I think the evidence for this is surprisingly slim. Generally in developing countries contraception promotion has both positive and negative effects on abortions—it reduces the chance of a pregnancy in any given case of sexual intercourse, but a) increases sexual intercourse, disproportionately in ‘risky’ situations; and b) potentially increases the unwantedness of any given pregnancy as well. Moreover, the unmet need for contraception in developing countries is also pretty low, and the proportion of this which is due to lack of access is very small—so the number of women not using contraception because they lack access to it is pretty miniscule.
Do you have a source for the claim that providing contraception disproportionately increases risky sex + the unwantedness of a pregnancy?
the unmet need for contraception in developing countries is also pretty low—so the number of women not using contraception because they lack access to it is pretty miniscule.
Also, can you quantify this? Not sure what your source is, but a brief google search suggests that “sub-Saharan Africa had the lowest use of modern contraceptives (24%) and demand satisfied (52%).”
The same source suggests that ~10% of women globally with a need for contraception do not have it met (for a total of ~160million women with unmet need), and ~half of these women live in sub-Saharan Africa and South Asia. I haven’t checked the methodology personally, but probably not the number I’d consider “pretty miniscule”.
Thanks for asking, Bruce. Yes, regarding contraception increasing risky sex, it’s been a while since I looked at this literature but here are some of the references from my notes on it:
I don’t agree that the conclusions regarding low unmet need for contraception in developing countries, and this being due to access, is correct based on the sources that you have linked (although thanks for providing sources).
I just had a very quick (<5 minute) look at some of the sources regarding the low unmet needs for contraception in developing countries, largely because it goes against what I would expect (lower resource settings having proportionally higher resources in this area than high resource settings). Because I looked very quickly I’ve so far only looked at the abstract/highlights, however I expect that nothing in the main text would contradict this.
The source you gave for ‘low unmet need for contraception in developing countries’: https://pubmed.ncbi.nlm.nih.gov/23489750/
It does say that generally contraceptive prevalence has gone up and unmet needs have gone down (this is a good thing, i.e. progress), unless this was already high or low respectively (not surprising, a low unmet need can only decrease by a lesser degree than a high unmet need).
However: “The absolute number of married women who either use contraception or who have an unmet need for family planning is projected to grow from 900 million (876-922 million) in 2010 to 962 million (927-992 million) in 2015, and will increase in most developing countries.”
This suggests that the unmet need is projected to increase more in developing countries compared to others.
The sources on access: https://www.guttmacher.org/sites/default/files/pdfs/pubs/Contraceptive-Technologies.pdf
It does suggest that 7 in 10 cases access may not be main the issue: “Seven in 10 women with unmet need in the three regions cite reasons for nonuse that could be rectified with appropriate methods: Twenty-three percent are concerned about health risks or method side effects; 21% have sex infrequently; 17% are postpartum or breast-feeding; and 10% face opposition from their partners or others.” But: “In the short term, women and couples need more information about pregnancy risk and contraceptive methods, as well as better access to high-quality contraceptive services and supplies.”
It also says that a quarter of women in developing countries have an unmet need: “In developing countries, one in four sexually active women who want to avoid becoming pregnant have an unmet need for modern contraception.” I would not call that low, and I think this is one of those cases of it being important to put number on it otherwise people may have different definitions of what is/isn’t low.
(A very quick estimate using the first links that come up on Google: 152 developing countries, population approx 6.69 billion total, say therefore around 3.35 billion who are female.
Turns out a quick Google does not bring up the proportion of women who are of childbearing age (15-49), but an interesting 2019 UN source on the need for family planning does come up which breaks down the unmet needs by region and is consistent with saying around 1⁄4 of women in developing countries have unmet needs: https://www.un.org/en/development/desa/population/publications/pdf/popfacts/PopFacts_2019-3.pdf That UN source has a quote: “In 2019, 42 countries, including 23 in sub-Saharan Africa, still had levels of demand satisfied by modern methods below 50 per cent, including three countries of sub-Saharan Africa with levels below 25 per cent ”
Back to that raw numbers estimate I was attempting: 1⁄4 of 3.35 billion is around 840 million for the unmet needs part. Maybe classing 1⁄3 of those women being of childbearing age/benefiting from contraceptives. That’s around 280 million people.)
