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Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 165176

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Best Practice & Research Clinical


Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Contraception in historical and global perspective


John Cleland, MA, FBA, Professor of Medical Demography *
Centre for Population Studies, London School of Hygiene and Tropical Medicine, 4951 Bedford Square, London WC1B 3DP, UK

Keywords:
family planning programmes
contraceptive prevalence
method-specic use
unintended pregnancy
population growth
social marketing
community-based approaches

This chapter describes the rise in contraceptive practice and fall in


fertility from around 1880 to the present day. Two main phases are
identied: the rst conned to European populations and
involving methods of low efcacy, and the second embracing the
whole planet involving modern methods. Today, sub-Saharan
Africa is the only region where low levels of contraceptive use and
high fertility persist. Nevertheless, nearly half of pregnancies
worldwide are still unintended, and much scope remains for
improvement in contraceptive protection. The main international
priority is Africa, where demographic factors jeopardize the goals
of reducing poverty and hunger.
2008 Elsevier Ltd. All rights reserved.

The freedom of couples to choose when and how often to become pregnant is a fundamental human
right.1 The level of contraceptive practice in a society also carries huge health, economic and environmental implications, because it is the major determinant of the birth rate and hence of the rate of
population growth or decline. Between 1950 and 2005, the planets population rose from 2.5 to 6.5
billion. Global fertility has now fallen from an average of 5.0 live births per woman in 1950 to 2.55 live
births in 2005, and is expected to decline further to approximately 2.0 live births by mid-century.
Under this scenario, the worlds population will nevertheless grow to 9.2 billion by 2050. However, if
fertility is half a birth higher or lower than expected between 2005 and 2050, the mid-century population of the planet will be 10.75 or 7.8 billion, respectively.2 Two things are clear. First, modest
changes in human reproduction have colossal effects on population growth, and second, the distinctions between future global populations of 8, 9 or 10 billion could be of critical importance to the
prospects of achieving reasonable and sustainable living standards for the whole of humanity.
The aim of this chapter is to provide the historical, political and cultural context for the more
specialized chapters that follow. The narrative starts in Europe and countries of predominantly

* Tel.: 44 20 7299 4621; Fax: 44 20 7299 4637.


E-mail address: john.cleland@ishtm.ac.uk
1521-6934/$ see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.bpobgyn.2008.11.002

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J. Cleland / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 165176

