We are witnessing unprecedented acceleration of societal challenges around the world, especially for women. Every year, 303,000 women die from complications during pregnancy and childbirth. And approximately one-third of maternal deaths could be prevented annually if women who did not wish to become pregnant had access to and used effective contraception; globally, 214 million women have an unmet need for modern contraception.
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Happily, the responses to these challenges are also accelerating, fueled by new knowledge, innovations in technology, and an expansion of service delivery through both the private and public sectors. In Ethiopia, for example, contraceptive use has increased from about 6% in 2000 to over 40% by 2014. Despite policies that limit access to services — including the U.S. “global gag rule” and Tanzanian restrictions on advertising — women around the world are obtaining the information they need through social media and websites. Meanwhile, Levoplant contraceptive implants, self-injection contraception, and medical abortions are being introduced into new markets.
We predict the following eight issues and trends in the reproductive health space will impede and facilitate access to and use of contraceptives and safe abortion products and technology:
1. Regulatory constraints will continue to present major stumbling blocks in increasing access to contraception around the world. Bureaucratic government procedures, coupled with overburdened oversight bodies — often ministries of health or local government drug agencies — slow down approval of safe and well-established drugs and medical devices. DKT International’s work to register injectable and oral contraceptives in the former French West African region, for example, has taken more than four years. Many governments impose tariffs and duties on family planning products, adding costs that are passed on to consumers or donors. Regulations around family planning education and promotion often prohibit or limit what can be communicated — both in mass media and direct-to-consumer settings.
2. There will be increased scrutiny by donors on ensuring that contraceptive manufacturers meet international standards of quality, often by obtaining regulatory approval via a stringent regulatory authority or WHO’s prequalification process. While well-intended, these efforts to ensure quality assurance are accompanied by challenges. Meeting these standards inevitably increases prices for implementing agencies and consumers. Furthermore, such stamps of approval do not guarantee quality on an ongoing basis; continuous monitoring, independent field testing of product quality, and other risk mitigation measures are still necessary. Those who procure and distribute donor-funded contraceptives should be aware of these constraints.
3. Debate and brainstorming around long-term financing to support access to reproductive health care will continue — particularly as donors increasingly shift resources to countries with the highest fertility rates. Work is underway in Indonesia to cover the cost of family planning in its universal health care program, launched in earnest in 2014. Private insurance programs are increasingly eyed as a way to support reproductive health, and strategies to better leverage commercial and social marketing actors to provide services and products to paying customers are being refined. For example, DKT utilizes such cross-subsidization models in Nigeria, Indonesia, and Ghana. And governments and programs in middle-income countries will feel increasing pressure to fully cover family planning costs on their own.
4. Family planning options are expanding. For example, misoprostol, a drug used for postpartum hemorrhaging as well as inducing abortion, is now available in a majority of the world’s countries. Misoprostol played a major role in the rapid decrease in fertility rates — now at 2.04 live births per woman — in Latin America in recent decades, with an estimated 6.5 million induced abortions taking place in the region each year. “Experience shows that no country has achieved a total fertility rate under 2.2 without abortion,” according to one article on the topic. With the expansion of misoprostol elsewhere, we expect this trend to be replicated, most notably in Africa. Approvals and availability of the drug mifepristone and combination packs — which include both mifepristone and misoprostol — have greatly expanded and are already being marketed in key countries like Nigeria and Congo. These abortion pills are expanding the way women view their fertility-control options. We should expect declining fertility rates to follow.
5. Although the principles of self-medication have been around for some time, they are increasingly being accepted and implemented. New contraceptive products are facilitating this trend. In many countries, the abortion pill is taken without medical supervision, supported by websites such as howtouseabortionpill.org and safe2choose.org. There is now a contraceptive that can be self-injected. Emergency contraception is available over the counter in the U.S. and many other countries. In some of them, oral contraceptives can also be purchased at pharmacies without a prescription. All of these technologies, coupled with abundant online resources, allow women and their partners to take their birth control needs into their own hands. We expect this trend to continue — and a reduction in unwanted pregnancies as a result.
6. In 2012, the reproductive health community set targets for increased contraceptive use by the end of 2020. While these ambitious targets won’t be fully met, a great deal of progress has been made. According to FP2020, as of July 2019, there were 53 million more women and girls using modern contraception than there were in 2012. As we enter 2020, donors and agencies are pondering and discussing what comes next.
7. There will be increasing cross-pollination and discussion around the synergies between population and climate change, but these may be somewhat misplaced. According to Yale Climate Connections, “Some scientists now say family planning might help in providing some relief” on climate change issues, but we are skeptical that family planning can have an impact on the environment anytime soon. As the late Hans Rosling aptly pointed out, the provision of family planning services today will have very little impact on the demographic momentum of the next 50 years. One exception will be the impact of increasing financial and material prosperity that family planning facilitates: Better incomes and stronger economies make environmental improvements possible.
8. The world will continue to get better. It is worth remembering that prosperity is growing throughout the world, with roughly 2 billion people brought out of poverty in recent decades. More children are surviving infancy and childhood, more girls are in school, and more parents are controlling the size of their families. These wondrous trends will continue, and we should celebrate these successes along the way.
As these predictions detail, the importance of family planning extends beyond that of its health benefits — it is also critical in empowering women, encouraging self-care and personal responsibility, and improving overall quality of life. These developments will continue to impact women and couples around the world, not only in their ability to easily access contraceptives and health services, but also in the positive shift they create in turning a taboo conversation into a global imperative.