1. How Contraception Saves Lives Anna Buchsbaum, MD, MPH Family Planning Fellow Emory University June 2, 2013

2. Developing Tomorrow’s Leaders in Reproductive Health For more information and to apply online, please visit www.familyplanningfellowship.orgwww.familyplanningfellowship.org Advanced clinical and research training Generous funding package, including MPH or MSc tuition and meeting attendance Fully funded global health opportunity Research funding Post-fellowship academic career opportunities and funding support Connection to a national network of more than 250 family planning specialists The Fellowship in Family Planning 29 sites in the US Research and clinical skills in contraception and abortion.

3. MICHIGAN Fellowship in Family Planning Program Sites 29 programs in departments of Obstetrics and Gynecology in 17 States CALIFORNI A NEVADA OREGON WASHINGTON IDAHO UTAH ARIZONA COLORADO NEW MEXICO MONTANA WYOMING SOUTH DAKOTA NORTH DAKOTA MINNESOTA WISCONSIN IOWA MISSOURI NEBRASKA KANSAS OKLAHOMA TEXAS ALASKA HAWAII ARKANSAS LOUISIANA MISSISSIPPI ALABAMA GEORGIA FLORIDA TENNESSEE KENTUCKY INDIANAILLINOIS OHIO PENNSYLVANIA WEST VIRGINIA VIRGINIA NORTH CAROLINA SOUTH CAROLINA WASHINGTON, DC MARYLAND DELAWARE NEW YORK NEW JERSEY CONNECTICUT RHODE ISLAND MASSACHUSETTS NEW HAMPSHIRE MAINE VERMONT States with a Current Fellowship Site States with a Potential Fellowship Site States with No Fellowship Sites

4. Objectives  Review history of global family planning  Describe Millennium Development Goals in context of family planning  The Role of Family Planning & Contraception in Preventing Maternal Mortality  Physician’s Role in Promoting Family Planning  WHO Tools for Family Planning guidance

5. Cairo Conference  International Conference of Population and Development  Sept 5-13, 1994  Programme of Action  15 Principles

6. Principle IV  Advancing gender equality  Empowerment of women  Elimination of all kinds of violence against women  Ensuring women's ability to control their own fertility  Universal human rights for all including women and girls  Full and equal participation of women in civil, cultural, economic, political, and social life, at the national, regional and international levels,  Eradication of sex discrimination

7. Principle VIII  Right to the enjoyment of the highest attainable standard of physical and mental health  Universal access to health-care services, including those related to reproductive health care, which includes family planning and sexual health  Reproductive health-care programs should provide the widest range of services without coercion  All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so.

8. Goals  Sustained economic 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 reproductive health services, including family planning and sexual health

9. Millenium Development Goals (MDG) Adapted from: Cates. Family planning: the essential link to achieving all eight Millennium Development Goals. Contraception 2010;81(6):460-61.

10. MDG 1: Eradicate extreme poverty and hunger  Per capita gross national product is correlated with the prevalence of modern contraceptive methods  FP reduces demand for scarce food products  1997: 775 million undernourished  2017: 1.2 billion undernourished  Birth spacing reduces low birth weight and poor maternal nutrition  FP results in more wealth and less hunger Cates et al. Family Planning and the Millenium Development Goals. Science. Sept 2010. Barnett, Stein.

11. MDG 2: Achieve Universal Primary Education  Girls drop out of school due to unintended pregnancies or the need to care for younger siblings  Family Planning prolongs education Cates et al. Family Planning and the Millenium Development Goals. Science. Sept 2010.

12. MDG 3: Promote gender equality and empower women  FP empowers women and supports development efforts  FP Allows work and career progression for women  Women who use contraceptives:  more likely to be employed in Egypt  Long-acting user more likely to work for pay in Brazil and Indonesia  Involving men can change gender norms  Ability to achieve desired family size is the most important driver of modern development efforts Cates et al. Family Planning and the Millenium Development Goals. Science. Sept 2010.

