World Population Prospects and Unmet Need for Family Planning

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1 World Population Prospects and Unmet Need for Family Planning Scott Moreland Ellen Smith Suneeta Sharma April 2010 (revised October 2010) Futures Group One Thomas Circle, NW Washington, DC United States of America Prepared with support from the William and Flora Hewlett Foundation

2 Table of Contents Abbreviations... v Acknowledgments... vi Executive Summary... 1 Introduction... 3 I. Methodology... 4 II. Scenarios... 5 Assumptions: Demographic Parameters and Values... 7 Assumptions: Family Planning... 7 Results III. Global Results IV. Developing Countries V. Regional Projections VI. Africa VII. Asia and the Near East VIII. India IX. Latin America and the Caribbean X. Transition Countries XI. United States XII. Summary and Conclusions Appendix P a g e ii

3 List of Figures Figure 1. Relationship between Unmet Need and CPR... 6 Figure 2. Global: Contraceptive Prevalence, Total Fertility, Population, and Cumulative Family Planning Cost Figure 3. Developing Countries: Contraceptive Prevalence, Total Fertility, Population, and Cumulative Family Planning Cost Figure 4. Africa: Contraceptive Prevalence, Total Fertility, Population, and Cumulative Family Planning Cost Figure 5. Asia and the Near East: Contraceptive Prevalence, Total Fertility, Population, and Cumulative Family Planning Cost Figure 6. India: Contraceptive Prevalence, Total Fertility, Population, and Cumulative Family Planning Cost Figure 7. Latin America and the Caribbean: Contraceptive Prevalence, Total Fertility, Population, and Cumulative Family Planning Cost Figure 8. Transition Countries: Contraceptive Prevalence, Total Fertility, Population, and Cumulative Family Planning Cost Figure 9. United States: Contraceptive Prevalence, Total Fertility, Population, and Cumulative Family Planning Cost Figure 10. Global Population in 2050 under Four Scenarios Figure 11. Developing Countries: Population in 2050 under Four Scenarios P a g e iii

4 List of Tables Table 1. Changes in Percentage of Women in Union by Region... 8 Table 2. Average Annual Change in the Percentage of All Users Who Use a Modern Method in Countries with More than One DHS by Region... 9 Table 3. Average Family Planning Cost per User Table 4. One-Year Cost of Contraceptives in the United States Table 5. Average CPR and Unmet Need for Family Planning by Region and Years to Meet Unmet Need. 12 Table A 1: List of Countries Included in the Analysis Table A 2. CPR and Unmet Need Table A 3. Regression Results on Unmet Need Table A 4. Regression Results for Percentage of Women in Union Table A 5. Percentage of Women in Union, Ages Table A 6. Method Effectiveness Assumptions Table A 7. CPR Projections Table A 8. Global Demographic Results Table A 9. Developing World Demographic Results Table A 10. Africa Demographic Results Table A 11. Asia and Near East Demographic Results Table A 12. India Demographic Results Table A 13. Latin America Demographic Results Table A 14. Transition Countries Demographic Results Table A 15. United States Demographic Results Table A 16. Cumulative Family Planning Costs Table A 17. Present Value of Cumulative Family Planning Costs Table A 18. Annual Family Planning Costs P a g e iv

5 Abbreviations ANE CPR DHS LAC TFR AIDS US WRA Asia and the Near East Contraceptive prevalence rate Demographic and Health Survey Latin America and the Caribbean Total fertility rate United Nations Joint United Nations Programme for AIDS United States Women of reproductive age P a g e v

6 Acknowledgments This study has benefited from the efforts of many people. We would like to first acknowledge the assistance of Priya Emmart, Krishna Aditi, Elizabeth Miller, Manal El Fiki, and Sarah Staveteig, all of whom spent long hours helping to produce the projections presented in this report. We would also like to thank our colleagues at the Futures Group, especially Sarah Clark and Rachel Sanders, for their advice and assistance in terms of some of the approaches and data that we have drawn upon. Katrina Dusek provided valuable administrative support during the report production stage. We are also grateful for the advice provided by Jennifer Frost and Jacqui Darroch at the Allan Guttmacher Institute, Leiwen Jiang of the National Center for Atmospheric Research, and Ilene Speizer of the University of North Carolina at Chapel Hill. Last, we wish to thank the Hewlett Foundation for providing us with the opportunity to conduct this study and especially to Peter Belden who has provided invaluable guidance and feedback throughout the study. P a g e vi

