The U.S. Government and International Family Planning & Reproductive Health
Access to family planning and reproductive health (FP/RH) services is critical to the health of women and children worldwide. The U.S. government first provided support for international family planning efforts in the mid-1960s and has since been a leading donor to FP/RH. Still, the U.S. role has changed over time, sometimes influenced by U.S. domestic political debates and differing views in Congress and the Administration, as well as in the international community. Historically, these debates have concerned both the amount of U.S. funding provided to international FP/RH as well as its use, particularly related to abortion. The latter is governed by several legislative and policy restrictions, including a legal ban on the direct use of U.S. funding overseas for abortion as a method of family planning, which has been in place since 1973, as well as more stringent restrictions in some years (e.g., the “Mexico City Policy”).1
Family Planning (FP): The ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of births.2
Reproductive Health (RH): The state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive processes, functions, and system at all stages of life.3, 4
The Obama Administration has stated its strong support for FP/RH as a key part of the overall U.S. global health portfolio, including within its Global Health Initiative (GHI), a six-year (FY09–FY14) effort announced in May 2009. The GHI calls for a more comprehensive U.S. global health agenda and includes, among its key principles, a focus on women, girls, and gender equality and a specific FP/RH target to prevent 54 million unintended pregnancies.5
The Administration has also reversed prior restrictions on U.S. funding for family planning assistance by rescinding the Mexico City Policy6 and restoring funding to the United National Population Fund (UNFPA).1, 6 U.S. support for achieving the goal of universal access to reproductive health, as specified in the 1994 Cairo International Conference on Population and Development’s (ICPD) Programme of Action and the Millennium Development Goals (MDGs), has been reaffirmed.7
Current Global Snapshot
Improving access to FP/RH services globally can help prevent maternal deaths and reduce unintended pregnancies. Each year, approximately 350,000 women die from complications during pregnancy and childbirth, almost all in developing countries.8, 9 It is also estimated that approximately one-third of maternal deaths could be avoided annually if women who did not wish to become pregnant had access to and used effective contraception.10 Contributing factors to maternal deaths and unintended pregnancy include: lack of access to antenatal care, which increases the risk of complications during pregnancy and childbirth; high adolescent birth rates, since adolescents (ages 15–19) are more likely to die or face complications during pregnancy and childbirth; unsafe abortions, which are those performed by individuals without the necessary skills or in an unsanitary environment and often lead to complications and death; and unmet need for FP services.11, 12 The 2007 addition to MDG 5 (which aims to improve maternal health) of a specific target to achieve universal access to reproductive health was a recognition by governments and world leaders of the need to address these challenges.11 Of all 8 MDGs, however, countries have made the least progress toward MDG 5.11
- Global Status: Worldwide, more than 200 million women have an unmet need for contraceptives (i.e., they do not wish to get pregnant and are using no contraceptive method).13 Access to family planning methods varies significantly by region (see Figure 1). While the percentage of women receiving the recommended minimum number of at least four antenatal care visits has been on the rise, it is still only 53% globally and lower in Africa. Similarly, adolescent fertility rates have declined slowly and remain particularly high in Africa, which also has the highest rate of unmet need for FP services.11, 12 Each year, approximately 47,000 women die from complications associated with unsafe abortion.14 Access to and use of effective contraception reduces unintended pregnancies and the incidence of abortion.15
|Figure 1: Key FP/RH Indicators by Region16|
|WHO Region||Unmet Need for FP
|Adolescent Birth Rate
|Antenatal Care Coverage
- Selected Challenges: Reasons for the lack of access to and, in some cases, utilization of FP/RH services include low awareness of the risks of sexual activity, such as pregnancy and HIV; cost; gender inequality; and laws in some countries that require women and girls to be of a certain age or have third party authorization, typically from their husband, to utilize services.12
- Effective FP/RH Interventions: FP/RH encompasses a wide range of services that have been shown to be effective in decreasing the risk of unintended pregnancies, maternal and child mortality, and other complications; these include birth spacing; contraception; sexuality education, information and counseling; post-abortion care; screening/testing for HIV and other sexually transmitted diseases (STDs); repair of obstetric fistula; antenatal and postnatal care; genital human papillomavirus (HPV) vaccine to prevent cervical cancer and genital warts; and research into new methods such as microbicides.17, 18, 19, 20, 21
The U.S. Government Response
Congress first authorized research on international family planning and population issues in the Foreign Assistance Act of 1961.1 In 1965, USAID launched its first FP program and, in 1968, began purchasing contraceptives to distribute in developing countries. In the 1980s USAID programs expanded to address maternal, newborn, and child health (MNCH) and the relationship between population, health, and the environment (PHE). Beginning in the 1990s, USAID began to recognize the need for male involvement in FP/RH and focus on the needs of young people.22 Today the U.S. is one of the largest purchasers and distributors of contraceptives internationally.22, 23
Structure and Approach
- USAID has long served as the lead U.S. agency for FP/RH activities. Other agencies involved include the Centers for Disease Control and Prevention (CDC) (research, surveillance, technical assistance, and a designated WHO Collaborating Center for Reproductive Health),24 the Department of State (diplomatic role), the National Institutes of Health (NIH) (research), and the Peace Corps (volunteer activities).
