While slow and uneven progress has been made on maternal health, attaining the 1994 Cairo International Conference on Population and Development (ICPD) goal for achieving universal access to reproductive health remains elusive for many developing countries. Assuring access to sexual and reproductive health services, including integrated family planning services, remains a critical strategy for improving the health and well-being of women and alleviating poverty. Family planning not only prevents maternal, infant, and child deaths, but also empowers women to engage fully in socioeconomic development and provides them with reproductive choices. This paper will discuss the current landscape of contraception in developing countries, including options available to women and couples, as well as the challenges to its provision. Finally, we review suggestions to improve access and promising strategies to ensure all people have universal access to reproductive health options.
Introduction
The 1994 Cairo ICPD Program of Action was visionary when, among others, it asserted: “Recognize that appropriate methods for couples and individuals vary according to their age, parity, family size preference and other factors (e.g. reproductive stage and intention), and thus policies and programs should ensure that women and men have information and access to the widest possible range of safe and effective family planning methods, in order to enable them to exercise free and informed choice” . Twenty years later, although great strides have been made in access to reproductive health choices, adolescents, women, and couples living in low- and middle-income countries still often lack access to a full range of contraceptive options and to comprehensive reproductive and sexuality education. The Millennium Development Goals (MDGs) offered an aspirational vision for improved health for billions of people worldwide, but reproductive health services such as family planning were not included in the original MDGs due to political pressure from countries opposed to sexuality education for adolescents and abortion .
In the early 2000s, countries and donors focused on significant new health challenges, such as human immunodeficiency virus (HIV), and on meeting the measurable goals specified in the MDGs; funding for contraceptive services dropped, even as the world’s population grew larger and the benefits accrued from investing in family planning became increasingly evident . In 2007, however, MDG 5b target was added, calling for universal access to reproductive health by 2015 (measured by contraceptive prevalence, adolescent birth rate, antenatal care coverage, and unmet need for family planning) . In 2012, at a summit sponsored by the UK Department for International Development and the Bill and Melinda Gates Foundation, wealthy countries pledged over 2 billion US dollars for family planning programming in developing countries; additionally, over 20 developing countries pledged to improve access to contraception through their domestic programs . Contraception is now recognized worldwide as a critical requirement for the health of girls, women, and families. Increasing contraceptive use in developing countries has reduced the number of maternal deaths by 40% over the past 20 years, merely by reducing the number of unintended pregnancies . By preventing high-risk pregnancies, in particular in women of high parity and those that would have ended in unsafe abortion, contraceptive use has reduced maternal mortality ratio by about 26% in just above a decade. However, many challenges remain to ensure that its benefits are available in an equitable manner and with fully informed choice in low-income countries.
Choices and availability of contraception within countries in the developing world
A key determinant for achieving universal access to sexual and reproductive health is ensuring access to and availability and affordability of good-quality methods of contraception. For all persons to exercise a choice among contraceptive options, a range of methods must be readily available . Contraceptive prevalence rate is highest in countries where access to more choices, for example, female sterilization, the intrauterine device (IUD), the pill, injectables, and the condom, is uniformly high. Absence of full choice restricts personal access to each method as well as the use of all methods in a population . To the extent that the ability to choose satisfactory contraceptive protection depends on ready access to multiple methods, there is a clear need for greater policy and programmatic attention to the provision of a full range of methods.
The reality in most developing countries is that only a limited choice of contraceptive methods is offered, particularly within the public sector, and women cannot easily or readily choose the method that best suits their reproductive needs. Although all modern contraceptives are highly effective, for some women long-acting, reversible contraceptive (LARC) methods, such as the IUD and contraceptive implants, are more effective with actual use, as they do not require women to remember to use them with each sex act as with condoms, or daily or tri-monthly as with oral contraceptive pills or injectables. For instance, while oral contraceptive pills are 99.7% effective with perfect use, with typical use 9% of women using the method will become pregnant in a year of use . While some women are able to use oral contraceptives perfectly, or are willing to run the risk of increased chance of pregnancy with imperfect use, other women will prefer a method that is less user-dependent. Because LARC methods require no routine action to maintain their high efficacy, they are equally effective with both perfect use and typical use. Easy accessibility to such methods is, therefore, critical to ensuring women’s contraceptive needs are met.
