Improving Reproductive, Maternal and Newborn Health: Reducing Unintended Pregnancies

"One intervention to increase awareness and lead to behaviour change was a series of workshops among stakeholders in abortion care in Limpopo province in South Africa. Stakeholders self-reported behaviour change and increased awareness..."

This paper from the United Kingdom (UK) Department for International Development (DFID) represents the fourth in a series of reviews summarising the current state of evidence on what works to improve reproductive, maternal, and newborn health (RMNH). It provides a summary of the evidence on reducing the burden of unintended pregnancies in terms of two main packages of care: family planning and safe abortion. For each of these packages, the scope and magnitude of benefits to women and to broader society are reviewed, and the component interventions and delivery modalities are outlined. The main body of the paper then synthesises the evidence on interventions to reduce barriers to the supply of and demand for these services, including estimates of cost-effectiveness.

The paper begins by outlining the rationale for family planning, noting that, each year, 75 million unintended pregnancies occur in the developing world (out of a total 186 million), because some 215 million women have an unmet need for contraception. Unmet need for modern contraceptives ranges from 28% of married women aged 15-49 in sub-Saharan Africa and 23% in Asia (excluding East Asia) to 18% in Latin America and the Caribbean. The reasons for this unmet need are lack of knowledge, difficult access to supplies and services, financial costs, fear of side effects, and opposition from spouses, other family members, and often the wider cultural or legal environment. Failing to prevent unwanted pregnancy leads some women and girls to induce abortion: every year, 42 million or 20% of all pregnancies end in induced abortion. In 2008, an estimated 22 million unsafe abortions took place, resulting in about 70,000 deaths of women and girls. More than 97% of all unsafe abortions were in developing countries.

An excerpt from the report, with a focus on communication-related findings and suggestions, follows:

"What do we know about raising awareness for family planning?
There is good country case study evidence demonstrating the important role of political leadership and support for family planning. Experiences from Rwanda and Kenya emphasise the importance of stimulating demand for family planning at the level of national policy and budgets. For instance in Kenya family planning champions used national survey evidence to advocate for a renewed commitment to contraceptive services. By reframing family planning as an important issue for the nation's economic growth and social development, their efforts ultimately led to government funds being allocated to contraceptive commodities in the 2005 national budget, a first for Kenya. At the same time, this evidence review clearly shows that there is no evidence supporting coercive government population policies.

At the programme level, awareness raising and demand creation interventions have moved from traditional 'Information, Education Communication' activities to include elements that explicitly motivate a behaviour change through specific actions. This recognises that individual and family decisions are usually influenced by social and gender norms. There is now strong evidence from systematic reviews to suggest that so-called 'Social and Behaviour Change Communication' (S/BCC) interventions can be effective in changing behaviour in settings with higher than socially desired levels of wanted and unwanted fertility. There is a need to further develop and rigorously test S/BCC interventions in settings or among populations with high wanted fertility.

What do we know about delivery mechanisms for family planning?
...Evidence from a recent systematic review suggests that outreach and community based distribution are effective and acceptable ways of increasing access to contraceptives, particularly injectables and long acting and permanent methods.

Engaging the private sector is important for delivering quality products and services. There is increasing evidence to suggest that social marketing and social franchising can be effective approaches to increasing the coverage of affordable family planning services and commodities by both increasing demand and making produces more affordable and accessible. However it is less clear whether they can reach the very poorest.

Meeting the needs of adolescents requires specific interventions to reduce the additional barriers they face in accessing information and services. Yet to date, surprisingly few youth-friendly interventions have been rigorously evaluated in developing countries. A number of promising practices are emerging from quasi-experimental studies....These point to the need for context-specific combinations of interventions, including comprehensive BCC, community sensitisation, evidence-based sex education and life skills curricula, youth-friendly clinical services, referral networks between schools and health centres. Plus there is promising evidence for broader interventions to delay age of marriage, such as support for girls to remain in school, group formation and community awareness. There is an urgent need for more rigorous evaluations of such interventions...

What do we know about barriers to access to safe abortion services?
Barriers to access to safe abortion include its legal status, lack of information and knowledge (even where it is legal), shame and secrecy around clandestine abortion and lack of donor funding...

As more developing countries have reformed their abortion laws, new evidence is emerging to suggest that legal abortion can save lives. For instance in South Africa, six years after liberalising its abortion law, deaths due to unsafe abortion dropped by at least 50% and the number and severity of post abortion complications also fell.

Qualitative evidence on how to reduce the impact of restrictive abortion laws or broaden the conditions under which abortion can be legally performed suggests that a combination of research, coalition building and communication strategies can be effective.

What do we know about improving the delivery of safe abortion services?
Based on country case study evidence, effective interventions to improve the quality of safe abortion services are likely to include the training of health personnel in safe abortion techniques, including medical abortion and counselling, for comprehensive abortion care... Overall, however there is still limited evidence on interventions to improve the quality and delivery of safe abortion services in different settings and for different populations, including adolescents. More research is needed to monitor progress in improving health outcomes. Important unknowns include how to reach the poorest and most vulnerable groups and what are the best interventions to reduce delays and its effect on the safety of abortion..."