European descent around 1880. The rise in contraceptive practice in poorer regions, often with strong
government support, is then described. The story here is essentially positive; many experts have been
surprised by the speed of reproductive change, even in some of the poorest and most illiterate states.
However, much unnished business remains. Contraceptive practice remains low in much of subSaharan Africa, with the consequence that populations are set to double or even treble in size in the
coming decades. This rate of increase jeopardizes the goal of reducing poverty and hunger. The chapter
ends with a review of such future challenges.
The rst contraceptive revolution European populations, 18801930
In the absence of any restraints on fertility, it is estimated that the average woman would bear 15
children over her reproductive lifetime.3 In contrast, fertility achieved in pre-modern societies typically
ranged from 4.5 to 6.5 live births per woman, sufcient to offset high mortality but insufcient to fuel
sustained population growth. On average, only two children per couple survived to adulthood.
Historically, two factors, prolonged breast feeding and restrictions on entry to sexual partnerships,
operating through marriage rules and customs, were largely responsible for this huge gap between
potential and achieved childbearing. The contribution of contraception, and abortion, to the moderation of fertility is hotly contested. References to contraception are found in Graeco-Roman texts and in
mediaeval Arabic writings.4 The methods mentioned by ancient scholars are a mixture of the fanciful,
those that seemed reasonable at the time but which have since been shown to be ineffective (e.g.
avoidance of intercourse on the days following menses), and those of potential effectiveness, mainly
pessaries and barriers. Some scholars, notably John Riddle, have argued that herbal preparations, taken
orally, were both effective and widely used in classical times.5
Whatever may have been the case in civilizations of the distant past, the study of European fertility
by demographers suggests that contraception was not widely practised until relatively recently. The
hallmarks of regulated fertility do not appear in Europe until around 1880, with the exception of France
where the shift occurred approximately 100 years earlier.6 This verdict for Europe is consistent with
results from the earliest surveys of women in Africa and Asia, conducted before international
promotion of family planning started. Very few women were aware of contraceptive methods and even
fewer reported any form of contraceptive precaution.7
It may seem implausible that our ancestors exercised little or no conscious control over childbearing
within marriage, but it should be stressed that postnatal adjustments of family size and composition
acted as a partial substitute.8 It is likely that all traditional societies made use of some of the following
postnatal adjustments: infanticide, child abandonment, adoption, fostering, and release of children in
their early teens as apprentices and domestic labour. In past times, reproduction was a lottery because
of the unpredictability of child death. Couples who had too many surviving children to support were
balanced by those with a dearth of surviving children. The solution was obvious; children owed from
surplus to decit families.
Why French couples started to limit family sizes towards the end of the 18th Century remains one of
the great puzzles of demography. Easier to understand is the fertility decline that spread rapidly across
the rest of Europe from 1880 to 1930. By 1880, child mortality, although not necessarily of infants, had
fallen in many countries, implying an increase in surviving children, mass education was spreading,
and ideas about the status of women and religious authority were beginning to shift. Industrialization
and urbanization were well advanced in parts of Europe, and scientic progress was rapid. It became
inevitable that the increasing human mastery over nature would extend to reproduction. By 1930,
fertility had fallen below replacement level (a little above two births per woman) in many countries.
This rst revolution in reproductive control took place more or less synchronously in all countries of
predominantly European descent as well as in Europe itself, although perhaps somewhat earlier in
parts of the USA. In the Soviet Union, it spread east until it reached the Muslim populations of Central
Asia. The non-European parts of the world remained largely unaffected. In striking contrast to the
sequence of events in developing countries after 1960, this rise of contraception in European populations occurred in the face of widespread initial opposition from political elites, religious leaders and
the medical profession. At different times and in different countries, two of the most prominent birth
control pioneers, Annie Besant and Margaret Sanger, fell victim to the hostility that the subject evoked.

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In London, Besant was taken to court for republishing, in 1877, an American tract on birth control
quaintly called The Fruits of Philosophy. Sanger was arrested in 1916 for opening a birth control clinic
in Brooklyn.
Reliable evidence of the prevalence of different methods of contraception is unavailable before the
1950s. In Great Britain, it is likely that childbearing was initially reduced by coitus interruptus, but that
condoms and spermicides became more widely available and used in the early decades of the 20th
Century.9 In the USA, diaphragms and periodic abstinence were more commonly used, but coitus
interruptus was less popular than in Great Britain.10 The fact that these methods have low efcacy
testies to the determination of couples to restrict family size, although resorting to illegal abortion no
doubt acted as an important back-up to contraception. This rst contraceptive revolution was not
essentially a response to improved methods. It is more aptly characterized as the consequence of
a motivational and moral change. Family size limitation became a central pre-occupation and the
repugnance of coitus interruptus waned.
Developments in European populations since 1960
Fertility regulation in European populations underwent a radical modernization that started in the
1960s. Oral contraceptives were approved for use in the USA in 1960, and in many European countries
at around the same time. Modern intra-uterine devices (IUDs) also became more widely available.
Techniques of contraceptive sterilization were rened and, in the 1970s, many countries enacted laws
that explicitly permitted the procedure. Finally, widespread liberalization of abortion laws occurred.
These changes in technology and access had almost immediate effects in North America, and
Western and Northern Europe. In the USA between 1955 and 1965, the percentage of married nonHispanic White female contraceptors who used oral contraceptives rose from zero to 24%, while the
percentage using periodic abstinence, condoms and diaphragms fell.11 By 1982, condom and diaphragm use among contraceptors had fallen to 7% and 4%, respectively, in this same population group,
but a huge rise in sterilization had taken place; 43% of contraceptors had been sterilized (26% females
and 17% males).12 Since 1982, changes have been modest.
In the UK, oral contraception was already challenging the popularity of the two male methods
(condoms and coitus interruptus) by 1967, and by 1976, 38% of married contracepting women reported
use of the pill. Prior to 1970, the level of contraceptive sterilization was negligible, but by 1976, 19% of
contracepting couples had been sterilized and this proportion rose to 37% by 1986.10
This transformation from less effective methods that require the active participation of men to more
effective methods controlled by women was slower to arrive in Southern and Eastern Europe, and has
still not occurred in some countries. For instance, coitus interruptus remains the most commonly used
method in Albania, Bosnia and Greece, as was also the case in Italy at the time of the most recent survey
in 19951996.13
Between 1950 and 2005, fertility in developed countries fell from 2.8 to 1.5 births per woman. More
effective contraception, together with greater access to abortion, is partly responsible. In the USA, for
instance, the fraction of live births reported as unwanted at the time of conception fell sharply.14 With
high life expectancy and no net migration, a fertility rate sustained at 1.5 births will result in a halving
of population size every 60 years and severe population ageing. This demographic prospect is an
increasing concern of governments.
The contraceptive revolution in developing countries: the role of state intervention
In contrast to the rst contraceptive revolution in European populations, the history of family
planning in poorer countries is inextricably linked to government policies and programmes, motivated largely by demographiceconomic considerations. In the 1950s and 1960s, radical declines in
mortality were achieved but fertility remained resolutely high at ve to eight births per woman; this
widening gap resulted in a sharp acceleration in the rate of population growth. By 1960, many Asian,
Latin American and African populations were growing at a pace that implied a doubling in size every
25 years or so.