13. MDG 4: Reduce Child Mortality  Prevention of unintended pregnancies averts 1.2 million infant deaths each year  640,000 newborn deaths could be prevented If all contraceptive needs were met  FP is less expensive than treating complications of unintended pregnancy  FAMILY PLANNING INCREASES CHILD SURVIVAL Cates et al. Family Planning and the Millenium Development Goals. Science. Sept 2010 WHO Best Practice Guidelines Singh et al, AGI 2009.

14. MDG 5: Improve Maternal Health  Reduce maternal mortality ratio by three quarters  Universal access to reproductive health  Main causes of maternal morbidity and mortality:  Pregnancy and delivery in low-resource settings  Complications from unsafe abortion Cates et al. Family Planning and the Millenium Development Goals. Science. Sept 2010.

15. Causes of Maternal Death

16. Distribution of Maternal Mortality Source: WHO 2012

17. Distribution of Unsafe Abortion

18. Family Planning Needs  Unwanted pregnancy & unsafe abortion are signs that contraceptive services are not meeting women’s needs  40% of pregnancies worldwide are unintended  >80% of unintended pregnancies in developing countries occur to women who have an unmet need for contraception

19. Contraception as Primary Prevention

20. Indirect Impact 220,000 children worldwide lose mothers each year from abortion related death Haddad, 2009

21. Indirect Impacts

23. Investing in Family Planning  215 million women with unmet need  Drop in unintended pregnancies by 66%  75 million to 22 million per year  Avert 70% maternal deaths  550,000 to 160,000  Avert 44% newborn deaths  3.5 million to 1.9 million  Drop in unsafe abortion by 73%  20 million to 5.5 million Adding it Up, 2009.

24. UNFPA, 2009

25. Contraception What can we do?

26. Contraception  Counseling opportunities – information dissemination  Who can use which method  Efficacy of method  How to use the method

27. Opportunities for Contraception Counseling  Post-abortion  Avoid future unintended pregnancy and repeat abortion  Post-partum  Pregnancy spacing  Prenatal care  Pregnancy spacing  General Gynecology visit  Postpone initial or subsequent pregnancy  General Medical visit  Prevent pregnancy with medical comorbidities

28. Opportunities for Contraception Counseling  Vital signs  LMP  Sexual activity  Contraception  Future fertility goals

29. Four Cornerstones of Family Planning

30. WHO Medical Eligibility Criteria (MEC) Purpose: who can use contraceptive methods

31. Why is evidence-based guidance needed?  To base family planning practices on the best available evidence  To address misconceptions regarding who can safely use contraception  To reduce medical barriers  To improve access and quality of care in family planning

32. Conditions associated with increased risk as a result of unintended pregnancy  Breast cancer  Complicated valvular heart disease  Diabetes: insulin-dependent; with nephropathy/retinopathy/neuropathy or other vascular disease; or of >20 years’ duration  Endometrial or ovarian cancer  Epilepsy  Hypertension (systolic >160 mm Hg or diastolic >100 mm Hg)  History of bariatric surgery within the past 2 years  HIV/AIDS  Ischemic heart disease

33. Conditions associated with increased risk as a result of unintended pregnancy  Malignant gestational trophoblastic disease  Malignant liver tumors (hepatoma) and hepatocellular carcinoma of the liver  Peripartum cardiomyopathy  Schistosomiasis with fibrosis of the liver  Severe (decompensated) cirrhosis  Sickle cell disease  Solid organ transplantation within the past 2 years  Stroke  Systemic lupus erythematosus  Thrombogenic mutations  Tuberculosis

34. WHO MEC  1 – No restriction for use of contraception  2 – Advantages of method generally outweigh theoretical or proven risks  3 – Theoretical or proven risks usually outweigh advanctages of using method  4 – Unacceptable health risk if method is used

35. WHO MEC HYPERTENSION E+PPCu-IUD Controlled42 1 Uncontrolled32 1

36. Efficacy

39. WHO Standard Practice Recommendations Purpose: How to use contraceptive methods

40. Summary  Maternal mortality is a significant problem globally  Family planning and contraception can save maternal lives but indirectly can improve child and infant mortality  We must improve access and quality of contraceptive services to all women  WHO tools to guide family planning decision making

41. Thank You