Poor fall behind in birth control

Modern contraception has come a long way in the past 20 years, what with diaphragms, hormones, implants, intrauterine devices, condoms, spermicides, and sterilization. But the boom in birth control has been a bust for the poorest women in the world.

According to a study by researchers at Harvard University and the World Health Organization, international efforts to make pregnancy control a human right are bypassing people who live on a few dollars a day in developing nations from Bangladesh to Zimbabwe.

“Widespread increase in the use of contraception is one of the most dramatic social transformations of the second half of the 20th century,” notes Emmanuela Gakidou of the Harvard Initiative for Global Health. She and Effy Vayena of the World Health Organization in Geneva decided to determine if this contraceptive revolution includes the poorest women on Earth. The short answer is “no.”

Gakidou and Vayena analyzed surveys done between 1985 and 2003 in 55 developing nations in Latin America, Southeast Asia, and Africa. Information was collected on the wealth and contraception use of married, divorced, and widowed women ranging in age from 15 to 49 years. The World Health Organization estimates that 123 million women worldwide want to limit the number of children they have but are not using contraceptives.

During the 18-year period of the surveys, levels of health services, average wealth, education, and rates of contraceptive use all increased globally. But the poorest benefited the least. As developing nations thrive, the gap between average and poor has widened as far as controlling births is concerned.

Women in middle or sub-Saharan Africa fare the worst as far as availability of health services that deal with birth control. South and Southeast Asia boast a higher relative use of modern contraceptives, although absolute use among the poor is low. In Latin America, contraceptive use is higher than in Africa, but the gap between use by poor versus average women is higher than in Asia.

Richer countries in the survey, such as Brazil, boast greater use of contraceptives. In these nations, however, the gap in services between rich and poor is greatest.

Solutions

Considering all the variations in income, education, and culture that the research involved, Gakidou and Vayena homed in on availability of physicians, nurses, and other skilled birth assistance as the best way of increasing contraceptive rates. “If the measure is valid,” they write, “our results demonstrate that contraceptive prevalence is highly sensitive to the supply of reproductive health services. This finding is consistent with studies that illustrate contraceptive use increases as more types of methods become available.” According to this, if modern contraceptive prevalence in the poorest 20 percent of households worldwide can be significantly increased by enhanced supply, “the widening gap between rich and poor could be avoided through targeted interventions,” Gakidou says.

In Latin America, the gap between rich and poor is greater than in Asia and Africa, even after considering the larger supply of skilled birth assistance. To the researchers, this means that “Latin American health systems may need to pay particular attention to policies that affect delivery of reproductive health services to the poorest people.”

In addition to being wider in the richer developing nations, the contraception discrepancy seems to be increasing worldwide. The solution, Gakidou and Vayena say in the Feb. 6 issue of PloS Medicine, is to take advantage of increasing fiscal capacities in developing countries. Paradoxically, they say, “in an era of increased international and national resource flows for global health through mechanisms like the Global Fund for AIDS, tuberculosis, and malaria, contraceptive use and reproductive health services seem increasingly difficult to place on the health agenda. The trends that have been observed provide strong evidence that, without new priority attention to modern contraception, the poor will remain deprived of the fundamental right to its demonstrated benefits.”