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In 1958, a seminal book by Coale and Hoover argued that the social and economic progress of poor
countries was jeopardized by rapid population growth, largely because of the inherent age structure of
rapid growth, in which half the population is aged 15 years or less.15 Household and government
savings have to be diverted from investment to develop industry and modernize agriculture to support
the huge burden of the unproductive young. In this era before the Green Revolution, serious doubts
arose about the ability of large Asian populations to feed the ever-increasing number of mouths. India,
at the time, was dependent on imports of US grain to avert the consequences of recurring food
shortages. These concerns, coloured by an element of xenophobia, were dramatized and popularized
by Paul Ehrlich and others.16 Conviction grew, particularly in the USA, that action was needed to stem
uncontrolled population growth.
No blueprint for action existed. The European experience offered no guidance and it was uncertain
whether couples in Asia and elsewhere wanted smaller families or were interested in using contraception. To answer these questions, research was needed and knowledge, attitude and practice surveys
of contraception proliferated. The next step was to assess, on a small scale, whether provision of
contraceptive services and accompanying information and publicity would work. Luckily, an apparently ideal, newly rened IUD became available; the Lippes Loop. It was cheap, effective, required little
contribution from the user, and modest skills to insert. The earliest demonstration projects, notably in
Taiwan and South Korea, relied heavily on this IUD and proved successful. In USA, President Lyndon
Johnson and Robert McNamara, Head of the World Bank (19681981), became enthusiastic supporters
of contraception. In 1969, a new United Nations (UN) agency, the UN Fund for Population Activities, was
created, with the shrewd choice of a Roman Catholic Filipino as its rst executive director. The stage
was set for the era of state-sponsored family planning programmes. In 1960, only two developing
countries had ofcial policies to promote contraception, but this number rose to 74 by 1975 and further
to 115 by 1996. International funding increased in parallel from US$168 million in 1971 to US$512
million in 1985.
Asian developments
Most Asian governments quickly embraced the messages from New York and Washington that
population control was a priority, but several of the early programmes were poorly designed. In
Pakistan and Bangladesh (then one country), President Ayub Khan launched a crash programme
centred on the IUD. The patient, the recruiter and the clinician all received a small payment for each
insertion, which gave rise to massive corruption. Little medical back-up for women experiencing side
effects was available, with the consequence that the IUD became deeply unpopular. The programme
collapsed after 5 years in 1969 as a complete failure. The cause of family planning languished in
Pakistan from then until the 1990s.17
Events in newly independent Bangladesh took a very different course. In 1977, population control
was proclaimed by President Ziaur Rahman to be a top national priority. Staff at district hospitals were
trained to perform tubectomies and vasectomies, and a new cadre of literate, married, female
community-based workers was created, called family welfare assistants (FWAs). FWAs were trained
for a month or so in basic family planning and child care, and then returned to their own villages to
provide a domiciliary service, supplying oral contraceptives and condoms, and referring women for
clinical or surgical methods. This strategy proved to be the sociologically effective way of popularizing
contraception. FWAs, being literate, were usually respected in their communities; they could act as
a bridge between village life and the alien world of scientic medicine and, perhaps most importantly
in a culture that makes it difcult for women to travel alone outside their immediate neighbourhood,
they brought contraceptives to the doorstep and acted as companions when trips to health facilities
were necessary.18 The success of Bangladeshs strategy can be seen in Fig. 1. Contraceptive prevalence
among married women rose from 12% in 1979 to 49% in 1996, although increases in the past decade
have been modest. Fertility has fallen from historic levels of six to seven births per women to three
births.
As in Pakistan, early efforts to deliver family planning services in India were unsuccessful. A rather
passive clinic-based approach, initiated in the 1950s, achieved little. In the 1960s, the programme was
extended, and contraceptive and demographic goals were set but again impact was minimal. In the