The second source of access: https://pubmed.ncbi.nlm.nih.gov/24931073/
This has less information than the others as I can by default only see the abstract
“Our findings suggest that access to services that provide a range of methods from which to choose, and information and counseling to help women select and effectively use an appropriate method, can be critical in helping women having unmet need overcome obstacles to contraceptive use. ” Suggesting that access is critical, and might imply that this is at least in part a reason for the unmet needs.
Edit: me reading the sources took about 5 minutes, the above writeup including me looking some stuff up (perhaps unsurprisingly) took a bit longer than that. I see having posted that Matt Sharp has also made a reply which says something very similar to what I am, would recommend reading that as well.
Thank you Lin for your thoughtful comment. I gave some further thoughts to Matt above, and it felt rude to copy and paste that comment again here. But if you have a particular hesitation which I haven’t addressed to Matt above please do let me know and I’ll do my best to come back to you on it.
“In 2010, 146 million (130-166 million) women worldwide aged 15-49 years who were married or in a union had an unmet need for family planning. The absolute number of married women who either use contraception or who have an unmet need for family planning is projected to grow from 900 million (876-922 million) in 2010 to 962 million (927-992 million) in 2015, and will increase in most developing countries.
Interpretation: Trends in contraceptive prevalence and unmet need for family planning, and the projected growth in the number of potential contraceptive users indicate that increased investment is necessary to meet demand for contraceptive methods and improve reproductive health worldwide.”
Seven in 10 women with unmet need in the three regions cite reasons for nonuse that could be rectified with appropriate methods: Twenty-three percent are concerned about health risks or method side effects; 21% have sex infrequently; 17% are postpartum or breast-feeding; and 10% face opposition from their partners or others.
In these three regions, the typical woman with reasons for unmet need that could be addressed with appropriate methods is married, is 25 or older, has at least one child and lives in a rural area.
In the short term, women and couples need more information about pregnancy risk and contraceptive methods, as well as better access to high-quality contraceptive services and supplies.
In the medium term, adaptations of current methods can make these contraceptives more acceptable and easier to use.
Investment in longer-term work is needed to discover and develop new modes of contraceptive action that do not cause systemic side effects, can be used on demand, and do not require partner participation or knowledge.
Overcoming method-related reasons for nonuse of modern contraceptives could reduce unintended pregnancy and its consequences by as much as 59% in these regions.
Our findings suggest that access to services that provide a range of methods from which to choose, and information and counseling to help women select and effectively use an appropriate method, can be critical in helping women having unmet need overcome obstacles to contraceptive use
I’d also note that because demand for contraception tends to increase with better education, we would expect demand to increase over time. If supply does not increase to meet this demand, then unmet need will increase.
Thanks, Matt. Sorry I was heading out earlier so didn’t have time to elaborate as much as I would have liked. When I say unmet need for contraception (UMC) is low, I meant proportionally—by 2010 it was just over 10%, and I would guess is significantly lower still now. Of course, 10% globally is still a lot of people, but these are presumably the hardest people to reach and it is not clear how cost-effective doing so would be—moreover, it seems clear that even if we did manage to reach those 10%, the abortion rate would hardly decline by that much—so it is a pretty limited strategy for reducing abortions, if it is effective at all.
Regarding the second paper, table 5 indicates that only 8% of women with UMC globally lacked access (including because of cost). Table 3 in the third paper shows similar. So it still seems that only a very small proportion of women globally—perhaps 1% in 2010 - have a UMC because of lack of access to contraception.
There probably are interventions which could increase contraceptive uptake—but I don’t think they are by any means simple, and they are not generally solving lack of access per se. The access is there, even if the relevant education or empowerment of women is not. As indicated in the rest of my previous post, even if this were solved, it is still not clear to me that it would reduce abortions, given the counterbalancing effects contraception promotion has on sexual behaviour and desired family size. It seems particularly doubtful that it would reduce abortions by a large amount.
You are right that as education increases, desired family size generally falls, and contraception demand will grow. But I don’t see that there is a significant risk of contraception supply failing anytime soon. Even under the Mexico City Policy, which was widely held to significantly impede access to contraception, contraceptive use in the affected countries (turquoise—unaffected countries in orange) rapidly increased:
This, I suppose, is relevant to the EA discourse on neglectedness—with the emphasis on contraception in international development circles, it seems unlikely that slightly trimmed down support for it is going to significantly impede it or significantly increase abortion rates. But I confess I am only really on the peripheries of EA so I might be outdated with the neglectedness stuff.
