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The U.S. Government and International Family Planning & Reproductive Health Efforts

Overview

Access to family planning and reproductive health (FP/RH) services is critical to the health of women and children worldwide. The U.S. government (USG) has supported international FP/RH efforts for 50 years and is one of the largest donors to FP/RH in the world. Over time, the U.S. role in global FP/RH has changed, sometimes influenced by differing views and political debates related to FP/RH that have arisen both domestically and internationally. 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. Abortion 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”, which is described below).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

In recent years, the U.S. government (USG) has highlighted FP/RH efforts as a key part of the overall U.S. global health portfolio.4  The USG has reversed prior restrictions on U.S. funding for family planning assistance – rescinding the Mexico City Policy and restoring funding to the United National Population Fund (UNFPA)5 – and reaffirmed USG support for achieving the global goal of universal access to reproductive health.6

Current Global Snapshot

Improving access to FP/RH services globally can help prevent maternal deaths and reduce unintended pregnancies. Each year, approximately 303,000 women die from complications during pregnancy and childbirth, almost all in developing countries.7 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.8

Table 1: Key Family Planning/Reproductive Health (FP/RH) Indicators by Region9
Region10 Unmet Need
for FP
(%)
2015
Contraceptive Prevalence
(%)
2015
Adolescent Birth Rate
(per 1,000)
2015
Antenatal Care Coverage
(%)
2014
Developing Regions 12 63 56 52
Developed Regions 17
Sub-Saharan Africa 24 28 116 49
Southern Asia 14 59 47 36
Oceania 25 39 53
Caucasus and Central Asia 14 57 32
South-Eastern Asia 12 64 44 84
Western Asia 14 58 45
Northern Africa 12 61 38 89
Latin America and the Caribbean 11 73 73 97
Eastern Asia 4 83 6
NOTES: — indicates data not available. Antenatal Care Coverage for women attended four or more times by any provider during pregnancy.

Global Status

Key factors contributing to maternal deaths and unintended pregnancy include: unmet need for FP services; high adolescent birth rates, since adolescents (ages 15-19) are more likely to die or face complications during pregnancy and childbirth; lack of access to antenatal care, which increases the risk of complications during pregnancy and childbirth; and unsafe abortions, which are those performed by individuals without the necessary skills or in an unsanitary environment and often lead to complications and death.11

Worldwide, more than 225 million women have an unmet need for modern contraception (i.e., they do not wish to get pregnant and are using no contraceptive method or a traditional method).12 Access to FP methods varies significantly by region (see Table 1). Unmet need for FP is highest in regions like sub-Saharan Africa and Oceania where contraceptive prevalence is lowest.13 Adolescent fertility rates have declined slowly and remain particularly high in sub-Saharan Africa, where child marriage remains common, and in Latin America and the Caribbean.14 While the percentage of pregnant women receiving the recommended minimum number of four antenatal care visits has been on the rise, it is 52% in developing countries and lower still in sub-Saharan Africa and Southern Asia.15 Each year, approximately 47,000 women die from complications associated with unsafe abortion.16 Access to and use of effective contraception reduces unintended pregnancies and the incidence of abortion.17

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.18

Effective 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.19

Global Goals

Key global goals for expanding access to and improving FP/RH services include:

  • Achieving universal access to reproductive health. This goal was originally specified in the 1994 Cairo International Conference on Population and Development’s (ICPD) Programme of Action and was added in 2007 as a specific target of Millennium Development Goal 5 (MDG 5), which aims to improve maternal health.20 This addition to MDG 5 was a recognition by governments and world leaders of the need to address challenges related to access and utilization of RH services.21 The world did not reach this target, but some progress was made, with more women attending a health provider four times or more during pregnancy and using contraceptives, though these indicators still vary widely across regions.22 The current goal, adopted in 2015 as part of Sustainable Development Goal (SDG) 3, is to “ensure universal access to sexual and reproductive health care services, including for family planning, information, and education, and the integration of reproductive health into national strategies and programmes.”23
  • Providing access to voluntary FP to an additional 120 million women. In July 2012, the U.K. Government and the Bill & Melinda Gates Foundation – in partnership with the United Nations Population Fund (UNFPA), civil society organizations, developing countries, donor governments, the private sector, and multilateral organizations – co-sponsored the London Summit on Family Planning, an effort to provide voluntary family planning services to an additional 120 million women and girls in developing countries by 2020 through new commitments. This goal is being monitored by Family Planning 2020 (FP2020), a global partnership created as an outcome of the Summit.

The U.S. Government Response

The USG has a long history of engagement in international family planning and population issues, and today, the USG is one of the largest purchasers and distributors of contraceptives internationally and is the largest donor to global FP/RH efforts.24 Congress first authorized research in this area in the Foreign Assistance Act of 1961.25 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 (MCH) and the relationship between population, health, and the environment (PHE); and in the 1990s, USAID FP/RH programs began to recognize the need for male involvement in FP/RH and focus on the needs of young people.26 More recently, the USG has adopted a longer term global health goal of ending preventable child and maternal deaths by 2035 and highlighted the important role of FP/RH efforts in achieving this goal.27

Structure and Approach

USAID has long served as the lead U.S. agency for FP/RH activities, with other agencies also carrying out FP/RH activities.