7 Executive Summary Over the past 30 years, the use of modern family planning methods has increased dramatically in the developing world, leading to a fall in fertility rates. Yet there are still significant levels of demand for family planning that are unmet. If this unmet need were met, unintended pregnancies would be fewer, women s health and lives would be improved, and the consequent impact on fertility would result in lower population growth and measured development benefits. This paper estimates what the demographic impact of meeting this unmet need would be for the developing world and the United States, and compares this scenario with three United Nations fertility variants. The United Nations () provides estimates of future fertility trajectories for the countries of the world through These estimates are widely used by researchers, planners, and policy makers and are a widely respected reference source when detailed population projections prepared at the country level are unavailable. The estimates are based on projections of fertility derived from past trends, as well as estimates of future life expectancy. We estimate the family planning implications of the three projections and compare them with the fourth unmet need scenario. We compare the demographic implications of the unmet need scenario with those of the three scenarios, as well as the implied family planning costs. To prepare the four projection scenarios, we used the DEMPROJ and FAMPLAN modules of the Spectrum model and applied this to each of the 99 countries we modeled. This approach combines a cohort-component population projection with the proximate determinant model of fertility. For the unmet need scenario, we assumed that the contraceptive prevalence rate (CPR) would increase at a rate that was reasonable, given past trends, until all currently observed unmet need was satisfied. We also developed future projections of the percentage of women who are in union, and the contraceptive method mix. For the scenarios, we used the model to estimate the level of CPR that, in conjunction with the other proximate determinants would yield the fertility assumptions. Family planning costs were projected for each scenario based on family planning unit costs and the projected number of users. The results for all countries together show that the CPR and total fertility rate (TFR) projections under the unmet need scenario first follow the medium scenario, then steadily move toward the low scenario in later years. Global population under the unmet need scenario follows a trajectory between that of the medium and low scenarios, although closer to the medium scenario. The 2005 starting population is 4.05 billion, and by 2050, the total population is 5.78 billion, 6.7 billion, and 7.7 billion, respectively, under the low, medium, and high scenarios, and 6.3 billion under the unmet need scenario. The cumulative costs of the family planning program for the entire projection period ( ) for the unmet need scenario is slightly less than that estimated for the low ($ United Nations World Population Prospects: The 2008 Revision. Department of Economic and Social Affairs/Population Division, New York. P a g e 1

8 trillion vs. $1.126 trillion). Costs for the medium and high scenarios are estimated to be $1.027 trillion and $948 billion, respectively. For the developing countries that were modeled, the CPR and TFR paths under the unmet need scenarios are very similar to the medium scenario in earlier years, and then approach and nearly meet the low scenario by the end of the projection period. The unmet need projection of total population is similar to the medium total population path, diverging significantly only in the later years. This later divergence reflects the unmet need scenario s effect on continued decline in TFR in later years, when the TFR declines in the scenarios are small. The initial 2005 population in the developing countries is 3.7 billion, with a projected 2050 population of 6 billion for the unmet need scenario, compared with 5.4 billion for the low, 6.3 billion for the medium, and 7.2 billion for the high scenarios. The estimated cumulative cost for the unmet need scenario is $638 billion, which falls between the estimated costs for the low scenario of $665 billion and the costs for the medium scenario of $603 billion. Assuming the high scenario as a baseline, the additional annual costs to meet unmet need for family planning are estimated to be approximately $3.7 billion per year over the 45-year projection period; $1.4 billion of this would be from the United States, and $2.3 billion from the 99 developing countries. P a g e 2