- The U.S. government’s stated FP/RH objective is to expand sustainable access to quality voluntary FP/RH services and information (see Figure 2) to: enhance efforts to reduce high-risk pregnancies; allow sufficient time between pregnancies; provide information, counseling, and access to condoms to prevent HIV transmission; reduce the number of abortions; support women’s rights; and stabilize population growth.20, 25 USAID’s FP/RH and MNCH efforts are linked, although Congress directs funding to and USAID operates these programs separately. In recent years, there has also been an increasing emphasis on linking FP/RH and HIV through the President’s Emergency Plan for AIDS Relief (PEPFAR).26, 27
|Figure 2: U.S. Government-Funded FP/RH Interventions17, 18|
|Linking family planning with maternity services||Training of health workers|
|HIV/AIDS & STD information and services||Counseling and services such as birth spacing|
|Sexuality & reproductive health education||Contraceptive supplies and their distribution|
|Eliminating female genital mutilation||Financial management|
|Post-abortion care||Public education and marketing|
|Prevention and repair of obstetric fistula||Biomedical and contraceptive research and development|
|Multilateral contributions to UNFPA|
- USAID operates FP/RH programs in 48 countries (see Figure 3), including 24 “priority countries,” most of which are in Africa.28, 29 Countries are selected based on high rates of unmet need for FP, prevalence of high risk births, low contraceptive use, and significant population pressures on land and water resources.30
U.S. Government Funding28
- Most U.S. funding for FP/RH is specified by Congress in annual appropriations bills and is part of USAID’s Global Health Programs (GHP) account (formerly the Global Health and Child Survival account); GHP funding for FP/RH is counted as part of the GHI. Additional funding is provided through other accounts (e.g., the Economic Support Fund) but is not currently counted as part of the GHI.
- U.S. funding for international FP/RH began in the 1960s. Over time, it has fluctuated and decreased as a share of the U.S. global health budget. After reaching approximately $575 million in FY 1995, it dropped or remained relatively flat for more than a decade, not surpassing this level until FY 2010 when it reached $648.5 million. In FY 2012, FP/RH was funded at $610 million, reflecting reductions by Congress (see Figure 4). Despite recent increases, designated funding for FP/RH has not kept pace with U.S. global health funding overall, declining from 12% of the U.S. global health budget in FY 2004 to about 6% in FY 2012.31
Legal and Policy Requirements32
There are several legal, policy, and programmatic requirements for U.S. funding for international FP. A few are highlighted below:
- Helms Amendment: Since 1973, through the Helms Amendment, U.S. law has prohibited the use of foreign assistance to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion.1 Several other legal provisions that have been passed since then also govern how U.S. assistance for family planning activities can be spent.
- Mexico City Policy: First instituted by President Reagan in 1984 through executive order, the Mexico City Policy, also known as the “Global Gag Rule,” required foreign NGOs to certify that they would not perform or promote abortion as a method of family planning using funds from any source as a condition for receiving U.S. funding. This policy has been a highly debated issue, rescinded by President Clinton, reinstated by President Bush, and rescinded again by President Obama in January 2009.1, 6
- UNFPA & the Kemp-Kasten Amendment: Although the U.S. helped create the UN Population Fund (UNFPA) in 1969 and was a leading contributor for many years, there have been several years in which funding has been withheld due to executive branch determinations that UNFPA’s activities in China violated the Kemp-Kasten Amendment, which prohibits funding any organization or program, as determined by the President, that supports or participates in the management of a program of coercive abortion or involuntary sterilization.33 In March 2009, President Obama announced the U.S. would restore UNFPA funding; $50 million was provided in FY 2009, $55 million in FY 2010, $40 million in FY 2011, and $35 million in FY 2012.28, 34
- Voluntarism and Informed Choice: The principles of ensuring voluntary use of FP/RH services as well as informed choice of FP/RH options are specified in legislative language and program guidance.