My understanding was as well that improved contraceptive access in poor countries is one of the best things we can do to lower abortions.
I think the evidence for this is surprisingly slim. Generally in developing countries contraception promotion has both positive and negative effects on abortions—it reduces the chance of a pregnancy in any given case of sexual intercourse, but a) increases sexual intercourse, disproportionately in ‘risky’ situations; and b) potentially increases the unwantedness of any given pregnancy as well. Moreover, the unmet need for contraception in developing countries is also pretty low, and the proportion of this which is due to lack of access is very small—so the number of women not using contraception because they lack access to it is pretty miniscule.
Do you have a source for the claim that providing contraception disproportionately increases risky sex + the unwantedness of a pregnancy?
Also, can you quantify this? Not sure what your source is, but a brief google search suggests that “sub-Saharan Africa had the lowest use of modern contraceptives (24%) and demand satisfied (52%).”
The same source suggests that ~10% of women globally with a need for contraception do not have it met (for a total of ~160million women with unmet need), and ~half of these women live in sub-Saharan Africa and South Asia. I haven’t checked the methodology personally, but probably not the number I’d consider “pretty miniscule”.
Thanks for asking, Bruce. Yes, regarding contraception increasing risky sex, it’s been a while since I looked at this literature but here are some of the references from my notes on it:
https://www.tandfonline.com/doi/abs/10.1080/07350015.2011.652052
https://onlinelibrary.wiley.com/doi/full/10.1111/ecin.12757
https://www.amazon.co.uk/AIDS-Behavior-Culture-Questions-Anthropology/dp/1598744798
https://pubmed.ncbi.nlm.nih.gov/11939239/
https://www.thelancet.com/journals/lancet/article/PIIS0140673606697870/fulltext
On unwantedness of pregnancy: https://pubmed.ncbi.nlm.nih.gov/31196674/ and Relationships Between Contraception and Abortion: A Review of the Evidence (guttmacher.org)
For low unmet need for contraception in developing countries: https://pubmed.ncbi.nlm.nih.gov/23489750/
And for low proportion of unmet need attributable to lack of access: https://www.guttmacher.org/sites/default/files/pdfs/pubs/Contraceptive-Technologies.pdf and https://pubmed.ncbi.nlm.nih.gov/24931073/
I don’t agree that the conclusions regarding low unmet need for contraception in developing countries, and this being due to access, is correct based on the sources that you have linked (although thanks for providing sources).
I just had a very quick (<5 minute) look at some of the sources regarding the low unmet needs for contraception in developing countries, largely because it goes against what I would expect (lower resource settings having proportionally higher resources in this area than high resource settings). Because I looked very quickly I’ve so far only looked at the abstract/highlights, however I expect that nothing in the main text would contradict this.
The source you gave for ‘low unmet need for contraception in developing countries’: https://pubmed.ncbi.nlm.nih.gov/23489750/ It does say that generally contraceptive prevalence has gone up and unmet needs have gone down (this is a good thing, i.e. progress), unless this was already high or low respectively (not surprising, a low unmet need can only decrease by a lesser degree than a high unmet need).
However: “The absolute number of married women who either use contraception or who have an unmet need for family planning is projected to grow from 900 million (876-922 million) in 2010 to 962 million (927-992 million) in 2015, and will increase in most developing countries.” This suggests that the unmet need is projected to increase more in developing countries compared to others.
The sources on access: https://www.guttmacher.org/sites/default/files/pdfs/pubs/Contraceptive-Technologies.pdf It does suggest that 7 in 10 cases access may not be main the issue: “Seven in 10 women with unmet need in the three regions cite reasons for nonuse that could be rectified with appropriate methods: Twenty-three percent are concerned about health risks or method side effects; 21% have sex infrequently; 17% are postpartum or breast-feeding; and 10% face opposition from their partners or others.” But: “In the short term, women and couples need more information about pregnancy risk and contraceptive methods, as well as better access to high-quality contraceptive services and supplies.” It also says that a quarter of women in developing countries have an unmet need: “In developing countries, one in four sexually active women who want to avoid becoming pregnant have an unmet need for modern contraception.” I would not call that low, and I think this is one of those cases of it being important to put number on it otherwise people may have different definitions of what is/isn’t low.
(A very quick estimate using the first links that come up on Google: 152 developing countries, population approx 6.69 billion total, say therefore around 3.35 billion who are female.
