Dr. Anne Peterson, MD, MPH explains how using family planning to safely time and space births improves maternal and child health and survival and reduces abortion rates. Dr. Peterson also explains how recent research has shown previous beliefs that some contraceptive methods were abortifacients to be inaccurate.

1. Family Planning:
Contribution to Health
& How it Works
Epidemiology Disease of Major
Importance
Fall Trimester

2. WHO definition



Family planning allows individuals and
couples to anticipate and attain their desired
number of children and the spacing and
timing of their births.
It is achieved through use of contraceptive
methods and the treatment of involuntary
infertility.
A woman’s ability to space and limit her
pregnancies has a direct impact on her health
and well-being as well as on the outcome of
each pregnancy.
◦ Decreases mother, infant & child death rates
◦ Can reduce abortion rates
◦ Assists in prevention of AIDS

5. Better Birth Spacing Saves the Lives of
Children

6. Maternal Factors Associated with
High Infant Mortality

Age of mother at birth
◦ too young or too old






Preceding birth interval: too short
Birth order: too high
Birth size: small/below average
Availability of care
Access to care
Education

7. Risk of death among under-five children with a
preceding birth interval of 36-41 months
compared to risk of death at other birth
intervals
317%
316%
300%
Relative risk (percent)
281%
200%
151%
143%
140%
126%
137%
116%
105%
100%
105%
100%
82%
0%
<18
18-23
24-29
30-35
36-41
42-47
48-53
54-59
60+
Duration of preceding birth interval (months)
Neonatal Mortality
Infant Mortality
Under-Five Mortality
Perinatal Mortality
Source: United States Agency for International Development (USAID), Bureau for Global Health, Office of Population and Reproductive Health, Washington,
D.C. 20523-3600. December 2002. (WWW.USAID.GOV)

8. Positive Outcomes When
Pregnancies well timed
Children born 3 but less than 5 years apart compared
to children born less than 2 years apart are:




1.5
2.2
2.3
2.4
times
times
times
times
more
more
more
more
likely
likely
likely
likely
to
to
to
to
survive
survive
survive
survive
first 7 days
first 28 days
first year
to age 5

After A Miscarriage: spacing < 6 months more than
2x as likely to have low birth weight or preterm
delivery compared to spacing of 18- 23

Closely spaced births or births to very young mothers
increases the risk of death 2 ½ to 3 fold compared to
births spaced 3-5 years apart for the mothers, their
newborn children and the previously born child.

9. Percent of Birth Intervals that are Short
76
70
69
68
67
66
64
64
64
<36 months
<24 months
62
61
61
61
60
59
58
58
55
48
45
36
36
28
27
24
20
Nepal
India
Bolivia
Egypt
Zambia
Morocco
Nigeria
Uttar Pradesh
Guatemala
Madhya Pradesh
Uganda
Jordan
0
Philippines
19
24
23
17
16
18
15
Indonesia
20
27
26
Ghana
28
Peru
27
28
Tanzania
34
33
Kenya
40
Cote d'Ivoire
Percent
49
Bangladesh
80
Source: United States Agency for International Development (USAID), Bureau for Global Health, Office of Population and Reproductive Health, Washington,
D.C. 20523-3600. December 2002. (WWW.USAID.GOV)

10. Increased Contraceptive use
impact on mortality

11. Deaths averted with Family Planning
If there had been no
change in contraceptive
prevalence there would
have been 3.8m
additional maternal
deaths in the two
decades between 1985
and 2005
Source: John Stover, The Policy Project, The Futures Group, 2006

12. Family Planning as a priority in
high HIV prevalence areas?
For:
 Will reduce pregnancies in known HIV+ women >
decreased AIDS transmission
 Will reduce pregnancies in HIV+ women who have not
yet been diagnosed (90% still undiagnosed)
 Ongoing and regular Family planning – will reduce
pregnancy occurring during the first weeks of AIDS
when viral load is highest
 Birth Spacing allows HIV+ women to recover from
previous pregnancies, maximizing her health before
the challenge of another pregnancy
Against:
 Mixed evidence on increased HIV transmission to men
when on long acting hormone contraception.
Conclusion:
 Recent WHO technical consultation concluded proven
benefits of FP outweighed the inconsistent potential

