INTRODUCTION
Have you ever imagined not being able to control your own fertility? According to the United Nations Population Division, in 2019, 190 million women worldwide reported that although they did not want to become pregnant, they are not using any method of contraception. This gap represents ten percent of all women of reproductive age worldwide, and is referred to as the unmet need for family planning. With an increasing number of women of reproductive age each year, the gap has remained the same as twenty years ago. The number of women with unmet needs has gone up by 34 million since 2000 [1].
Closing this gap would come with a number of important benefits. At the individual level, family planning helps women and couples gain control over their fertility, and can improve their economic situation; prevents a number of sexual and reproductive health risks; and has positive effects on women’s empowerment. At the global level, family planning helps countries manage unsustainable population growth, which in turn creates progress towards development goals, helps the environment, and improves animal welfare. Although family planning is less neglected, with recent commitments to increase funding allocation to family planning programs, there is a relatively large body of evidence on how to tackle the different barriers to contraception and little prioritization work. This makes progress in this field potentially cost-effective. Charity Entrepreneurship (CE) has therefore decided to dedicate part of our research to this area in 2020. Through a systematic research process, we aim to identify the best idea for a new charity to be founded in this space. This post goes over why we think family planning is an important cause area, why CE is well-positioned to have an impact in this field, and what the potential limitations are.
WHY IS FAMILY PLANNING AN IMPORTANT CAUSE AREA
The scale of family planning needs worldwide is huge. Close to 200 million women are unable to get information on, access, or afford these services. This has a number of effects on health, income, women’s empowerment, growth, and sustainable development.
IMPACT ON HEALTH
Maternal health: A lot of progress in the area of maternal health can be made through improved contraceptive use. About 89 million pregnancies in 2017 were unintended, resulting in 30 million unplanned births, and 48 million induced abortions. Out of the 308,000 women who die each year from pregnancy-related causes, 76,000 could be prevented by universal contraceptive coverage. Although improving coverage of quality maternal care is crucial, improving access to family planning is generally less costly than direct maternal care [2].
Source: Darroch JE, Sully E, Biddlecom A., Adding it up: investing in contraception and maternal and newborn health, 2017. Fact sheet. New York: Guttmacher Institute; 2017.
Mental health: Pregnancy can lead to mental disorders such as postpartum depression, which affects 10% of women worldwide after childbirth, and close to 20% of women in developing countries [3]. A systematic review of the evidence on determinants of postpartum mental disorders suggests that accidental pregnancy is associated with a higher risk of these conditions [4]. Adolescent health: Even though they do not necessarily identify with family planning, unmet needs for contraception for adolescent girls (15-19 years old) is twice larger than for all women of reproductive age. For young girls, complications during pregnancy and childbirth are the leading cause of death, and 3.9 million adolescent girls undergo unsafe abortions every year. Young women are also more at risk of having obstetric fistula, a condition which affects two million young women in sub-Saharan Africa and Asia. It is an abnormal opening between the urinary tract or rectum and the birth canal, and results in incontinence and health issues. It also leads to great mental suffering for women affected, due to shame and social segregation. Addressing this issue through surgery is one of GiveWell’s priority programs [5], but there are also ways to prevent it altogether. One of the main solutions recommended by WHO to avoid obstetric fistula is to delay the age at first pregnancy [6], which is why adolescent girls could benefit greatly from higher access to family planning and contraceptives. Neonatal health: Helping mothers and couples plan their pregnancies prevents women from having children too early, and can space their births to preserve their health and that of their babies. Every year, 2.7 million babies die in the first month of life [2]. A WHO working group notes that a birth-to-pregnancy (BTP) interval shorter than six months is associated with higher risks of stillbirths, and a BTP shorter than 18 months is associated with higher risks of neonatal mortality (up to 28 days old) [7]. HIV and other sexually transmitted diseases: Some forms of contraception, such as condoms, prevent the transmission of HIV, which killed 770,000 people in 2018 [8]. Condoms also protect people from other sexually transmitted infections (STIs) such as the human papillomavirus (HPV), which causes 300,000 deaths from cervical cancer each year; and syphilis, which caused 200,000 stillbirths among pregnant women in 2016 [9].
