Sexual and reproductive health care encompasses a broad range of services that ensure people can decide whether and when to have children, experience safe pregnancy and delivery, have healthy newborns, and have a safe and satisfying sexual life. These services are important investments both because they enhance individual well-being and allow people to exercise their sexual and reproductive rights, and because they have far-reaching benefits for societies and for future generations.

This report examines core services that women need and use during their reproductive years: contraceptive services, pregnancy-related care (including maternal health care and abortion services), newborn care and treatment for STIs. It identifies services that, if expanded and strengthened, could improve the health of women, their partners and their children. It focuses on low- and middle-income countries (LMICs) and, like prior Adding It Up reports, presents the need for, impacts of and costs associated with providing services at internationally defined standards of care. The report’s goal is to illustrate for national and local governments, the private sector and international development partners the investments needed to expand and improve sexual and reproductive health services, which are essential components of health care.

Unmet needs for services

New estimates for 2019 show that sexual and reproductive health services fall well short of needs in LMICs. Approximately 218 million women of reproductive age (15–49) in these countries have an unmet need for modern contraception—that is, they want to avoid a pregnancy but are not using a modern method. About half (49%) of pregnancies in LMICs—111 million annually—are unintended.

In addition, 127 million women give birth each year, and tens of millions of them do not receive adequate pregnancy-related and newborn health care.

• 50 million make fewer than four antenatal care visits
• 31 million do not deliver in a health facility
• 16 million do not receive the care they need following a major obstetric complication
• 13 million have newborns who do not receive needed care for major complications

Many women whose pregnancies do not end in a live birth also lack needed services.

• 2 million do not receive the care they need after experiencing a miscarriage
• 35 million have abortions in unsafe conditions
• 9 million do not receive the necessary care for complications after an unsafe abortion

Furthermore, an estimated 133 million women of reproductive age in LMICs need but do not receive treatment for one of the four major curable STIs—chlamydia, gonorrhea, syphilis or trichomoniasis.

Adolescents, in particular, have substantial unmet needs for sexual and reproductive health care. For example, women aged 15–19 who want to avoid a pregnancy have much higher unmet need for modern contraception than do all women of reproductive age who want to avoid a pregnancy (43% vs. 24%). Adolescent women face many barriers to obtaining contraceptive care, including fear of exposing that they are sexually active (if they are unmarried) and social pressure to have a child (if they are married). Adolescents in LMICs have an estimated 21 million pregnancies each year, 50% of which are unintended.

Impacts of expanded services

If all women in LMICs wanting to avoid a pregnancy were to use modern contraceptives and all pregnant women and their newborns were to receive care at the standards recommended by the World Health Organization, the impacts would be dramatic:

• Unintended pregnancies would drop by 68%
• Unsafe abortions would drop by 72%
• Maternal deaths would drop by 62%

Providing the recommended maternal and newborn care would also vastly improve newborn health. Newborn deaths would drop by 69%, and new HIV infections among babies six weeks and younger would drop by 88%.

In addition, if all women infected with chlamydia or gonorrhea were given effective and timely treatment, cases of pelvic inflammatory disease and infertility caused by these STIs would be eliminated.

Total cost of a package of care

A package of care that would meet all women’s needs for modern contraception, pregnancy-related and newborn care, and treatment for the major curable STIs would cost $68.8 billion annually in 2019 U.S. dollars, or approximately $10.60 per capita (i.e., per total population in LMICs) per year. This represents an increase over current costs of about $4.80 per capita per year. This investment would improve the quality of services women currently receive and enable all women to receive the care they need.

The total recommended investment represents a $31 billion (83%) increase over current annual costs for LMICs. Two subregions, Sub-Saharan Africa and Southern Asia, account for more than three-quarters ($24 billion) of the total increase. Low-income countries, which are mostly concentrated in Sub-Saharan Africa, require the largest boost in resources—an increase from $3.40 to $15.80 per capita annually—because these countries’ unmet needs for services are the highest and the health systems supporting these services require the most expansion and improvement.

Importantly, fully investing in contraceptive services would result in a substantial decrease in unintended pregnancies, which would in turn reduce the need for pregnancy-related and newborn care. Every dollar spent on contraceptive services beyond the current level would reduce the cost of pregnancy-related and newborn care by three dollars. Thus, investing in both sets of services would result in cost savings of $11 billion, compared with investing in pregnancy-related and newborn care alone.

Expanding and improving care

For approximately $10.60 per capita annually in LMICs, or about $4.80 more per capita than current costs, all women of reproductive age would receive the pregnancy-related and STI care that they need; all newborns would receive essential, lifesaving care during and just after birth; and women would receive the contraceptive services they need to be able to decide whether and when to have children. These gains would address substantial health burdens in LMICs and provide good value for money. In addition, the interventions that make up this service package have proven feasible to implement in diverse settings.

Investments are also critically needed to address other sexual and reproductive health needs, although they are not quantified in this report because the necessary data are lacking. Cervical cancer—which can be prevented with low-cost interventions—accounts for more deaths in many LMICs than do pregnancy-related complications. Nearly one in three women experience intimate partner violence, which has profound physical and mental health consequences. Young women continue to account for a disproportionate share of new HIV infections. People in humanitarian crises face heightened risks of STIs, unintended pregnancy and unsafe abortion, while services in these settings are uneven and usually inadequate. And infertility affects millions of couples worldwide, yet treatment is out of reach for those with modest incomes.

The funds for expanding and improving sexual and reproductive health care will need to come from a combination of sources that currently support services: national governments, nongovernmental organizations, international donor agencies and the individuals receiving care. Although financing models vary from one country to another, the objective of universal health coverage—which is now a widely accepted goal in the global health community—is to ensure access to care for the people most in need. In countries with high health burdens and limited domestic budgets, external donor funding and effective donor-recipient partnerships will continue to be necessary for expanding access to care.

The speed at which countries can expand provision of high-quality sexual and reproductive health care will vary greatly, depending on their starting points and capacity for making needed improvements. Not acting at all would result in high costs, financially, developmentally and from a human rights perspective. By investing in proven sexual and reproductive health interventions, countries can make greater progress toward their national health and development goals, and toward achieving the Sustainable Development Goals by 2030.