9 Introduction World Population Prospects and Unmet Need for Family Planning Over the past 30 years, the use of modern family planning methods has increased dramatically in the developing world leading to a fall in fertility rates. Yet there are still significant levels of demand for family planning that are unmet. For example, Westoff has estimated unmet need between 5% and 33% in the countries of Asia, 6% and 40% for Latin America and the Caribbean, and between 13% and 38% in sub-saharan Africa. 2 Another recent study estimates that more than 200 million women in the developing world have an unmet need for family planning. 3 If this unmet need were met, unintended pregnancies would be fewer, women s health and lives would be improved, and the consequent impact on fertility would result in lower population growth and measurable development benefits. This paper estimates what the demographic impact of meeting this unmet need would be for the developing world and compares it with three United Nations population scenarios. The United Nations provides estimates of future population trajectories for the countries of the world through These estimates are widely used by researchers, planners, and policy makers and are a widely respected reference source when detailed population projections prepared at the country level are unavailable. The estimates are based on projections of fertility derived from past trends, as well as estimates of future life expectancy. If population growth is to be viewed as a possible factor in economic or environmental change, the policy and program variables that affect population need to be taken into account. This paper estimates the family planning implications of the projections and compares them with a family planning policy scenario. Specifically, the paper estimates the impact on population growth of satisfying observed base levels of the unmet need 5 for family planning in the developing world and the United States. Another question addressed by the paper is the cost of providing the levels of family planning required in each of the scenarios. A few existing studies look at the family planning implications of the projections and of meeting unmet need for family planning. Guengant evaluated the contraceptive prevalence required to reach the 2025 and 2050 medium variant fertility levels proposed in the 2000 revision of the projections. 6 Ross 2 Charles F. Westoff New Estimates of Unmet Need and the Demand for Family Planning. DHS Comparative Reports No. 14. Macro International Inc., Calverton, Maryland. 3 Susheela Singh, Jacqueline E. Darroch, Lori S. Ashford, and Michael Vlassoff Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health. the Guttmacher Institute, New York. 4 United Nations 2008, op. cit. 5 Unmet need for family planning is the percentage of women of reproductive age in a union who do not want a birth in the next two years or who do not want any more children, but are not using contraception. 6 Jean-Pierre Guengant The Proximate Determinants during the Fertility Transition, in Expert Group Meeting on Completing the Fertility Transition. March 11-14, 2002: United Nations Department of Economic and Social Affairs, Population Division, New York. P a g e 3

10 et al. project family planning needs for 116 countries using a statistical model in conjunction with the population projections. 7 I. Methodology The relationship between fertility and contraceptive use has long been established. Various methods of analyzing the relationship are available. Ross et al. use a statistical model of the association between the TFR and the CPR. 8 Similarly, Westoff uses a regression equation to predict the impact on fertility of increasing contraceptive use by a level sufficient to satisfy the unmet need for family planning. 9 In this paper, we used a modeling, rather than statistical approach. A modeling approach has the advantage of taking into account more factors than a statistical approach. We used a standard cohort-component population projection with an additional family planning module to prepare the estimates. Specifically, we used two relevant submodules of the SPECTRUM software program: DEMPROJ, the population projection program, and FAMPLAN, which handles the proximate determinants of fertility, 10 including family planning. Assumptions about the future trajectory of family planning use (as measured by contraceptive prevalence), along with other proximate determinants of fertility (such as the percentage of women in union, spontaneous abortion rates, etc.), are used to project the fertility rate, which in turn is fed into the population projection through the calculation of births. Family planning costs were projected for each scenario based on family planning unit costs and the level of family planning use. For this paper, we used the number of users as our level of family planning use and regional estimates of average costs per user. 11 (These data are discussed in more detail below.) We assumed constant unit costs (in 2006 United States [US] dollars) over the 45-year period. There is some evidence that family planning unit costs may decline with the level of CPR due to economies of scale. 12 If that holds true, the cost estimates in this paper would be overestimates. We projected for 99 individual developing countries and the United States and aggregated the data up to the regional and global levels. While it was possible to project at a more aggregate level, for example, by region, we thought that projecting at the country level would give more precision and allow us to maximize the use of country-specific data. It would also allow us to create a database that could be used for other purposes at the country level. However, in this paper we only report at the regional level. The 99 countries that were included in the analysis (listed in Table A1 in the Appendix) represent a population of 4.03 billion in We did not project for countries with fewer than 1 million inhabitants, 7 John Ross, John Stover, and Demi Adalaja Profiles for Family Planning and Reproductive Health Programs. Second Edition. Futures Group International, Washington, D.C. 8 Ross, Stover, and Adalaja. 2005, op. cit. 9 Westoff. 2006, op. cit. 10 J. Bongaarts "A Framework for Analyzing the Proximate Determinants of Fertility." Population and Development Review 4 (1): For the United States, we used cost per user for short-term methods and cost per acceptor for long-term or permanent methods. 12 John Stover, Laura Heaton, and John Ross FAMPLAN, Version 4. Futures Group International, Washington, D.C. P a g e 4