Other methods must also be available, as every woman has unique needs, which may change throughout her life course. For women with certain medical conditions, combined oral contraceptives can serve simultaneously as an effective family planning method and as treatment for various medical conditions, such as pre-menstrual syndrome or menorrhagia . For women and men who have completed their childbearing, surgical sterilization is an excellent option that does not require use of hormones, which are contraindicated for women with certain medical or other conditions, and has no side effects. Additionally, vasectomy is the only highly effective method for men, although it is particularly underutilized in developing countries and by men of lower socioeconomic status in those countries .
Multiple barriers exist to providing surgical sterilization in developing countries. Often, resources are inadequate to provide any surgical services. Factors impeding access to surgery in low-income countries include poor roads, lack of resources and surgical expertise, and the high costs of surgical care . In general, permanent contraceptive methods have higher upfront costs than do shorter-acting or LARC methods, and as with LARC methods the materials necessary to perform the procedures often fail to be included in essential medication and medical supply lists. They also are often left out of programmatic strategies that focus heavily on provision of commodities rather than services. However, family planning programs that do not include permanent methods fail to offer complete and full choice, and are thus short-changing families for whom such options would be best .
Many women rely on traditional methods of contraception, particularly in developing countries. These methods range in effectiveness. Some are backed by evidence, such as fertility awareness methods, which range from 0.4% to 5% failure rates with 1 year of perfect use and approximately 24% with typical use . Withdrawal can also be fairly effective with perfect use, although with typical use 22% of couples using this method will become pregnant in 1 year . Similarly, lactational amenorrhoea, when practiced correctly, is highly effective temporarily, for a maximum of 6 months post-partum . However, many women and couples who are using “traditional” methods either do not use these methods in such a manner as to be able to rely on high efficacy, or use other traditional methods that are less effective, such as the rhythm method, periodic abstinence, or other traditional methods such as herbs or other practices that may vary significantly depending on the country and region. The appeal of these methods for some women is significant; they may seem more natural and less likely to cause side effects, may be more acceptable to male partners, and are accessible without having to visit a health provider for initiation or continuation, allowing for better accessibility and privacy . Unfortunately, many people using these methods are likely unaware of their limited efficacy when used typically (for science-based fertility awareness methods), the limited amount of time they are effective (for lactational amenorrhea), or the lack of evidence suggesting that they are effective at all (for many other traditional methods). Even couples using fertility awareness-based methods that are based on good evidence who participated in trials, in which there was a higher degree of support to continue the method than would be expected in typical practice, had very high method discontinuation rates . Many couples choosing such methods may be therefore expected to use them incorrectly or to discontinue their use quickly. As a result, people may be using methods they think will be more effective than they are, and are thus at risk for unintended pregnancy and its attendant potential harms.
Although emergency contraception is not a regular, long-term contraceptive method, it can play a key role in preventing unintended pregnancy when other methods were forgotten, failed, or in a situation where a woman was unable to negotiate contraceptive use. Emergency contraception has failed to show a net pregnancy prevention benefit on a population level , and is usually less effective at preventing pregnancy than regular contraceptive methods, but remains a critical option for preventing pregnancy in certain situations . Emergency contraceptive pills, such as levonorgestrel, are widely available and are included in the WHO Essential Medicines List, but accessibility remains limited due to the lack of their inclusion in national health-care programs, family planning social marketing efforts, and educational programs . A newer emergency contraceptive pill, ulipristal acetate, may be more effective at preventing pregnancy than levonorgestrel, especially when more than 72 h have passed since intercourse or the woman weighs more than 70 kg , but is more expensive than levonorgestrel and is not yet widely available in many developing countries , nor is it on the WHO Essential Medicines List . Another option for post-coital contraception, the copper IUD, is highly effective regardless of weight, and is effective for up to 7 days after unprotected intercourse, but is not widely available to many women on a scheduled, much less urgent, basis in many high-income countries , let alone low-income countries. Quick availability of emergency contraceptive methods is particularly important in the context of post-rape care, gender-based violence, and in settings where women have limited opportunities to access and use regular contraceptive methods. All women accessing emergency contraceptive services should be offered the opportunity to initiate a more effective regular contraceptive method. The copper IUD is an ideal emergency contraceptive for women who wish to initiate regular contraception, as the method both works as an emergency contraceptive and is a highly effective LARC method.
