Family planning

• 1. Introduction

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  Family planning sits at the intersection of medicine, economics, politics, and the most intimate choices a person ever makes. Philosopher L. A. Paul has argued that becoming a parent is a transformative experience so profound that a person cannot make that decision rationally, because they cannot know in advance what kind of person they will become as a result. That observation cuts to the heart of why family planning is so contested and so consequential. What does it mean to plan for a child, or to plan against one? Who decides, and who is denied that choice? And what happens to societies, economies, and individuals when those decisions are taken away?

• 2. What Family Planning Actually Means

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  The United Nations and the World Health Organization define family planning as encompassing services leading up to conception, not just the use of contraception. A 2017 textbook by Poston and Bouvier draws a useful distinction: "family planning" refers to attempts by couples to regulate the number and spacing of their births, while a "family planning program" is a systematic, often government-sponsored effort to supply information and services for modern fertility control.

  The phrase has become a catch-all. It covers sex education, management of sexually transmitted infections, pre-conception counseling, infertility treatment, and abortion, though abortion is not considered a primary method. Crucially, many people who use contraception are not planning a family at all. Unmarried adolescents and young married couples delaying childbearing while building careers are among those who want contraception but may not identify with the phrase.

  Contemporary practice increasingly places a woman and her childbearing decisions at the center of the discussion. This shift reflects the growing traction of women's empowerment and reproductive autonomy worldwide. Family planning programs used widely between 1950 and 1995 in developing countries remain controversial in cases where coercion was involved, particularly in China, India, and Peru. A World Bank Group report nonetheless concluded that those programs contributed substantially to the rise in contraceptive use and the decline in fertility across the developing world.

• 3. The Economics of Having Children

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  Childbirth and prenatal care averaged $7,090 for a normal delivery in the United States in 1996. A U.S. Department of Agriculture estimate for a child born in 2007 put the cost of raising that child at $11,000 to $23,000 per year for the first 17 years, with total inflation-adjusted expenditure ranging from $196,000 to $393,000 depending on household income.

  Family planning is described as among the most cost-effective of all health interventions. The UNFPA calculates that for every dollar invested in contraception, the cost of pregnancy-related care is reduced by $1.47. In the United States, contraceptive use saves roughly $19 billion in direct medical costs each year. The $1.9 billion spent on publicly funded family planning in 2008 saved an estimated $7 billion in short-term Medicaid costs.

  The macro-level returns are striking. The Copenhagen Consensus, produced by Nobel laureates in collaboration with the UN, ranks universal access to contraception as the third-highest policy initiative in terms of social, economic, and environmental benefits per dollar spent. The costs of universal access would amount to roughly $3.6 billion per year; the projected benefits exceed $400 billion annually. If adolescent girls in Brazil and India were able to delay childbearing until their early twenties, the increased economic productivity would equal more than $3.5 billion and $7.7 billion respectively, according to UNFPA.

  At the household level, economists speak of a quality-quantity trade-off: parents choosing fewer children can invest more in each child's education and health. Research in Vietnam by Dang and Rogers in 2015 found direct evidence that families near family planning centers invested more in each child's education, consistent with this trade-off. Children with fewer siblings, in general, tend to stay in school longer than those from larger families.

• 4. Health Stakes for Mothers and Infants

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  About 99% of maternal deaths occur in less developed countries. Of those, less than half occur in sub-Saharan Africa and almost a third in South Asia. The CDC's 2021 report noted racial disparity in maternal mortality outcomes, finding higher rates among Hispanic women compared to their counterparts.

  Both early and late motherhood carry heightened risk. Young teenagers face elevated rates of complications and death from pregnancy. The WHO recommends waiting until at least 18 years of age before attempting pregnancy to improve outcomes for both mother and child. After a previous birth, waiting at least two years but not more than five years before attempting to conceive is considered healthier; after a miscarriage or abortion, waiting at least six months is recommended.

  Older mothers face a different set of risks: higher chances of having a child with autism or Down syndrome, increased likelihood of multiple births, greater risk of gestational diabetes, a higher need for Caesarian section, and increased risk of prolonged labor.

  Universal access to contraception, if achieved, would prevent 640,000 newborn deaths, 150,000 maternal deaths, and 600,000 children losing their mother, according to the Copenhagen Consensus projections. The UNFPA calculates that meeting the unmet need for modern contraceptives worldwide would prevent an additional 24 million abortions, 6 million miscarriages, 70,000 maternal deaths, and 500,000 infant deaths.

• 5. Contraception and Its Methods

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  Long-acting reversible contraceptive methods, including intrauterine devices and implants, are among the most effective options available and require little user action. When the cost of failure is included in the calculation, IUDs and vasectomy are substantially less costly than other methods over time.

  Fertility awareness methods have been practiced since antiquity, though scientific advances over the past century have expanded their variety. The Symptothermal method achieves success rates above 99% when used correctly. The Catholic Church promotes fertility awareness as the only acceptable form of family planning, calling it Natural Family Planning. These methods carry no drug-related side effects and can be used to either achieve or prevent pregnancy.