13. Family Planning Use: Impact on
Abortion Rates



Classic relationship
in post-Soviet
countries
Mixed in places with
falling fertility where
there is very high
unmet need for
fertility control
Reaffirms need for
additional FP access
Increased access to FP estimated to reduce induced abortions
in the developing world by 70% (from 35 million to 11
million), also reducing deaths and post-abortion costs due to
unsafe abortions.
International Family Planning Perspectives, 2003, 29(1):6-13

14. CPR

Coverage globally in
2010 ~28%

15. Comparing effectiveness of methods
More effective
How to make your
method most effective
Less than 1 pregnancy per
100 women in one year
After procedure, little or nothing
to do or remember
Implants
Female
Sterilization
Vasectomy
Vasectomy: Use another method
for first 3 months
IUD
Injections: Get repeat injections
on time
LAM (for 6 months): Breastfeed
often, day and night
Injectables
LAM
Pills
Patch
Ring
Pills: Take a pill each day
Patch, ring: Keep in place,
change on time
Condoms, diaphragm: Use correctly
every time you have sex
Male
Condoms
Female
Condoms
Withdrawal
Less effective
About 30 pregnancies per
100 women in one year
Diaphragm
Fertility-Awareness
Based Methods
Spermicide
Fertility-awareness based methods:
Abstain or use condoms on fertile
days. Newest methods (Standard Days
Method and TwoDay Method) may be easier
to use.
Withdrawal, spermicide: Use
correctly every time you have
sex

17. Side Effects & Obstacles








Oral Contraceptives – Take every day
IUDs – Medical procedure to insert
Sterilization – Permanent
Injectable – Menstrual disturbance
Norplant – Cost
Condom – Use every time
Diaphragm – Use every time
Natural family planning – precision in timing
Myth: Family Planning methods are abortifacients
IN THE PAST, there was an incorrect understanding of the
mechanisms of action that limited unified faith-based support for
family planning.
TRUTH: Family Planning methods prevent conception
 Most methods accepted by people of faith as contraceptive
 But incorrect understanding of EC & IUD mechanism limited
acceptance

18. How DO EC and IUDs work?
Emergency contraception: prevent pregnancy
 Effective only in the first few days following intercourse
 before the ovum is released from the ovary and before the
sperm fertilizes the ovum.
 Prevent ovulation, change cervical mucous to inhibits
entry of sperm to uterus, disrupt sperm binding to the
egg.
 Emergency contraceptive pills cannot interrupt an
established pregnancy or harm a developing embryo.
Hormonal & Copper IUD: prevent pregnancy by
 Chemical change that damages sperm and egg before
they can meet.
 Cervical mucous change that inhibits entry of sperm to
uterus

19. Economic Benefits too:
Costs & net health effects of contraceptive
methods.
Compared with use of no contraception,
 Cost savings over 2 years,
◦ US$5907/woman for tubal sterilization
◦ US$9936 for vasectomy

Health gains
◦ 0.088 QALYs for diaphragm
◦ 0.147 QALYs for depot medroxyprogesterone
acetate.

Even modest increases in the use of the most
effective methods result in financial savings
and health gains.
Sonnenberg FA, Burkman RT, Hagerty CG, Speroff L, Speroff T.
Contraception. 2004 Jun;69(6):447-59.

20. Conclusion
Family planning is one of the most effective
life saving interventions we have to reduce
maternal and child mortality.
 Increased use of family planning can
significantly reduce abortion rates
 Unmet need for contraceptives is still at about
24% for Sub-Saharan Africa.
 Effective, non-abortifacient methods,
including natural family planning methods,
exist that are acceptable to people of all
faiths


21. Take Action
Get the word out
 We promote family planning because we
value women and children
 Use the growing & compelling evidence
 Debunk the myths

People of all faiths can now unify in support
of family planning to improve health and
well-being of millions.

22. Thank you

24. Unmet Family Planning Need 1st
Year Postpartum (blue) & All
Women (purple)
80
70
60
50
1st Year PP
40
All Women
30
20
10
0
B-desh
Haiti
Kenya
Nigeria
Source: Borda, M. and W. Winfrey. Family Planning Needs
during the First Year Postpartum. ACCESS-FP.

