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1

Contraception in historical and global perspective

John Cleland, MA, FBA, Professor of Medical Demography *

Centre for Population Studies, London School of Hygiene and Tropical Medicine, 4951 Bedford Square, London WC1B 3DP, UK

Keywords:

family planning programmes

contraceptive prevalence

method-specific use

unintended pregnancy

population growth

social marketing

community-based approaches

This chapter describes the rise in contraceptive practice and fall in

fertility from around 1880 to the present day. Two main phases are

identified: the first confined to European populations and

involving methods of low efficacy, and the second embracing the

whole planet involving modern methods. Today, sub-Saharan

Africa is the only region where low levels of contraceptive use and

high fertility persist. Nevertheless, nearly half of pregnancies

worldwide are still unintended, and much scope remains for

improvement in contraceptive protection. The main international

priority is Africa, where demographic factors jeopardize the goalsof reducing poverty and hunger.

2008 Elsevier Ltd. All rights reserved.

The freedom of couples to choose when and how often to become pregnant is a fundamental human

right.1 The level of contraceptive practice in a society also carries huge health, economic and envi-

ronmental implications, because it is the major determinant of the birth rate and hence of the rate of

population growth or decline. Between 1950 and 2005, the planets population rose from 2.5 to 6.5

billion. Global fertility has now fallen from an average of 5.0 live births per woman in 1950 to 2.55 live

births in 2005, and is expected to decline further to approximately 2.0 live births by mid-century.Under this scenario, the worlds population will nevertheless grow to 9.2 billion by 2050. However, if

fertility is half a birth higher or lower than expected between 2005 and 2050, the mid-century pop-

ulation of the planet will be 10.75 or 7.8 billion, respectively.2 Two things are clear. First, modest

changes in human reproduction have colossal effects on population growth, and second, the distinc-

tions between future global populations of 8, 9 or 10 billion could be of critical importance to the

prospects of achieving reasonable and sustainable living standards for the whole of humanity.

The aim of this chapter is to provide the historical, political and cultural context for the more

specialized chapters that follow. The narrative starts in Europe and countries of predominantly

* Tel.: 44 20 7299 4621; Fax: 44 20 7299 4637.

E-mail address: [email protected]

Contents lists available atScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecologyj o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m/ l o c a t e / b p o bg y n

1521-6934/$ see front matter 2008 Elsevier Ltd. All rights reserved.

doi:10.1016/j.bpobgyn.2008.11.002

Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 165176
mailto:[email protected]://www.sciencedirect.com/science/journal/15216934http://www.elsevier.com/locate/bpobgyn/www.elsevier.com/locate/bpobgynhttp://www.elsevier.com/locate/bpobgyn/www.elsevier.com/locate/bpobgynhttp://www.sciencedirect.com/science/journal/15216934mailto:[email protected]

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European descent around 1880. The rise in contraceptive practice in poorer regions, often with strong

government support, is then described. The story here is essentially positive; many experts have been

surprised by the speed of reproductive change, even in some of the poorest and most illiterate states.

However, much unfinished business remains. Contraceptive practice remains low in much of sub-

Saharan Africa, with the consequence that populations are set to double or even treble in size in the

coming decades. This rate of increase jeopardizes the goal of reducing poverty and hunger. The chapterends with a review of such future challenges.

The first contraceptive revolution European populations, 18801930

In the absence of any restraints on fertility, it is estimated that the average woman would bear 15

children over her reproductive lifetime.3 In contrast, fertility achieved in pre-modern societies typically

ranged from 4.5 to 6.5 live births per woman, sufficient to offset high mortality but insufficient to fuel

sustained population growth. On average, only two children per couple survived to adulthood.