J. Cleland / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 165176

100
90
80

169

China
Indonesia
Bangladesh
India
Philippines
Pakistan

% Using

70
60
50
40
30
20
10
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007

Fig. 1. Trends in current use of contraception among married women of reproductive age, selected Asian countries.

early 1970s, the focus shifted to promotion of vasectomy by means of nancial incentives, typically
amounting to several weeks wages for an unskilled labourer.19 Many vasectomies were performed in
carnival-like settings where thousands of people would gather for entertainment. These high-pressure
tactics culminated in instances of outright physical coercion during the 2 years of Prime Minister
Ghandis emergency rule (19751977). The annual number of sterilizations rose to a huge gure of 8.26
million. A backlash was inevitable; Mrs Ghandi lost the 1977 election and the programme was discredited. It took about a decade for family planning to regain momentum, and progress, as measured by
contraceptive prevalence, has been steady but not spectacular (Fig. 1).
The comparison of family planning progress in the Philippines and Indonesia is intriguing. In 1960,
the Philippines had an income per head double that in Indonesia and much higher levels of adult
literacy and womens labour force participation. However, by 20022003, contraceptive prevalence in
Indonesia was 60% compared with 49% in the Philippines (Fig. 1). The reason for this unexpected
outcome lies with religion and politics. In Indonesia, the Government skilfully circumvented the
danger of opposition from Islamic leaders by agreeing not to legalize abortion or promote sterilization.
It mounted a forceful programme with the strong involvement of local leaders. In common with several
other Asian countries, the family planning agency sidestepped the weakness of Ministry of Health
services by creating its own dedicated network of centres and staff. In the Philippines, by contrast, no
agreement between state and church was reached and Roman Catholic leaders remained openly and
vocally opposed to most forms of contraception. In a predominantly Catholic country, this opposition
prevented the development of a comprehensive programme.
No account of family planning in Asia is complete without consideration of China. In 1974 at the
Bucharest World Population Conference, China was the main opponent of US calls for a worldwide
effort to arrest rapid population growth. However, 2 years earlier, the Chinese Government had
initiated its own massive programme to reduce fertility. This voluntary programme proved to be a huge
success, partly because of Chinas uniquely effective organizational abilities. However, in 1979,
economic planners successfully argued that deeper cuts in population growth were necessary and the
one- child policy was introduced, with benets for couples pledging to have only one child and
penalties for those exceeding the quota. In the cities, the grip of the Communist Party and support of
the populace were sufcient to ensure almost total compliance. However, in rural areas, opposition was
entrenched and local authorities eventually had to relax the rule and permit two children, regardless of
their sex, or alternatively allow a second child if the rstborn was a daughter.20 The fertility rate in
China is now approximately 1.5 births per woman. In an increasingly overcrowded planet, huge global

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benets have accrued from Chinas population policy because the country accounts for approximately
one-fth of humanity. Chinas economy has also beneted. The cost, however, has been high, not least
in terms of sex-selective abortion and the abandonment of unwanted daughters.21