  Mass media campaigns have measurable effects. The 1989 Kenya Demographic and Health Survey found that half the women who recalled seeing or hearing family planning messages on radio, print, or television subsequently used contraception, compared with 14% of women who did not recall such exposure, even after controlling for age, residence, and socioeconomic status. In Tanzania, a USAID-funded project run from January 1991 through December 1994 used radio spots, drama series, posters, and audio cassettes to promote modern contraception. Contraceptive use among women aged 15-49 rose from 5.9% to 11.3%, and the total fertility rate dropped from 6.3 lifetime births per individual in 1991-1992 to 5.8 in 1994.

• 6. Coercion and Reproductive Injustice

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  With the eugenics movement of the 20th century, 60,000 people were sterilized in 32 states across the United States, with state-sanctioned sterilizations peaking in the 1930s-40s. More recently, unwanted sterilizations were performed on over a thousand women in California prisons between 1997 and 2010. The Supreme Court has not issued a widespread ruling declaring forced sterilization unconstitutional.

  Long-acting reversible contraception, including IUDs and progestin implants, and permanent sterilization have been disproportionately recommended to individuals from marginalized communities, communities of color, lower socioeconomic classes, and those with intellectual disabilities, compared to white, high-income individuals.

  In Xinjiang, an investigative report by The Associated Press published on the 28th of June 2020 documented that the Chinese government was taking systematic measures to slash birth rates among Uyghurs and other minorities. Between 2015 and 2018, population growth in largely Uyghur areas fell by 84%. Between 2014 and 2018, the rate of IUD placements increased by more than 60% in Xinjiang while it dropped elsewhere in China. In 2021, the Uyghur Tribunal in London concluded that China subjected the Muslim minority to forced sterilizations and abortions approved at the highest levels in Beijing. One survivor testified that she was given injections and kicked repeatedly in the stomach and is no longer able to have children.

  In Uzbekistan, the government has pushed for uteruses to be removed from women to sterilize them forcibly. In Peru, forced sterilization was carried out against indigenous women during the 1990s. In Rwanda, the National Population Office estimated that between 2,000 and 5,000 children were born as a result of sexual violence during the genocide, while victims' groups estimated the number exceeded 10,000.

• 7. The Unmet Need

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  According to the United Nations Department of Economic and Social Affairs, 64% of the world's population uses contraceptives, while 12% of the world population's need for contraceptives remains unmet. Africa has the lowest contraceptive use rate at 33% and the highest rate of unmet need at 22%. North America has the highest contraceptive use rate at 73% and the lowest unmet need at 7%.

  In sub-Saharan Africa, drug shops and pharmacies account for most private-sector contraception, particularly for condoms, pills, injectables, and emergency contraception. The Family Guidance Association of Ethiopia, working with more than 150 enterprises, tracked health outcomes in one factory over 10 years and found contraceptive use rose from 11% to 90% between 1997 and 2000.

  In the United States, only 6.2 million women accessed publicly funded services from 10,700 clinics in 2015, despite an estimated 20 million women who could benefit. Title X-funded programs saw 1.2 million fewer patients in 2015 compared to 2010, as funding decreased by $31 million. A 2017 study found that children born after county-level family planning programs were introduced between 1964 and 1973 had 2.8% higher household incomes, were 7% less likely to live in poverty, and 12% less likely to live in households receiving public assistance.

  The COVID-19 pandemic added acute pressure: as of March 2020, an estimated 450 million women were using modern contraceptives across 114 priority low- and middle-income countries. Projections suggested that for every three months of lockdown continuing with high disruption levels, up to 2 million additional women could be unable to use modern contraceptives, with an estimated 7 million additional unintended pregnancies expected if disruptions continued for six months.

• 8. Climate, Rights, and What Comes Next

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  At the 1994 International Conference on Population and Development, global consensus was formalized in Principle 8 of the Programme of Action: 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.

  The 2012 London Summit on Family Planning, hosted by the UK government and the Bill and Melinda Gates Foundation, produced Family Planning 2020, a global movement in which more than 20 governments committed to addressing policy, financing, delivery, and socio-cultural barriers to women accessing contraception. The WHO and World Bank estimate that $3 per person per year would provide basic family planning, maternal, and neonatal health care to women in developing countries.

  The research project Drawdown ranks family planning as the seventh most efficient action against climate change, placing it ahead of solar farms, nuclear power, and afforestation. A 2021 paper in Sustainability Science by William J. Ripple, Christopher Wolf, and Eileen Crist argues that population policies can advance social justice while reducing human impact on the climate, noting that the richer half of the world's population is responsible for 90% of emissions.

  September 26 is designated World Contraception Day, with a stated vision of a world where every pregnancy is wanted. The international coalition supporting it includes the International Planned Parenthood Federation, Marie Stopes International, Women Deliver, and Population Services International, among others. The founding of that federation traces back to Hong Kong's Family Planning Association, which in 1950 grew from the Eugenics League established in 1936 and went on to help found the global body with counterparts in seven other countries.