Historically, two factors, prolonged breast feeding and restrictions on entry to sexual partnerships,

operating through marriage rules and customs, were largely responsible for this huge gap between

potential and achieved childbearing. The contribution of contraception, and abortion, to the moder-ation of fertility is hotly contested. References to contraception are found in Graeco-Roman texts and in

mediaeval Arabic writings.4 The methods mentioned by ancient scholars are a mixture of the fanciful,

those that seemed reasonable at the time but which have since been shown to be ineffective (e.g.

avoidance of intercourse on the days following menses), and those of potential effectiveness, mainly

pessaries and barriers. Some scholars, notably John Riddle, have argued that herbal preparations, taken

orally, were both effective and widely used in classical times.5

Whatever may have been the case in civilizations of the distant past, the study of European fertility

by demographers suggests that contraception was not widely practised until relatively recently. The

hallmarks of regulated fertility do not appear in Europe until around 1880, with the exception of France

where the shift occurred approximately 100 years earlier.6 This verdict for Europe is consistent with

results from the earliest surveys of women in Africa and Asia, conducted before internationalpromotion of family planning started. Very few women were aware of contraceptive methods and even

fewer reported any form of contraceptive precaution.7

It may seem implausible that our ancestors exercised little or no conscious control over childbearing

within marriage, but it should be stressed that postnatal adjustments of family size and composition

acted as a partial substitute.8 It is likely that all traditional societies made use of some of the following

postnatal adjustments: infanticide, child abandonment, adoption, fostering, and release of children in

their early teens as apprentices and domestic labour. In past times, reproduction was a lottery because

of the unpredictability of child death. Couples who had too many surviving children to support were

balanced by those with a dearth of surviving children. The solution was obvious; children flowed from

surplus to deficit families.

Why French couples started to limit family sizes towards the end of the 18th Century remains one ofthe great puzzles of demography. Easier to understand is the fertility decline that spread rapidly across

the rest of Europe from 1880 to 1930. By 1880, child mortality, although not necessarily of infants, had

fallen in many countries, implying an increase in surviving children, mass education was spreading,

and ideas about the status of women and religious authority were beginning to shift. Industrialization

and urbanization were well advanced in parts of Europe, and scientific progress was rapid. It became

inevitable that the increasing human mastery over nature would extend to reproduction. By 1930,

fertility had fallen below replacement level (a little above two births per woman) in many countries.

This first revolution in reproductive control took place more or less synchronously in all countries of

predominantly European descent as well as in Europe itself, although perhaps somewhat earlier in

parts of the USA. In the Soviet Union, it spread east until it reached the Muslim populations of Central

Asia. The non-European parts of the world remained largely unaffected. In striking contrast to thesequence of events in developing countries after 1960, this rise of contraception in European pop-

ulations occurred in the face of widespread initial opposition from political elites, religious leaders and

the medical profession. At different times and in different countries, two of the most prominent birth

control pioneers, Annie Besant and Margaret Sanger, fell victim to the hostility that the subject evoked.

J. Cleland / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 165176166

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In London, Besant was taken to court for republishing, in 1877, an American tract on birth control

quaintly called The Fruits of Philosophy. Sanger was arrested in 1916 for opening a birth control clinic

in Brooklyn.

Reliable evidence of the prevalence of different methods of contraception is unavailable before the

1950s. In Great Britain, it is likely that childbearing was initially reduced by coitus interruptus, but that

condoms and spermicides became more widely available and used in the early decades of the 20thCentury.9 In the USA, diaphragms and periodic abstinence were more commonly used, but coitus

interruptus was less popular than in Great Britain.10 The fact that these methods have low efficacy

testifies to the determination of couples to restrict family size, although resorting to illegal abortion no

doubt acted as an important back-up to contraception. This first contraceptive revolution was not

essentially a response to improved methods. It is more aptly characterized as the consequence of

a motivational and moral change. Family size limitation became a central pre-occupation and the

repugnance of coitus interruptus waned.

Developments in European populations since 1960

Fertility regulation in European populations underwent a radical modernization that started in the

1960s. Oral contraceptives were approved for use in the USA in 1960, and in many European countries

at around the same time. Modern intra-uterine devices (IUDs) also became more widely available.

Techniques of contraceptive sterilization were refined and, in the 1970s, many countries enacted laws

that explicitly permitted the procedure. Finally, widespread liberalization of abortion laws occurred.

These changes in technology and access had almost immediate effects in North America, and

Western and Northern Europe. In the USA between 1955 and 1965, the percentage of married non-

Hispanic White female contraceptors who used oral contraceptives rose from zero to 24%, while the

percentage using periodic abstinence, condoms and diaphragms fell.11 By 1982, condom and dia-

phragm use among contraceptors had fallen to 7% and 4%, respectively, in this same population group,

but a huge rise in sterilization had taken place; 43% of contraceptors had been sterilized (26% females

and 17% males).12 Since 1982, changes have been modest.