Developments in other poorer regions


Whereas the 1958 book by Coale and Hoover provided the economic rationale for family planning
promotion in Asia, the equivalent in Latin America was a 1966 article that showed a disturbing trend in
Chile of increasing hospital admissions for the consequences of illegal and unsafe abortions.22 This
compelling medical rationale for the promotion of contraception led to the formation of nongovernmental organizations, such as Bemfam in Brazil and Profamilia in Colombia, typically led by local
physicians but funded from abroad. Governments were reluctant to engage because of the inuence of
the military (typically pronatalist), the Catholic Church and perhaps because of an inherent antipathy
to messages emanating from the USA.
In Brazil, the military regimes that governed the country from 1964 to 1985 maintained their
indifference to population issues and contraception. However, a demand for smaller families arose
spontaneously. It is probable that the spread of television and its hugely popular soap operas, featuring
small families, played an important role in changing reproductive attitudes.23 In the absence of public
sector contraceptive services, the private sector lled the vacuum. Pharmaceutical companies sold oral
contraceptives through pharmacies, and doctors circumvented a law prohibiting tubal ligation by
offering the procedure together with elective caesarean section. By 1996, contraceptive prevalence had
risen to 77% (predominantly sterilization and oral contraceptives) and fertility was close to replacement level. This high level of use is typical of Latin American countries, although there are laggards
such as Bolivia and Guatemala (Fig. 2).
In sub-Saharan Africa, family planning programmes were initiated by the White-minority regimes
in South Africa and Zimbabwe (then Rhodesia), and contraceptive use remains higher in these two
countries than in other countries. Elsewhere in sub-Saharan Africa, governments were slow to embrace
the cause of family planning sponsorship. One reason was genuine doubt that programmes would be
successful. Numerous surveys showed that unlike their Asian or Latin American counterparts, African
men and women typically wanted large numbers of children.24
Despite this obstacle, most African countries had adopted population policies by 1990, in some
cases under pressure from the World Bank and other donors.25 Prompted by a survey showing that the
country had one of the highest fertility rates in the world and a rate of population growth that, if
100

Colombia
Mexico
Peru
Bolivia
Guatemala

90
80

% Using

70
60
50
40
30
20
10
0
75 977 979 981 983 985 987 989 991 993 995 997 999 001 003 005 007
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1

19

Fig. 2. Trends in current use of contraception among married women of reproductive age, selected Latin American countries.

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171

unchanged, would result in a doubling of population in 19 years, Kenyas Government launched


a comprehensive programme in the early 1980s. The support of elites (churches, civil servants and local
leaders) was sought, extensive use was made of the mass media, and access to contraception was
expanded through health centres, social marketing schemes and community-based efforts. Success
was soon apparent. Between 1977 and 1988, the percentage of married women using contraception
rose from 7% to 27%, and desired family sizes fell dramatically (Fig. 3). The rise in contraception
continued until the mid-1990s but then plateaued, as did fertility. Between 1998 and 2003, the
percentage of births reported as unwanted rose and the percentage of contraceptive users relying on
public sector sources of supply fell.26 Both trends suggest that the family planning programme had
deteriorated and this interpretation is consistent with the fact that, in the 1990s, funds, staff, vehicles
and government commitment shifted from family planning to human immunodeciency virus/
acquired immunodeciency syndrome (HIV/AIDS).
Although prevention of HIV and unintended pregnancies have a common interest in reducing
unsafe sex, the relationship between the two movements is better characterized by competition than
by cooperation. Family planners were reluctant to promote condoms to married women instead of
more effective hormonal methods, and were poorly placed to reach men or sexually active single
people; prime targets for HIV prevention. Vertical funding by donors undermined the international
rhetoric that strongly favoured integration. However, the social marketing of condoms with HIV funds
has had a major effect on the contraceptive practices of unmarried young people in Africa (and in Latin
America). Condom use has risen sharply among the young, and pregnancy prevention, rather than
disease prevention, appears to be the dominant motive.27 Condoms have become the most common
contraceptive method in young people. Regrettably, resistance to condoms in married couples remains
strong; a tragedy in view of the fact that, in mature generalized epidemics, the majority of infections
occur among them.
Few countries in sub-Saharan Africa have matched Kenyas determination in the 1980s and early
1990s to reduce fertility via family planning promotion and, as in Kenya, family planning has often been
displaced as a government and donor priority by AIDS. In West and Central Africa, contraceptive
prevalence remains very low; the trends in Nigeria and Senegal are typical (Fig. 3). Among countries
with relevant data from national surveys, the prevalence of modern method use is below 10%, with
a few exceptions such as Ghana. In East Africa, the level of contraceptive use is more variable than in
West Africa, and in Southern Africa, it is higher than in other sub-regions.
Attitudes to family planning in the Arab states of North Africa and the Middle East have varied
considerably. The oil-rich countries, with small indigenous populations and large numbers of migrant
workers, have typically had no interest in moderating population growth or promoting contraception.
100

