Adding It Up THE COSTS AND BENEFITS OF INVESTING IN FAMILY PLANNING AND MATERNAL AND NEWBORN HEALTH Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health Susheela Singh Jacqueline E. Darroch Lori S. Ashford Michael Vlassoff With assistance from the Technical Division of the United Nations Population Fund Acknowledgments Adding It Up: The Costs and Benefits of Investing in Family independent consultant; Steven Sinding, independent Planning and Maternal and Newborn Health was produced consultant; J. Joseph Speidel, Bixby Center for Global in recognition of the 15th anniversary of the International Reproductive Health, University of California, San Conference on Population and Development. Francisco; Ann Starrs, Family Care International; Amy Tsui, Gates Institute and The Johns Hopkins University; The report was written by Susheela Singh, Jacqueline and Carolyn Vogel and Suzanna Dennis, Population Darroch and Michael Vlassoff, all of the Guttmacher Action International. Institute, and Lori Ashford, independent consultant. The following staff of the United Nations Population Fund Financial support for the research and production of this (UNFPA) Technical Division reviewed drafts of the report report was provided by UNFPA and the Guttmacher Institute. and provided substantive guidance: Dennia Gayle, Ralph Hakkert, Werner Haug, Katja Iversen, Mona Kaidbey, Edilberto Loaiza and Nuriye Ortalyi provided feedback on drafts; Stan Bernstein and Howard Friedman provided technical assistance on costing data and analyses; and Jacqueline Mahon and Sharif Egal coordinated UNFPA’s inputs, reviewed drafts and provided valuable help on references. Haley Ball, Guttmacher Institute, edited the report; Kathleen Randall, also of the Guttmacher Institute, supervised production. The authors thank the following Guttmacher colleagues for their comments and help in developing this report: Aparna Sundaram helped with reviewing the literature and analyzing data; Suzette Audam, Liz Carlin and Gabrielle Oestreicher provided research support; and Akinrinola Bankole, Sharon Camp, Susan Cohen, Leila Darabi, Patricia Donovan, Cory Richards, Gustavo Suárez and Jonathan Wittenberg reviewed drafts of the report. The authors are also grateful for the comments offered by the following colleagues, who reviewed the manuscript: John Cleland, London School of Hygiene and Tropical Medicine; Alex Ezeh, Africa Population and Health Research Center; Anibal Faúndes, State University of Campinas; Wendy Graham, University of Aberdeen; Jane Hutchings, PATH; Shireen Jejeebhoy, Population Council, India; Scott Moreland, Futures Group International; Scott Radloff and Mary Ellen Stanton, U.S. Agency for International Development; John Ross, Adding It Up 2 Guttmacher Institute Table of Contents Executive Summary 4 Chapter 1: Introduction 6 Chapter 2: Progress and Challenges in Women’s and Newborns’ Health 9 The New Estimates 14 Chapter 3: Meeting the Need for Modern Family Planning Services 16 Chapter 4: Meeting the Need for Maternal and Newborn Health Services 21 Chapter 5: Investing in Both Family Planning and Maternal and Newborn Care 26 Chapter 6: Conclusion 31 Data and Methods Appendix 35 References 37 Guttmacher Institute 3 Adding It Up Executive Summary n the developing world, deaths and poor health among care (including routine care and care for complications), women and newborns have remained too high for too and many who get care do not receive all the compo- long, despite decades of international agreements nents of care they need; and declaring the need for urgent action to improve well- I n about 20 million women have unsafe abortions each being among these groups. More effective action is needed year, and three million of the estimated 8.5 million who now, especially given the strong evidence of the benefits of need care for subsequent health complications do not investing in the health of women and their newborns: fewer receive it. unintended pregnancies; fewer maternal and newborn deaths; healthier mothers and children; greater family sav- New analyses also show that the direct health benefits of ings and productivity; and better prospects for educating meeting the need for both family planning and maternal children, strengthening economies and reducing the pres- and newborn health services would be dramatic. sure on natural resources in developing countries. n Unintended pregnancies would drop by more than two- Because of these far-reaching benefits, increased invest- thirds, from 75 million in 2008 to 22 million per year. ment in family planning and maternal and newborn health services could accelerate progress toward achiev- n Seventy percent of maternal deaths would be averted— ing the Millennium Development Goals (MDGs), which