Family planning is a worthwhile investment that could reduce the cost of maternal and new-born health care by US$11.3 billion annually and provide much-needed support to some 222 million women globally who need contraceptives but do not have access to them, according to the UN Population Fund's (UNFPA) annual State of the World's Population report.
The report notes that by investing an additional $4.1 billion in modern contraceptive services in developing countries, "the world would save approximately $5.7 billion in maternal and new-born health services through the prevention of unintended pregnancies and unsafe abortions." However, funding for family planning - both from donors and governments - is shrinking, losing ground to other health issues.
"Governments should invest in family planning; it is about human capital development," UNFPA executive director Babatunde Osotimehin, told IRIN. "Donor economies can complement this investment, but sustainability comes from domestic economies."
The report noted that access to sexual and reproductive health services gave women a better chance to enter the workforce by enabling them to control the spacing of their children and "expand their participation in labour markets".
It is now almost 20 years since the Cairo Conference on Population and Development. That meeting saw memorable battles over reproductive health, with an alliance of the Vatican and conservative Islamic states, but it did, in the end, establish a broad consensus that everyone had the right to have access to effective reproductive and sexual health services, including family planning, and 179 nations accepted its Programme of Action.
A "fundamental human right"
UNFPA insists that family planning is not optional; it is a fundamental right, and the obligation to fulfil it is a formal treaty obligation. "No right exists without obligation," the report says, and "no obligation is meaningful without accountability. UN treaty monitoring bodies are charged with tracking government compliance with major human rights treaties and now routinely recommend that governments take action to protect sexual and reproductive health and reproductive rights."
"Accessing family planning is a fundamental human right, because every parent has a right to decide when, how often and when to stop. Every pregnancy should be a wanted pregnancy," Robina Biteyi, national coordinator of the Uganda chapter of The White Ribbon Alliance for Safe Motherhood, told IRIN. "The cost of ignoring the right access to family planning is reflected in health, social, and economic outcomes. Unsafe abortions are a consequence of poor access to information and reproductive health services. Money spent on treating unsafe abortion can be used on other critical services such as emergency obstetric care."
In 2011 alone, UNFPA's report says, the UN issued strong recommendations to Nepal, Zambia and Costa Rica to ensure the sexual and reproductive rights of their citizens.
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Things have come a long way in the past 20 years, but the report pinpoints the many groups in society which are still often excluded and makes the case for putting considerably more effort into reaching them.
All-inclusive family planning
Part of the problem, the report states, is society's notion of who should be having sex and thinking about babies. For example, despite the norms in many societies expecting only married adults to engage in sex, adolescents have sex, and in many countries are sexually active for five years or more before they marry. Other groups that often miss out on family planning services are unmarried adults, the divorced, the widowed, the disabled and people living with HIV.
"These services should be inclusive, right from age-appropriate sex education to the provision of services to HIV-positive women, who often miss out on these services but should not be denied their right to have children and to prevent the transmission of the virus to these children," said UNFPA's Osotimehin.
Sexual and reproductive health services are often rather unwelcoming to the largest group of all, men and boys, who are made to feel out of place in family planning clinics, and get very little encouragement to take responsibility for their own fertility. The report highlights the fact that female sterilization - a serious operation - is much more common than male vasectomies (a far more minor procedure). There has been very little effort put into developing new male contraceptives.
"The role of the male in reproductive health is very central... In a male dominated society the male makes most of the decisions. He also makes decisions about when to access health care, and where to access financial resources," said White Ribbon's Biteyi. "This is changing with time and women's education. However, the challenges remain."
Perhaps the most worrying gaps are in the provision for the poor, and for very young women. "Demographic and Health Surveys from 24 sub-Saharan African countries find that the poorest and least educated women have `lost ground', with poor adolescent girls having the lowest levels of sustained contraceptive use and the highest unmet needs for family planning," UNFPA says.
UNPFA accepts that these are the hard-to-reach groups and that reaching out to them will cost more than mainstream provision, but says it needs to be done.