Egypt
Kenya
Ghana
Nigeria
Senegal

90
80

% Using

70
60
50
40
30
20
10

07

05

20

03

20

01

20

99

20

97

19

95

19

93

19

91

19

89

19

87

19

85

19

83

19

81

19

79

19

77

19

19

19

75

Fig. 3. Trends in current use of contraception among married women in reproductive age, selected African countries.

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Despite their huge wealth, fertility remains high and contraceptive use remains low in countries such
as Saudi Arabia and the United Arab Emirates. In the poorer, more populous countries, policies have
been more positive. Trends in contraceptive use are shown for Egypt in Fig. 3. The current prevalence of
approximately 60% is similar to that in Jordan, Syria, Algeria, Morocco and Tunisia.
Since the Russian Revolution in 1917, abortion in the Soviet block has been legal and widely
accessible for most of the time, but access to modern contraceptives has been extremely limited. This
combination led to widespread reliance on coitus interruptus and very high abortion rates. Since the
collapse of the Soviet Union in 1991, modern contraceptives have been promoted, in part by foreign
non-governmental organizations. In the Central Asian Republics (e.g. Uzbekistan, Kazakhstan), IUDs
are now the most commonly used form of contraceptive method and reliance on abortion has fallen.28
In the countries of the Caucasus (Armenia, Azerbaijan and Georgia), however, coitus interruptus
remains the most prevalent method.
Distilling the lessons from family planning promotion in poorer countries
Perhaps the single most important lesson from the experience of family planning promotion in Asia,
Latin America and Africa is that success can be achieved in poor and illiterate settings. The widespread
use of modern contraception in a country such as Bangladesh rebuts the pernicious, patronising but
nevertheless common belief that poor couples are uninterested in family planning because they need
and want many children. Similarly, it has also become apparent that high levels of female education,
labour force participation or national wealth do not automatically translate into low fertility (e.g. the
Philippines and oil-rich Arab states). While it is clear from the example of Brazil that state promotion is
not always necessary for the spread of contraception and achievement of low fertility, the balance of
evidence supports the view that governments can accelerate the pace of reproductive change and, less
commonly, initiate a change.29 Like any other government programme, effective family planning
programmes require political commitment, adequate funding, clear lines of management and supervision, competent staff, and sound logistics and management information systems. Beyond these nuts
and bolts of effectiveness, more interesting lessons can be learnt and these are summarized below.
The better family planning programmes have succeeded in large measure because they dismantled
the barriers to contraception. Reasonable geographical access to advice and supplies is an obvious
crucial consideration. Early on, family planning managers realized that exclusive reliance on static
health facilities as sources of supply was insufcient. One supplementary strategy is mobile clinics. In
the mountainous regions of Nepal, for instance, most contraceptive sterilizations are performed by
mobile teams of surgeons. Of greater signicance is the incorporation of commercial outlets into
contraceptive provision. Partly in response to the AIDS pandemic, most developing countries have
condom social marketing schemes, and the majority of users of this method obtain supplies at
subsidized prices from pharmacies and shops. Approximately 40 countries make oral contraceptives
available through social marketing which, typically, accounts for over 40% of demand. Approximately
30 countries allow social marketing of injectables.30
Social marketing works best in urban settings where exposure to the mass media is high, outlets are
abundant and demand for contraception is strong. Where these conditions do not apply, for instance in
more remote rural areas with fragile demand, community-based approaches are more effective. Many
community-based schemes are run by non-governmental organizations and their characteristics are
very variable. Typically, they involve lay staff who are trained for a brief period before returning to work
in their own communities. A critical strength is that workers share a language and customs with their
clientele. Programmes relying on volunteers are rarely durable and thus income in the form of a regular
salary or from contraceptive sales is a necessary ingredient. Experience from Africa suggests that
workers offering simple health products and advice as well as contraception are more effective than
dedicated family planning workers.
Community-based approaches have been widely deployed in developing countries, and have been
central to programmes in Bangladesh, Iran and Zimbabwe. However, they are difcult to scale up
because of the complexities of ensuring uninterrupted supplies and adequate supervision. Costs also
tend to be high. For these reasons, only minorities of contraceptive users rely on community-based
supplies.30