11 and we did not project for developed countries, except for the United States. China, although the largest developing country, was excluded because of its already low fertility and high contraceptive use. Also, most observers, including the authors, assume that there is no aggregate unmet need for family planning in China, given that desired fertility is higher than actual. The United States was included because it actually has a significant, if small, level of unmet need for family planning. We grouped the 99 countries into the following major regions: Asia and the Near East (ANE), sub-saharan Africa, Latin America and the Caribbean, transition countries (formerly part of the Soviet Union), India, and the United States (see Table A1). II. Scenarios As mentioned, we prepared four projections. It is not unusual when preparing family planning projections to define a base or reference projection in which fertility and contraceptive use are constant. While such an approach may be acceptable for a short period, we wanted to project for 45 years ( ). An assumption of constant fertility and contraceptive use for comparative purposes would be unrealistic, given the steady rise in contraceptive use and fall in fertility that have been observed in the last 25 years. We therefore chose as our basis of comparison three of the population projection variants (low, medium, and high) as reported in World Population Prospects: The 2008 Revision. 13 The medium projection is based on an analysis of past fertility trends, which are then continued into the future. The medium variant scenarios were prepared assuming an eventual convergence of the total fertility rate of 1.85, although not all countries reach 1.85 by Fertility in high- and medium-fertility countries follows a path derived from models of fertility decline estimated by the on the basis of historical experience. For low-fertility countries, recently observed trends are used. 14 The high projection adds 0.5 to the medium scenario s variant fertility rate each year, and the low variant subtracts 0.5 from the fertility rate over most of the projection period. The three scenarios have floor TFRs of 1.35, 1.85, and 2.35, respectively. We used the FAMPLAN model to estimate the family planning levels that would correspond with each of the three fertility scenarios, while taking account of expected changes in other proximate determinants of fertility, as described below. In the fourth scenario, referred to as the unmet need scenario, we used the most current estimates of unmet need for family planning from the Demographic and Health Surveys (DHSs). We assumed that baseline unmet need will be met in all countries in a given target year. (Although the target years varied by region, they were the same for all countries within each region.) This required calculating a trajectory for the CPR that started at its observed or estimated value in 2005 and increased linearly until reaching the base year total demand. The year in which that level of CPR was met is the target year. While it may have been preferable to choose country-specific target dates, we did not have access to all the countryspecific factors that would have allowed that level of detail. International targets, such as the Millennium Development Goals, are often specified at a global level and require some countries to have more ambitious goals than others; by varying the target year by region, we took into account regional 13 United Nations. 2008, op. cit. 14 accessed February 17, P a g e 5

12 Unmet Need (%) differences. We discuss how we arrived at the target years for each region in more detail below, and Table A2 in the Appendix shows the CPR assumptions for the unmet need scenario. Some caution is required, however, in interpreting the unmet need scenarios. First, while we added the base year unmet need percentage to the base year CPR to arrive at a target CPR equal to 2005 total demand, it should be recognized that levels of unmet need change over time and with the CPR. Hence, when a country reaches the target CPR, it is very likely to still have unmet need for family planning. This is because, as the CPR increases, there may be a demonstration effect that increases the acceptability of family planning among couples. Furthermore, as fertility preferences decrease, total demand for family planning increases, and this may change levels of unmet need. Figure 1 below, for example, shows how unmet need varies with the level of CPR. We regressed the observed levels of total unmet need against the overall CPR for all women for 150 DHS surveys and present the results in Table A3. Figure 1. Relationship between Unmet Need and CPR CPR Second, as Westoff 15 points out, some adjustment may be required in the use of levels of unmet need to predict fertility. He reduces the birth spacing component of unmet need by 30%, because at some point, some women who currently want to space births will want to become pregnant. Third, Westoff also adjusts total unmet need downward to take account of women with an unmet need who have never used contraceptives and say they do not intend to use them. 15 Westoff. 2006, op. cit. P a g e 6

