“Achieving true progress on sexual and reproductive health and rights requires a comprehensive approach and a commitment to tackling deeply entrenched inequities and injustices of which marginalized communities continue to bear the brunt,” said Dr. Herminia Palacio, President and CEO of the Guttmacher Institute. She spoke at a recent Wilson Center event where speakers analyzed findings from the Guttmacher Institute on the state of sexual and reproductive health and rights (SRHR) globally.

The current COVID-19 pandemic threatens to roll back progress made towards SRHR.  “A growing body of evidence shows that the pandemic is already limiting access to sexual and reproductive health care worldwide, especially in low- and middle- income countries,” said Sarah Barnes, Project Director of the Maternal Health Initiative at the Wilson Center. These impacts go unrecognized because they are indirect results of health system disruption rather than the direct impact of a virus, said Zara Ahmed, Associate Director of Federal Issues at the Guttmacher Institute.

Research shows that if contraception use declines by just 10 percent due to COVID-19, said Ann Biddlecom, Director of International Research at the Guttmacher Institute, another 49 million women of reproductive age would have unmet need for modern contraception and 15 million more unintended pregnancies would occur. Likewise, if 10 percent of safe abortions become unsafe due to the pandemic, Guttmacher estimates 3.3 million more unsafe abortions and another 1,000 preventable maternal deaths would occur.

Persistent Unmet Need for Modern Contraception

According to Guttmacher research, each year from 2015–2019, there were 121 million unintended pregnancies and 73 million abortions. “Globally, 48 percent of all pregnancies were unintended and 61 percent of unintended pregnancies ended in abortion,”  said Biddlecom. More than half of all women of reproductive age in low- and middle-income countries want to avoid a pregnancy, but one in four have an unmet need for modern contraception. This means that they are sexually active and do not want any more children or want to delay their next child but are not using any method of contraception. People living in the poorest countries of the world were three times more likely to experience unintended pregnancy than those in the wealthiest. And unintended pregnancy was more common in countries where abortion is restricted compared to countries where abortion is broadly legal.

If all unmet need for modern contraception were met; unintended pregnancy, unsafe abortion, and maternal deaths would decline by approximately two-thirds, said Biddlecom. Fulfilling this need for modern contraception saves maternal lives, it saves infant lives, and it saves money, said Dr. Palacio. Each dollar spent on contraceptive services would save $3 in maternal, newborn, and abortion care costs in low- and middle-income countries. “It is rare that we have a confluence of both economic benefit and health benefits on this order of magnitude,” she said.

Potential Life-Saving Benefit of Closing Gaps in Pakistan

While the SRHR priorities in the Guttmacher-Lancet Commission all remain important, said Zeba Sathar, Senior Associate and Pakistan Country Director of Population Council, each country has to weigh these priorities against country-specific data to make progress. In Pakistan, family planning and maternal health innovations can be difficult to advocate for due to a lack of funds for health services. If Pakistan met all contraceptive needs for women of reproductive age, there would be 3 million fewer unintended pregnancies across the country, according to Guttmacher’s Adding It Up report. Reducing unmet need for maternal and newborn health and family planning to zero would cut maternal deaths by 57 percent.

Meeting this need, said Sathar, would cost $7.73 per capita for maternal and newborn health and $0.81 per capita for family planning. Currently, the country spends $5.71 per capita on maternal and newborn health and $0.38 per capita on family planning, leaving a gap of $2.02 and $0.43, respectively. To fill this gap, investing in maternal health and family planning should be reframed to communicate the health saving benefits. “Saving mothers’ lives is seen quite differently from fulfilling the unmet gaps in modern contraception,” said Sathar. 

The Global Gag Rule’s Impact

The Trump administration’s expanded Mexico City Policy, or the “Global Gag Rule,” has impacted countries’ ability to provide sexual and reproductive health services, according to Guttmacher research. The Global Gag Rule is a United States foreign policy that blocks foreign (non-U.S.) non-governmental organizations that receive U.S. foreign assistance from providing, advocating for, counseling on, or referring for abortion services. Versions of this policy have been in effect off and on since the Reagan administration, said Margaret Giorgio, Senior Research Scientist at the Guttmacher Institute. While previous iterations of the Global Gag Rule only applied to family planning funding, the current policy applies to all global health assistance, which has affected roughly $7.4 billion in foreign aid. If an organization wants to accept U.S. funds, it must sign and abide by the Global Gag Rule, said Giorgio. That may mean they have to change or drop the reproductive health services they previously offered or the partnerships that made these services possible.

While the impact of this policy can be difficult to capture, research from Uganda showed that health services were greatly reduced, especially among community health workers, who are an essential part of family planning service delivery, said Giorgio. Groups less exposed to the policy saw increasing rates of contraceptive use and decreasing rates of unplanned births, whereas more exposed groups saw these rates stagnate, according to preliminary results on SRHR outcomes.

Incorporating SRHR into a Larger Health Savings Service

Issues like unmet need for modern contraception can be difficult to solve because the challenges differ by demographics, said Biddlecom. Adolescent girls and women have a higher unmet need compared to older women, and unmet need varies widely by wealth status worldwide. And while investing in SRHR makes sense and saves money, it still doesn’t happen in many countries, said Sathar. Presenting the “full package” of SRHR services as part of an integrated health savings service can address some of the systemic issues that arise from isolating and segregating the issues, she said.

“The decisions that people make about their families—these are decisions that impact generations,” said Dr. Palacio. “And so these are time sensitive decisions. These are our policy issues that affect the here and now, and they affect the future in very real ways.”