25. Non-users: 55% intend to use--Their
preferred methods for future (Kenya DHS
08-09)









Injectables
Unsure
Pill
Female sterilization
Implants
Male condom
IUD
Periodic abstinence
Female condom
52%
13
12
8
8
2
2
2
0.3

26. Contraceptive use in USA among women at risk of
unintended pregnancy* by religious affiliation (Natl Surv
Fam Grwth 2006-08; n=7,356 women)
Protestant
Catholic Mainline Evangelical No Relig
Contraceptive Method All Women
Affil
Highly Effective
69%
68%
73%
74%
62%
Sterilization
33
32
34
41
26
Pill & other hormonal 31
31
35
28
30
Intrauterine device
5
5
4
4
6
Condom
14
15
13
10
17
Natural FP
1
2
1
1
1
Other
5
4
4
6
7
None
11
11
10
9
14
* % of women sexually active but not pregnant, post-partum or trying to
become pregnant.
Christian Connections for International Health, at Center for Bioethics &
Human Dignity, 13 July 2012

27. The 2 classic female hormones
(progesterone and estrogen) vary
throughout the cycle
Cervical mucus is amenable to sperm
penetration only mid-cycle, when estrogen
peaks and before progesterone rises.
Any contraceptive that has progestin in it
will make cervical mucus hostile to sperm.

28. IUDS

Hormonal IUDs - progestin levonorgestrel.
Prevention of pregnancy due to subsequent
thickening of cervical mucus, which prevents
the passage of sperm, inhibition of sperm
mobility and inhibition of endometrial growth.

Copper IUD – endometrium releases white
blood cells, enzymes and prostaglandins; and
these reactions of the endometrium appear
to prevent sperm from reaching the fallopian
tubes. In addition, release copper ions into
the the uterus, enhancing the debilitating
effect on sperm.

29. Hormonal contraceptive methods have at
least 2 major mechanisms of action:
 Inhibiting/disrupting
 Thickening
 Other?
ovulation
cervical mucus

30. Population growth

31. RH bulge to come

32. Health in Afghanistan
Maternal Mortality Rates:
 VA is 7/100,000
 Puerto Rico 18/100,000
 2001 was 1600/100,000
 NE Corner Badakshan
province 6400,100,000
 Now (2010)
337/100,000
Key Findings
• Fewer Women die during Pregnancy and Childbirth.
• More Children survive to their Fifth Birthday.
• Women are having fewer children.
• More Women Use Life Saving Care.

33. USAID and State Family Planning and
Reproductive Health Budgets - FY2009
- FY 2011
FY 2009
Enacted
FY 2010
653(a) Initial
FY 2011
Request
Congressional
Earmark/Direc
tive
$545,000
$648,457
-
Family
Planning and
Reproductive
Health
$572,401
$666,590
$715,740
$27,401
$18,133
-
Delta
Earmark/Direc
tive vs.
Programmed
FY09 included $50m as a USG contribution to UNFPA.
FY10 includes $55m as a USG contribution to UNFPA.
FY11 includes $50m as a USG contribution to UNFPA.

34. Funding comparisons

36. Equity for the Moms and Babies!
We cannot be complacent!!!

37. Impact of FP on abortion rates


Rising contraceptive use results in
reduced abortion incidence in settings
where fertility itself is constant.
The parallel rise in abortion and
contraception in some countries occurred
because increased contraceptive use
alone was unable to meet the growing
need for fertility regulation in situations
where fertility was falling rapidly.

38. Resources


Jim Shelton: FP Myths
Mary Ellen Stanton: MH

National Family Planning and Reproductive
Health Association –
http://www.nfprha.org/main/index.cfm
WHO Family Planning Site http://www.who.int/topics/family_planning/en/
K4Health (knowledge for Health)project:
Hopkins,


◦ Family Planning Guidebook for providers & Wall chart



CEDPA: women’s empowerment & RH
PATH: new technology & coverage expansion
FHI:http://www.fhi.org/en/index.htm