Family planning saves maternal and newborn lives: Why universal access to contraception must be prioritized in national maternal and newborn health policies, financing, and programs

We highlight why integrating contraceptive services within maternal and newborn health programs is essential for improving outcomes. We offer effective, actionable recommendations that can be implemented easily.


| INTRODUC TI ON
The first ever progress report, 1 issued jointly by both the Every Newborn Action Plan (ENAP) initiative and the strategies for Ending Preventable Maternal Mortality (EPMM), was launched at the International Maternal Newborn Health Conference (IMNHC) in May 2023.This landmark report and the IMNHC event highlighted the alarming stagnation and setbacks since maternal and newborn health were prioritized in the Sustainable Development Goals for Health in 2015: preventable maternal deaths, stillbirths and newborn deaths remain unacceptably high in all regions of the world and they are still declining too slowly to reach the SDG targets for 2030.
To save more maternal and newborn lives, a significant change in the way health systems address the determinants of maternal and newborn mortality is needed.
"Family planning saves lives" has been a popular and influential slogan for three decades as it recognizes and seeks to communicate the long-established scientific evidence that use of contraception contributes to the survival of women before and during childbirth and to the health of their babies.Universal access to contraception has been prioritized in the SDGs as a means for women and their partners to exercise their rights to decide freely and responsibly the number and spacing of their children.However, the maternal and newborn health benefits of using contraception are not explicit in the SDG indicators; consequently, not all national maternal and newborn health policies, financing budgets, and service delivery programs integrate contraception within their maternal and newborn health efforts.
Maternal and newborn health as well as family planning are recognized and promoted as essential and interrelated elements of sexual and reproductive health and rights (SRHR).However, delivery of services for protecting maternal and newborn health and for contraception vary in terms of provider, location, and availability, often through separate budgets and programs.Sustained progress in the reduction of maternal and newborn deaths requires much greater integration of these services in health systems' policies, financing, implementation, monitoring and accountability.
Evidence from the 1980s onwards consistently shows that investments in programs that have increased the use of modern contraception has averted millions of maternal deaths that would otherwise have occurred.For example, it is estimated that between 1990-2005, over one million maternal deaths were averted because of increased contraceptive use. 2 This evidence has shown that the use of contraception can significantly improve maternal and newborn survival and health through two mechanisms: or morbidity associated with pregnancy, delivery, and infanthood.WHO's guidance on reducing maternal mortality clearly recognizes this: "to avoid maternal deaths, it is vital to prevent unintended pregnancies.All women, including adolescents, need access to contraception, safe abortion services to the full extent of the law, and quality post-abortion care". 3By preventing pregnancies and births that could be higher-risk, especially those that are closely spaced together, are among adolescents and older women, and among women having four or more births.

| PRE VENTING UNINTENDED PREG NAN CIE S REDUCE S MATERNAL D E ATH S
From 2015-2019, an estimated 121 million pregnancies globally were unintended every year, 4 which is approximately half of all pregnancies.In 2019 among the 111 million unintended pregnancies in low-and middle-income countries (LMICs) 5 it is estimated that: • 35 million were ended through an unsafe abortion • 34 million were ended through a safe abortion • 30 million continued as unplanned births • 12 million resulted in a miscarriage and 1 million in a stillbirth.
All of these outcomes have potential health risks, with approximately 89 000 maternal deaths associated with an unintended pregnancy -representing 30% of all maternal deaths in a year. 5Moreover, live births following an unintended pregnancy are more likely to be associated with a maternal death (0.30%) than births following an intended pregnancy (0.21%). 6 (Unpublished estimate based on Table MA3. 3)ntraception is the primary health service intervention available for women and girls to control whether and when they become pregnant.Currently, approximately 705 million women living in LMICs are using contraception, which prevents an estimated 376 million unintended pregnancies.Preventing these unintended pregnancies averts 39 million miscarriages, two million stillbirths 5 and 131 000 maternal deaths annually. 6 (Unpublished estimate based on Table MA7. 4)reover, use of contraception currently prevents 100 million unsafe abortions every year 5 and consequently over 23 000 abortionrelated maternal deaths. 6 (Table MA7.4)