13 Working in the opposite direction, however, is the approach taken by the Guttmacher Institute. 16 Its calculations of women with an unmet need for family planning include users of traditional methods. We did not do this, because in our projections, we take account of expected changes in the method mix away from traditional methods in favor of modern methods. For the developing countries in our study, 9.3% used a traditional method of family planning in the base year. If we had followed the Guttmacher methodology, we would have needed to increase the unmet need by that same percentage. Assumptions: Demographic Parameters and Values For all scenarios, we used the population estimates for the base year (2005) population by age and sex. While other country-specific population data are undoubtedly available for some countries, especially those with a recent census, the figures ensure consistency. Mortality is defined from the appropriate life-table survivor rates that are applied using values of life expectancy at birth. We used the life expectancy values in the medium variant projections in all scenarios. Depending on the inferred level of the infant mortality rate, either the Coale-Demny Model West or Model North tables were used. The 2008 estimates are consistent with Joint United Nations Program for AIDS (AIDS) figures for HIV prevalence and AIDS mortality. 17 For total fertility, in all three scenarios, we used the values of the TFR in each scenario for that same projection by the United Nations, so our population projection for each scenario duplicates the three projections. Other demographic parameters, such as the age distribution of fertility, international migration, and the sex ratio at birth, are all taken from the medium variant projection estimates for all scenarios. Assumptions: Family Planning Projections of family planning require a number of parameters and assumptions, which we discuss in this section. We first estimated family planning level as measured by the CPR for the three variant projections. As stated, we did so because one goal of this analysis was to compare the family planning level required under the unmet need scenario with that of the scenarios. Another objective was to estimate how much it would cost to meet each of the four scenarios. We needed to estimate the contraceptive levels for each country that correspond to the TFRs in the three projections so these could be compared with those in the unmet need scenario. To do this, as mentioned above, we used the proximate determinant model of fertility, but solved it for the CPR using the TFRs in each of the scenarios as an input. It should be noted that the CPR in this paper is for all women of reproductive age (WRA) using all methods, including traditional methods, and not only for married women (or women in union). 16 Michael Vlassoff, Susheela Singh, Jacqueline E. Darroch, Erin Carbone, and Stan Bernstein Assessing Costs and Benefits of Sexual and Reproductive Health Interventions: Occasional Report, No. 11. New York: The Alan Guttmacher Institute. 17 United Nations. 2008, op. cit., pp P a g e 7

14 Proximate determinants and percentage of women in union. Because we prepared a 45-year projection in which TFR was changing, we wanted also to take account of likely changes in factors that affect fertility other than family planning. The other proximate determinants of fertility are (1) percentage of women years of age in union, (2) number of months of postpartum insusceptibility, (3) percentage of women who are sterile, and (4) the abortion rate. Among these proximate determinants, changes in the percentage of women in union are likely to be the most important influence on fertility change over a 45-year period, especially for developing countries. So, with one exception, we held the other proximate determinants constant at their 2005 levels and we modeled the percentage of women in union. As the abortion rate is a significant proximate determinant in the transition region, we assumed that abortion rates in these countries would decline linearly from their baseline values to 0 in 2050; elsewhere, abortion rates were assumed to be 0 throughout the projection period. In order to model changes in percentage of WRA in union, we hypothesized that marriage and union patterns would be influenced by levels of female education: as women become more educated, they stay in school longer, enter the labor force more, and generally delay decisions on marriage. To model the percentage of women in union, we used DHS data to estimate a regression equation that takes into account the percentage of women who had achieved a primary education and the percentage of women with a secondary education; we used a dummy variable for countries that were in the transition region as independent variables. The regression results are shown in Table A4 in the Appendix. We then used the estimated regression equation to project the percentage of women in union from 2005 until As inputs for the two education variables, we used the GET education projections computed by the International Institute for Applied Systems Analysis (IIASA). 18 The results of these projections are shown in Table A4 of the Appendix. We see that, in all countries, there is a projected decline in the percentage of women in union. Average declines by region are shown in Table 1 below. For our sample of countries, we predicted an average 6.36% decline in the percentage of women in union over the 45-year period. Table 1. Changes in Percentage of Women in Union by Region (unweighted averages) Region Change in Percentage of Women in Union Africa 8.58 Asia and Near East 8.58 India LAC 3.87 Transition 3.10 United States 4.59 All countries K. C. Samir, B. Barakat; A. Goujon; V. Skirbekk, and W. Lutz Projection of Populations by Level of Educational Attainment, Age, and Sex for 120 Countries for IIASA Interim Report IR P a g e 8

