Global Unmet Needs for Contraception,

Reproductive Health and Justice

John W Townsend Future of Contraceptive Initiative (FOCI)

Meeting Seattle, Washington

29 October 2011

Outline of Presentation

• Definition of unmet needs

• Unmet needs and MDGs

• Reasons for non-use of contraception

• Context of Unmet Need – population growth, age structure and urbanization

• Implications for new products and services

• Potential risks

• Challenges for the future

Three perspectives on same Issue

• On October 31, the 7 billionth person, a girl, will be born in poverty in Africa or Asia

• On the same day, a young pregnant mother will have died due to post-partum hemorrhage in the next village

• During the same week, a woman is beaten by her spouse as she cannot conceive. He suspects that that she is infected with HIV

Right to Health

Realization of the right to health requires the removal of barriers that interfere with individual decision-making on health-related issues and with access to health services, education and information, in particular on health conditions that only affect women and girls. Report of Special Rapporteur of the Human Rights Council, August 2011

Definition of Unmet Need and Magnitude of Expression

• “Fertile sexually active women who do not want to get pregnant in next two years but are not using a contraceptive method” -Survey

• About 215 million women (26%) in developing countries have unmet need for spacing or limiting

• These women account for 82% of all unintended pregnancies

Unmet need and Maternal Child Health: MDGs 4, 5 and 6

• MDG 5: 75% reduction in maternal mortality ratio and universal access to reproductive health by 2015

• Indicators for universal access

Contraceptive prevalence rate Adolescent birth rate Antenatal care coverage Unmet need for family planning

• MDG 5 on maternal health, MDG 4 on child health and

MDG 6 on HIV are linked on issues of unmet needs – potential synergies with health system development

Why do unintended pregnancies

happen?

• Unmet need: Non-use of contraception – when sexually active and a pregnancy is not desired • Switching or discontinuing a contraceptive method • Incorrect use or method failure • Unplanned sex • Unwanted sex

Non-consensual and/or violent sex Early marriage

Fertility Use of

contraception

Fertility

preferences

Unmet need,

Unsatisfied

demand

Cost/benefits

of children

Costs

of birth control

Socioeconomic

development

and mortality

decline

Family planning

programs

Demand for

birth

control

Analytic framework for the determinants of fertility

Planning status and outcome of all

pregnancies in developing countries 2008

Source: S. Singh et al Studies in Family Planning 41, 241-250 (2010).

0

20

40

60

80

100

120

Per

cen

t o

f A

ll P

reg

nan

cies

Pregnancy Planning Status

Unintended

Intended

Pregnancy Outcome

Abortion

Unintended Birth

Miscarriage

Intended Birth

Reasons for non-use of contraception in SS Africa, SE Asia and South Central Asia

22%

21% 17%

10%

16%

8% 4% 2%

Health/Side Effects

Infrequent Sex

Postpartum/Breastfeeding

Partner opposed

Woman opposed

No access/high cost

Unaware of methods

Perceived subfecund

Women with unmet need are diverse in goals but more likely to be young, poor and rural

Sub-Saharan Africa

49%

68%

56%

70%

58%

59%

62%

68%

46%

64%

49%

70%

58%

0% 20% 40% 60% 80% 100%

Urban

Rural

Nonpoor

Poor

35+

25-34

20-24

<20

Unmarried

Married

Stop births

Space births

Delay f irst birth

South Central Asia

29%

35%

29%

40%

23%

33%

51%

72%

7%

34%

25%

63%

78%

0% 20% 40% 60% 80% 100%

Southeast Asia

31%

30%

29%

33%

30%

30%

33%

37%

55%

30%

29%

32%

74%

0% 20% 40% 60% 80% 100%

% of women with unmet need for modern methods

Unmet need declines in married women but can it be eliminated?

18 16

18

26

12 10

11

24

0

5

10

15

20

25

30

LAC N Africa & WAsia

S & SE Asia SS Africa

1990-1994

2000-2005

Source: Guttmacher, 2008

% o

f m

arri

ed w

om

en 1

5-4

9 w

ith

un

met

ne

ed

Less developed regions: alternative population projections: 2005-2050 and components of

population growth

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

1950 2000 2050 2100

Po

pu

lati

on

siz

e (

mill

ion

s)

Standard projection

Effect of: - High fertility - Mortality, migration - Young age structure

Effect of Age Structure on Growth

Urbanization in sub-Saharan Africa

• In 2009 Africa’s total population exceeded one billion, of which 395 million (40%) lived in urban areas

• Africa’s population will increase 60% between 2010 and 2050, with the urban population tripling to 1.23 billion during this period

Source: UNEP, 2010

Implications for Contraceptive Development and Product Use in Developing Countries

• New products with health benefits as side effects, and are easier to use, especially those compatible with infrequent sex, do not interfere with intercourse or necessarily involve partners

• Adaptations of current contraceptive approaches to make products more acceptable to young users, more accessible and affordable in diverse segments at scale

• Long-term investment in new modes of contraceptive action that do not cause systemic side effects, can be used on-demand but not at intercourse, and address multiple unmet needs, including prevention of HIV

Potential Outlets: Clinic , Pharmacy, and Community

Potential Risks of Pursuit of Elimination of Unmet Need

• Uncertain link between unmet need and demand at individual level

• Potential demand is uncertain and anticipated costs are too high

• Miss opportunities for integration with HIV, working with men in multiple roles, to support market development with private sector

• Risk of coercion to meet development goals

Challenges for the Future

• New methods that respond to needs and rights of women and men in developing countries

• Development of technologies that support health system development , RH justice and gender equity

• Products that address multiple purposes (MPTs): contraception, infection prevention, pleasure

• News financing strategies that support outreach in diverse market segments to complement and challenge public sector care systems