Method mix and choice
Although a wide range of contraceptive options is critical to ensuring women and couples can exercise their rights to reproductive options, many countries fail to offer a broad mix of methods. Additionally, many people continue to rely heavily on less-effective or ineffective “traditional” contraceptive methods. An analysis by Sullivan et al. reviewed comparative method mixes that were unbalanced, defining as skewed if a single method constituted 50% or more of all contraceptive use in a country . Of 96 countries, 34 had a skewed method mix, 16 in which traditional methods dominated, especially in sub-Saharan Africa; four in which female sterilization was predominant, in India and three Latin American countries; and 14 that relied either on the pill, or IUD, or injectables, spread across various regions. Such a skewed method mix most likely is indicative of lack of true choice and options, given the stark contrast between the methods used by women in countries where women have ready access to multiple contraceptive methods and the methods used by women in countries with fewer choices. Women in the UK, for instance, use a wide variety of methods, including pills, LARC methods, permanent methods, and traditional methods. Meanwhile, in countries such as Indonesia and Kenya, fewer women are using long-acting or permanent methods, and more are relying on shorter-acting methods such as oral contraceptive pills or injectables. Although Indonesia has a much higher rate of modern contraceptive use (61.9%) than Kenya (38.9%), similar percentages of women in both countries use less reliable methods for contraception. Finally, in Nigeria, where the rate of modern method use is quite low (8.8%), fewer than 10% of women using a method are using long-acting or permanent methods, while nearly half of those using a method are using less reliable traditional methods ( Fig. 1 ). Although variability is to be expected from region to region in which methods are preferred, it is unlikely that the observed differences solely reflect women’s preferences. Rather, women do not have access to a full range of options in some countries, and the methods they use (or do not use) reflect the lack of access.
Personal choice is critical to initiation and continuation of contraceptive use. In settings with access to more contraceptive methods, a greater mix of methods are used . Women who are given a full range of choices, with full information, may be more likely to continue their method and to be more satisfied with their method, although evidence for this is limited . Regardless, human rights principles dictate the need for full information and choice to the greatest extent possible . This need for personal choice among contraceptive options presents the need for the availability of multiple methods. A recent review on trends in contraceptive use found that, although the use of modern contraceptive methods has increased between 2003 and 2012, in regions and subregions of developing countries, unmet need for contraceptives was still very high. In 2012, 222 million women had an unmet need for contraception, especially in sub-Saharan Africa (60%), South Asia (34%), and Western Asia (50%) . To meet this unmet need, the authors concluded that countries need to increase resources, improve access to contraceptive services and supplies, and provide high-quality services and large-scale public education interventions to reduce barriers to contraceptive use.
The role of choice and access in contraceptive use
Even though access and choice are limited in many countries, these are precisely what is required to ensure more women use contraceptive methods. Although there is a paucity of information regarding whether having multiple methods to choose from impacts contraceptive use on an individual level , countries with a broader method mix have been noted to have higher contraceptive prevalence. In a review of survey data on contraceptive use from 80 countries, the prevalence of use for five modern contraceptive methods was correlated with a variety of access measures . Greater access was accompanied by a better balance among methods for both access and use. In the same study, this trend was also seen in sub-Saharan Africa, though at lower levels. Studies during the early emergence of contraception showed that the addition of each new method raised contraceptive prevalence. In Thailand, when the contraceptive pill was added to the family planning program through the national network of auxiliary nurse midwives, its use was double of that for the preexisting methods . In Egypt, regulatory constraints to IUD provision were removed and the new Copper-T IUD was introduced, leading to a doubling of contraceptive use .