USAID. USAID operates FP/RH programs in nearly 40 countries, with a focused effort in 24 priority countries (see Figure 1) that are mostly in Africa and Southern Asia.28 The agency’s stated FP/RH objective is to expand sustainable access to quality voluntary FP/RH services, commodities, and information (see Table 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.29 These efforts aim to contribute to the global goal of reaching more than 120 million more women and girls in the world’s poorest countries with access to voluntary FP information, contraceptives, and services by 2020.30

Figure 1: U.S. Government Global Family Planning/Reproductive Health (FP/RH) Priority Countries, FY 2016

Figure 1: U.S. Government Global Family Planning/Reproductive Health (FP/RH) Priority Countries, FY 2016

Table 2: USAID-Funded Family Planning/Reproductive Health (FP/RH) Interventions31
Contraceptive supplies and their distribution Counseling and services such as birth spacing Linking FP with HIV/AIDS & STD information/services
Training of health workers Financial management Post-abortion care
Prevention and repair of obstetric fistula Sexuality & reproductive health education Public education and marketing
Eliminating female genital mutilation Linking FP with maternity services Contributions to UNFPA
Addressing child marriage Addressing gender-based violence Biomedical and contraceptive research and development

Other USG FP/RH and Related Global Health Efforts. Also carrying out FP/RH efforts are the Centers for Disease Control and Prevention (CDC) (research, surveillance, technical assistance, and a designated WHO Collaborating Center for Reproductive Health),32 the Department of State (diplomatic and humanitarian efforts), the National Institutes of Health (NIH) (research), and the Peace Corps (volunteer activities). Additionally, USAID’s FP/RH and MCH efforts are closely linked, although Congress directs funding to and USAID operates these programs separately. Recent years have also seen greater emphasis on coordinating FP/RH investments with HIV efforts through the President’s Emergency Plan for AIDS Relief (PEPFAR).33

Multilateral Efforts. The USG partners with international institutions (such as UNFPA and, as a core partner, FP2020) and other major donors (for example, through the Alliance for Reproductive, Maternal and Newborn Health34).

U.S. Government Funding35

Total USG funding for FP/RH, which includes the U.S. contribution to UNFPA, has increased from $425 million in FY 2006 to $608 million in FY 2016 (see Figure 2). The President’s FY 2017 budget request for FP/RH totaled $620 million. If approved by Congress, this would be a 2% increase over the FY 2016 enacted level. Most USG funding for FP/RH is part of the Global Health Programs (GHP) account at USAID, with additional funding provided through the Economic Support Fund (ESF) account. FP/RH funding is also provided through the International Organizations & Programs (IO&P) account at the State Department for the U.S. contribution to UNFPA.

Figure 2: Family Planning/Reproductive Health (FP/RH), FY 2006-FY 2017 Request

Figure 2: Family Planning/Reproductive Health (FP/RH), FY 2006-FY 2017 Request

Legal and Policy Requirements36

Several legal, policy, and programmatic requirements exist for USG 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.

Mexico City Policy. First instituted by President Reagan in 1984 through executive order, the Mexico City Policy (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. A highly debated issue, this policy was rescinded by President Clinton, reinstated by President Bush, and rescinded again by President Obama in January 2009.37

UNFPA & the Kemp-Kasten Amendment. Although the USG helped create 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.38 In March 2009, President Obama announced the U.S. would restore UNFPA funding.39

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.

Looking Ahead

In recent years, growing global attention has highlighted the need to augment FP/RH services worldwide and increase coverage and access, and the USG has increasingly stressed the importance of FP/RH within the U.S. global health portfolio. As the global community endeavors to support and fund efforts to achieve SDG 3’s FP/RH targets, key issues and challenges for USG efforts include: continuing to expand access to and the quality of FP/RH services in the current restrained fiscal environment; further integration of FP/RH efforts with other U.S. global health programs (such as MCH and PEPFAR) and broader U.S. development efforts (including education); and coordinating these efforts with the activities of other donors and partner countries in order to maximize the impact of available resources. Additionally, the policy debates and discussions within and among Congress and the Administration regarding the U.S. role in FP/RH; USG funding, legal and policy requirements; and the USG role in fostering progress toward global efforts to promote access to FP/RH are likely to continue.

Endnotes
  1. KFF, Statutory Requirements & Policies Governing U.S. Global Family Planning and Reproductive Health Efforts, May 2012.

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  2. World Health Organization (WHO), Family Planning website, http://www.who.int/topics/family_planning/en/.

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  3. WHO, Reproductive Health website, http://www.who.int/topics/reproductive_health/en/; ICPD, Programme of Action, Cairo, 1994.

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  4. White House, “Statement by the President on Global Health Initiative,” May 5, 2009; White House, “The Obama Administration’s Comprehensive Efforts to Promote Gender Equality and Empower Women and Girls Worldwide,” fact sheet, April 19, 2013.

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  5. White House, “Statement of Barack Obama on Rescinding the Mexico City Policy,” Jan. 23, 2009.

