PRB

J.M. Ian Salas is an incoming David E. Bell Research Fellow at the Harvard Center for Population and Development Studies. He recently obtained his Ph.D. in economics at the University of California, Irvine. He was a participant in PRB’s 2012-2013 Policy Communication Fellows Program, funded by USAID through the IDEA project. This article was written as part of the Fellows Program.

(August 2013) The 2012 London Summit on Family Planning brought renewed attention to the cause of providing women with options for managing their fertility—enabling them to have the number of children they want when they want them and spaced at healthy intervals. In that conference, countries and donor agencies expressed their commitment to increase funding for family planning programs to ensure that reliable contraceptive supplies are available and affordable to all women who express a desire to postpone or avoid childbearing.

To understand what the likely impact of this increased funding might be, one can look at recent research that considers the extent to which subsidized contraceptives influence the use of family planning supplies in several developing countries.

Contraceptive Use in Indonesia Little Affected by Economic Crisis

Indonesia’s experience with the effects of an economic crisis is at one end of the spectrum. Research by Christopher McKelvey, Duncan Thomas, and Elizabeth Frankenberg considered the effect of the country’s 1998 financial crisis on contraceptive use. Even though family incomes declined by 15 percent and the prices of subsidized contraceptives increased by anywhere from 10 percent to 51 percent until 2000, the crisis had a minimal effect on contraceptive use. This result suggests that contraceptive users in Indonesia valued the benefits of family planning so much that these two challenges—being poorer and facing higher prices—did not deter them from practicing contraception.¹

But Indonesia’s family planning program, begun in 1970, has had strong government support since it started. This program led to a large share of couples using modern contraceptives long before the crisis, so that the practice of contraception is well-ingrained. Moreover, the income loss that accompanied the crisis may have made it more important for Indonesian families to curb childbearing. Given this unusual situation, a similar response may not apply to other settings.

More Abortions in Africa When Contraceptives Are Limited

Two studies in Africa assessed the incidence of abortions when subsidized family planning commodities became limited. These studies focused on the consequences of the Mexico City Policy, a U.S. government policy that prohibited aid to nongovernmental organizations that perform or promote abortion services. Kelly Jones found that for rural women in Ghana, the incidence of pregnancies and abortions increased while this policy was in effect from 1985 to 1992 and from 2001 to 2008.² She ties this result to cutbacks in funding for family planning services in rural outreach areas, an unintended consequence of this policy.

Eran Bendavid, Patrick Avila, and Grant Miller reached a similar conclusion when they looked at the abortion rates in 20 countries in sub-Saharan Africa before and after this same policy was reinstated in 2001. Classifying these countries by the level of their previous reliance on U.S. financial assistance for family planning and reproductive health (above or below the median aid per capita received in 1995-2000), they found that under the policy, women in more-dependent countries like Ghana, Malawi, and Tanzania had more cases of induced abortions than women in less-dependent countries like Kenya, Nigeria, and Uganda. The increase over time in contraceptive use also slowed down in the more-dependent countries compared to the less-dependent countries.³

These two studies suggest that some groups of women in countries with low contraceptive use may be substituting abortion for contraception when it is harder for them to access or afford contraceptives.

Disadvantaged Women in the Philippines Hit Hardest by Lack of Contraceptives

My research looks at the gradual phase-out of USAID’s contraceptive donations to the Philippines from 2004 to 2008, an action that severely cut the supply of free contraceptives.⁴ This action was part of a broader effort by USAID to encourage country ownership of family planning programs worldwide. Before 2004, more than two-thirds of the country’s modern contraceptive users relied on free supplies from the public sector, which in turn relied entirely on donations from international aid agencies—largely USAID—for its contraceptive supplies. In a policy reversal, the newly installed president of the Philippines decided not to fill the supply shortage because of her close ties to the local Catholic church, which opposed the promotion and use of modern contraceptives.

Despite the phase-out of donated commodities, the Philippines’ contraceptive prevalence rate for modern methods (such as the pill and IUD) seems to have barely moved: about 20 percent for all women and 33 percent for married women. However, the country’s birth rate actually went up three years after the phase-out started. Moreover, provinces that had the biggest decline in the share of women that had provisions for free contraceptives also had the biggest increase in provincial birth rates. These contrasting results suggest that because of inadequate supplies of free contraceptives, some women may have experienced gaps in contraceptive use, leading to increases in unintended pregnancies and in the birth rate.

To investigate this hypothesis, I tracked the quarterly distribution of these contraceptive supplies to each province from 2000 to 2008, paying close attention to possible gaps in availability because of shipment delays, lack of inventory, and inconsistent delivery sizes; I then linked this distribution data to data on women’s reproductive histories. I found that if a woman was poor or had little education, she was more likely to get pregnant and have an unplanned birth after her province saw unexpected drops in free contraceptive supplies. This finding implies that, unlike in Indonesia, Filipino women from disadvantaged backgrounds could not easily cope with such a loss, however temporary, in free family planning supplies. Research that may offer explanations for why certain groups of women react differently to lack of subsidized access to contraceptive supplies is underway.

Public Funding for Contraception Is Important

These studies are providing the evidence for the importance of subsidized family planning supplies for disadvantaged women and couples. Together, they suggest that countries with strong family planning programs may be able to withstand unexpected decreases in public funding, and that high contraceptive use could be sustained after a critical point has already been reached. However, in most other settings where modern contraceptive use is low, the availability of subsidized contraceptives is still a huge factor in allowing women from disadvantaged backgrounds to manage their fertility. As such, increased funding for family planning, such as those committed in the London summit, should be targeted toward helping countries where contraceptive use is low and supply is inconsistent, and in particular toward women who may have difficulties paying for family planning services.

References

1. Christopher McKelvey, Duncan Thomas, and Elizabeth Frankenberg, “Fertility Regulation in an Economic Crisis,” Economic Development and Cultural Change 61, no. 1 (2012): 7-38.
2. Kelly Jones, “Evaluating the Mexico City Policy: How U.S. Foreign Policy Affects Fertility Outcomes and Child Health in Ghana,” IFPRI Discussion Paper 01147 (2011).
3. Eran Bendavid, Patrick Avila, and Grant Miller, “United States Aid Policy and Induced Abortion in Sub-Saharan Africa,” Bulletin of the World Health Organization 89 (2011): 873-80C.
4. J.M. Ian Salas, “Consequences of Withdrawal: Free Condoms and Birth Rates in the Philippines,” University of the Philippines School of Economics Discussion Paper 2012-20 (2012).