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Despite their limitations, static facilities remain the dominant mode of contraceptive service. Even
with this type of service, the dismantling of medical barriers to quick and convenient access is
important.31 It was demonstrated that nurses could insert IUDs as safely as physicians, and that it was
justiable to provide hormonal methods without a medical prescription. Outdated eligibility criteria
had to be scrapped and the requirement for husbands consent abandoned. In the past 15 years, the
quality of clinical services has been scrutinized intensively in response to criticisms of poor quality,
particularly in some Asian programmes. Partly because of a paucity of experimental research designs,
few decisive gains have been made in our understanding of which of the many possible elements of
service quality matter most to women.32 It is still unclear, for instance, whether extended counselling
improves uptake and persistent use. Perhaps the most emphatic nding concerns method choice. Most
women present at a clinic with a preferred method in mind. If that method is unavailable, alternatives
are often deemed unsatisfactory and rejected or discontinued.33
Although service provision, of course, is the backbone of family planning programmes, information,
education and communication are vital components and it would be a great mistake to conclude that
adequate access to services is sufcient to ensure widespread uptake of contraception. Acceptability is
equally important. Just as in Europe and the USA 100 years ago, the idea of contraception often
encountered initial moral and social opposition in poorer countries that was often expressed in the
form of deep mistrust of specic contraceptive methods.34 This initial resistance to family planning is
partly a consequence of misinformation but, at a deeper level, it is a reection of disquiet with a radical
innovation that goes to the core of one of lifes central pre-occupations; reproduction. Winning over
hearts and minds has been as important as providing adequate access to services. No blueprint exists
for transforming contraception from an alien, frightening and morally ambiguous behaviour into
a humdrum part of everyday life, but extensive use of mass media together with more targeted efforts
to gain the support of inuential groups, such as teachers, religious leaders and village heads, have
been a common feature of many of the more successful programmes.
Current status of global contraception: method-specic prevalence by region
Between 1960 and 2003, the percentage of married women in developing regions using any form of
contraception rose from approximately 10% to 60%, and fertility halved from six to three births per
woman. In industrialized countries, contraceptive practice also rose and fertility fell, but changes were
less dramatic because family sizes were already modest in 1960 and contraception was already well
established. In 2003, it was estimated that approximately 63% of all married and cohabiting women use
contraception.13 Female sterilization was the most commonly used method with a prevalence of
approximately 20%; much higher than vasectomy at 2.7%. The IUD was the next most commonly used
method, with a global prevalence of 15.5%; however, this gure is somewhat misleading because it is
largely a reection of the very high prevalence of IUD use (45%) in Chinas vast population. Excluding
China, global IUD prevalence drops to 6.7%; a little less than the prevalence of oral contraceptives
(8.5%). Condoms were used by an estimated 5.7% of couples, and injectables or implants by 3.4% of
women. Finally, 7% used so-called traditional methods (mainly coitus interruptus and periodic abstinence) and a tiny residue (0.5%) used other modern methods.
Regional variations in method-specic use are shown in Fig. 4 and some marked contrasts are
apparent. The prevalence of female sterilization exceeds 20% in Northern America, Latin America and
Asia, but is below 5% in other regions. Condoms are twice as popular in Europe and Northern America
than in poorer regions, and in Europe, the prevalence of traditional methods is twice the world average.
Intercountry differences become even more intriguing. The prevalence of condom use is 41% in Japan
and 35% in Hong Kong, but is only 5% in China. In Bangladesh, 26% of women use oral contraception
while the corresponding gure is 3% in neighbouring India. In Egypt, the IUD is the dominant method;
in Morocco, it is the pill.
Extreme skewness in method-specic use is common. In 34 of 96 countries, one method accounts
for over half of contraceptive protection, and this trait is just as common in rich countries as in poor
countries.35 In India, 66% of contraceptors are sterilized and the gure in Canada is similar (61%). In
Germany, France and the Netherlands, approximately three-quarters of all users rely on oral contraception. The explanation is multi-layered. Legal prohibitions, especially with regard to sterilization,