IMPACT ON INCOME AND POVERTY
Through research into the most cost-effective development policies, the Copenhagen Consensus recommended expanding access to contraception universally as the third-best policy with a return to investment estimated at $120 per dollar spent [10]. Their calculation encompasses many benefits beyond economic ones, but let’s focus on the economic aspects briefly. Education: Increasing access to contraception can reduce teenage pregnancies, and have a direct impact on keeping girls in school. The Center for Global Development (CGD) has summarized the evidence on educational and economic effects of family planning, and notes that increased family planning access results in longer education, greater participation in the labor force, and improved earnings [11]. Moreover, certain interventions work on both levels, incentivizing girls to stay in school while lowering their chances to get pregnant and drop out as a result. Some of these incentives include sharing information to parents about future economic opportunities for their young daughters - which may lead us to conclude that the best contraceptive is hope. A study conducted by J-PAL has found that this pushes parents to invest in girls’ education, which in turn delays child marriage and early childbearing. Additionally, there is evidence that more educated women have a higher opportunity cost of bearing children, which means that if young girls stay longer in schools, they not only delay the age at which they have their first child, they are also more likely to have fewer children later in life [12]. Opportunity cost of health care: Pregnancy and maternal health require a lot of care and attention. Contraception prevents these future health care needs, lessening their burden for the women and the family’s income. Requirements can include antenatal care visits, abortion (which concerns around 35% of women, and is frequently unsafe in countries where it is not legal [13]), postpartum care, etc. Additionally, income is lost during the final months of pregnancy and when the baby is born. Again, we are speaking about women who did not initially want or plan the pregnancy. Family size: Finally, smaller families share a higher income per head, which might mean more investment in each child.
IMPACT ON WOMEN’S EMPOWERMENT
More equal opportunities and autonomy: Pregnancy restricts women from a lot of opportunities, putting them at a disadvantage compared to men. Enabling women to have control over their pregnancies can enhance gender equality and a woman’s overall autonomy in her life.
Overcoming social and cultural norms: Access to contraception does not always translate to use, which can be challenged by social and cultural norms. For example, data from Demographic and Health Surveys (DHS) indicate that, in many countries, men desire larger families than women. Decision power is often held by the husband in the household, lowering a woman’s control over her fertility even when contraception is accessible. For this reason, family planning also needs interventions to tackle these social and cultural barriers. When contextually appropriate, the best program might focus on promoting communication within the couple, or teaching husbands about maternal health risks of repeated pregnancies. Such interventions could have benefits beyond contraceptive use and improve women’s decision-making power in the household.
Reduced sexual vulnerabilities: Controlling fertility is even more challenging in non-consensual sex, which affects a shocking number of women in low resources settings. A study in Liberia found that for 30% of young women, their first sexual encounter was nonconsensual [14]. Although it does not tackle the problem at its core, which requires changing men’s attitudes and behaviors, female contraception (e.g. oral contraceptive pill) can be a way to reduce rape-related pregnancies, which is one of the consequences of sexual violence.
IMPACT ON POPULATION GROWTH AND SUSTAINABLE DEVELOPMENT
All benefits discussed so far operate at the individual and human level. But expanding family planning access offers benefits at the country level and for animals, too.
Population growth: Expert opinion here seems mixed. Some economists have argued that family planning programs do not contribute to fertility changes at the macro level, but some evidence suggests that it can influence a portion of these outcomes at the country level. The proportion of country level fertility change attributed to increased access to family planning varies among researchers. Some argue that it explains 4% to 20% [15] of the change, while some have argued an increase in 0.2 standard deviation in family planning efforts can lead to 0.4 fewer children per woman [16].
Sustainability and climate change: Slowing population growth would benefit sustainability and climate change. Project Drawdown, which assesses the best policies to tackle climate change, recommends family planning as the seventh-best of 100 ideas to reduce worldwide carbon emissions. It estimates that if contraception were accessible to all women and girls, the effect on population would reduce global emissions by 51.48 gigatons of carbon dioxide - the equivalent of China’s total emissions over five years.
Counted over a lifetime, a meat-eating population leads to a huge amount of animal suffering. Fewer people born per household ultimately reduces consumption. Preventing unintended births thus also impacts animal welfare.