15 Method mix. Contraceptive method mix is another important parameter that can influence the relationship between contraceptive use and fertility. Since modern methods tend to be more effective at preventing pregnancy than traditional methods, a country with more modern methods would be expected to have a lower TFR than a country with the same CPR, but a higher proportion of users of traditional methods. 19 If the TFR or the CPR changes appreciably during a projection period, it is likely that method mix will also change. In particular, we expect that as a country modernizes and as family planning becomes more prevalent, the proportion of users of modern methods would tend to increase over time. In an analysis similar to that used for women in union, we again used DHS data to perform regression analyses of the method-specific CPR, with education and urbanization as independent variables, as well as a dummy variable for Muslim countries. The statistical results were mixed, and often the independent variables were not statistically significant. In a similar exercise, Ross et al. project the method mix based on a set of regression equations, but again the level of statistical significance is low. 20 We therefore calculated the average annual change in the modern CPR for countries and used regional averages to project the proportion of modern users among all users (see Table 2). The table shows that only in sub-saharan Africa, where CPR tends to be low and where traditional methods are more popular, have there been significant increases in modern methods. To project the method mix distribution, we assumed that the distribution of each modern method as a percentage of all modern methods did not change. Table 2. Average Annual Change in the Percentage of All Users Who Use a Modern Method in Countries with More than One DHS by Region Sub-Saharan Africa 1.71 North Africa, West Asia, and Europe 0.02 South & Southeast Asia 0.00 Latin America & Caribbean 0.65 India 0.02 Costs of family planning. Estimating the costs of family planning, as with other health services, is challenging. Gathering data on a specific health service is time consuming and subject to many different factors, depending on the country and institutional setting. Costs for the same services will vary depending on how those services are delivered. For example, services delivered at an urban tertiary institution will be higher than the same services delivered by a community organization in a rural setting. Moreover, many cost studies only take account of the costs of providing the services and do not take account of any costs in generating demand for those services. In this paper, we used cost per user and multiplied that by cost per user times the number of users. The number of users was calculated by multiplying the modern CPR times the number of women of reproductive age. The modern, rather than overall, CPR was used for this calculation in order to align 19 The effectiveness assumptions for the main methods included in our analysis are in Table A6 in the Appendix. 20 Ross, Stover, and Adalaja. 2005, op. cit. P a g e 9

16 with the methodology used to create the cost-per-user data. For the United States, we used costs per user for temporary methods and costs per acceptor for long-term and permanent methods Costs per user were taken from the 2004 Guttmacher Institute report. 21 While the Guttmacher report recognizes the wide range of unit cost estimates for family planning, we thought that it did a good job of summarizing the available unit cost information and providing it in a format that was usable for the present analysis. Moreover, unlike many cost studies, the Guttmacher data cover drugs and supplies, labor, overheads, and other clinic-related costs. Table 3 shows the unit costs that were used after adjusting 2003 US dollar costs in the Guttmacher report to 2005 US dollars based on a 3% inflation rate. Table 3. Average Family Planning Cost per User Annual User Costs (2005 dollars) Africa $27.60 Asia $18.00 LAC $22.30 Source: Vlassoff et al. 2004, Table For the United States, we used data on the annual costs per user from a recent study by Trussell et al. 22 In their paper, method costs were calculated that covered drugs or supplies and professional fees. The costs included in the US projections in this paper are listed below in Table 4. As mentioned, the FAMPLAN model distinguishes between temporary and long-term methods, so the cost of a tubal ligation, for example, is only applied to new users. Table 4. One-Year Cost of Contraceptives in the United States Intrauterine device $758 Vasectomy $707 Male condom $120 Implant $961 Injectable $551 Tubal ligation $2,896 Pills $674 Source: Trussell et al., Table 2a. Unmet need scenario. As discussed in the methodology section, the fourth scenario assumes that countries can satisfy currently observed levels of unmet need after a specified period. The choice of any target date is always somewhat arbitrary, but for this analysis, we wanted a target date that was ambitious, yet feasible. We looked at the experiences of countries with more than one DHS and calculated the average annual CPR changes by countries in a region. The results are shown in Table 5 below. It can be seen that countries in the Latin America and Caribbean (LAC) and transition regions 21 Vlassoff et al. 2004, op. cit. 22 Trussell, James, Anjana M. Lalla, Quan V. Doan, Eileen Reyes, Lionel Pinto, and Joseph Gricar Cost Effectiveness of Contraceptives in the United States. Contraception 79: P a g e 10