a decline from 550,000 to 160,000. were set in 2000 with targets for 2015. These services for n Forty-four percent of newborn deaths would be averted— women and infants are highly cost-effective, and they are a decline from 3.5 million to 1.9 million. complementary because the health of mothers and of their babies is intertwined. A continuum of care is needed to n Unsafe abortions would decline by 73%, from 20 million help individuals and couples plan their pregnancies and to 5.5 million (assuming no change in abortion laws), to provide timely antenatal, delivery and postpartum ser- and the number of women needing medical care for vices, including urgent care for complications that arise complications of unsafe procedures would decline from among women and newborns. 8.5 million to two million. Caring for the health of women and their babies is essen- n The healthy years of life lost due to disability and pre- tial, yet family planning and maternal and newborn ser- mature death among women and their newborns would vices fall well short of needs in developing countries. Using be reduced by more than 60%. (This is measured in new estimates for 2008, this report shows that disability-adjusted life years, or DALYs, an internation- ally used standard for comparing the cost-effectiveness n an estimated 215 million women who want to avoid a of health services.) More women would survive hem- pregnancy are not using an effective method of contra- orrhage and infection, and fewer would endure need- ception, despite increases in use in recent years; less suffering from fistula, infertility and other health n only about one-half of the 123 million women who give problems related to pregnancy or childbirth. Newborns birth each year receive antenatal, delivery and newborn Adding It Up4 Guttmacher Institute would have improved chances of surviving asphyxia, services available to all, funding from governments and low birth weight and infection. donor agencies has fallen far short of the amounts pledged for reproductive health. In fact, donor assistance dedi- Other benefits for the health sector and for societies as cated specifically to family planning has dropped dramat- a whole, though less quantifiable, are also profound. The ically in absolute dollar amounts since the mid-1990s. following are just a few. As it stands now, the health-related MDGs will not be met n The improvements in health systems that would pro- by 2015. Progress on reducing maternal and newborn vide lifesaving care to women and their newborns would deaths has been extremely slow, particularly in the two strengthen health systems’ responses to other urgent poorest regions, South Asia and Sub-Saharan Africa. medical needs. These regions—and the poorest people in other regions— n Greater use of condoms for contraception would reduce stand to gain the most from additional investments the transmission of HIV and other sexually transmitted because they suffer disproportionately from poor health infections, thereby helping to curb the AIDS pandemic. related to pregnancy and childbirth. n Reducing unplanned births and family size would save Many implementation challenges must be overcome as on public-sector spending for health, water, sanitation policymakers and program planners work to strengthen and social services and reduce pressure on scarce natu- health systems and make services accessible to everyone. ral resources, making social and economic development Still, funding shortfalls remain a major constraint to meet- goals easier to achieve. ing health-related goals. Thus, in full partnership, govern- ments and the international community need to increase n Reducing unintended pregnancies, particularly among funding immediately and target those resources toward adolescents, would improve educational and employ- the poorest populations to end preventable suffering, as ment opportunities for women, which would in turn well as the drag that poor health places on economies. contribute to improving the status of women, increas- ing family savings, reducing poverty and spurring eco- Is it too much for developing countries and the interna- nomic growth. tional community to contribute $12.8 billion more to improving the health of women and newborns? Hardly. How much will it cost to meet the needs for family plan- Saving one DALY through family planning and maternal ning and maternal and newborn services in developing and newborn care costs less than $100, which compares countries? favorably with other cost-effective health investments, such as antiretroviral therapy, childhood vaccination for n Fulfilling unmet need for modern family planning meth- tuberculosis and oral rehydration therapy. ods would cost $3.6 billion (in 2008 U.S. dollars),