WHY IS CE WELL-POSITIONED TO HAVE AN IMPACT NOW
Family planning may have large benefits and ripple effects on various sectors, and is a large problem at scale. But can entrepreneurs have an impact in this field? The answer depends on the funding available for this type of work, the evidence that family planning programs improve contraceptive use, and how cost-effective existing NGOs are.
INCREASING FUNDING AND MOMENTUM
Although neglectedness can be an important factor to identify promising cause areas, lack of funding can be a limiting factor in scaling a promising intervention. Family planning seems to be a promising cause from both these perspectives. It has been previously neglected in the global health space, but has seen a recent increase in allocated resources. This opens opportunities to scale effective programs [17]. Last year, funding commitments among large donors have increased by $870 million, raising the total funding to a bit more than a billion a year [18]. The Bill and Melinda Gates Foundation has increased its funding by $370 million, in addition to its existing funding in 2020. Canada has committed an additional $188 million dollars as well. The largest increase has come from the UK Department For International Development (DFID), who recently decided to double their allocation from £351 million to £600 million over the period 2020-2025 [19]. Stakeholders involved in the space have coordinated for the past few years around a structure called FP2020. This has helped improve cooperation, coordination, and accountability of commitments towards family planning goals. This illustrates the growth of an international movement for family planning, focused on achieving its goals.
THE EVIDENCE
There is rigorous evidence on the effectiveness of different contraception methods, and the WHO states efficacy rates of different methods with confidence. However, when evaluating programs, knowing how many contraceptives were distributed or are available at the clinic is not enough: it is also necessary to increase the number of women using these contraceptives. The current gap is the result of a number of barriers to using contraception, including lack of access to services; lack of information about the availability, efficacy and safety of different methods; and cultural and social barriers to using contraception. A large number of rigorous studies have tested different ways to overcome these barriers, including a number of randomized controlled trials. We have found several evidence maps illustrating the existence of impact evaluations and systematic reviews on behavioral and community engagement interventions to improve reproductive health [20], as well as interventions targeting adolescent sexual health [21]. Additionally, a study aiming to develop an impact framework for family planning interventions has searched all quantitative papers evaluating programs in this field, and found 96 relevant studies [22]. Compared to other sectors of global health and development there seems to be a greater amount and higher quality of evidence than some sectors (e.g. governance), but not as much as others (e.g. child health).
COST-EFFECTIVENESS
Family planning has not had as much attention from global health and development actors as other areas of health. This is partly because it is a sensitive and political topic, but also because it may be hard to find cost-effective solutions. However, cost-effectiveness comparisons often focus on one endline metric and may neglect the multiple benefits of family planning across cause areas. When all of these are taken into account, we believe it could be as cost-effective or more so than other possible interventions. Some organizations are already doing impactful work. Development Media International (DMI), a GiveWell standout charity, and Population Services International (PSI), recommended by The Life You Can Save, use rigorous evidence to estimate and improve the effectiveness of their programs. However, there does not seem to be much research comparing different interventions and finding those that should be prioritized for funding and scale-up. This leads us to believe that there might be interventions which are more cost-effective than the average programs currently implemented, and therefore that there is value in doing rigorous comparative research. Although there is a reasonable amount of evidence out there, rigorous evidence and cost-effective considerations are used less than they should be in creating family planning programs [18]. At least three experts we talked to during the first stage of our research confirmed this. Some actors, such as the USAID and FP2020 collaboration, have allocated great efforts to develop guidelines, such as the High Impact Practices briefs, to disseminate best practices using evidence-based approaches. However, there seems to be a long way to go for these guidelines to be perfectly used and implemented. Additionally, they do not provide a comparison of the best programs but promote all evidence-based programs equally, and do not take into account cost-effectiveness systematically. This makes it hard for us to draw conclusions based on their research. In sum, it seems that a lot of time has been spent on what works in family planning, but none on what works best.
ARE THERE POTENTIAL LIMITATIONS TO FOCUSING ON THIS AREA?
