Universal Access to Contraception

Abstract

This policy supports the universal right to contraception access in the United States and internationally. Contraceptive use confers significant health benefits through reductions in unwanted and high-risk pregnancies, maternal and infant morbidity and mortality, unsafe abortions, and medical therapy. These benefits are so significant that universal access to contraception is accepted internationally as essential to human rights. Most countries have not fulfilled this right, with political and religious opposition eroding access to existing services. Frequent barriers to access include financial, geographical, violence- or conflict-related, and sociocultural factors. Considering these barriers, as well as contraceptive failure rates, this policy supports the universal human right to voluntary, informed, affordable access to the full range of modern contraceptive methods, including emergency contraception. In addition, it urges all governments, health providers, and health funding systems to ensure the right to contraception without exceptions, through services including comprehensive evidence-based counseling, language translation, and referrals as needed. Finally, it urges governments and donor agencies to support contraceptive technology research as well as strategies to facilitate use and acceptability.

Relationship to Existing APHA Policy Statements

Through its policies and advocacy, APHA has long supported the right to contraception access; however, APHA has no up-to-date comprehensive policy addressing the necessity and public health benefits of universal, informed, and voluntary access to the full range of contraceptive methods both in the United States and internationally. Previous policy statements provide basic foundations for this proposed contraception policy. Policy Statement 7704 (Access to Comprehensive Fertility Related Services) focuses solely on the United States and espouses access to the “full range of fertility-related services (including all medically acceptable methods of contraception, abortion, prenatal and maternity care, infertility services, and genetic counseling and diagnosis).” Policy Statement 200314 (Support for Sexual and Reproductive Health and Rights in the United States and Abroad) establishes support for sexual and reproductive health rights in the United States and globally, emphasizing the right to safe abortion. Policy Statements 5918(PP) (The Population Problem), 6418(PP) (Policy Statement on Population), and 7119 (Replacement Reproduction and Zero Population Growth) encompass a wide range of health and development issues but do not highlight public health and human rights concerns. They are outdated, and we recommend archiving them. A review of other related APHA policy statements reveals additional outdated policies that refer to specific US legislative controversies.

All other relevant APHA policies address specific contraceptive methods only, focus solely on US policy developments, and/or include access to contraception among many other public health issues in broader policies.

At the center of this proposed APHA contraceptive policy is the fundamental belief in an individual’s right to informed and voluntary choice of contraceptive methods during her or his life cycle for the purpose of pregnancy prevention, delay of a pregnancy, disease prevention, or medical treatment. This right to contraception includes the right to information on the effectiveness of all methods, as well as their side effects, reversibility, and other related issues, to enable voluntary and informed contraception choice.[1–4] Ideally, a person’s literacy or income level or place of residency would not limit informed contraceptive choice.[1,4,5] This comprehensive policy on universal access to contraception contributes strongly to APHA’s mission to improve public health and achieve equity in health status; it is an essential component of APHA’s priority to ensure rights to health and health care.

Problem Statement

The development of safe, effective contraception is widely considered to be one of the greatest public health achievements of the 20th century.[6] Contraception allows individuals to safely space and limit their pregnancies and reduces unintended pregnancies, unsafe abortions,[7] and maternal morbidity and mortality.[8] Contraception also improves birth outcomes, slows population growth, and improves socioeconomic status.[9–12] Contraception plays a pivotal role in the well-being and health of women worldwide and gives individuals control over their sexuality, fertility, and reproduction. Many contraceptive methods reduce the risk of endometrial and ovarian cancers, are therapeutic agents for menstrual-related disorders, and have other proven health benefits.[12] Evidence has shown definitively that the relative risk associated with use of any tested method of contraception is significantly lower than the risks from pregnancy, childbirth, and unsafe abortion.[13]

The public health and development impact of contraception is well established and so profound that access to contraception is now considered an essential element of the human right to health in the international community. Human rights are universal legal guarantees protecting individuals and groups against actions and omissions that interfere with fundamental freedoms, entitlements, and human dignity.[14] The foundation in human rights law for universal voluntary access to contraception was established in 1968 at the International Conference on Human Rights, during which governments around the world agreed that “parents have a basic human right to decide freely and responsibly the number and spacing of their children.”[15] Subsequently, the international human rights legal system has reaffirmed the right of individuals and couples to access the means to achieve that standard.[16,17]

In 1994, the Programme of Action of the United Nations Population Fund’s International Conference on Population and Development (ICPD) established standards of reproductive rights that included universal access to contraception. ICPD established these rights on the basis of numerous other internationally recognized rights such as the rights to nondiscrimination, life, survival, development, the highest attainable standard of health, and education and information. ICPD and the international human rights system outlined the following core human rights related to contraception: (1) the right of all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children; (2) the right to sexual and reproductive health services, information, and education in order to attain the highest standards of sexual and reproductive health; and (3) the right to make decisions concerning reproduction free of discrimination, coercion, or violence.[18]

The international human rights system also identified four “interrelated and essential” principles that constitute the right to the highest attainable standard of health: availability, accessibility, acceptability, and quality.[19] Financial barriers to accessibility are of such significance that the principle of affordability is essential in all analyses of whether the right to health is being fulfilled in contraceptive policies and services.