Improved contraceptive choice and access could reduce unmet need for family planning; however, even with improved availability, women’s concerns about side effects, difficulties negotiating contraceptive use with partners, and a multitude of other barriers could all prevent effective use of contraceptive methods . Some of these barriers could be overcome with improved contraceptive technology, as methods with fewer side effects and that are less dependent on perfect use by the woman and partner agreement are developed. If methods-related reasons for nonuse of modern contraception could be overcome, unintended pregnancies could be reduced by as much as 59% in sub-Saharan Africa and South-Central and Southeast Asia .
Health workforce
In order to ensure that unmet need for contraceptives is decreased, significant health workforce investments must be made. Fortunately, unlike many higher-level functions, most contraceptive provision can be performed by mid-level providers, such as nurses, and some can be performed in the community by trained lay health workers and pharmacists. The World Health Organization recommends that, in the context of monitoring and evaluation, lay health workers may provide initiation and continuation of injectable contraceptives. Additionally, nurses and nurse midwives may insert and remove contraceptive implants and IUDs, and advanced-level associate clinicians may provide vasectomy and tubal ligation . Emergency contraceptive pills are available without a prescription to women through community pharmacies in many countries, which has been shown to increase timely access to the method . Pharmacists in some settings are taking active roles in provision of some contraceptive methods, such as injectables and oral contraceptive pills , and given the greater flexibility in the hours they are open and more convenient location may become key players in contraceptive provision in the future.
Contraception and equity
Contraceptive use has increased markedly worldwide in the past half-century. Unfortunately, these gains belie the uneven progress that has been made. While women living in wealthy countries increasingly use contraception, and use a wide range of methods, there remain significant gaps in use between the rich and the poor, and substantial regional variations in contraceptive use. A study of 55 developing countries with Demographic and Health Surveys (DHS) data available showed that modern contraceptive prevalence is substantially lower regardless of income group in sub-Saharan Africa, and to some degree in Latin America and the Caribbean, when compared to Asian countries . The study also found that countries with the greatest income inequality similarly had the greatest inequality in contraceptive use, with the poor less likely to use modern contraceptives, and that this inequality has increased over time. Another study of DHS data from 54 developing countries found that family planning was among the most inequitably distributed interventions in maternal, newborn, and child health, with 67% of people in the top economic quintile reporting their needs were satisfied, compared with 41.4% of people in the bottom economic quintile . The poorest women are also the least likely to be exposed to educational messages about the benefits of family planning .
There is evidence that, where significant public investment is made into family planning programs, these gaps are less prominent. For instance, in Bangladesh, where equity and health has been a subject of concerted effort and contraceptive programs have been a focus of investment for years , married women in the richest and poorest quintile are equally likely to be using a modern contraceptive method. On the other hand, significant differences by wealth quintile are evident in both Malawi, where great efforts to increase contraceptive use have been made , and in the Democratic Republic of the Congo (DRC), where contraceptive prevalence is very low for all wealth quintiles at <6%. In Malawi, 34.9% of women in the poorest households use a modern method, compared with 48.4% of those in the richest households. In DRC, <3% of the poorest women use modern methods, compared with 14.9% of women in the highest income quintile ( Fig. 2 ). Access to contraceptive methods, and the creation of conditions enabling their use, must be considered through a lens of equity. Promising potential service delivery mechanisms that may improve equity of access include voucher programs targeting poor populations .
Challenges, barriers, and cultural restraints to use of modern contraception
Although the benefits of modern contraception to women’s health outweigh the risks (real or perceived), barriers and challenges remain. Limited access to and choice of contraceptive methods are among the critical challenges. Unmet need remains high among the most vulnerable groups, such as the poor and young people. The barriers to serving the most vulnerable have not, however, been well elucidated in developing countries. Potential challenges include negative user attitudes towards contraception, provider beliefs, and those arising from the culture and health systems. Users who only infrequently engage in sexual activity may not believe they need contraceptives; additionally, many people are familiar with only a limited number of methods, or may subscribe to traditional and/or religious belief systems that preclude contraceptive use .