In the UK, oral contraception was already challenging the popularity of the two male methods

(condoms and coitus interruptus) by 1967, and by 1976, 38% of married contracepting women reported

use of the pill. Prior to 1970, the level of contraceptive sterilization was negligible, but by 1976, 19% of

contracepting couples had been sterilized and this proportion rose to 37% by 1986.10

This transformation from less effective methods that require the active participation of men to more

effective methods controlled by women was slower to arrive in Southern and Eastern Europe, and has

still not occurred in some countries. For instance, coitus interruptus remains the most commonly used

method in Albania, Bosnia and Greece, as was also the case in Italy at the time of the most recent survey

in 19951996.13

Between 1950 and 2005, fertility in developed countries fell from 2.8 to 1.5 births per woman. More

effective contraception, together with greater access to abortion, is partly responsible. In the USA, forinstance, the fraction of live births reported as unwanted at the time of conception fell sharply.14 With

high life expectancy and no net migration, a fertility rate sustained at 1.5 births will result in a halving

of population size every 60 years and severe population ageing. This demographic prospect is an

increasing concern of governments.

The contraceptive revolution in developing countries: the role of state intervention

In contrast to the first contraceptive revolution in European populations, the history of family

planning in poorer countries is inextricably linked to government policies and programmes, moti-

vated largely by demographiceconomic considerations. In the 1950s and 1960s, radical declines inmortality were achieved but fertility remained resolutely high at five to eight births per woman; this

widening gap resulted in a sharp acceleration in the rate of population growth. By 1960, many Asian,

Latin American and African populations were growing at a pace that implied a doubling in size every

25 years or so.

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In 1958, a seminal book by Coale and Hoover argued that the social and economic progress of poor

countries was jeopardized by rapid population growth, largely because of the inherent age structure of

rapid growth, in which half the population is aged 15 years or less.15 Household and government

savings have to be diverted from investment to develop industry and modernize agriculture to support

the huge burden of the unproductive young. In this era before the Green Revolution, serious doubts

arose about the ability of large Asian populations to feed the ever-increasing number of mouths. India,at the time, was dependent on imports of US grain to avert the consequences of recurring food

shortages. These concerns, coloured by an element of xenophobia, were dramatized and popularized

by Paul Ehrlich and others.16 Conviction grew, particularly in the USA, that action was needed to stem

uncontrolled population growth.

No blueprint for action existed. The European experience offered no guidance and it was uncertain

whether couples in Asia and elsewhere wanted smaller families or were interested in using contra-

ception. To answer these questions, research was needed and knowledge, attitude and practice surveys

of contraception proliferated. The next step was to assess, on a small scale, whether provision of

contraceptive services and accompanying information and publicity would work. Luckily, an appar-

ently ideal, newly refined IUD became available; the Lippes Loop. It was cheap, effective, required little

contribution from the user, and modest skills to insert. The earliest demonstration projects, notably inTaiwan and South Korea, relied heavily on this IUD and proved successful. In USA, President Lyndon

Johnson and Robert McNamara, Head of the World Bank (19681981), became enthusiastic supporters

of contraception. In 1969, a new United Nations (UN) agency, the UN Fund for Population Activities, was

created, with the shrewd choice of a Roman Catholic Filipino as its first executive director. The stage

was set for the era of state-sponsored family planning programmes. In 1960, only two developing

countries had official policies to promote contraception, but this number rose to 74 by 1975 and further

to 115 by 1996. International funding increased in parallel from US$168 million in 1971 to US$512

million in 1985.

