This anonymous essay was submitted to Open Philanthropy's Cause Exploration Prizes contest and posted to the Forum with the authors' permission.
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Key Takeaways
- Voluntary family-planning is unique among medical interventions in the breadth of its potential benefits: reduction of poverty, reduction of maternal and child mortality; empowerment of women by lightening the burden of unintended childbearing; increased ability to benefit from a demographic dividend and reduced human impact on the planet by slowing population growth.
- Unmet demand for modern contraception remains exceedingly high in many low and middle income countries (LMICs), particularly in Sub-Saharan Africa, leading to 111 million unintended pregnancies annually.
- Social marketing is one of several proven “high-impact practices” (HIPs) in family planning identified by the HIP partnership. Targeted work to support and scale up the sale and provision of long-acting reversible contraception (LARCs) as part of the method mix in pharmacies and drug shops in the countries with highest unmet need is required.
Why Family Planning?
218 million women of reproductive age LMICs have an unmet need for modern contraception. This means that they want to avoid a pregnancy but are not using a modern method. About half of pregnancies in LMICs—111 million annually—are unintended. These 111 million unintended pregnancies result in the following estimated outcomes:
● 30 million unplanned births
● 69 million abortions, of which 35 million are unsafe
● 12 million miscarriages
● 1 million still births
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.
Voluntary family planning information, services and supplies enable women and girls to decide whether, when and how often to get pregnant. This saves lives from unsafe childbirth and unsafe abortion. It is fundamental to women’s and girls’ empowerment, enabling them to plan their families and have control over their lives so they can avoid a life of early, multiple and frequently dangerous pregnancies and births, and instead complete their education, take up economic opportunities and fulfil their potential. In turn their children are healthier and better educated.
Unmet need is highest in low-income countries, where nearly half (46%) of women who want to avoid a pregnancy are not using a modern method. The proportion is even higher for adolescent women who face specific barriers arising from restrictive legislative frameworks, out-of-pocket costs, stigma, and community attitudes.
Large scale investment in family planning will address not only the high unmet need, but also increase birth spacing and therefore maternal and infant health. Supporting women to choose when and how many children they have via access to modern contraception also reduces demographic pressures that will impact on poverty reduction in future. Population dynamics matter for broader development because they impact economic growth and prosperity, human capital, food and agriculture, health and education, the availability of basic services, and more. Take the example of DRC, where the population has increased six-fold since independence in 1960. Population growth is 3.2% per year making DRC the 4th largest contributor to world population growth. High growth means that the population will double within 25 years. These high birth rates have rapid repercussions for human development sectors and government budgets because additional children entering the population have near immediate demands on health and education. For example, annual Government health expenditure in DRC will need to be 34% higher in 2030 just to stand still at current low levels of provision. Population growth will have implications for all sectors no matter which fertility scenario is realised.
No country has experienced a demographic dividend without concerted effort and investment in family planning. A demographic dividend is the social and economic benefit to a country that can take place when a country undergoes declines in mortality and fertility, producing smaller, healthier families and a large youth cohort. This demographic transformation leads to a period when a country has a large number of people of working age and smaller number of dependents. With fewer dependents to support, higher savings and a large youth cohort can boost the economic growth of the country. It is estimates that demographic change accounted for as much as a third to a half of the sustained high rates of income growth that came to be known as the East Asian "miracle." During 1965- 90 the working-age population of East Asia grew nearly ten times faster than the dependent population. People are at the heart of the demographic dividend, and the extent to which countries reap these dividends varies and depends on family planning policies and investments.
Family planning is one of the best investments in development. The Copenhagen Consensus estimated that achieving universal access to sexual and reproductive health services by 2030, and eliminating unmet need for modern contraception by 2040, would deliver $120 of social and economic benefits for every $1 invested.
What are the current barriers to family planning usage?
There are a number of key barriers to modern contraception usage, I use the Democratic Republic of Congo here as a specific case study:
- Low coverage and availability of clinical and community FP services (including youth-friendly services).
- Out-of-pocket expenditure and fees for FP services. In Kongo Central province for example, 28% of women accessing FP through the public sector had been asked to pay for a consultation even if they hadn’t obtained a method.
- Socio-cultural norms favouring high fertility, including pressure from family members not to use modern methods. Typically, married women need to get authorisation from their husbands to use contraception.
- Stigma particularly for adolescents in accessing contraception from health facilities. Almost half of 15-19 year old women thought that adolescents who used FP “ont des mœurs légères”, that FP only concerned married women and that FP only concerned women who didn’t want any more children.
- Provider bias particularly unwillingness to supply methods to young, unmarried or childless women
- Fear of side-effects particularly sterility. 26% of women in Kinshasa agreed with the statement that “if I use a method of FP, I will find it difficult to get pregnant when I want to have a child.”
- Lack of information leading to high discontinuation rate. 45% discontinue in a year in Kinshasa. Lack of information is a greater barrier for young women, only 7% of 15-19 year olds in Kinshasa had received information from a health provider about FP.
- Frequent stock-out of FP commodities through the public supply chain and parallel donor-funded procurement systems.
Why is Family Planning a neglected field?
