Global Rationales & Actual Benefits of Family Planning

Junice L.Demeterio-MelgarTraining of Medical Educators in

Family PlanningSilliman University, May 2010

Some early FP technology

pig intestine condoms

Crododile dung pessary

weasel’s testicles

Oral mercury Gold/silver diaphragm

lemon

Ian Fortey, Cracked.com

4 Pre Sept 1994 Rationales

• Population control – Government FP programs

• Birth control

• Contraception

• Responsible parenthood

Pop theory: too many people consume resources, destroy environment

World Pop in 2010: over 7 B

Thomas Malthus 1766-1834

“population increases geometrically while subsistence increases in arithmetic ratio”

http://www.economyprofessor.com/economictheories/malthusian-population-theory.php

“Overpopulation is not simply population density but the numbers of people in an area relative to its resources and the capacity of the environment to sustain human activities”.

Paul Ehrlich 1932-present

Women’s Reproductive Rights: pregnancy can be unwelcome

Margaret Sanger 1979-1966

"no woman can call herself free who doesn't own and control her own body.“http://www.nurses.info/personalities_margaret_sanger.htm

feminist writer (Married Love, Wise Parenthood)

Marie Stopes 1880-1958

Women’ right to FP (CEDAW 12.1 &General Recommendation No. 21

Article 16 (1) (e)

• 21. Women are entitled to decide on the no. and spacing of their children

• 22. Women need information and services on sexuality and contraception

• 23. Ensuring women’s right to FP results in family wellbeing, environmental protection and sustainable economic & social development.

Religious doctrine: all births are blessings

Pope Paul VI, 1897-1978

-Marriage & conjugal love are naturally ordained toward procreation and education of children. Every marital act must be open to the procreation of human life.

-Prohibited: abortion, temporary or permanent sterilization, contraception, includig emergency contraception

- Allowed: rhythm

Humanae Vitae (1968)

Humanae Vitae cont’d…

Dangers of artificial contraception:

1. Lowers moral standards, inc. marital infidelity

2. Causes men to disrespect women

3. Allows State to dictate on couples’ private decisions

http://www.vatican.va/holy_father/paul_vi/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae_en.html

Medical science: FP as necessary Health service to women

WHO, USFDA, FIGO, ACOG, Williams…

• Pregnancy is established when a fertilized egg implants on the uterine lining. USFDA, AMA, ACOG, FIGO, Williams Obstetrics 22nd ed.

• Contraception prevents pregnancy mainly through preventing ovulation and fertilization. WHO Expert Opinion on House Bill 4643 On Abortive Substances and Devices in the Philippines,2006

• Contraceptives are not abortifacients.WHO Expert Opinion on House Bill 4643 On Abortive Substances and Devices in the Philippines,2006

Abortion is different from contraception

Abortion is the termination of pregnancy, before the fetus develops sufficiently to survive – i.e. prior to 20 weeks gestation or less than 500g birthweight. Williams Obstetrics 22nd ed.

Medical abortion drugs: mifepristone, misoprostol;Surgical methods: transcervical procedures, eg vacuum aspiration, dilatation and curettage, and dilatation and evacuation. WHO Expert Opinion on House Bill 4643 On Abortive Substances and Devices in the Philippines,2006

Contraceptives very safe

• OCP nonsmoker, per 100T users:1.5Per year: 1:67,000

• OCP heavy smoker, per 100T: 59Per year: 1:1,700

-IUD (per year), per 100T users 0.01Per year: 1:10,000

• Barriers, per 100T per 100T users 0.0 Per year: 0

• FAB, per 100T users: 0.0 Per year: 0

• Female sterilization, per 100T users 2.6 Per year: 1:38,000

• Male sterilization, per 100T users 0.1 Per year: 1:1,000,000

Contraceptive Technnology 17th ed, 1998

…compared to• Risk of death from pregnancy & childbirth in Asia

– Per 100T livebirths 390– Lifetime risk: 1:65

• Other risks of death in US– Motorcycling, per 100T users: 100

• Per year:1:1,000

– Automobile driving, per 100T users: 16• Per year:

1:6,000

– Continuing the pregnancy, per 100T LB: 10• Lifetime risk: 1:10,000Contraceptive Technnology 17th ed, 1998

