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

Key Facts

• Improving access to family planning and reproductive health (FP/RH) services globally can help prevent maternal deaths and reduce unintended pregnancies. Each year, an estimated 287,000 women die from complications during pregnancy and childbirth, almost all in low- and middle-income countries. Approximately one-third of maternal deaths could be prevented annually if women who did not wish to become pregnant had access to and used effective contraception. Worldwide, 218 million women have an unmet need for modern contraception.
• The U.S. government (U.S.) has supported global FP/RH efforts for nearly 60 years and is the largest donor to FP/RH in the world. It is also one of the largest purchasers and distributors of contraceptives internationally.
• 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 as well as its use, particularly related to abortion.
• U.S. funding for FP/RH rose steadily in its first three decades but has remained relatively flat in recent years at approximately $600 million. In FY 2023, U.S. funding totaled $608 million, including funding for the United Nations Population Fund (UNFPA). After the Trump administration withheld funding from UNFPA from FY 2017 – FY 2020, under the Kemp-Kasten Amendment, it was restored by the Biden administration in FY 2021.
• U.S. funding for FP/RH is governed by several other legislative and policy requirements, including a legal ban on the direct use of U.S. funding overseas for abortion as a method of family planning (the Helms Amendment, which has been in place since 1973) and, when in effect, the Mexico City Policy (reinstated and expanded by President Trump as the “Protecting Life in Global Health Assistance” policy but rescinded by President Biden upon taking office).

Global Situation

Access to family planning and reproductive health (FP/RH) services is critical to the health of women and children worldwide. 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 and most in sub-Saharan Africa and South and Central Asia.¹ It is also estimated that approximately one-third of maternal deaths could be prevented annually if women who did not wish to become pregnant had access to and used effective contraception.²

Key Factors

Key factors contributing to maternal deaths and unintended pregnancy include:⁵

• 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.

Worldwide, 218 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).⁶ Access to modern FP methods varies significantly by region. Unmet need for modern FP is highest in regions like sub-Saharan Africa, Oceania, and Western Asia where modern contraceptive prevalence is low.⁷ 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 as well as Oceania.⁸ While the percentage of pregnant women receiving the recommended minimum number of four antenatal care visits has been on the rise, it is 49% in the least developed countries and has reached only 54% in sub-Saharan Africa and 55% in South Asia.⁹ Each year, approximately 47,000 women die from complications associated with unsafe abortion.¹⁰ Access to and use of effective contraception reduces unintended pregnancies and the incidence of abortion.¹¹

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

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.¹³

SDG 3: Achieving Universal Access to Reproductive Health

This goal, adopted in 2015 as part of Sustainable Development Goal (SDG) 3 – “ensure healthy lives and promote well-being for all at all ages,” 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”¹⁴ by 2030.

U.S. Government Efforts

The U.S. has a long history of engagement in international family planning and population issues, and today, the U.S. government is the largest donor to global FP/RH efforts and is one of the largest purchasers and distributors of contraceptives internationally.¹⁵ Congress first authorized research in this area in the Foreign Assistance Act of 1961.¹⁶ In 1965, the U.S. Agency for International Development (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 as well as the relationship between population, health, and the environment; 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.¹⁷ More recently, the U.S. 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.¹⁸ U.S. funding for FP/RH is governed by several legislative and policy requirements, 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, such as the Mexico City Policy (see below).

Organization

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 more than 30 countries, with a focused effort in 24 priority countries that are mostly in Africa and Southern Asia.¹⁹ The agency’s stated FP/RH objective is to help countries meet the FP/RH needs of their people.²⁰ It does this by expanding sustainable access to quality voluntary FP/RH services, commodities, and information (see Table 1²¹) that 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 by improving “women’s opportunities for education, employment, and full participation in society;” and stabilize population growth by advancing “individuals’ rights to decide their own family size.”²²

Table 1: U.S. Government-Funded Family Planning/Reproductive Health (FP/RH) Interventions

Addressing child marriage

Addressing gender-based violence

Biomedical and contraceptive research and development

Contraceptive supplies and their distribution

Contributions to UNFPA

Counseling and services such as birth spacing

Eliminating female genital mutilation

Financial management

Linking FP with HIV/AIDS & STD information/services

Linking FP with maternity services

Post-abortion care

Prevention and repair of obstetric fistula

Public education and marketing

Sexuality & reproductive health education

Training of health workers

Other U.S. FP/RH Efforts

Also carrying out FP/RH efforts are the Centers for Disease Control and Prevention (CDC) (research, surveillance, technical assistance, and a designated World Health Organization Collaborating Center for Reproductive Health);²³ 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 maternal and child health (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 global HIV efforts through the President’s Emergency Plan for AIDS Relief (PEPFAR).²⁴ See the KFF fact sheet on U.S. MCH efforts and the KFF fact sheet on U.S. PEPFAR efforts.

Multilateral Efforts

The U.S. works with several international institutions, partnerships, and other donors to carry out FP/RH efforts. Among them are the U.N. Population Fund (UNFPA, the largest purchaser and distributor of contraceptives worldwide); Family Planning 2030 (FP2030, an international partnership to expand access to rights-based family planning services in which the U.S. is a core partner²⁵); and the Global Financing Facility (GFF, a partnership to advance the health and rights of women, children, and adolescents through innovative financing, in which the U.S. is an investor and has recently enhanced its cooperation with a focus on how their combined efforts may further strengthen primary health care).²⁶

Funding²⁷

U.S. funding for FP/RH rose steadily in its first three decades²⁸ but then declined for several years before peaking at $715 million in FY 2010. More recently, funding has been relatively flat at approximately $600 million. Total U.S. funding for FP/RH, which includes the U.S. contribution to UNFPA, was $608 million in FY 2023 (see figure for the latest information). In several years during this period, the Trump administration withheld the U.S. contribution to UNFPA (FY 2017 – FY 2020) due to the Kemp-Kasten Amendment.²⁹ (See the KFF fact sheet on the U.S. Global Health Budget: Family Planning & Reproductive Health (FP/RH) and the KFF budget tracker for more details on historical appropriations for U.S. global FP/RH efforts.)

Most U.S. funding for FP/RH is part of the Global Health Programs account at USAID, with additional funding provided through the Economic Support Fund account. FP/RH funding is also provided through the International Organizations & Programs account at the Department of State for the U.S. contribution to UNFPA. Under current U.S. law, any U.S. funding withheld from UNFPA is to be made available to other family planning, maternal health, and reproductive health activities.³⁰

Requirements in Law and Policy³¹

Legal, policy, and programmatic requirements for U.S. funding for international FP include (also see the KFF fact sheet on these and other requirements):

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 non-governmental organizations (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, rescinded by President Obama, and reinstated – in an expanded form – by President Trump in January 2017. The Trump administration’s application of the policy extended to the vast majority of U.S. bilateral global health assistance, including funding for FP/RH, HIV under PEPFAR, maternal and child health, malaria, nutrition, and other programs; in past iterations, it applied to family planning assistance only, and under that administration, the policy was renamed “Protecting Life in Global Health Assistance.” The Biden administration rescinded the policy in January 2021. See the KFF explainer on the Mexico City Policy.

UNFPA & the Kemp-Kasten Amendment

Although the U.S. government helped create the U.N. 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.³² The Kemp-Kasten Amendment was most recently invoked to withhold funding for UNFPA for four years (FY 2017 – FY 2020) during the Trump administration; see the KFF explainer on UNFPA funding and the Kemp-Kasten Amendment.

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.