In a systematic review of 12 studies (six from sub-Saharan Africa, one from Southeast Asia) assessing the barriers to use of contraceptives in developing countries, hormonal method use was limited by lack of knowledge, obstacles to access, and concern over side effects especially fear of infertility . Although condoms were often more accessible, their use for contraception was limited by association with disease and promiscuity, together with greater male control. The review concluded that increasing modern contraceptive method use requires a community-wide, multifaceted intervention and the combined provision of information, life skills, support, and access to youth friendly services. Interventions should aim to counter negative perceptions of modern contraceptive methods and the dual role of condoms for contraception and sexually transmitted infection (STI)/HIV prevention should be underscored continuously.
A review of research evidence and programmatic experience on needs, barriers, and approaches to access and use of contraception by adolescents in low- and middle-income countries concluded that all adolescents, especially unmarried ones, face a number of barriers in obtaining and using contraception . The authors recommended enacting and implementing laws and policies on provision of sexuality education and adolescent-friendly health services, providing contraception through a variety of outlets and building community support for adolescent services.
A study among women in Nigeria proffered the most commonly perceived barriers accounting for low contraceptive use as perceived side effects (44%), ignorance (32.6%), misinformation (25.1%), superstition (22.0%), and cultural factors (20.3%) . Predictors of use of modern contraceptives included the awareness of a place of family planning service provision, respondents’ approval of the use of contraceptives, higher education status, and being married. The authors proposed to address the low point prevalence of contraceptive use through: community-based behavioral change communication programs that bridge the knowledge gap to address deep-seated negative belief systems. In a review on family planning in sub-Saharan Africa, attitudinal resistance was posited to be the cause of slow progress towards adoption of family planning in Western Africa .
The cost of family planning programs and methods may be a barrier to their wide availability in some developing countries. Some methods, particularly long-acting and permanent methods, are associated with significant initial costs, although their yearly costs tend to be less than yearly costs for injectables, pills, or condoms (notably, contraceptive implants cost a similar amount per year of use as other hormonal methods). It is estimated that providing improved, modern contraceptive services to all women with an unmet need for family planning would cost $8.1 billion ($3 billion more than current expenditures), and these increased costs would predominantly be borne by low- and middle-income countries . However, these costs lead to net benefits for those countries that invest in contraception; each $1 spent saves approximately $1.40 in maternal and child health services . Additional economic and noneconomic benefits from the fertility decline enjoyed by countries that invest in family planning include increased per capita income, improved social and economic standing for women, and healthier, better-educated children in future generations .
Increasing access to, and utilization of, family planning services
With all the benefits that accrue to women, families, and society in general when family planning services are used, increasing access to them, and their use, is clearly important. FP2020 has laid out a clear mandate to increase the number of contraceptive users to 120 million by 2020, in order to rally global support with a measurable outcome . While this goal is admirable, it is critical that women’s rights be maintained in the quest to achieve it, and that contraceptive use is truly voluntary. For human rights to be upheld, contraceptive services must be offered without coercion, with attention to adequate supplies, removal of barriers to access, and high-quality services . A framework has been proposed to ensure that family planning programs maintain human rights standards , and the World Health Organization recently issued guidelines on human rights in family planning service provision .
Despite the clear need, and decades of work on family planning programming, with a few exceptions it remains unclear which societal factors are most important to increased family planning uptake, and which programming strategies are most beneficial. Although improved economic conditions and effort put into programming are associated with increased contraceptive uptake , understanding of the specific programmatic interventions that are most beneficial remains elusive. This may be at least in part due to the complex nature of decisions within families about when to have children. A systematic review found that the majority of both supply-side and demand-side interventions had a beneficial effect on increasing contraceptive use (found in 36 of 49 studies published between 1995 and 2009), although fewer studies were able to show an effect on fertility-related measures such as unintended pregnancy or abortions (found in six of 13 studies included). It is notable that relatively few of the studies (only 13 of 63 identified) reported on these fertility-related measures , although these are truly the outcome of interest for policy-makers. Additionally, little information is available on the population-level impact of male involvement, public–private partnerships, and voucher programs, as well as the comparative costs of various programmatic strategies.
Creation of a conducive policy and programmatic environment
A conducive policy and programmatic environment is a major prerequisite for the successful access and uptake of family planning service. Successful family planning programs have been noted to include the components indicated in Table 1 .