The Obama Administration has highlighted the importance of FP/RH within the U.S. global health portfolio, including as part of the GHI. There is also growing global attention to the need to augment FP/RH services worldwide and increase coverage and access. Still, despite widespread recognition of the importance of FP/RH, it will likely continue to be at the center of policy debate and discussion within Congress and the Administration, particularly regarding U.S. funding, U.S. legal and policy requirements, and the broader U.S. role in fostering progress toward the MDGs and other global efforts to promote access to FP/RH.
CRS, International Population Assistance and Family Planning Programs: Issues for Congress, Jan. 2010.
WHO, Family Planning website, http://www.who.int/topics/family_planning/en/
WHO, Reproductive Health website, http://www.who.int/topics/reproductive_health/en/.
ICPD, Programme of Action, Cairo, 1994, http://www.un.org/ecosocdev/geninfo/populatin/icpd.htm#intro.
GHI, U.S. Government Global Health Initiative Strategy, March 2011.
White House, Statement of Barack Obama on Rescinding the Mexico City Policy, Jan. 23, 2009.
State Department, Remarks on the 15th Anniversary of the International Conference on Population and Development, Jan. 2010.
Hogan, et al., “Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5,” The Lancet, Vol. 375, No. 9726, 2010.
WHO, et al., Trends in maternal mortality: 1990 to 2008, 2010.
UN, Fact Sheet, Goal 5: Improve maternal health, Sept. 2008.
UN, The Millennium Development Goals Report 2009; 2009.
WHO, World Health Report 2005 – Making Every Mother and Child Count, 2005.
Guttmacher Institute/UNFPA, Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health, 2009.
WHO, Unsafe abortion: global & regional estimates of the incidence of unsafe abortion and associated mortality in 2008, 2011.
Eric Zuehlke, “Reducing Unintended Pregnancy and Unsafely Performed Abortion Through Contraceptive Use,” PRB, 2009.
WHO, World Health Statistics 2011; 2011.
USAID, Family Planning & Reproductive Health Programs - Saving Lives, Protecting the Environment, Advancing U.S. Interests, undated.
USAID, Fast Facts: Family Planning, Dec. 2009.
WHO, Johns Hopkins, and USAID, Family Planning: A Global Handbook for Providers, 2007.
USAID, Report to Congress: Global Health and Child Survival Progress Report – FY 2008, 2009.
UNESCO, International Technical Guidance on Sexuality Education, Dec. 2009.
USAID, USAID Family Planning Program Timeline: Before 1965 to the Present, undated.
UNFPA, Donor Support for Contraceptives and Condoms for STI/HIV Prevention (2008), 2009.
CDC, Global Reproductive Health website, http://www.cdc.gov/reproductivehealth/Global/index.htm.
USAID, Strategic Framework for Family Planning website, http://www.usaid.gov/our_work/global_health/pop/framework.html.
OGAC, U.S. PEPFAR: Five-Year Strategy; Dec. 2009.
KFF, The U.S. Government’s Efforts to Address Global Maternal, Newborn, and Child Health: The GHI and Beyond, #8074.
KFF analysis of U.S. government budget documents, January 2013.
KFF personal communication with USAID, April 2, 2010.
USAID, FP/RH Countries website, http://www.usaid.gov/our_work/global_health/pop/countries/index.html.
KFF calculation of funding designated for FP/RH through the GHCS account, as part of the GHI, as share of overall funding the programs now counted as part of the GHI.
USAID, USAID’s Family Planning Guiding Principles and U.S. Legislative and Policy Requirements website, http://www.usaid.gov/our_work/global_health/pop/voluntarism.html.
CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, Feb. 2010.
State Department, “U.S. Government Support for the United Nations Population Fund (UNFPA),” fact sheet, March 2010.