My 30 years of hope, empowerment, and politics in reproductive health

Departures often serve to kick-start reflection. After more than 30 years, I will be retiring from PATH and have been thinking about the “then,” when I joined PATH in 1983, and the “now” as I clearly see the conclusion of my time here.

PATH was the organization I was keen to join because of my passion for women’s health and, in particular, family planning and contraceptive access. I resolutely believed then that girls and women needed to be able to determine if and when to have children to build out their futures. That belief has not wavered.

When I was in graduate school, contraceptives were being touted as one of public health’s most cost-effective tools—a “best buy.” Over the years, rigorous evidence on this remarkable value has continued to accumulate. Contraceptive use indisputably prevents unintended pregnancies as well as pregnancies that increase a woman’s risks of death and disability. But the benefits do not stop there.

• Healthy timing and spacing of pregnancies significantly increases infant and child survival and ability to thrive.
• More broadly, accessible and affordable contraceptive services contribute to women’s education gains, household savings, and even national-level economies.
• The impact of successful contraceptive services programs contributed either directly or indirectly to all of the Millennium Development Goals and cuts across most of the Sustainable Development Goals.

One major change I’ve seen is that low- and middle-income country governments now recognize the important role family planning and contraceptive services play in attaining health and development goals. These governments no longer wrestle with whether to invest in voluntary contraceptive services but rather how best to meet the growing demand.

Also emerging is the acknowledgement that preventing pregnancy is not exclusively a “family planning” imperative. For example, communication materials 30 years ago almost invariably showed two parents and two children (typically a boy and a girl). We must appreciate and frame contraceptive services within a context of sexuality and sexual health—especially as the largest cohort of young people the world has seen is entering reproductive ages.

Another major change is the way in which demand is being met. I’ve witnessed the exciting expansion of the array of people who can provide contraceptive services and the venues where these can be accessed.

Over the decades, the safety of modern contraceptives has been validated by millions upon millions of uses. The advancement of the critical role pharmacists, druggists, and community-level workers—even women themselves—can play in delivering contraceptive services represents an almost 180 degree shift from the dominant clinic-based, highly medicalized model of contraceptive services that existed 30 years ago.

Thirty years ago, lack of contraceptive knowledge and access were the major impediments to use. A Lancet article on trends in contraceptive needs reports that in 2012, among the world’s low-income countries, about 75 percent of the 867 million women who wanted to avoid pregnancy and needed contraception relied on modern methods. This change is the result of significant financial, systems, and human resources investments.

Success in meeting contraceptive needs means an ever-growing demand. This is very different from what one would expect with a therapeutic medicine where, with use, the incidence of the target disease declines as well as the need for the treatment medicine. With contraceptives, although the proportion of women who wanted to avoid pregnancy and used modern contraceptives did not increase much between 2003 and 2012, the number of users increased by 139 million—averaging 15 million annually (“Trends in Contraceptive Need and Use in Developing Countries in 2003, 2008, and 2012: An Analysis of National Surveys” 209 KB PDF).

And while the success in reducing barriers to contraceptive access and use definitely is worth celebrating, it is sobering to consider that an additional 225 million women in low-income countries who do not want to get pregnant are not using modern contraceptives, many of whom are among the poorest in their countries. It will take a long-term and unflagging commitment well into the future to reach these women with voluntary contraceptive services and then continue to ensure everyone has access.

Over the past three decades there has been a broad realization that government-financed programs within the public sector cannot satisfy the current and growing demand for contraceptive services. More than ever, nongovernmental organizations and, particularly, the commercial sector play an ever-expanding role in meeting contraceptive needs. Their engagement is changing the scope and shape of contraceptive services.

While the number of different contraceptive types has expanded—largely through adaptations of existing technologies—they are not sufficient to meet the needs of all women. Unfortunately, compared with 30 years ago, resources for contraceptive research and development (R&D) are not as robust and, in fact, are markedly less than in other critical health areas. In 2013, for example, funding for contraceptive R&D was US$62.5 million (G-Finder Reproductive Health Report 2014). By comparison, the 2010 investment in HIV R&D was US$1.07 billion, tuberculosis US$575.4 million, and malaria US$547 million (G-FINDER Report 2011: Neglected Disease Research and Development: Is Innovation Under Threat?).

One thing I have given up trying to rationalize is the continuing politicization of contraceptive services. This has not changed in all my years at PATH. That a tenet of the basic right to health—one that draws from rigorous evidence, effective programming, decades of experience and, most importantly, addresses a need expressed by women and men throughout the world—should continue to cycle through a storm of political churn and retrenchment is beyond me.

Contraceptive services and family planning should not be considered any more controversial than other approaches to ensuring and sustaining good health. Having been buffeted by these political winds, I greatly appreciate those who stand up and advocate for all women throughout the world to have the ability to determine if and when to have children.

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