There is evidence that donor prioritisation of HIV/AIDS treatment and prevention in developing countries has displaced aid for family planning. For example, from 1992 to 2005 funding for HIV/AIDS rose rapidly not only in relative but also in absolute terms. In constant US dollars it increased more than twelve-fold from $213 million to $2.6 billion, an average annual growth rate of 41.8% (over the same time period the number of adults globally living with HIV rose approximately four-fold from around 10 million to 38.6 million). Meanwhile funding for family planning fared poorly, remaining largely stagnant in constant dollar terms with approximately the same amount in 1992 ($890 million) as in 2005 ($887 million).
Which Family Planning Intervention to support?
Social marketing is one the proven “high-impact practices” in family planning identified by the HIP partnership and best suited to targeting the barriers to family planning access as listed above. Four systematic reviews of social marketing family planning programs found positive impact on clients’ knowledge of, access to, and use of contraceptive methods.
Social marketing programs make family planning accessible to hard reach communities. This can be done through rural drug shops, mobile outreach, and community-based distribution programs. Importantly, social marketing can help to overcome the specific barriers that young people have to accessing these services. Studies show that family planning clients often find private providers, such as drug shop operators, more acceptable than public sector clinics. Pharmacies and drug shops offer clients proximity, expediency, flexibility in operating hours, and responsiveness to the client’s needs compared to public sector clinics.
Investing in social marketing is effective because pharmacies and drug shops are already a major source of contraception in the majority of countries with a mCPR of less than 20%. The use of these points of service highest in Nigeria, Cote d’Ivoire, the Democratic Republic of Congo, and Cameroon, where more than 40% of women obtained their contraceptive from a pharmacy or drug shop.
Despite their popularity and potential, pharmacies and drug shops have often not been considered part of the larger health system; they are typically missing from countries’ health strategies, policies and regulation, and monitoring. A conducive policy environment means that now is an opportune moment to enter this space. In February 2020, the Minister of Health in Rwanda approved a change in policy that would allow the administration of injectable contraceptives by private community pharmacists, in 2018 the National Drug Authority in Uganda allowed licensed and accredited private drug shops to stock and administer injectable contraception, and as recently as July 2022 the same licensing and accreditation for pharmacies was signed off by the Minister of Health in the DRC, a country of 97.4m.
And where to support them?
The focus of Effective Altruism’s investment should be on countries with highest unmet need for contraception and the slowest annual percentage point growth in modern contraceptive prevalence rate. The vast majority of these countries are in Sub-Saharan Africa where unmet need has decreased by less than two percentage points over the last decade, now standing at 19.9% far above any other world region. For countries such as Somalia, Niger and Chad, unmet need has actually increased over the 2012-22 period because family planning access has not kept pace with the increasing demand for birth spacing and limiting.
Conclusion
Social franchising and social marketing have already helped expand the role of private sector pharmacies and drug shops in increasing access to a range of contraceptives. Evidence shows that with training and support, pharmacy and drug shop staff can facilitate the use of a broad range of modern contraception, especially in areas where the unmet need is high, access to family planning services is poor, and health worker shortages and other barriers prevent women, men, and youth from accessing family planning services.
Supporting and strengthening pharmacies and drug shops to offer family planning, and specifically a broader range of LARCs such as injectables is key. Combining this with social marketing approaches is an effective way to complement public sector provision and expand the impact of a health system. With the conducive policy environment now in place in many Sub-Saharan African countries, a golden window has opened in which to invest in this field.
(Epistemic status: Just writing a quick comment without engaging deeply with the post)
Any intervention that significantly changes population size needs to grapple with population ethics. This cause proposal appears to make some strong assumptions about population ethics (e.g., reducing population size is a good thing) without justifying them. For more on how population ethics affects family planning, see Hilary Greaves' 2015 talk Repugnant Interventions.
I don't think this post made the strong assumptions about population ethics you assume.
More unplanned pregnancies does not necessarily equal larger population. In fact, at the very beginning the post highlights that there are twice as many abortions as unplanned births and more unsafe abortions than unplanned births. Including the still births, that is a lot of preventable human suffering. Is it worth those unplanned births?
I also think it's a bit ignorant to deny sub-Saharan Africa a technology we enjoy - would you also be against birth control use in the US?
Probably not, because the introduction of birth control and family planning did a lot of good - it allowed women to take a lot more control over their lives, some of it translated into the flood of women entering the workplace in the 60's. Roe vs. Wade alone was correlated with a much reduced crime rate in the US. Without contraception, I would have never dared to pursue a PhD and dedicate my career to EA. Is a world where half the population can't plan their futures a better world?
Additionally, more birth control does not equal fewer children. Israel has more access to birth control and legal abortion than many western countries, and it has a higher birth rate than the global average. Secular women in Israel alone have a higher birth rate than any other OECD country. Similarly, Eastern Europe has a lower birth rate than Western Europe despite having more strict control over abortion and birth control.
So the counterfactual does not mean fewer live births necessarily. And maybe it's wiser to try and shape a culture to be more pro-natalist rather than rob people of their choices. With the longtermist framework in mind and the timeframes of childbearing and raising we have the time to do these things, rather than reach for interventions that maximize the single metric that is population size in the short term but could have negative implications on culture and suffering.
I think in order to be against an intervention that gives people more choice you need to make a very strong argument. I also think that you're probably reaching this conclusion because you're underestimating the burden of childbearing. There is a reason why so many women choose to have unsafe abortions rather than give birth.