Turns out a quick Google does not bring up the proportion of women who are of childbearing age (15-49), but an interesting 2019 UN source on the need for family planning does come up which breaks down the unmet needs by region and is consistent with saying around 1⁄4 of women in developing countries have unmet needs: https://www.un.org/en/development/desa/population/publications/pdf/popfacts/PopFacts_2019-3.pdf That UN source has a quote: “In 2019, 42 countries, including 23 in sub-Saharan Africa, still had levels of demand satisfied by modern methods below 50 per cent, including three countries of sub-Saharan Africa with levels below 25 per cent ”
Back to that raw numbers estimate I was attempting: 1⁄4 of 3.35 billion is around 840 million for the unmet needs part. Maybe classing 1⁄3 of those women being of childbearing age/benefiting from contraceptives. That’s around 280 million people.)
The second source of access: https://pubmed.ncbi.nlm.nih.gov/24931073/ This has less information than the others as I can by default only see the abstract “Our findings suggest that access to services that provide a range of methods from which to choose, and information and counseling to help women select and effectively use an appropriate method, can be critical in helping women having unmet need overcome obstacles to contraceptive use. ” Suggesting that access is critical, and might imply that this is at least in part a reason for the unmet needs.
Edit: me reading the sources took about 5 minutes, the above writeup including me looking some stuff up (perhaps unsurprisingly) took a bit longer than that. I see having posted that Matt Sharp has also made a reply which says something very similar to what I am, would recommend reading that as well.
Thank you Lin for your thoughtful comment. I gave some further thoughts to Matt above, and it felt rude to copy and paste that comment again here. But if you have a particular hesitation which I haven’t addressed to Matt above please do let me know and I’ll do my best to come back to you on it.
The final 3 links seem to suggest the opposite of what you’re claiming (though I guess it depends what you mean by ‘low’):
Firstly, “for low unmet need for contraception in developing countries: https://pubmed.ncbi.nlm.nih.gov/23489750/″
From the abstract of that paper:
2. Secondly “And for low proportion of unmet need attributable to lack of access: https://www.guttmacher.org/sites/default/files/pdfs/pubs/Contraceptive-Technologies.pdf″
From the Highlights section of that paper:
3. Thirdly: https://pubmed.ncbi.nlm.nih.gov/24931073/
I’d also note that because demand for contraception tends to increase with better education, we would expect demand to increase over time. If supply does not increase to meet this demand, then unmet need will increase.
Thanks, Matt. Sorry I was heading out earlier so didn’t have time to elaborate as much as I would have liked. When I say unmet need for contraception (UMC) is low, I meant proportionally—by 2010 it was just over 10%, and I would guess is significantly lower still now. Of course, 10% globally is still a lot of people, but these are presumably the hardest people to reach and it is not clear how cost-effective doing so would be—moreover, it seems clear that even if we did manage to reach those 10%, the abortion rate would hardly decline by that much—so it is a pretty limited strategy for reducing abortions, if it is effective at all.
Regarding the second paper, table 5 indicates that only 8% of women with UMC globally lacked access (including because of cost). Table 3 in the third paper shows similar. So it still seems that only a very small proportion of women globally—perhaps 1% in 2010 - have a UMC because of lack of access to contraception.
There probably are interventions which could increase contraceptive uptake—but I don’t think they are by any means simple, and they are not generally solving lack of access per se. The access is there, even if the relevant education or empowerment of women is not. As indicated in the rest of my previous post, even if this were solved, it is still not clear to me that it would reduce abortions, given the counterbalancing effects contraception promotion has on sexual behaviour and desired family size. It seems particularly doubtful that it would reduce abortions by a large amount.
You are right that as education increases, desired family size generally falls, and contraception demand will grow. But I don’t see that there is a significant risk of contraception supply failing anytime soon. Even under the Mexico City Policy, which was widely held to significantly impede access to contraception, contraceptive use in the affected countries (turquoise—unaffected countries in orange) rapidly increased:
This, I suppose, is relevant to the EA discourse on neglectedness—with the emphasis on contraception in international development circles, it seems unlikely that slightly trimmed down support for it is going to significantly impede it or significantly increase abortion rates. But I confess I am only really on the peripheries of EA so I might be outdated with the neglectedness stuff.
Interesting points! Thanks for taking the time to respond and clarify.