MORAL UNCERTAINTIES
One of the main metrics we focus on for this area of research is the number of unintended births averted. The cost-effectiveness of this intervention - as well as the way it is estimated - depends on one’s ethical theory. How much should we care about a person's happiness and suffering (hedonic well-being)? Or should we ultimately value fulfilling what someone wants, whatever that may be (preferences)? If the latter, then how can we make a direct comparison between the preferences of the mother, and the preferences of a child whose birth was averted? Should the preferences of a being that will not come to existence be counted at all? There is currently no consensus on how those questions should be addressed, and methods currently used are limited in the types of questions they answer. At Charity Entrepreneurship, we use an internally-developed model to assign moral weights to different outcomes (although we recognize that this is still highly imperfect). We will soon publish the details of the model.
LOGISTICAL DIFFICULTIES
Family planning programs are complex and require a good understanding of existing health systems. Whether the goal is to improve the supply or demand for family planning services, the interventions we are considering are rarely isolated and need to consider contextual dynamics, systems, and actors. Although these considerations apply across other health areas, it appears to be most important in this field given its relation to sexuality, a taboo topic in most societies. Working on such sensitive issues requires trust from the population, and entrepreneurs may need to partner with a well-trusted existing organization to implement new programs. If the program is not careful enough about potential coercive forces, it can also have unintended negative consequences. In the sphere of social and behavior change, incentivizing women to use certain types of contraceptives could push them to go for a contraceptive that is not appropriate for them, for example, leading them to drop contraception altogether. It could even change their contraceptive decisions in ways that do not match their fertility preferences, which is not the objective at all. In some cases, it can put a woman in a vulnerable position towards her husband, who is often very much involved in these fertility decisions. As such, family planning is a delicate field, in which entrepreneurs will have to pay close attention to women’s well-being and preferences towards contraceptives.
MAXIMIZING MULTIPLE POSITIVE EFFECTS
Family planning has a variety of benefits, which can be stronger or weaker depending on the intervention selected and population targeted. Maternal health, empowerment, education and income, population management, are all desirable - but it is hard to pick an intervention that maximizes all of them. Some trade-off between these outcomes will be necessary. This makes the equation a little more complex than a typical linear intervention.
POTENTIAL PROBLEMS WITH METRICS
Availability of contraceptives does not always mean women can access them. If women do have access, they do not necessarily use them. And if they do use them, they do not necessarily use them correctly. There are many intermediary outcomes between the actions and the end metric we care about. This may force implementers to use speculative conversions to monitor their program and measure their impact. A lot of endline outcomes themselves are also very ambiguous and difficult to grasp. There’s uncertainty about how accurately metrics used in the existing evidence and programming captures the reality. The complexity of the outcomes lies in the intentions. In contrast to disease prevention, where it is clearly desirable for people to be protected, having a child is usually considered a good thing. It can be hard for implementers to assess whether there’s a need for family planning. Current surveys still struggle to capture fertility preferences, because it’s hard for parents to talk about an unplanned birth, and often rationalize after the birth. Monitoring data relies on such tricky questions to assess gaps in access (more detail on these instruments and potential bias in DCP3).
CAN BE CONTROVERSIAL
Family planning lacks worldwide consensus. For example, Republican president Donald Trump reinstated and expanded the Mexico City Policy, which restricts funding for NGOs working on abortion. The controversy surrounding family planning (despite its many benefits) is a limiting factor for entrepreneurs, as depending on how the program is communicated and framed, funding may be restricted.
REFERENCES
1. United Nations Publications. Family Planning and the 2030 Agenda for Sustainable Development (Data Booklet). UN; 2019.
2. Darroch JE, Sully E, Biddlecom A. Adding it up: investing in contraception and maternal and newborn health, 2017. Fact sheet. New York: Guttmacher Institute; 2017.