TYP

USE

.1 .15 .3 .5 .8 1 2 6-8 14 20 20 21 26 85

COR

CON

USE

.1 .1 .3 .5 .6 .5 .5 .1 3 6 1-9 5 6 85

NO

RP

LAN

TV

AS

EC

TOM

YIN

JEC

TAB

LEFS

TER

ILIZ

NTC

u380

AIU

DP

OP

brea

stfe

edin

gLA

M6m

osO

CP

CO

ND

OM

DIA

PH

+SP

ER

MC

IDFA

B

FCO

ND

OM

SS

PE

RM

CID

NO

ME

TH

OD

0-1: Always very effective

2-9: Effective as common-Ly used. Very effective when used correctly &consistently.

10-30: Only somewhat effective ascommonly used. Effective when used correctly & consistently

(0-1) (2-9) (10-30)

Pregnancies per 100 Women in 1st 12 mos Use

Modern Contraceptives: Very Effective

WHO, USAID, Bloomberfg, Family Planning A Global Handbook, 2007

Contraceptives: in WHO Core List of Essential Medicines

Minimum medicine needs for a basic health care system, listing the most efficacious, safe and cost-effective medicines for priority conditions. Priority conditionsare selected on the basis of current and estimated future public health relevance, and potential for safe and cost-effective treatment.

http://www.who.int/medicines/publications/essentialmedicines/en/

Women

PopulationChurch

Medical

ICPDPOA

1994

The Reproductive Health Consensus

ICPD POA major Goals (1.12)

– sustained econ growth in the context of sustainable development

– education, especially for girls – gender equity and equality – infant, child and maternal mortality reduction – provision of universal access to RH services,

FP & sexual health.

Reproductive Healthstate of health in all matters relating to the reproductive system,its functions and processes

Implies: • satisfying & safe sex life• capability to reproduce • freedom to decide if, when, and how often to

reproduce– right to FP

• access to health services that will enable women to survive pregnancy & child birth, and for infants to be born healthy

• right to sexual health Intl Conf. on Pop. & Devt. Programme of Action Ch 7 Para. 2

•FP counselling, IEC & services; •Maternal & child health •Infertility prevention & treatment of infertility•Abortion per para. 8.25, including prevention & management of consequences •RTIs, STIs & other conditions - prevention & treatment •Sexuality & responsible parenthood IE & counselling •Referrals for complicated cases•Active discouragement of harmful practices, such as FGM,

ICPD 7.6

RH services as part of Primary Health Care

•No promo of abortion as FP•Address public health impact•Prevention of unwanted pregnancy•Compassionate counselling of women with unwanted pregnancies •Abortion policy change must be done according to national legislative processes •In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. •Post-abortion counselling, education and family-planning services to avoid repeat abortions.

Abortion – according to ICPD POA 8.25

Goal: enable couples and individuals to decide freely and responsibly no.& spacing of their children

Ensure informed free choice, is essential to long-term success of FP programs.

Coercion, incentives and disincentives, targets & quotas have not worked

Governmental goals for FP should be defined in terms of UNMET NEED for information and services.

ICPD POA 7.12

FP Program principles

Bruce-Jain Framework of Quality FP Care (1990)

• Choice of contraceptive methods

• Full & accurate information

• Technical competence

• Interpersonal communication

• Continuity of care and follow up

• Appropriate constellation of servicesCreel et al, Overview of Quality of Care in Reproductive Health: Definitions and

Measurements of Quality of Care, PRB & PopCouncil 2002

FP Benefits

• Saves women’s, men’s & children’s lives

• Improves women’s & family’s productivity

• Generates public health savings

• Reduces population pressure on scarce resources

Guttmacher Institute and UNFPA, Adding it Up: The Costs and Benefits of Investing in Family Planning

and Maternal and Newborn Health, 2009; Population Reference Bureau, Family Planning Saves Lives, 2009

Comparative Cost-Effectiveness of FPIntervention Cost $ per

DALY saved

Insecticide-treated bednets 3-20Malaria prevntn for pregnant women 29TB treatment (epidemic sitns) 6-60Modern contraceptive methods 62ARV treatment India 150

ARV treatment Sub-Saharan Africa 252-547BCG vaccination of children 48-203Oral rehydration therapy 1,268Cholera immunization 3,516

Guttmacher Institute and UNFPA, Adding it Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health, 2009