Asian developments

Most Asian governments quickly embraced the messages from New York and Washington that

population control was a priority, but several of the early programmes were poorly designed. In

Pakistan and Bangladesh (then one country), President Ayub Khan launched a crash programme

centred on the IUD. The patient, the recruiter and the clinician all received a small payment for each

insertion, which gave rise to massive corruption. Little medical back-up for women experiencing side

effects was available, with the consequence that the IUD became deeply unpopular. The programme

collapsed after 5 years in 1969 as a complete failure. The cause of family planning languished in

Pakistan from then until the 1990s.17

Events in newly independent Bangladesh took a very different course. In 1977, population control

was proclaimed by President Ziaur Rahman to be a top national priority. Staff at district hospitals were

trained to perform tubectomies and vasectomies, and a new cadre of literate, married, femalecommunity-based workers was created, called family welfare assistants (FWAs). FWAs were trained

for a month or so in basic family planning and child care, and then returned to their own villages to

provide a domiciliary service, supplying oral contraceptives and condoms, and referring women for

clinical or surgical methods. This strategy proved to be the sociologically effective way of popularizing

contraception. FWAs, being literate, were usually respected in their communities; they could act as

a bridge between village life and the alien world of scientific medicine and, perhaps most importantly

in a culture that makes it difficult for women to travel alone outside their immediate neighbourhood,

they brought contraceptives to the doorstep and acted as companions when trips to health facilities

were necessary.18 The success of Bangladeshs strategy can be seen inFig. 1.Contraceptive prevalence

among married women rose from 12% in 1979 to 49% in 1996, although increases in the past decade

have been modest. Fertility has fallen from historic levels of six to seven births per women to threebirths.

As in Pakistan, early efforts to deliver family planning services in India were unsuccessful. A rather

passive clinic-based approach, initiated in the 1950s, achieved little. In the 1960s, the programme was

extended, and contraceptive and demographic goals were set but again impact was minimal. In the


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early 1970s, the focus shifted to promotion of vasectomy by means of financial incentives, typically

amounting to several weeks wages for an unskilled labourer.19 Many vasectomies were performed in

carnival-like settings where thousands of people would gather for entertainment. These high-pressure

tactics culminated in instances of outright physical coercion during the 2 years of Prime Minister

Ghandis emergency rule (19751977). The annual number of sterilizations rose to a huge figure of 8.26

million. A backlash was inevitable; Mrs Ghandi lost the 1977 election and the programme was dis-credited. It took about a decade for family planning to regain momentum, and progress, as measured by

contraceptive prevalence, has been steady but not spectacular (Fig. 1).

The comparison of family planning progress in the Philippines and Indonesia is intriguing. In 1960,

the Philippines had an income per head double that in Indonesia and much higher levels of adult

literacy and womens labour force participation. However, by 20022003, contraceptive prevalence in

Indonesia was 60% compared with 49% in the Philippines (Fig. 1). The reason for this unexpected

outcome lies with religion and politics. In Indonesia, the Government skilfully circumvented the

danger of opposition from Islamic leaders by agreeing not to legalize abortion or promote sterilization.

It mounted a forceful programme with the strong involvement of local leaders. In common with several

other Asian countries, the family planning agency sidestepped the weakness of Ministry of Health

services by creating its own dedicated network of centres and staff. In the Philippines, by contrast, noagreement between state and church was reached and Roman Catholic leaders remained openly and

vocally opposed to most forms of contraception. In a predominantly Catholic country, this opposition

prevented the development of a comprehensive programme.

No account of family planning in Asia is complete without consideration of China. In 1974 at the

Bucharest World Population Conference, China was the main opponent of US calls for a worldwide

effort to arrest rapid population growth. However, 2 years earlier, the Chinese Government had

initiated its own massive programme to reduce fertility. This voluntary programme proved to be a huge

success, partly because of Chinas uniquely effective organizational abilities. However, in 1979,

economic planners successfully argued that deeper cuts in population growth were necessary and the

one- child policy was introduced, with benefits for couples pledging to have only one child and

penalties for those exceeding the quota. In the cities, the grip of the Communist Party and support ofthe populace were sufficient to ensure almost total compliance. However, in rural areas, opposition was

entrenched and local authorities eventually had to relax the rule and permit two children, regardless of

their sex, or alternatively allow a second child if the firstborn was a daughter.20 The fertility rate in

China is now approximately 1.5 births per woman. In an increasingly overcrowded planet, huge global

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Fig. 1. Trends in current use of contraception among married women of reproductive age, selected Asian countries.


