions. In addition, 2.9 million babies die in the first month of life. Nearly all of these deaths among women and infants could be prevented with adequate medical care. 


HIV and Other STIs


Of the 1.6 billion women of reproductive age in the developing world, an estimated 66 million are at high risk of STIs, including HIV, and need prevention information, education and services.1 Nearly 14 million women of reproductive age are living with HIV, including 11.6 million in Sub-Saharan Africa. The global expansion of access to antiretroviral therapy has changed the course of the AIDS epidemic. Still, although just over two-thirds of women living with HIV need antiretroviral therapy, a large proportion (48%) of women living with HIV do not receive it. 


Pregnant women living with HIV have heightened sexual and reproductive health needs, including treatment for their own health as well as prevention of HIV transmission to their infants. Each year, 273,000 infants become infected with HIV during pregnancy and delivery or through breast-feeding. Of the 1.5 million women with HIV who give birth each year, more than one-third do not receive the antiretroviral therapy they need during pregnancy to prevent this transmission to newborns, and three-quarters do not receive ongoing antiretroviral care to protect their own health.

STIs other than HIV are extremely common, but often go untreated—ultimately taking an enormous toll on women’s reproductive health. Each year, about 200 million women of reproductive age are infected with one of four STIs: chlamydia, gonorrhea, syphilis and trichomoniasis. However, of those women, 83% do not receive services, even though all four STIs are curable. This gap may be due to a variety of factors, including asymptomatic infections, inadequate staff training and supplies, stigma surrounding STIs, and limited availability of STI testing and treatment in developing regions. However, untreated STIs can lead to serious health consequences, including infertility and increased risk of HIV acquisition, pregnancy complications and stillbirth. 


When Needs Are Met


Enabling women to plan their pregnancies and ensure healthy births would reap tremendous returns. If all 225 million women with an unmet need for modern contraception were to practice contraception, unintended pregnancies would drop by 70% and unsafe abortions would decline by 74%—leading to large and immediate health gains (see table).1

Fully meeting the unmet need for maternal and newborn health services would also lead to sizable declines in poor health outcomes. But because preventing unintended pregnancy is in itself a key component of improving maternal and newborn health outcomes, fully meeting the need for contraceptive care and maternal and newborn health care services simultaneously could achieve more dramatic improvements than investing in either one separately (see chart).1 In particular, fully meeting the need for these services, including HIV-related care for pregnant women and their newborns, would mean: 


 

  • maternal deaths would drop by two-thirds;
  • newborn deaths would drop by three-fourths;

  • the burden of disability related to pregnancy and delivery experienced by women and newborns would drop by three-fourths; and

  • mother-to-newborn HIV transmission would be nearly eliminated.


 

Adding It Up 2014 does not estimate the impact of HIV prevention or treatment services more broadly. For other STIs, data are limited, but the report provides new evidence that fully meeting women’s needs for chlamydia and gonorrhea treatment would prevent an additional 28 million women from developing pelvic inflammatory disease and seven million women from developing infertility. 



 

Beyond all of these direct and striking health gains, there is a bounty of other social and economic returns yielded by meeting women’s sexual and reproductive health needs. These benefits are felt from the micro to the macro level, by women, their families and their communities. When their needs are met, women and children are more likely to be able to stay in school and gain an education, which in turn will have a positive impact on their future labor force participation and earnings. Women experience an increase in social status, self-esteem and gender equity. Families face fewer orphaned children, and households can boost their savings and assets. Societies undergo improved living conditions, reduced poverty and fewer strains on environmental resources. All of these rippling benefits directly affect other global development goals.


Costs and Cost-Effectiveness


In 2014, the cost in developing countries for providing current levels of services related to modern contraception, maternal and newborn health care, HIV-related care for pregnant women and their newborns, and treatment for four common STIs totaled $18.7 billion.1 Fully meeting the need for this package of sexual and reproductive health services for women and their newborns would cost $39.2 billion annually, slightly more than double the current expenditure. 


Although all of these investments yield tremendous benefits, some are so cost-effective that they offset the cost of other services. In particular, contraceptive services reduce unintended pregnancies and unplanned births, which in turn lowers expenditures for maternal and newborn care, and frees up health system funds to provide other sexual and reproductive health services (see chart).1 In stark terms, every additional dollar invested in contraception reduces the cost of pregnancy-related care (including HIV care for pregnant women and newborns) by $1.47.



 

The case for combined investments makes sense in other ways too. Sexually active women are exposed to multiple health risks from adolescence through their reproductive years. Opportunities for care are maximized when services are offered as interconnected parts of a continuum of care that supports women throughout their sexual and reproductive life. 


The bottom line is that investing in this integrated package of services is both effective and cost-effective. And at an annual cost of only $25 per woman of reproductive age in the developing world—or $7 per person—it is a “best buy” in development. Indeed, a group of leading economists associated with the think tank Copenhagen Consensus Center conducted a cost-benefit analysis in 2014 of the proposed targets and goals under the post-2015 development framework and rated investment in sexual and reproductive health as “phenomenal”—among the top 13 out of 169 targets.3

Joining Evidence with Policy


Policymakers and other stakeholders involved in post-2015 negotiations should heed this overwhelming evidence that investing in sexual and reproductive health is effective and cost-effective too. The post-2015 framework is important not only as a policy statement, but because it will guide funding priorities at the country and global levels. Indeed, achieving a global consensus that calls explicitly for robust support for sexual and reproductive health—and rights—increases the chances that women throughout the developing world will continue to see gains in their health and in their quality of life more broadly. Although access to sexual and reproductive health services is important, assuring sexual and reproductive rights is equally so, because women must possess the ability to make informed choices from among a range of high-quality methods and services freely and without discrimination.