Reproductive rights are human rights, and therefore human rights principles apply. Under human rights laws, all duty bearers (governments as well as any other institutions that determine individuals’ abilities to exercise their rights to health) are responsible for facilitating the achievement of the highest standard of health for their populations through “respecting, protecting, promoting, and fulfilling rights.”[20]

Despite the proven effectiveness and benefits of contraception, advances in contraceptive technology, and the recognition of contraceptive access as a basic human right, neither the international community nor the United States has achieved universal access to contraception. To the contrary, political and religious opposition to contraception threatens to erode access to existing services both in the United States and internationally.

In 2014, approximately 225 million women worldwide who were married or in a union had an unmet need for modern contraception, 5% greater than the previous year.[5,21] This is an underestimate of actual need, since these estimates often do not include unmarried girls and women. In the United States, nearly half of all pregnancies are unintended, with the rates among young and poor women disproportionately high.[22] The need is greatest in developing countries where the risks of maternal and infant mortality are highest, rising to 25% in Oceania and sub-Saharan Africa, as well as among specific vulnerable populations in all countries, especially adolescent girls and young women.[21,23]

In 2013, 289,000 women worldwide died from pregnancy-related complications,[23]; as many as 13% of these deaths were due to unsafe abortions,[24] and 99% occurred in developing countries.[23] The primary causes of global maternal mortality are postpartum hemorrhage and unsafe abortions. Satisfying unmet needs for contraception may prevent another 104,000 maternal deaths per year, a 29% reduction.[13] Recognizing the strong relationship between contraceptive prevalence and maternal mortality rates, the United Nations, the World Health Organization, and other international organizations included addressing unmet need for contraception in the Millennium Development Goals, with the aim of no country having a maternal mortality rate greater than 140 per 100,000 live births by 2030.[21] Each year an estimated 80 million women in developing countries have an unintended pregnancy, resulting in an estimated 21.6 million unsafe abortions, of which more than 3.2 million are among adolescents.[24] Increasing universal access to high-quality contraception methods and services is a proven and critical health intervention to prevent both safe and unsafe abortions.[5]

Risks from pregnancy and childbirth increase significantly among women at extremes of age (younger than 18 years or older than 40 years), women who are undernourished, and women who have certain preexisting medical conditions.[25–28] Although global birth rates among adolescents have decreased, except in sub-Saharan Africa, more than 15 million of 135 million live births worldwide are among young women between 15 and 19 years of age.[21] Childbearing under the age of 18 years is especially risky for both mother and child and remains highest in developing regions.[26] Prevention of high-risk pregnancies and lengthening the space between births improve perinatal and child survival outcomes.

Universal contraception access has a significant role in global population growth and sustainability. Three main factors account for much of future global population growth: proportion of the population in the reproductive age range, unwanted births, and high desired family size (more than universally sustainable). Universal contraception access would reduce population growth by about 20%.[5]

Both in the United States and globally, specific populations encounter greater barriers to contraception access than the general population. These underserved populations include residents of rural areas, adolescents (unmarried and married girls), minority and indigenous communities, groups living in conflict zones or in areas affected by natural disasters, refugees and migrants (especially undocumented migrants), people with mental or physical disabilities, people living in extreme poverty, girls and women in violent intimate relationships, women and girls living in societies where their mobility outside the home is restricted, employees of religious organizations that oppose contraception, and residents of areas where health services are overseen by such organizations.[21,28–30] Lack of access to contraception among these populations may result in higher pregnancy-related health and mortality risks. In some cultural settings, unmarried girls and women may face ostracism, violence, and/or death if their unintended pregnancy is discovered.[31] Religious teachings opposing birth control and promoting procreation can affect laws and policies regarding contraceptive access. For example, in 2015 the US Supreme Court ruled that privately owned corporations can be exempt from providing their employees with mandated health care coverage for contraceptive services on the basis of religious opposition.[32]