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  6. State Department, “Remarks on the 15th Anniversary of the International Conference on Population and Development,” Jan. 2010.

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  7. WHO, et al., Trends in maternal mortality: 1990 to 2015, 2015.

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  8. S. Ahmed, et al., “Maternal deaths averted by contraceptive use: an analysis of 172 countries,” The Lancet, July 14, 2012 (Vol. 30, no. 9837: 111-125).

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  9. United Nations (UN), The Millennium Development Goals Report 2015, 2015.

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  10. Country classifications are based on MDG regional designations.

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  11. UN, The Millennium Development Goals Report 2009, 2009; WHO, World Health Report 2005 – Making Every Mother and Child Count, 2005.

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  12. Guttmacher Institute, Adding It Up: The Costs and Benefits of Investing in Sexual and Reproductive Health 2014, 2014.

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  13. UN, The Millennium Development Goals Report 2015, 2015.

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  14. UN, The Millennium Development Goals Report 2015, 2015.

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  15. WHO, World Health Statistics 2014, 2014; UN, The Millennium Development Goals Report 2015, 2015.

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  16. WHO, Unsafe abortion: global & regional estimates of the incidence of unsafe abortion and associated mortality in 2008, 2011.

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  17. Eric Zuehlke, “Reducing Unintended Pregnancy and Unsafely Performed Abortion Through Contraceptive Use,” PRB, 2009.

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  18. WHO, World Health Report 2005 – Making Every Mother and Child Count, 2005.

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  19. USAID, “Family Planning & Reproductive Health Programs - Saving Lives, Protecting the Environment, Advancing U.S. Interests,” fact sheet, undated; USAID, “Fast Facts: Family Planning,” fact sheet, 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.

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  20. ICPD, Programme of Action, Cairo, 1994; UN, The Millennium Development Goals Report 2009, 2009.

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  21. UN, The Millennium Development Goals Report 2009, 2009.

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  22. UN, The Millennium Development Goals Report 2015, 2015.

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  23. UN, Transforming our world: the 2030 Agenda for Sustainable Development, 2015.

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  24. USAID, USAID Family Planning Program Timeline, undated; UNFPA, Donor Support for Contraceptives and Condoms for STI/HIV Prevention (2008), 2009; KFF, Mapping the Donor Landscape in Global Health: Family Planning and Reproductive Health, 2014; KFF,  Donor Government Assistance for Family Planning in 2013, 2014.

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  25. Congressional Research Service (CRS), International Population Assistance and Family Planning Programs: Issues for Congress, Jan. 2010.

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  26. USAID, USAID Family Planning Program Timeline, undated.

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  27. USG Global Health Programs website, www.ghi.gov; USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014.

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  28. KFF analysis of data from the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov; USAID, “Family Planning Countries,” webpage, https://www.usaid.gov/what-we-do/global-health/family-planning/family-planning-countries. 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. KFF personal communication with USAID, April 2, 2010.

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  29. USAID: “Family Planning and Reproductive Health,” webpage, http://www.usaid.gov/what-we-do/global-health/family-planning; Report to Congress: Global Health and Child Survival Progress Report – FY 2008, 2009.

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  30. USAID, “USAID Global Health Programs: FY 2016 President’s Budget Request, Ending Preventable Child and Maternal Deaths,” fact sheet, March 2015.

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  31. USAID, “Family Planning & Reproductive Health Programs - Saving Lives, Protecting the Environment, Advancing U.S. Interests,” fact sheet, undated; USAID, “Fast Facts: Family Planning,” fact sheet, Dec. 2009.

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  32. CDC, Global Reproductive Health website, http://www.cdc.gov/reproductivehealth/Global/index.htm.

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  33. For example: OGAC, PEPFAR Fiscal Year 2014 Country Operational Plan (COP) Guidance, Version 2, Nov. 8, 2013; OGAC, PEPFAR Blueprint:

    Creating An AIDS-free Generation, Nov. 2012; OGAC, U.S. PEPFAR: Five-Year Strategy, Dec. 2009.

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  34. The Alliance was launched by the USG, the Australian Agency for International Development, the UK’s Department of International Development, and the Gates Foundation; see http://www.usaid.gov/what-we-do/global-health/family-planning/alliance-reproductive-maternal-newborn-health.

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  35. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. For an in-depth discussion of USG FP/RH funding, including trends, see KFF, U.S. Funding for International Family Planning & Reproductive Health, April 2016.

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  36. KFF, Statutory Requirements & Policies Governing U.S. Global Family Planning and Reproductive Health Efforts, 2012; KFF, “The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies,” fact sheet; USAID, USAID's Family Planning Guiding Principles and U.S. Legislative and Policy Requirements webpage, http://www.usaid.gov/what-we-do/global-health/family-planning/usaids-family-planning-guiding-principles-and-us-0.

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  37. White House, “Statement of Barack Obama on Rescinding the Mexico City Policy,” Jan. 23, 2009.

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  38. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, Feb. 2010.

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  39. State Department, “U.S. Government Support for the United Nations Population Fund (UNFPA),” fact sheet, March 2009.

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