Who then will provide the additional funding to meet these needs? Most likely it will come from those already paying: individuals receiving services and their national governments—who together cover the bulk of current expenditures—and from international donors and nongovernmental organizations. Among donors, the United States plays a leading role in all three areas of sexual and reproductive health covered in the Adding It Up 2014 analysis. In particular, it has always been and remains the single largest donor toward family planning and reproductive health programs overseas. It is also the largest donor toward HIV and AIDS programs in the developing world, and is responsible for the creation of PEPFAR (President’s Emergency Plan for AIDS Relief), which has significantly contributed to combating the global AIDS epidemic. In the area of maternal and newborn health, the United States is spearheading a new initiative to end preventable child and maternal deaths by dramatically accelerating progress through setting new priorities and streamlining resources in 24 focus countries. The overarching goal of the initiative is to end preventable child deaths by 2035, and it acknowledges that family planning is an essential, high-impact intervention to reach its goals on maternal, newborn and child health. It goes further by noting that “family planning is one of the most effective interventions in the history of public health.”4


In recent years, the United States under the leadership of the Obama administration has joined with many other nations in advocating strongly at the UN for continued global support for women’s sexual and reproductive health, and for at least reproductive—if not sexual—rights. Indeed, a broad swath of governments and stakeholders participating in the post-2015 discussions appears to have heard the message. A high-level panel appointed by the UN Secretary General to advise him on the post-2015 agenda identified universal access to sexual and reproductive health and rights as a priority. In particular, the influential panel, co-chaired by the Presidents of Indonesia and Liberia and the Prime Minister of the United Kingdom, held a series of consultations with stakeholders and thereafter issued recommendations that included ensuring universal sexual and reproductive health and rights as a target under the goal of ensuring healthy lives.5

In parallel, an official high-level UN working group had been undergoing its own process for a proposal on a new set of sustainable development goals. In its final report, the working group recommended 17 goals and 169 targets, two of which referenced sexual and reproductive health. Specifically, under a broader health goal, the document identified a target that countries “by 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.”6 Additionally, the goal on gender equality includes a target to “ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences.”6

In this final year of post-2015 negotiations, government negotiators and civil society must grapple with many worthy competing priorities to formulate a consensus around a new global development framework. In addition, certain socially conservative countries and activists that are hostile to sexual and reproductive health and rights are sure to agitate specifically against addressing these issues in the final framework. The new evidence about the value and wisdom of investing in sexual and reproductive health and rights, however, is unequivocal. It reaffirms and bolsters the earlier research in this area and confirms that an individual’s ability to attain sexual and reproductive health is essential and integral to societies’ success in achieving sustainable development. Fundamentally, women everywhere want and acutely need sexual and reproductive health services to lead healthy sexual lives, have the number of children they want when they want them, deliver their babies safely and ensure that their newborns thrive. And donors and developing nations alike have a responsibility to ramp up investment and support for sexual and reproductive health and rights, because all have a stake in the cascade of benefits that accrue to women, children, families, communities, countries and the planet.

This article was made possible by a grant from the Universal Access Project of the United Nations Foundation. The conclusions and opinions expressed in this article, however, are those of the author and the Guttmacher Institute.

Note: A few changes to STI-related estimates from Adding It Up—the primary source for most of the data presented in this article—were needed to correct a calculation error. None of these corrections changes the monograph’s summary findings or conclusions. Several numbers in this article were changed slightly to reflect these corrections; see the errata at the end of Adding It Up for details.

REFERENCES

1. Singh S, Darroch JE and Ashford LS, Adding It Up: The Costs and Benefits of Investing in Sexual and Reproductive Health 2014, New York: Guttmacher Institute, 2014, <http://www.guttmacher.org/pubs/AddingItUp2014.pdf>, accessed Dec. 22, 2014. 


2. Sedgh G and Hussain R, Reasons for contraceptive nonuse among women having unmet need for contraception in developing countries, Studies in Family Planning, 2014, 45(2):151–169, <http://www.guttmacher.org/pubs/journals/j.1728-4465.2014.00382.x.pdf>, accessed Dec. 22, 2014. 


3. Copenhagen Consensus Center, Preliminary benefit-cost assessment of the final OWG outcome, 2014, <http://www.copenhagenconsensus.com/sites/default/files/owg_ccc_preliminary_cost-benefit_final_assessment.pdf>, accessed Dec. 22, 2014.

4. United States Agency for International Development (USAID), Acting on the Call: Ending Preventable Child and Maternal Deaths, Washington, DC: USAID, 2014, <http://www.usaid.gov/what-we-do/global-health/acting-call-ending-preventable-child-and-maternal-deaths-report>, accessed Dec. 22, 2014. 


5. Secretary-General’s High-Level Panel of Eminent Persons on the Post-2015 Development Agenda, A New Global Partnership: Eradicate Poverty and Transform Economies Through Sustainable Development, New York: United Nations, 2013, <http://www.un.org/sg/management/pdf/HLP_P2015_Report.pdf>, accessed Dec. 22, 2014. 


6. Open Working Group of the General Assembly on Sustainable Development Goals, Open Working Group Proposal for Sustainable Development Goals, New York: United Nations, 2014, <https://sustainabledevelopment.un.org/content/documents/1579SDGs%20Proposal.pdf>, accessed Dec. 22, 2014.