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benefits have accrued from Chinas population policy because the country accounts for approximately

one-fifth of humanity. Chinas economy has also benefited. The cost, however, has been high, not least

in terms of sex-selective abortion and the abandonment of unwanted daughters.21

Developments in other poorer regions

Whereas the 1958 book by Coale and Hoover provided the economic rationale for family planning

promotion in Asia, the equivalent in Latin America was a 1966 article that showed a disturbing trend in

Chile of increasing hospital admissions for the consequences of illegal and unsafe abortions.22 This

compelling medical rationale for the promotion of contraception led to the formation of non-

governmental organizations, such as Bemfam in Brazil and Profamilia in Colombia, typically led by local

physicians but funded from abroad. Governments were reluctant to engage because of the influence of

the military (typically pronatalist), the Catholic Church and perhaps because of an inherent antipathy

to messages emanating from the USA.

In Brazil, the military regimes that governed the country from 1964 to 1985 maintained their

indifference to population issues and contraception. However, a demand for smaller families arosespontaneously. It is probable that the spread of television and its hugely popular soap operas, featuring

small families, played an important role in changing reproductive attitudes.23 In the absence of public

sector contraceptive services, the private sector filled the vacuum. Pharmaceutical companies sold oral

contraceptives through pharmacies, and doctors circumvented a law prohibiting tubal ligation by

offering the procedure together with elective caesarean section. By 1996, contraceptive prevalence had

risen to 77% (predominantly sterilization and oral contraceptives) and fertility was close to replace-

ment level. This high level of use is typical of Latin American countries, although there are laggards

such as Bolivia and Guatemala (Fig. 2).

In sub-Saharan Africa, family planning programmes were initiated by the White-minority regimes

in South Africa and Zimbabwe (then Rhodesia), and contraceptive use remains higher in these two

countries than in other countries. Elsewhere in sub-Saharan Africa, governments were slow to embracethe cause of family planning sponsorship. One reason was genuine doubt that programmes would be

successful. Numerous surveys showed that unlike their Asian or Latin American counterparts, African

men and women typically wanted large numbers of children. 24

Despite this obstacle, most African countries had adopted population policies by 1990, in some

cases under pressure from the World Bank and other donors.25 Prompted by a survey showing that the

country had one of the highest fertility rates in the world and a rate of population growth that, if

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Fig. 2. Trends in current use of contraception among married women of reproductive age, selected Latin American countries.


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unchanged, would result in a doubling of population in 19 years, Kenyas Government launched

a comprehensive programme in the early 1980s. The support of elites (churches, civil servants and local

leaders) was sought, extensive use was made of the mass media, and access to contraception was

expanded through health centres, social marketing schemes and community-based efforts. Success

was soon apparent. Between 1977 and 1988, the percentage of married women using contraception

rose from 7% to 27%, and desired family sizes fell dramatically (Fig. 3). The rise in contraceptioncontinued until the mid-1990s but then plateaued, as did fertility. Between 1998 and 2003, the

percentage of births reported as unwanted rose and the percentage of contraceptive users relying on

public sector sources of supply fell.26 Both trends suggest that the family planning programme had

deteriorated and this interpretation is consistent with the fact that, in the 1990s, funds, staff, vehicles

and government commitment shifted from family planning to human immunodeficiency virus/

acquired immunodeficiency syndrome (HIV/AIDS).

Although prevention of HIV and unintended pregnancies have a common interest in reducing

unsafe sex, the relationship between the two movements is better characterized by competition than

by cooperation. Family planners were reluctant to promote condoms to married women instead of

more effective hormonal methods, and were poorly placed to reach men or sexually active single

people; prime targets for HIV prevention. Vertical funding by donors undermined the internationalrhetoric that strongly favoured integration. However, the social marketing of condoms with HIV funds

has had a major effect on the contraceptive practices of unmarried young people in Africa (and in Latin

America). Condom use has risen sharply among the young, and pregnancy prevention, rather than

disease prevention, appears to be the dominant motive.27 Condoms have become the most common

contraceptive method in young people. Regrettably, resistance to condoms in married couples remains

strong; a tragedy in view of the fact that, in mature generalized epidemics, the majority of infections

occur among them.

