Potential for lives saved

JOHN CLELAND: In the last step, we learned that around 225 million women have an unmet need for family planning. In other words, this number of women wanted to avoid having a child for at least two years but were using no effective modern method of contraception. In this step, I will discuss the potential health benefits that will be gained if all these 225 million women started using an effective contraceptive method. And the main message I want to convey to you is that family planning is the most cost-effective way of improving the survival of mothers and children.

Now, if all these 225 million women with unmet need used a modern method, there would be a reduction, as you can see on this slide, of 52 million unintended pregnancies. Not all such pregnancies would be eliminated, because some result from contraceptive failure. But a large majority would be prevented. Now, when a pregnancy occurs, there are four possible endings– miscarriage, stillbirth, induced abortion, and a live birth or baby. As the slide shows, the prevention of these 52 million unintended pregnancies would result in six million fewer miscarriages and slightly over half a million fewer stillbirths. When a pregnancy is unintended, the woman and her partner have to decide whether to have a baby or seek an abortion.

Evidence suggests that about half decide to keep the baby and half decide to have an abortion. In many countries, abortion is legal and safe, but in many others, it is illegal. And thus, women are driven to seek unsafe backstreet abortions that put their lives at risk. Every year, there are around 20 million unsafe abortions and about 22,000 women die as a consequence. Contraception could cut the number of unsafe abortions by 15 million– in other words, by 75% percent– and save 18,000 deaths from abortion. Clearly, the promotion of effective contraception is the way to reduce the need for abortion, be it safe or unsafe.

Even bigger reductions in the number of maternal deaths would result from the prevention of 21 million unplanned or unintended births. Each pregnancy and birth threatens the life of the mother. The risk is tiny in richer countries with good obstetric services, but in poorer countries, where many deliveries take place at home rather than in the hospital, the risks are much greater. Each year, over a quarter of a million women die from complications of pregnancy or childbirth. The tragedy is that many die from pregnancies that they did not wish to have. Contraception could cut the number of maternal deaths by over 20%.

Contraceptive services to avoid an unintended pregnancy cost about $33. But over seven times this amount would be saved by a reduction in health-care costs for the mother during pregnancy and childbirth and in health care for the baby.

Turning now to the effect of contraception on the health of infants, the survival of newborn infants and children can also be improved by using contraceptives to widen the gaps between one pregnancy and the next. Pregnancies that start within 20 months of a previous birth are more likely than those conceived after a longer gap to result in premature births and in low birth weight babies. The reasons for this link between short pregnancy spacing and adverse birth outcomes are not fully understood. But it almost certainly reflects the fact that the mother’s body has not fully recovered from the earlier birth. Nearly half of all deaths to children before their fifth birthday occur in the first four weeks of life.

And prematurity is the leading cause of deaths to infants in these first four weeks, and low birth weight is an additional cause. Therefore, there’s a strong link between pregnancy spacing and child survival. This link is shown in this slide. The vertical axis shows the risk of death relative to children conceived three to four years after an earlier birth, and the horizontal axis across the bottom shows the pregnancy interval in months. That is the time between the end of one birth and the start of the new pregnancy. There are two lines.

A blue line for neonatal mortality– that is death of a baby in the first month of life– and the green line for post-neonatal mortality, between the second month and the first birthday. The shape of the two lines is similar, indicating that the risk of a baby dying when pregnancies are too close together extends beyond the first month of life. Compared to the children conceived after a three to four year gap, children conceived after a gap of less than six months have over twice the risk of dying, children conceived after a gap of 6 to 11 months have a 60% greater risk, and children conceived after a gap of 12 to 17 months have a 35% greater risk.

You can also see from this figure that very long intervals of more than four years are also associated with a higher risk of death of the baby in the first month of life. That’s that upturn on the right hand side of the blue line. So the safest gap between a birth and the start of the next pregnancy is between two and three years. And finally, if all short pregnancy intervals were eliminated by contraceptive use, it’s estimated that about 450,000 of the six million child deaths per year could be avoided.

Let’s summarise the lessons here. Eliminating unmet need for effective contraception would cut the number of abortions per year by 3/4 and save the lives of 18,000 women, nearly all in poorer countries of the world. Eliminating unmet need would reduce the number of women who die in pregnancy or childbirth from unintended pregnancies by 53,000. These are big numbers. Family planning is the most cost-effective way of reducing maternal deaths. Roughly $1 spent on contraception saves $7 on antenatal care, delivery care, and care of the newborn. It’s a hugely impressive cost-benefit ratio. Over a quarter of new pregnancies in developing countries start less than 18 months after a previous birth, and these short intervals increase the risk of early child death.

Use of contraceptive methods to space pregnancies could cut the number of children dying each year by 450,000. That’s another very, very big number.