3. WHO | Maternal mental health. World Health Organization; 2015 [cited 2020 Jan 31]; Available from: https://www.who.int/mental_health/maternal-child/maternal_mental_health/en/
4. Fisher J, de Mello MC, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review [Internet]. Bulletin of the World Health Organization. 2012. p. 139–49H. Available from: http://dx.doi.org/10.2471/blt.11.091850
5. Hollander C. Update on our work on Fistula Foundation - The GiveWell Blog [Internet]. The GiveWell Blog. 2020 [cited 2020 Jan 31]. Available from: https://blog.givewell.org/2020/01/02/update-on-our-work-on-fistula-foundation/
6. WHO | 10 facts on obstetric fistula. World Health Organization; 2018 [cited 2020 Jan 31]; Available from: https://www.who.int/features/factfiles/obstetric_fistula/en/
7. Who. Report of a WHO technical consultation on birth spacing. WHO Geneva, Switzerland; 2005.
8. Global HIV. AIDS statistics—2018 fact sheet. UNAIDS website unaids org/en/resources/fact-sheet Accessed May. 2019;31.
9. Sexually Transmitted Infections (STIs). J Midwifery Womens Health. 2013;58:601–2.
10. The Economist | Copenhagen Consensus Center [Internet]. [cited 2020 Jan 31]. Available from: https://www.copenhagenconsensus.com/post-2015-consensus/economist
11. Reproductive Choices to Life Chances: New and Existing Evidence on the Impact of Contraception on Women’s Economic Empowerment [Internet]. Center For Global Development. [cited 2020 Jan 31]. Available from: https://www.cgdev.org/publication/reproductive-choices-life-chances-new-and-existing-evidence-impact-contraception-women
12. Pradhan E. Female education and childbearing: A closer look at the data. World Bank Blog http://blogs worldbank org/health/femaleeducation-and-childbearing-closer-look-data. 2015;
13. Darroch JE, Sully E, Biddlecom A. Adding It Up: Investing in Contraception and Maternal and Newborn Health, 2017—Supplementary Tables. New York, NY: The Guttmacher Institute [Internet]. 2017; Available from: https://www.rhsupplies.org/uploads/tx_rhscpublications/Adding_it_up._Investing_in_Contraception_and_Maternal_and_Newborn_Health__2017_-_Supplementary_Tables.pdf
14. Sexual Violence against children, mentoring programs, and small cash transfers [Internet]. World Bank Blogs. [cited 2020 Jan 31]. Available from: https://blogs.worldbank.org/impactevaluations/sexual-violence-against-children-mentoring-programs-and-small-cash-transfers?CID=WBW_AL_BlogNotification_EN_EXT
15. Miller G, Babiarz KS. Family Planning: Program Effects [Internet]. National Bureau of Economic Research; 2014. Available from: http://www.nber.org/papers/w20586
16. Günther I, Harttgen K. Desired Fertility and Number of Children Born Across Time and Space. Demography. 2016;53:55–83.
17. Lomborg B. Why Family Planning Is a Smart Investment by Bjørn Lomborg [Internet]. Project Syndicate. 2019 [cited 2020 Jan 31]. Available from: https://www.project-syndicate.org/commentary/family-planning-universal-access-benefits-by-bjorn-lomborg-2019-10?barrier=accesspaylog
18. The Future of Family Planning – Podcast with Rachel Silverman [Internet]. Center For Global Development. [cited 2020 Jan 31]. Available from: https://www.cgdev.org/blog/future-family-planning-podcast-rachel-silverman
19. Department for International Development. Healthcare for everyone must prioritise women’s sexual and reproductive health and rights, says UK at UN General Assembly [Internet]. GOV.UK. GOV.UK; 2019 [cited 2020 Jan 31]. Available from: https://www.gov.uk/government/news/healthcare-for-everyone-must-prioritise-womens-sexual-and-reproductive-health-and-rights-says-uk-at-un-general-assembly
20. Map G. Social, behavioural and community engagement interventions for reproductive, maternal, newborn and child health. 2017; Available from: https://www.3ieimpact.org/sites/default/files/2018-02/egm-11-rmnch.pdf
21. Rankin K, International Initiative for Impact Evaluation (3ie), Jarvis-Thiébault J, Pfeifer N, Engelbert M, Perng J, et al. Adolescent sexual and reproductive health: an evidence gap map [Internet]. 2016. Available from: http://dx.doi.org/10.23846/egm0005
22. Weinberger M, Williamson J, Stover J, Sonneveldt E. Using Evidence to Drive Impact: Developing the FP Goals Impact Matrix. Stud Fam Plann. 2019;50:289–316.
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