57. Contraception

Abstract

Contraception to prevent pregnancies is not really a health intervention, since users usually have motives other than improved health; but it does have substantial health consequences for users of contraception, their sexual partners, and their children. High fertility and close spacing of births lead to greater risks of death in pregnancy or from unsafe abortion for women, and greater risks of malnutrition, orphanhood, and death for their infants.

Contraception can be achieved by several different methods, either permanent or temporary, and can be delivered by a variety of programs. Some are dedicated to providing only family planning services; some incorporate additional reproductive health services; and some use social marketing techniques to promote distribution and use of contraceptive commodities.

The output of family planning programs is usually measured in couple–years of protection (CYP). The cost varies by region, method, and type of program and ranges from US$2.34 on average for sterilization to US$18.21 on average for clinic–based services combined with community–based distribution. However, CYP does not measure impact, which depends on how a CYP translates into fewer births, maternal deaths, infant or child deaths, or lost disability–adjusted life years (DALYs). Modeling of those relations yields estimated costs per birth averted that range from US$87 to US$163 among regions. Costs per infant death averted range from US$1,367 to US$4,907, and for maternal deaths averted, from US$5,172 to US$12,880. Because averting a birth also reduces future fertility, life years and DALYs saved can exceed the gains possible from the health benefits to just one generation; thus, contraception can be very cost–effective, with costs per DALY below US$60 on average in all regions.

Priorities for research and development include (1) development of more acceptable contraceptives that protect against both pregnancy and HIV infection; (2) operations research, such as how to stimulate demand for family planning in Sub–Saharan African countries and among adolescents; and (3) policy research to further understand the relationship between fertility and other reproductive health and economic outcomes.