| REDUCING HIG H -RIS K PREG NAN CIE S REDUCE S MATERNAL AND NE WBORN D E ATH S
Globally, the lowest maternal mortality ratios (MMR) occur between the ages of 20-30 years (190-240 per 100 000 live births). 7,8By far the highest MMRs are among women aged 30 years and older, and especially over 35 years (710-2800) when the MMR can be 3-5 times higher than young women and adolescents.In addition to risks associated with the changing physiology of older women during pregnancy, especially those having four or more births, in many countries older women are less likely to attend antenatal care during pregnancy, to have skilled attendance during delivery, and to access postpartum care. 8Ensuring that older women are able to start or continue to use contraception that enables them to prevent unintended pregnancies, especially women with higher parity, should be prioritized by national family planning programs.Integration of contraceptive counseling and services in antenatal and postnatal care for women of all ages could improve the likelihood of reducing higher-risk pregnancies among older women.
On average, adolescents aged 15-19 years have a slightly higher MMR (260); for example, compared with women aged 20-24 years the average MMR for adolescent girls is 17%-28% higher. 8It is important to note that 20 countries 9 -all in Africa and Asia -account for 82% of all maternal deaths globally among adolescents.Counterintuitively, however, for some of these countries 10 the MMR for adolescents is actually the lowest for all age categories. 7Evidence indicates that pregnant adolescents may be at increased risks of eclampsia, puerperal endometritis, systemic infections, preterm delivery, severe neonatal conditions, and are more likely use an unsafe method for abortion, 11 and deaths are most likely among poor, rural, less educated adolescents who have limited access to maternal and newborn health services.[14][15] Reducing high-risk pregnancies and births through increasing use of contraception to avoid unintended pregnancies also reduces the likelihood of death among newborns.Evidence indicates that newborn and infant births are more likely to be risky: • For nulliparous adolescents aged less than 18 years, when compared with women having 1-2 children and with women aged 18-35 years.They have higher rates of preterm births, neonatal and infant mortality, and their newborns are more likely to be small-for-gestational age (SGA).Women with three or more children and/or aged over 35 years are also more likely to have these adverse newborn outcomes. 16When birth intervals are shorter than 18 months, which increases the likelihood of SGA and prematurity, and infant (but not newborn) mortality.Birth intervals of more than 5 years may also be more likely to have SGA and term-SGA newborns. 17timates indicate that current levels of contraceptive use (and current levels of pregnancy care) avert 544 000 newborn deaths every year in LMICs. 6 (Unpublished estimates based on Table A12, cell E5) Increased use of contraception will further reduce newborn deaths, thus family planning services should be considered an essential element in national budgets and UHC strategies for newborn health.

| ENHAN CING THE IMPAC T OF CONTR ACEP TIVE US E ON MATERNAL AND NE WBORN HE ALTH
The evidence provided above summarizes and reinforces the need for greater integration of contraceptive services within health system budgets and programs intended to protect girls and women from morbidities and death during the perinatal period.Contraceptive services are often budgeted, financed, delivered and evaluated separately from maternal and newborn health services.
Based on this evidence, FIGO and FP2030 recommend several actions that could be taken to support such integration.

| Increase access to and use of contraception by women wanting to avoid a pregnancy
Currently, 24% (218 million) of women wanting to avoid pregnancy have an unmet need for modern contraception; among adolescents this proportion is higher at 43%.If all this need could be met, the number of unintended pregnancies would be reduced to 35 million each year resulting in 21 million fewer unplanned births, 46 million fewer abortions (of which 26 million would still be unsafe because of legal restrictions), 8 million fewer miscarriages, and 0.7 million fewer stillbirths 5 (Figure 2.5) ; furthermore, fulfilling all unmet need (with current levels of pregnancy care) would avert an additional 414 000 newborn deaths every year. 6 (] and would prevent 414 000 newborn deaths.The total direct cost for the 705 million contraceptive users in LMICs is US$3.5 billion, an average of only US$5.00 per user.Enabling the 218 million women with unmet need to use a modern method would require an additional US$1.3 billion, but this would only increase the average direct cost per user byly US$0.16. 5 (p. 17) This figure illustrates the powerful and cost-effective impact of fulfilling all needs for modern contraception and justifies the inclusion of universal access to contraception in national UHC strategies and budgets.