Few countries in sub-Saharan Africa have matched Kenyas determination in the 1980s and early

1990s to reduce fertility via family planning promotion and, as in Kenya, family planning has often been

displaced as a government and donor priority by AIDS. In West and Central Africa, contraceptive

prevalence remains very low; the trends in Nigeria and Senegal are typical (Fig. 3). Among countrieswith relevant data from national surveys, the prevalence of modern method use is below 10%, with

a few exceptions such as Ghana. In East Africa, the level of contraceptive use is more variable than in

West Africa, and in Southern Africa, it is higher than in other sub-regions.

Attitudes to family planning in the Arab states of North Africa and the Middle East have varied

considerably. The oil-rich countries, with small indigenous populations and large numbers of migrant

workers, have typically had no interest in moderating population growth or promoting contraception.

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Fig. 3. Trends in current use of contraception among married women in reproductive age, selected African countries.


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Despite their huge wealth, fertility remains high and contraceptive use remains low in countries such

as Saudi Arabia and the United Arab Emirates. In the poorer, more populous countries, policies have

been more positive. Trends in contraceptive use are shown for Egypt in Fig. 3. The current prevalence of

approximately 60% is similar to that in Jordan, Syria, Algeria, Morocco and Tunisia.

Since the Russian Revolution in 1917, abortion in the Soviet block has been legal and widely

accessible for most of the time, but access to modern contraceptives has been extremely limited. Thiscombination led to widespread reliance on coitus interruptus and very high abortion rates. Since the

collapse of the Soviet Union in 1991, modern contraceptives have been promoted, in part by foreign

non-governmental organizations. In the Central Asian Republics (e.g. Uzbekistan, Kazakhstan), IUDs

are now the most commonly used form of contraceptive method and reliance on abortion has fallen. 28

In the countries of the Caucasus (Armenia, Azerbaijan and Georgia), however, coitus interruptus

remains the most prevalent method.

Distilling the lessons from family planning promotion in poorer countries

Perhaps the single most important lesson from the experience of family planning promotion in Asia,

Latin America and Africa is that success can be achieved in poor and illiterate settings. The widespreaduse of modern contraception in a country such as Bangladesh rebuts the pernicious, patronising but

nevertheless common belief that poor couples are uninterested in family planning because they need

and want many children. Similarly, it has also become apparent that high levels of female education,

labour force participation or national wealth do not automatically translate into low fertility (e.g. the

Philippines and oil-rich Arab states). While it is clear from the example of Brazil that state promotion is

not always necessary for the spread of contraception and achievement of low fertility, the balance of

evidence supports the view that governments can accelerate the pace of reproductive change and, less

commonly, initiate a change.29 Like any other government programme, effective family planning

programmes require political commitment, adequate funding, clear lines of management and super-

vision, competent staff, and sound logistics and management information systems. Beyond these nuts

and bolts of effectiveness, more interesting lessons can be learnt and these are summarized below.The better family planning programmes have succeeded in large measure because they dismantled

the barriers to contraception. Reasonable geographical access to advice and supplies is an obvious

crucial consideration. Early on, family planning managers realized that exclusive reliance on static

health facilities as sources of supply was insufficient. One supplementary strategy is mobile clinics. In

the mountainous regions of Nepal, for instance, most contraceptive sterilizations are performed by

mobile teams of surgeons. Of greater significance is the incorporation of commercial outlets into

contraceptive provision. Partly in response to the AIDS pandemic, most developing countries have

condom social marketing schemes, and the majority of users of this method obtain supplies at

subsidized prices from pharmacies and shops. Approximately 40 countries make oral contraceptives

available through social marketing which, typically, accounts for over 40% of demand. Approximately

30 countries allow social marketing of injectables.30

Social marketing works best in urban settings where exposure to the mass media is high, outlets are

abundant and demand for contraception is strong. Where these conditions do not apply, for instance in

more remote rural areas with fragile demand, community-based approaches are more effective. Many

community-based schemes are run by non-governmental organizations and their characteristics are

very variable. Typically, they involve lay staff who are trained for a brief period before returning to work

in their own communities. A critical strength is that workers share a language and customs with their

clientele. Programmes relying on volunteers are rarely durable and thus income in the form of a regular

salary or from contraceptive sales is a necessary ingredient. Experience from Africa suggests that

workers offering simple health products and advice as well as contraception are more effective than

dedicated family planning workers.

