1. Fertility Regulation Behaviors and Their Costs Elizabeth Lule Washington, DC July 16, 2008

2.  Global Trends in fertility behavior  Unmet need for contraception and unintended pregnancies  Costs associated with Fertility Regulation  Recommendations and Policy Implications Presentation Outline

3.  Review existing research on global trends in fertility regulation behaviors, economic medical and social consequences, costs and cost effectiveness of interventions  Regional reviews of Africa and ECA with contrasting contexts to examine the role of contraception and induced abortion and supply and demand factors  Two country case studies to estimate costs to families, households, and national health systems  Nigeria: Survey in 8 states, household based survey interviews of women, interviews of hospital physicians and cost data collected  Kazakhstan: Three stage stratified sampling of health facilities to look at provider attitudes and gather direct and indirect costs and intervention costs  Identify study limitations and research gaps  Identify and discuss policy implications with governments Study Methodology

4. Trends in Total Fertility Rate by Region, 1950 -2005 Sources: UN 2004; World Bank 2007.

5. Trends in Contraceptive Prevalence Rates (modern methods) in Select African countries NOTE: CPR represents women ages 15-49 years old using modern methods of contraception Source: Demographic and Health Surveys

6. Trends in Contraceptive Prevalence Rates (modern methods) in Select ECA Countries Source: Westoff 2005

7. Mean ideal number of children, by current age of woman in ECA Source: Westoff 2005

8. Contraceptive Prevalence Rate (CPR) by Region and Wealth Quintile (DHS 1995-2005, most recent country data) Note: Regional CPR averages are unweighted. Source: Demographic and Health Surveys

9. Unintended Pregnancy and Unmet Need for Contraception By region and Unmet need by Region Source: Sedgh G. et al 2007 Pregnancy Outcomes (205 million)

10. Mortality due to Unsafe Abortion Source: Ahman and Shah, 2007

11. Progress Towards MDGs: Inadequate Trend In Under-five Deaths, 1960-2015 (Millions Deaths Per Year)

12. Trends in skilled attendant at birth:off track Source: UNICEF

13. Direct and Indirect Costs Globally, cost to women’s health – 5 million suffer from disability including infertility, poor mental health and stigma Transport costs are high especially for the poor Loss of productivity and earnings Hospitalization costs – mean per patient cost estimated at US $96-$131 Cost to health systems – In Nigeria, 185,000 cases of post abortion complications cost $19 million in 2005. In Kazakhstan, contraceptive use as an alternate to abortion is at least 3.2 times more cost-effective to avert one birth

14. Recommendations and Policy Implications (1) Failure to provide access to convenient, safe, affordable and acceptable choices for contraception appears to perpetuate unnecessary reliance on abortion To reach MDGs 4 and 5, countries and donors need to address unmet need and growing demand for contraception especially for young, poor and rural women and men in developing countries Given that contraception is more cost effective than abortion, countries and donors need to invest more in: –improving access to contraceptive knowledge and services, particularly to young women –ensuring commodity security in the long-term

15. Recommendations and Policy Implications (2) Improve health systems and overall family planning provision including supply chains Improve access to affordable, basic social and health services, particularly education for girls and labor participation for women More research on socio- economic impact of unsafe abortion on women, households and health systems and document benefits

16. Acknowledgements Donor support from the Swedish International Development Cooperation Agency (SIDA), UNFPA, and the Hewlett Foundation Co-authors Susheela Singh and Sadia Chowdhury and contributing authors Other institutions: Guttmacher Institute, Princeton University, UNFPA, and USAID

17. Thank You