17 were able to add about 1% annually to the CPR for all methods for all women. However, in sub-saharan Africa and Asia, these increases were lower. Levels of unmet need vary by country and region. Table 5 also presents the average number of years that a country in each region would require to meet the current level of unmet need. In Africa and India, the required time is more than the 45-year projection period in the current study. We therefore chose a target number of years to meet unmet need that is optimistic, given current trends, but still somewhat feasible. Our criteria for a feasible target date came down to what required annual change in CPR would be needed to meet unmet need and how that compared with recent historic experience. The last two columns of Table 5 show the required annual changes and the difference between these changes and the historic record. The sub-saharan African rate is above its recent historic experience, but we thought that it was feasible, given that the CPR is so low in this region that large gains are possible if a significant family planning commitment were made. Recent experience in Rwanda, where the CPR among married women rose from 13% in 2000 to 36% in 2007, demonstrates that large CPR annual increases are possible in this region. 23 In LAC and Asia, levels of unmet need tend to be lower and CPR tends to be higher than in Africa. The required change to meet unmet need in 15 years in North Africa, the Middle East, and Asia is 1.1 CPR points. For both India and the United States, which appear to have experienced recent CPR plateaus, the required CPR annual changes are also above the recent historic experience. Some discussion of how we calculated unmet need for the United States is in order. As there is no DHS for the United States, we used data from the 2002 National Survey of Family Growth to provide data on the contraceptive prevalence rate, the method mix, infecundability, the percentage of women in union, and unmet need for family planning. 24 In most studies, the unmet need for family planning is calculated for women in union or married women, all of whom are presumed to be sexually active. It is possible to calculate unmet need for sexually active unmarried women in developing countries, but many researchers feel the quality of those data may be problematic, since fertility intentions of this population may be less clear. 25 Since we are applying both the contraceptive prevalence rate and by implication unmet need to all women, and since the proximate determinants model already account for sexual activity through the women in union variable, we calculated unmet need as the percentage of all women who are sexually active, not seeking to be pregnant, not pregnant intentionally, and not using contraception. The National Survey of Family Growth reported, for example, that the percentage of US women who are sexually active and not using contraception in 2002 was 7.4%. The report also says that 34.9% of births in the previous five years were unwanted or mistimed. We applied this 34.9% to the percentage of women who were currently pregnant in 2002 (5.3%) to arrive at an estimate of the percentage of those women who were pregnant unintentionally, and added that to those who were sexually active, but not using contraception. This gave us a base year estimate of 9.2% unmet need for family planning among all women. 23 Rwanda, Ministry of Health (MOH), National Institute of Statistics of Rwanda (NISR), and ICF Macro Rwanda Interim Demographic and Health Survey Calverton, Maryland. 24 A. Chandra, G. M. Martinez, W. D. Mosher, J. D. Abma, and J. Jones Fertility, Family Planning, and Reproductive Health of U.S. Women: Data from the 2002 National Survey of Family Growth. Vital Health Stat 23 (25). National Center for Health Statistics, Atlanta. 25 Westoff. 2006, op. cit. P a g e 11

18 The CPR projections for the unmet need scenario are reported in Table A7. As stated, these projections used levels of unmet need, as well as the base year CPRs. We used recent DHS data whenever possible. For countries with no recent DHS, we relied on the Population Reference Bureau s 2009 World Population Data Sheet. 26 Table 5. Average CPR and Unmet Need for Family Planning by Region and Years to Meet Unmet Need Base CPR Unmet Need Historic Annual Change in CPR Years to Meet Unmet Need at Historic Trend Target Number of Years to Meet Unmet Need Required Annual Change Increase over Historic Rate Africa ANE India a LAC Transition b US c a. Between and b. Kazakhstan only c Results Major findings of the projections are presented in Figures The CPR, TFR, total population, and cumulative family planning costs are shown aggregated across all countries ( global ) for the group of developing countries included in this study, and for each of the six regions analyzed, under the four scenarios. Detailed projection data are found in the Appendix in Tables A8- A15.. In each region, the CPR and TFR of the unmet need scenario display a more linear trajectory than do the paths of the scenarios. This is because the unmet need scenario assumed a constant CPR increase, both before and after meeting unmet need for family planning, up to a cap of 80%. The unmet need scenario produces 2050 CPRs and TFRs that are in the range of the low scenario; in ANE, LAC, and the United States, the unmet need scenario produces the highest CPR and lowest TFR, whereas in Africa, India, and the transition countries, the unmet need scenario falls between the low and medium scenarios. All 2050 low scenarios produce TFRs below the standard replacement level of 2.1, as do all of the medium and unmet need scenarios, except Africa. None of the high scenarios produces TFRs below Population Reference Bureau World Population Data Sheet, 2009.Washington, DC. P a g e 12

