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 (USG) 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
The Obama Administration has stated its strong support for FP/RH as a key part of the overall U.S. global health portfolio.2 The Administration has also reversed prior restrictions on U.S. funding for family planning assistance by rescinding the Mexico City Policy and restoring funding to the United National Population Fund (UNFPA),3 and it has reaffirmed USG support for achieving the global goal of universal access to reproductive health.4
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.6
Current Global Snapshot
Improving access to FP/RH services globally can help prevent maternal deaths and reduce unintended pregnancies. Each year, approximately 287,000 women die from complications during pregnancy and childbirth, almost all in developing countries.7It 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
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.9
- Worldwide, more than 220 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), with unmet need for FP highest in regions like Africa and the Eastern Mediterranean where contraceptive prevalence is lowest.10 Access to FP methods varies significantly by region (see Figure 1).
|Figure 1: Key FP/RH Indicators by Region11|
|Region12||Unmet Need for FP
|Adolescent Birth Rate
|Antenatal Care Coverage
|NOTES: — indicates data not available.|
- Adolescent fertility rates have declined slowly and remain particularly high in Africa, where child marriage remains common, and Latin America and the Caribbean.13
- While the percentage of pregnant women receiving the recommended minimum number of at least four antenatal care visits has been on the rise, it is still only 56% globally and lower still in Africa and Southern Asia.14
- Each year, approximately 47,000 women die from complications associated with unsafe abortion.15Access to and use of effective contraception reduces unintended pregnancies and the incidence of abortion.16
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.17
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.18
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.19This addition to MDG 5 was a recognition by governments and world leaders of the need to address these challenges.20 Of all 8 MDGs, however, countries have made the least progress toward MDG 5.21
- 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. Congress first authorized research in this area in the Foreign Assistance Act of 1961.22 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); and in the 1990s, it began to recognize the need for male involvement in FP/RH and focus on the needs of young people.23 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 With the May 2009 launch of the U.S. Global Health Initiative (GHI), the USG set an FP/RH target to prevent 54 million unintended pregnancies by 2015 as part of its strengthened focus on “women, girls, and gender equality.”25
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 at least 38 countries (see Figure 2), including 24 “priority countries” that are mostly in Africa and South Asia.26 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.27 Its stated FP/RH objective is to expand sustainable access to quality voluntary FP/RH services and information (see Figure 3) 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.28
- Other USG Agencies: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),29 the Department of State (diplomatic role), the National Institutes of Health (NIH) (research), and the Peace Corps (volunteer activities).
- Related USG Efforts: USAID’s FP/RH and MNCH efforts are closely linked, although Congress directs funding to and USAID operates these programs separately. Recent years have also seen greater emphasis on linking FP/RH with HIV through the President’s Emergency Plan for AIDS Relief (PEPFAR).30
|Figure 3: USAID-Funded FP/RH Interventions31|
|Contraceptive supplies and their distribution||Training of health workers||Eliminating female genital mutilation|
|Counseling and services such as birth spacing||Financial management||Post-abortion care|
|Prevention and repair of obstetric fistula||Sexuality & reproductive health education||Public education and marketing|
|Linking FP with HIV/AIDS & STD information/services||Linking FP with maternity services||Contributions to UNFPA|
|Biomedical and contraceptive research and development|
U.S. Government Funding32
Most USG funding for FP/RH is specified by Congress in annual appropriations bills and is part of USAID’s Global Health Programs (GHP) account. While GHP funding for FP/RH is counted as part of the GHI, additional funding provided through other accounts (e.g., the Economic Support Fund) is not currently counted as part of the GHI.
USG 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 $715 million (which included significant supplemental funding for Haiti and Afghanistan). GHP funding has remained relatively flat since then, while funding through other accounts has had some fluctuation (see Figure 4). Despite increases during the Obama Administration, designated funding for FP/RH has not kept pace with U.S. global health funding overall, declining from 22% of the U.S. global health budget in FY 2001 to about 6% in FY 2013.33
Legal and Policy Requirements34
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 2009.35
- 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.36 In March 2009, President Obama announced the U.S. would restore UNFPA funding.37 $50 million was provided in FY 2009, $51.4 million in FY 2010, $37 million in FY 2011, $35 million in FY 2012, $33.3 million in FY 2013, and $35 million in FY 2014.
- 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. As demonstrated by the London Family Planning Summit in 2012, there is also growing global attention to the need to augment FP/RH services worldwide and increase coverage and access. However, the policy debates and discussions within Congress and the Administration regarding the U.S. role in FP/RH; USG funding, legal and policy requirements; the USG role in fostering progress toward global efforts to promote access to FP/RH; and initiatives to better link FP/RH with HIV and other global health programs are likely to continue.
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; Rachel Vogelstein, “Improving Maternal and Child Health Around the World,” White House blog: Council on Women and Girls, Oct. 6, 2010.
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.
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.
WHO, et al., Trends in maternal mortality: 1990 to 2010, 2012.
Saifuddin Ahmed, et al., “Maternal deaths averted by contraceptive use: an analysis of 172 countries,” The Lancet, July 14, 2012 (Vol. 30, no. 9837: pp. 111-125).
UN. The Millennium Development Goals Report 2009, 2009; WHO, World Health Report 2005 – Making Every Mother and Child Count, 2005.
Susheela Sing and Jacqueline E. Darroch, Adding It Up: Costs and Benefits of Contraceptive Services, Estimates for 2012, Guttmacher Institute/UNFPA, 2012; UN, The Millennium Development Goals Report 2013, 2013.
WHO, World Health Statistics 2014, 2014.
Country classifications are based on WHO regional designations.
UN, The Millennium Development Goals Report 2013, 2013; UN, The Millennium Development Goals Report 2014, 2014.
WHO, World Health Statistics 2014, 2014; UN, The Millennium Development Goals Report 2014, 2014.
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 Report 2005 – Making Every Mother and Child Count, 2005.
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.
ICPD, Programme of Action, Cairo, 1994; UN, The Millennium Development Goals Report 2009, 2009.
UN, The Millennium Development Goals Report 2009, 2009.
UN, The Millennium Development Goals Report 2009, 2009.
CRS, International Population Assistance and Family Planning Programs: Issues for Congress, Jan. 2010.
USAID, USAID Family Planning Program Timeline, undated.
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 2012, 2013.
GHI, U.S. Government Global Health Initiative Strategy, March 2011.
KFF analysis of data from ForeignAssistance.gov; USAID, “Family Planning Program Overview,” fact sheet, April 2013.
KFF personal communication with USAID, April 2, 2010.
USAID, Report to Congress: Global Health and Child Survival Progress Report – FY 2008, 2009; USAID, Strategic Framework for Family Planning webpage, http://www.usaid.gov/our_work/global_health/pop/framework.html (June 2, 2009).
CDC, Global Reproductive Health website, http://www.cdc.gov/reproductivehealth/Global/index.htm.
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.
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.
KFF analysis of data from ForeignAssistance.gov, the Office of Management and Budget, congressional budget justifications, and appropriations bills.
KFF calculation of funding designated for FP/RH through the GHP account, as part of the GHI, as share of overall funding for the programs now counted as part of the GHI.
KFF, Statutory Requirements & Policies Governing U.S. Global Family Planning and Reproductive Health Efforts, May 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.
White House, “Statement of Barack Obama on Rescinding the Mexico City Policy,” Jan. 23, 2009.
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 2009.