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J. Cleland / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 165176

80

Female Sterilisation
Male Sterilisation
Pill

70

Injectable/implant
IUD

60

Condom
Other method
Traditional

% Using

50
40
30
20
10
0
World

Northern
America

Europe

Asia

Latin
America

North Sub-Saharan
Africa
Africa

Fig. 4. Method-specic contraceptive prevalence by major region (most recent estimates).

occasionally restrict choice. More commonly, one or two methods have been promoted at the expense
of others. Staff may have their own preferences. However, probably the most important reason for the
limited range of methods used in many countries is the power of social imitation. Once, through some
quirk of history or policy, one or two methods become widely used, they become the preferred choice.
A further feature of contraceptive behaviour that unites rich and poor populations is the high
discontinuation of reversible methods for reasons that imply dissatisfaction with the method. In the
USA, 44% of couples stop use within 12 months of starting a method.36 In developing countries, similar
discontinuation probabilities are recorded for condoms and injectables, but lower estimates are typical
for oral contraceptives (34%) and IUDs (12%).37 Major reasons for stopping are side effects and health
concerns. The majority switch to another method. In the USA, inconsistent and incorrect use, together
with a small contribution from method failure, accounts for approximately half of all unintended
pregnancies, while the other half is attributable to non-use. In developing countries, contraceptive
avoidance or non-use remains the dominant direct cause of unintended pregnancies.
Future priorities and challenges
Since 1950, huge progress has been made in both the technology of contraception and in service
delivery. Yet from both a rights and health perspective and from economic considerations, much
unnished business remains. It is estimated that, globally, approximately 40% of recognizable pregnancies are unintended and unwelcome at the time of conception.38 Half of these are terminated,
causing an estimated 50 000 deaths per year from unsafe procedures. Approximately 30% of the
500 000 non-abortion-related maternal deaths per year could be prevented by the elimination of
unintended pregnancies taken to term, and at least 10% of child deaths could be averted by wider
spacing between successive births.39 Unmet need for contraception, that is the percentage of women
who do not want a child for at least 2 years but who are using no contraceptive method, remains at 20%
or more among married women in over half of developing countries with available data.13 Unmet need
in sexually active single women is even higher.30
From an economic perspective, the main priority for contraception is sub-Saharan Africa where
fertility is still very high (ve births per women), and where the population is projected to grow from
0.75 billion to 1.7 billion between 2005 and 2050; an increase of 125%. These demographic factors
greatly diminish the chances of achieving radical reductions in poverty and hunger. Population growth

J. Cleland / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 165176

175

has outstripped food production in Africa for several decades and, at the turn of the century, Africa was
importing US$20 billion of food per year, equivalent to the annual total of ofcial development
assistance.40 The recent rise in world grain prices, increasing water shortages compounded by the
uncertainties of climate change, together with rapid population increase pose a severe challenge to the
attainment of food security in Africa. Luckily, no tension need exist between the economic imperative
of population stabilization and a reproductive rights approach, because unmet need for contraception
is exceptionally high in sub-Saharan Africa.
Modern contraception has a wider range of potential benets than any other single medical
intervention: better maternal and child health, enhanced empowerment of women by reducing the
burden of excessive childbearing, alleviation of poverty and hunger, and contributions to environmental sustainability by stabilizing population sizes. It is deeply regrettable, therefore, that the subject
has fallen out of favour and international funding has dropped. The reasons for its demise include the
premature sense that the population problem had been solved, criticisms of inept and sometimes
coercive programmes in Asia, and displacement by newer concerns, particularly AIDS. The agenda is
badly in need of revitalization. The deepening disquiet that homo sapiens may be destroying the planet
by pressure of numbers and proigate life styles will surely lead to this revitalization.
Practice points
 only deect patients from their desired method when strong indications for this exist
 as discontinuation for method-related reasons is universally common, anticipate this
possibility in counselling and stress the need for prompt switching to an alternative

Research agenda
 interventions need to be developed and tested to assess whether the resistance to condom
use within marriage can be reduced in settings with generalized HIV epidemics
 assess the cost-effectiveness of using mobile phones in low-income countries to remind
women to return for re-supplies, particularly of injectables

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