Many factors affect an individual’s capacity to actualize his or her right to choose desirable contraceptive methods, including access to and availability of the full range of methods, affordability, availability of skilled medical personnel, method effectiveness, method safety and side effects, and medical eligibility. Sociocultural factors can either facilitate or pose barriers to choice; the most common barriers are lack of partner/spousal support, gender-based and sexual violence, sexual harassment, and discrimination in the wider society or from medical providers on the basis of gender, age, marital status, sexuality, ethnicity, religious preference, or legal status.[1,3,30]

A multifaceted and comprehensive rights-based approach to contraception thus extends beyond mere contraceptive prevalence to consider both supply-side factors (availability and accessibility of high-quality contraceptive services and goods) and sociocultural factors such as cultural acceptability and competence of the information and health care available.[11,33] Contraceptive services and counseling should be evidence based, client centered, and customized to fit the needs and expectations of any given individual, even if the person finds less effective methods to be culturally acceptable.[33,34] Comprehensive counseling integrates information on return to fertility after cessation of reversible methods, resources to facilitate removal of long-acting reversible contraception devices, “dual protection” to prevent HIV and pregnancy, and how to access and use emergency contraception in the event that a contraceptive method fails or in other necessary circumstances.[33,35–39] Special attention to ensure full autonomy and informed choice must be given to vulnerable population groups, including but not limited to lesbian, gay, bisexual, transgender, intersex, and questioning individuals; adolescents; people with physical and mental disabilities; HIV-positive individuals; and refugees/displaced populations.[1] In addition, informed choice should be supported by comprehensive sex and sexuality education, which contributes to healthy adolescent development as well as sexual and reproductive behaviors that promote health and well-being.[2]

Contraception failure and the many circumstances (sexual violence, financial and social barriers) in which a woman cannot use contraception can result in unintended pregnancies, necessitating that health care providers offer comprehensive options, including abortion, for all pregnancies and resources for all women, regardless of their age, religion, legal status, marital status, or other demographic characteristics. If a provider is unable to do so, she or he has an ethical and professional obligation to refer women to other providers who are available and willing to do so. If women choose to terminate a pregnancy, health systems are obliged to provide them with the option of safe, legal, affordable, and high-quality abortion services.[36,40,41] Comprehensive abortion care also encompasses safe induced abortion and emergency treatment for incomplete or septic abortions (via technologies recommended by the World Health Organization), along with information and services for post-abortion contraception and other reproductive health needs.[33,42]

The estimated global cost of fulfilling unmet need for contraception is $5.3 billion, in addition to the $4.1 billion spent each year serving current users of modern methods. Reducing unintended pregnancies by meeting contraception needs would save $4.3 billion that would otherwise be required to provide the recommended care to pregnant women and newborns. If all women wanting to avoid a pregnancy used modern contraception, the resulting decline in unintended pregnancies would reduce the cost of providing the recommended standard of care by $7.8 billion (to $2.7 billion). If the contraceptive needs of all women in developing nations were met, the costs would be $11 per contraceptive user for a year of supplies and services and $33 to prevent an unintended pregnancy.[5]

Given the limitations of existing contraceptive options for women and men, research on and development of new methods of contraception might leader to safer and more acceptable, affordable, and effective options. However, sufficient resources have not been devoted to closing this gap. In 2013, only $63 million globally was devoted to research and development for contraceptive products that would benefit women and men in developing countries, and only $13 million of this total was provided by the public sector.[43] From 1980 to 2000, funding for contraceptive research in the National Institutes of Health branches was essentially flat in terms of constant dollars, at about $10 million per year. The US foundations that were significant sponsors of contraceptive research have redirected their resources to other areas.[44] Given the high cost of developing new reproductive health products and the high return on investment in contraception for users and countries alike, current funding is clearly inadequate to address the needs in this area.

Evidence-Based Strategies to Address the Problem

With universal access to contraception, individuals make choices resulting in positive public health outcomes. There is extensive historical and evolving evidence over the past 60 years, both domestically and internationally, supporting many strategies to improve contraception access and use. In particular, studies[21,45–48] have shown the success of the following strategies:

• Comprehensive, evidence-based sexuality and contraception education and counseling without bias, discrimination, or coercion
• A focus on antenatal, childbirth, and postpartum visits as key opportunities to reach clients for family planning services
• Advocacy and community outreach projects engaging multiple disciplines and including social media, social and community gathering locations, peer-to-peer engagement, behavioral modification programs, condom negotiation training, and group engagement
• Voluntary and client-centered choices of contraceptive methods
• Availability of community-based reproductive health services
• Low- or no-cost provision of contraception and reproductive health services
• Adequate and accessible referral systems in the case of conscientious objection
• Safe and affordable access to emergency contraception and abortion in contingency situations

These strategies have demonstrated higher rates of effective contraception use, lower unintended pregnancy rates, and improved birth spacing. Use of these findings to drive health policies has demonstrated the same results on a larger scale.