Community-based approaches have been widely deployed in developing countries, and have beencentral to programmes in Bangladesh, Iran and Zimbabwe. However, they are difficult to scale up

because of the complexities of ensuring uninterrupted supplies and adequate supervision. Costs also

tend to be high. For these reasons, only minorities of contraceptive users rely on community-based

supplies.30


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Despite their limitations, static facilities remain the dominant mode of contraceptive service. Even

with this type of service, the dismantling of medical barriers to quick and convenient access is

important.31 It was demonstrated that nurses could insert IUDs as safely as physicians, and that it was

justifiable to provide hormonal methods without a medical prescription. Outdated eligibility criteria

had to be scrapped and the requirement for husbands consent abandoned. In the past 15 years, the

quality of clinical services has been scrutinized intensively in response to criticisms of poor quality,particularly in some Asian programmes. Partly because of a paucity of experimental research designs,

few decisive gains have been made in our understanding of which of the many possible elements of

service quality matter most to women.32 It is still unclear, for instance, whether extended counselling

improves uptake and persistent use. Perhaps the most emphatic finding concerns method choice. Most

women present at a clinic with a preferred method in mind. If that method is unavailable, alternatives

are often deemed unsatisfactory and rejected or discontinued.33

Although service provision, of course, is the backbone of family planning programmes, information,

education and communication are vital components and it would be a great mistake to conclude that

adequate access to services is sufficient to ensure widespread uptake of contraception. Acceptability is

equally important. Just as in Europe and the USA 100 years ago, the idea of contraception often

encountered initial moral and social opposition in poorer countries that was often expressed in theform of deep mistrust of specific contraceptive methods.34 This initial resistance to family planning is

partly a consequence of misinformation but, at a deeper level, it is a reflection of disquiet with a radical

innovation that goes to the core of one of lifes central pre-occupations; reproduction. Winning over

hearts and minds has been as important as providing adequate access to services. No blueprint exists

for transforming contraception from an alien, frightening and morally ambiguous behaviour into

a humdrum part of everyday life, but extensive use of mass media together with more targeted efforts

to gain the support of influential groups, such as teachers, religious leaders and village heads, have

been a common feature of many of the more successful programmes.

Current status of global contraception: method-specific prevalence by region

Between 1960 and 2003, the percentage of married women in developing regions using any form of

contraception rose from approximately 10% to 60%, and fertility halved from six to three births per

woman. In industrialized countries, contraceptive practice also rose and fertility fell, but changes were

less dramatic because family sizes were already modest in 1960 and contraception was already well

established. In 2003, it was estimated that approximately 63% of all married and cohabiting women use

contraception.13 Female sterilization was the most commonly used method with a prevalence of

approximately 20%; much higher than vasectomy at 2.7%. The IUD was the next most commonly used

method, with a global prevalence of 15.5%; however, this figure is somewhat misleading because it is

largely a reflection of the very high prevalence of IUD use (45%) in Chinas vast population. Excluding

China, global IUD prevalence drops to 6.7%; a little less than the prevalence of oral contraceptives

(8.5%). Condoms were used by an estimated 5.7% of couples, and injectables or implants by 3.4% ofwomen. Finally, 7% used so-called traditional methods (mainly coitus interruptus and periodic absti-

nence) and a tiny residue (0.5%) used other modern methods.

Regional variations in method-specific use are shown in Fig. 4 and some marked contrasts are

apparent. The prevalence of female sterilization exceeds 20% in Northern America, Latin America and

Asia, but is below 5% in other regions. Condoms are twice as popular in Europe and Northern America

than in poorer regions, and in Europe, the prevalence of traditional methods is twice the world average.

Intercountry differences become even more intriguing. The prevalence of condom use is 41% in Japan

and 35% in Hong Kong, but is only 5% in China. In Bangladesh, 26% of women use oral contraception

while the corresponding figure is 3% in neighbouring India. In Egypt, the IUD is the dominant method;

in Morocco, it is the pill.

