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Fertility Regulation Behaviors
and Their Costs
Elizabeth Lule
Washington, DC
July 16, 2008
Presentation Outline
Global Trends in fertility behavior
Unmet need for contraception
and unintended pregnancies
Costs associated with Fertility
Regulation
Recommendations and Policy
Implications
Study Methodology
Review existing research on global trends in fertility regulation
behaviors, economic medical and social consequences, costs and
cost effectiveness of interventions
Regional reviews of Africa and ECA with contrasting contexts to
examine the role of contraception and induced abortion and supply
and demand factors
Two country case studies to estimate costs to families, households,
and national health systems
Nigeria: Survey in 8 states, household based survey
interviews of women, interviews of hospital physicians and
cost data collected
Kazakhstan: Three stage stratified sampling of health
facilities to look at provider attitudes and gather direct and
indirect costs and intervention costs
Identify study limitations and research gaps
Identify and discuss policy implications with governments
Trends in Total Fertility Rate by
Region, 1950 -2005
8.0
7.0
6.0
5.0
TFR
4.0
3.0
2.0
1.0
0.0
1950- 1955- 1960- 1965- 1970- 1975- 1980- 1985- 1990- 1995- 2000-
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
Year
High income East Asia & Pacific Europe & Central Asia
Latin America & Caribbean South Asia Middle East & North Africa
Eastern Africa Middle Africa Southern Africa
Western Africa
Sources: UN 2004; World Bank 2007.
Trends in Contraceptive Prevalence Rates
(modern methods) in Select African countries
45
40 Zimbabwe
35
30
25
Kenya
20
Zambia
Tanzania
15 Ghana Uganda
10
Nigeria
5 Rwanda
Madagascar
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Uganda Zimbabwe Tanzania Madagascar Ghana
Kenya Zambia Nigeria Rwanda
NOTE: CPR represents women ages 15-49 years old using modern methods of contraception
Source: Demographic and Health Surveys
Trends in Contraceptive Prevalence Rates
(modern methods) in Select ECA Countries
Source: Westoff 2005
Mean ideal number of children, by
current age of woman in ECA
Source: Westoff 2005
Contraceptive Prevalence Rate (CPR) by
Region and Wealth Quintile
(DHS 1995-2005, most recent country data)
70
60
(% women 15-49)
50
40
CPR
30
20
10
0
East Asia & Europe & Latin Middle East South Asia Sub-
Pacific Central Asia America & & North Saharan
Caribbean Africa Africa
Poorest Quintile Richest Quintile
Note: Regional CPR averages are unweighted.
Source: Demographic and Health Surveys
Unintended Pregnancy and Unmet
Need for Contraception By region and
Pregnancy Outcomes
Unmet need by Region
(205 million)
15% 20%
27%
55%
7% 16%
8%
3%
49%
South & Southe ast Asia Ce ntral Asia
Latin Ame rica & Caribbe an North Africa & We st Asia Induced abortions Unwanted or mistimed births Wanted births S pontaneous abortions
Sub-Saharan Africa
Source: Sedgh G. et al 2007
Mortality due to Unsafe Abortion
700 650
Deaths per 100,000 abortions, 2003
600
500
400 350
300
300
200
100 50
10
0
All Developing Africa Asia Latin America Developed
Source: Ahman and Shah, 2007
Progress Towards MDGs: Inadequate
Trend In Under-five Deaths, 1960-2015 (Millions Deaths Per Year)
25
Africa Asia Other
20
4.1
3.6
15
2.7
1.8
1.4
10 13.5 1.1
10.9 0.8
8.3 7 5.1 4.1 3
5 0.1
2.2
4.1 4.6 4.9 5.1
2.9 3.2 3.5
2
0
1960 1970 1980 1990 2000 2005 2015 with 2015 with
achievement of current Trend
MDGs
Trends in skilled attendant at birth:off track
Source: UNICEF
Direct and Indirect Costs
• Globally, cost to women’s health – 5 million suffer
from disability including infertility, poor mental health
and stigma
• Transport costs are high especially for the poor
• Loss of productivity and earnings
• Hospitalization costs – mean per patient cost
estimated at US $96-$131
• Cost to health systems – In Nigeria, 185,000 cases of
post abortion complications cost $19 million in 2005.
In Kazakhstan, contraceptive use as an alternate to
abortion is at least 3.2 times more cost-effective to
avert one birth
Recommendations and Policy Implications (1)
• Failure to provide access to convenient, safe, affordable
and acceptable choices for contraception appears to
perpetuate unnecessary reliance on abortion
• To reach MDGs 4 and 5, countries and donors need to
address unmet need and growing demand for
contraception especially for young, poor and rural
women and men in developing countries
• Given that contraception is more cost effective than
abortion, countries and donors need to invest more in:
– improving access to contraceptive knowledge and services,
particularly to young women
– ensuring commodity security in the long-term
Recommendations and Policy Implications (2)
• Improve health systems and
overall family planning provision
including supply chains
• Improve access to affordable,
basic social and health services,
particularly education for girls
and labor participation for
women
• More research on socio-
economic impact of unsafe
abortion on women, households
and health systems and
document benefits
Acknowledgements
• Donor support from the Swedish International
Development Cooperation Agency (SIDA),
UNFPA, and the Hewlett Foundation
• Co-authors Susheela Singh and Sadia Chowdhury
and contributing authors
• Other institutions: Guttmacher Institute, Princeton
University, UNFPA, and USAID
Thank You