19 III. Global Results In this section, we present the results for all countries modeled, aggregated on a global level. In doing so, it is important to understand the weight that each region s population plays. The results from the global projections are most heavily weighted by the Asian countries with large populations and numbers of WRA. For instance, in 2005 the ANE region accounts for 32% of the WRA and India for an additional 28%; in that year, Africa contributed 17%, LAC 14%, and transition countries and the United States only 2% and 7%, respectively. By 2050 the makeup of the global projection has shifted slightly; for example, the global WRA in the medium projection consists of 29% from the ANE region, 24% from India, 31% from Africa, 10% from LAC, 1% from transition, and 5% from the United States. The regional breakdown is important to keep in mind, as some regions contribute significantly more or less to the global projections. As seen in Figure 2a, the unmet need scenario s global CPR moves steadily from a path similar to the medium scenario to almost meeting the low CPR in The 2005 CPR is 45%, increasing to 71% in the low scenario, 61% in the medium scenario, 51% in the high scenario, and 70% in the unmet need scenario. As we will see in other CPR and TFR trajectories, the path through time of the unmet need CPR is different from that of the scenarios. Whereas the scenarios can reach specific TFR floors (and in some cases do reach them earlier in the projection period) and display a leveling off of CPRs, the unmet need scenario assumes a constant increase in CPR up to and before meeting the baseline unmet need, only leveling off if and when CPR reaches the assumed ceiling of 80%. These underlying assumptions create different shapes of CPR and TFR projections between the scenarios and the unmet need scenario. Like the CPR projections, the global TFR projection (see Figure 2b) under the unmet need scenario first follows the medium scenario, then steadily moves toward the low TFR in later years. The baseline TFR is 3.17, falling to 1.55, 2.04, and 2.54 respectively under the low, medium, and high scenarios and to 1.62 under the unmet need scenario. Global population (Figure 2c) under the unmet need scenario follows a trajectory between that of the medium and low scenarios, although closer to the medium scenario. The 2005 starting population is 4.05 billion; by 2050 the total population is 5.78 billion, 6.7 billion, and 7.7 billion under the low, medium, and high scenarios, respectively, and 6.3 billion under the unmet need scenario. 27 We see the cumulative costs of the family planning program for the entire projection period ( ) under the four scenarios in Figure 2d. The costs under the low, medium, and high scenarios are estimated to be $1.126 trillion, $1.027 trillion, and $948 billion, respectively, while the unmet need scenario family planning program costs are estimated at $1.116 trillion. These costs are heavily influenced (in terms of population size or number of family planning users) by the US costs, which represent 41% of the global costs in the low and medium scenarios, 44% of the costs in the high scenario, and 43% of the costs in the unmet need scenario. This is due to much higher costs per user in 27 As noted in the methodology section, these differences are due only to differences in fertility rates, as mortality is assumed to follow the medium mortality pattern in all scenarios, and international migration is assumed to be zero. P a g e 13

20 the United States than in the other regions. The general pattern of costs across the three scenarios is to be expected in all regions, given that the most users are in the low scenario and the fewest users in the high scenario. The unmet need cumulative costs are also a function of the number of users; however, the cumulative cost is less straightforward to predict than the scenarios for two reasons. First, the different shape of its CPR curve can lead to a different number of users in some years, even though the population trajectory of the unmet need scenario closely matches the scenario. Second, because of population momentum, CPR increases early in the projection period lead to lower cumulative family planning costs more than CPR increases do later in the projection period, because they reduce numbers of WRA in subsequent years. Thus, the fact that global unmet need scenario costs are nearly as high as the global low scenario costs is partly due to the United States aggressive compared with the scenarios family planning program in the unmet need scenario (see Figure 9a) and partly due to the developing countries slower initial CPR increases in the unmet need scenario compared with the scenarios in the earlier years of the projection period (see Figure 3a). P a g e 14

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