| Increase availability of contraceptive information, supplies, and services during antenatal care, childbirth and postpartum care to improve birth spacing and reduce high parity births
Data from 57 LMICs in 2005-2013 estimates that 32%-62% of postpartum women had an unmet need for family planning. 18suring that antenatal care includes opportunities to discuss, educate and inform pregnant women about their contraceptive options during the immediate and extended postpartum period is critical to enable timely initiation and use of a method appropriate to their needs, whether to space the next pregnancy or have no more children.Different methods can be provided at various times after delivery.Facilities providing delivery, postnatal care, infant and child health and immunization services should be equipped to provide a range of contraceptive methods at the appropriate times.Counseling on contraceptive use and the offer of and referral for method provision should be continued throughout routine contacts for postpartum, infant and child health services to support timely use, enable switching if there are problems, and to reduce discontinuation.

| Include contraception within national maternal and newborn Essential Health Service Packages (EHSP) and Health Benefit Plans (HBP) to ensure inclusion in national Universal Health Coverage (UHC) strategies
The majority of countries include contraception in their UHC strategies, both as an essential intervention in their essential health service packages (EHSP) and as a publicly financed service within their health benefit plans (HBP).For those countries that do not include it in their EHSP, or do not fully or partially finance contraception through the HBP, advocacy efforts should consider promoting "family planning saves maternal and newborn lives" messages based on evidence available here and elsewhere, for example, through using estimates generated through impact modeling programs. 19Indeed, a recent modeling simulation found that "A strategy to simultaneously increase facility births, improve the availability of clinical services and quality of care at facilities, and improve linkages to care would yield a projected global MMR of 72 in 2030… adding family planning and community-based interventions would have an even larger impact, with a projected MMR of 58". 20As the evidence above indicates, investments in contraception can be justified not only to meet a country's goals concerning people's reproductive decision-making (e.g., SDGs 3.7, 5.6), but also the goals for maternal and newborn health (e.g., SDGs 3.1, 3.3).

| Link indicators for contraception with MNH indicators to support integrated strategic planning, financing, delivery and monitoring and evaluation
Several SDG targets and indicators address maternal, health, newborn health and contraception, but these are not always integrated within national UHC strategies, plans, budgets, monitoring, evaluation and reporting mechanisms.Consequently, the links between contraceptive use and maternal and newborn health care do not feature prominently in SDG policy-making, financial allocations and performance assessments.Improving the dialogue around these links would strengthen understanding of the benefits of investing in contraceptive programming for improving maternal and newborn health.
For example, the Ending Preventable Maternal Mortality (EPMM) strategy includes the SDG target (5.6.1) of empowering women to make informed and autonomous decisions on contraceptive use.However, the Every Newborn Action Plan (ENAP) does not include a target on contraceptive use, despite evidence that contraceptive use currently averts over half a million newborn deaths annually through preventing unintended pregnancies.The ongoing alignment of these two strategies provides an opportunity to also align around common objectives and targets to reduce unmet need for contraception.

| Include unintended pregnancy and contraception in analyses of causes of maternal and newborn mortality and morbidity and in recommendations of preventative interventions
The reasons why women and adolescents suffer death, disability and disease during pregnancy and childbirth are most frequently presented in terms of direct, obstetric complications (e.g., severe bleeding; infections; pre-eclampsia and eclampsia; complications from delivery; unsafe abortion) experienced after pregnancy starts, and indirect causes resulting from pre-existing disease, or non-obstetric disease, that develops or is exacerbated during pregnancy (e.g., HIV infection, malaria, cardiac disease, diabetes).
Missing from these categories, however, are the impacts on maternal mortality and morbidity associated with the intendedness, timing and spacing of a pregnancy.Explicitly including these factors in the framing of indirect causes would facilitate broader understanding of the benefit of promoting contraceptive use as the primary intervention to prevent unintended pregnancies and avert their consequences.

| Support research to improve measures and estimates linking contraception with maternal and newborn health
Being able to estimate these potential impacts of preventing mortality and morbidity is critically important because they provide the evidence needed for advocacy of how contraception contributes to maternal and newborn health.It is also important to clarify when communicating the estimates whether they are based on reductions in risk of adverse outcomes, or on the demographic impact of fewer pregnancies resulting in fewer deaths and morbidities.These different approaches are not comparable and produce different estimates of differing orders of magnitude. 20,21More research and improved data from service statistics are needed to verify the estimated associations, and especially for generating the country-specific estimates necessary to convince national stakeholders.

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By contributing to the prevention of unintended pregnancies and unplanned births, thereby reducing the number of times a woman and newborn are exposed to the risks of mortality This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.© 2023 The Authors.International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.