Opposing Arguments

APHA recognizes that individuals may possess conscientious objections to contraception, especially certain methods, or abortion. Conscientious objection to the provision of essential information and contraceptive services or, in cases of failure, safe abortion services cannot compromise the rights of individuals to information, services, and effective referrals.[49] When this conflict occurs, health systems, health funding programs, and facility directors have the responsibility to respond primarily to the needs of their clients rather than simply responding to individual providers’ preferences or beliefs. This applies to all reproductive health services, just as for other public health programs. In cases of conscientious objection, health systems should have effective referral systems for contraceptive or abortion services to promote the best interests and health of individuals, and they are accountable for doing so. Providers have obligations to refer clients in a timely manner to other providers that they believe, on the basis of good-faith professional judgment and without stigma or discrimination, offer high-quality services appropriate to clients’ needs.[50] Evidence suggests that there is little or no accountability in many cases and that “the obligation to refer is systematically ignored or abused.”[49]

Recognizing that some providers experience moral or ethical conflicts between their own conscience and their obligations to individuals’ health and rights, providers and professional medical/public health societies must lead attempts to respond to conscience-based refusals by giving highest priority to safeguarding reproductive health, medical integrity, and women’s lives.[48] A clinical care framework emphasizes minimization of harm, increased access to quality care and respect, compassion, accountability, and altruism on the part of all medical care providers. International and US obstetric and gynecological societies representing 130 nations have stipulated three principles of client-centered care: the principle of primary patient welfare, the principle of patient autonomy, and the principle of social justice. The fundamental guideline is that conscientious commitment recognizes the tension between the right to exercise conscientious objection and the right for women to receive needed care. This right for women to receive care falls under a government’s responsibility to protect patient care. The right to refuse care becomes secondary to the first duty, which is to the patient. The individual integrity of health providers is recognized within this framework, with an emphasis on providing solutions and identifying options for a provider to exercise (such as a referral to another health provider in a timely manner) that will not cause a woman to be without care as the first priority.[51]

Action Steps

Support Universal Rights to Contraception Access

1. APHA strongly urges protection and fulfillment of universal rights to safe, voluntary, confidential access to the full range of contraceptive methods without barriers, regardless of age, marital status, gender identity, ethnicity, sexual orientation, religious background, socioeconomic status, geography, health status (including chronic disease, especially HIV/AIDS), nationality, or other demographic characteristics.
2. APHA urges governments and international organizations to respect, protect, and fulfill sexual and reproductive health and rights, including actions to make modern contraception and safe legal abortion universally available, accessible, and affordable for all people around the world.

 Ensure Universal Access to Evidence-Based Contraceptive Information and Services

3. APHA supports comprehensive and evidence-based reproductive health education curricula for doctors, nurses, clinicians, and nonclinicians providing primary health care so that relevant content on all currently available contraceptive methods is routinely integrated into the education of all individuals involved in the delivery of contraceptive services.
4. APHA urges all health systems to address the main barriers to access to contraception in their local/national context, such as legal, financial, and geographical factors; gender-based violence; armed conflict; and sociocultural factors. Also, measures should be taken to ensure implementation of referral systems for contraceptive or abortion services in cases of conscientious objection.
5. APHA supports the right of all individuals to evidence-based, comprehensive contraceptive counseling and education free from personal bias, including information on risks, benefits, effectiveness, proper usage, alternatives, and adverse effects, accompanied by a comprehensible, culturally/linguistically appropriate informed consent process.
6. APHA urges that all health policies and regulations guarantee universal access to emergency contraception in cases of sexual violence, rape, contraception failure, and other instances of unprotected sexual intercourse.
7. APHA supports the principle of voluntary and informed choice under all circumstances and opposes all practices that coerce or exert undue pressure to use contraception or to use methods unacceptable to the user. Groups that have suffered such coercion historically include indigenous or ethnic minorities, HIV-positive individuals or couples, prisoners, and individuals with mental or physical disabilities.

Ensure Adequate Funding

8. APHA urges that all health funders, public and private, cover the cost of all contraceptives that have been shown to be effective in preventing pregnancy or are medically indicated.
9. APHA advocates (for all women and men, regardless of citizenship status) adequate government funding of domestic and international programs and services aimed at prevention and management of unintended pregnancies. These services must include full provision of contraceptive methods and access to emergency contraception and safe abortion.

Support Contraceptive Access through Research and Development

10. APHA urges the continued development of contraceptive technology to improve the safety, effectiveness, and acceptability of methods for both men and women. APHA further urges new, ongoing, and increased funding (from both public and private sources) to support research designed to address factors enhancing or limiting voluntary and informed contraceptive use in diverse cultural and social settings.

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