Extreme skewness in method-specific use is common. In 34 of 96 countries, one method accountsfor over half of contraceptive protection, and this trait is just as common in rich countries as in poor

countries.35 In India, 66% of contraceptors are sterilized and the figure in Canada is similar (61%). In

Germany, France and the Netherlands, approximately three-quarters of all users rely on oral contra-

ception. The explanation is multi-layered. Legal prohibitions, especially with regard to sterilization,


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occasionally restrict choice. More commonly, one or two methods have been promoted at the expense

of others. Staff may have their own preferences. However, probably the most important reason for the

limited range of methods used in many countries is the power of social imitation. Once, through some

quirk of history or policy, one or two methods become widely used, they become the preferred choice.

A further feature of contraceptive behaviour that unites rich and poor populations is the highdiscontinuation of reversible methods for reasons that imply dissatisfaction with the method. In the

USA, 44% of couples stop use within 12 months of starting a method.36 In developing countries, similar

discontinuation probabilities are recorded for condoms and injectables, but lower estimates are typical

for oral contraceptives (34%) and IUDs (12%).37 Major reasons for stopping are side effects and health

concerns. The majority switch to another method. In the USA, inconsistent and incorrect use, together

with a small contribution from method failure, accounts for approximately half of all unintended

pregnancies, while the other half is attributable to non-use. In developing countries, contraceptive

avoidance or non-use remains the dominant direct cause of unintended pregnancies.

Future priorities and challenges

Since 1950, huge progress has been made in both the technology of contraception and in service

delivery. Yet from both a rights and health perspective and from economic considerations, much

unfinished business remains. It is estimated that, globally, approximately 40% of recognizable preg-

nancies are unintended and unwelcome at the time of conception. 38 Half of these are terminated,

causing an estimated 50 000 deaths per year from unsafe procedures. Approximately 30% of the

500 000 non-abortion-related maternal deaths per year could be prevented by the elimination of

unintended pregnancies taken to term, and at least 10% of child deaths could be averted by wider

spacing between successive births.39 Unmet need for contraception, that is the percentage of women

who do not want a child for at least 2 years but who are using no contraceptive method, remains at 20%

or more among married women in over half of developing countries with available data.13 Unmet need

in sexually active single women is even higher.

30

From an economic perspective, the main priority for contraception is sub-Saharan Africa where

fertility is still very high (five births per women), and where the population is projected to grow from

0.75 billion to 1.7 billion between 2005 and 2050; an increase of 125%. These demographic factors

greatly diminish the chances of achieving radical reductions in poverty and hunger. Population growth

0

10

20

30

40

50

60

70

80

World Northern

America

Europe Asia Latin

America

North

Africa

Sub-Saharan

Africa

%Using

Female Sterilisation

Male Sterilisation

Pill

Injectable/implant

IUD

Condom

Other methodTraditional

Fig. 4. Method-specific contraceptive prevalence by major region (most recent estimates).


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has outstripped food production in Africa for several decades and, at the turn of the century, Africa was

importing US$20 billion of food per year, equivalent to the annual total of official development

assistance.40 The recent rise in world grain prices, increasing water shortages compounded by the

uncertainties of climate change, together with rapid population increase pose a severe challenge to the

attainment of food security in Africa. Luckily, no tension need exist between the economic imperative

of population stabilization and a reproductive rights approach, because unmet need for contraceptionis exceptionally high in sub-Saharan Africa.

Modern contraception has a wider range of potential benefits than any other single medical

intervention: better maternal and child health, enhanced empowerment of women by reducing the

burden of excessive childbearing, alleviation of poverty and hunger, and contributions to environ-

mental sustainability by stabilizing population sizes. It is deeply regrettable, therefore, that the subject

has fallen out of favour and international funding has dropped. The reasons for its demise include the

premature sense that the population problem had been solved, criticisms of inept and sometimes

coercive programmes in Asia, and displacement by newer concerns, particularly AIDS. The agenda is

badly in need of revitalization. The deepening disquiet that homo sapiens may be destroying the planet

by pressure of numbers and profligate life styles will surely lead to this revitalization.

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only deflect patients from their desired method when strong indications for this exist

as discontinuation for method-related reasons is universally common, anticipate this

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Research agenda

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assess the cost-effectiveness of using mobile phones in low-income countries to remind

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