[version 1; peer review: 1 approved with reservations, 1 not approved]
No competing interests were disclosed.
Family planning (FP) is a high-impact, cost-effective solution to achieving sustainable development and attaining improvements in sexual and reproductive health. Ensuring access to FP is one of the key transformative strategies that underpin health and sustainable development. It confers fertility choices for women and couples within a human rights framework. By meeting contraceptive needs of all women, significant public health impact and development gains accrue. At the same time, governments face the complex challenge of allocating finite resources to competing priorities, each of which presents known and unknown challenges and opportunities. As such, there is a need to carefully consider the estimated costs and benefits for each proposed investment in health, education, social welfare, and security. Zambia has experienced a slow but steady increase in contraceptive prevalence, with slight decline in total fertility rate (TFR), over the past 20 years. Increasing voluntary modern contraceptive use among women offers opportunities to reduce unintended pregnancy while effectively harnessing the demographic dividend in order to bolster socioeconomic outcomes for households and communities. Drawing from the Zambian context, we present a case for making investments in voluntary FP, underpinned by a human rights framework, as a pillar for accelerating development and socioeconomic advancement. Through multilevel interventions aimed at averting unintended pregnancies, Zambia – and other low- and middle-income countries – can reduce their age dependency ratios and harness economic growth opportunities awarded by the demographic dividend while improving the health and quality of life of the population.
DHS: Demographic and Health Survey, FP: Family planning, GRZ: Government of the Republic of Zambia, SSA: Sub-Saharan Africa, SDGs: Sustainable Development Goals, TFR: Total fertility rate
The views expressed in this article are those of the authors. Publication in Gates Open Research does not imply endorsement by the Gates Foundation.
Among the goals set by the global community for sustainable development is Goal 3.7,
Low-income countries with high fertility rates are at risk of having poor maternal and child health, economic stagnation, environmental degradation, and political unrest
Investments in high-quality FP services yield increased uptake and continued use of modern contraception, which have positive impacts on the health of women and children
Additionally, when population dynamics shift due to a reduction in mortality and fertility rates, there is a resulting increase in the proportion of working-age adults
The results of research on the impact of FP vary widely across settings and intervention contexts; nonetheless, a systematic review demonstrated that cross-cutting investments in women’s health yield healthier and more productive societies, broadly
Another systematic review found that scaling FP interventions was the most cost-effective strategy for reducing maternal mortality
Other cost–benefit and economic analyses of FP interventions have attributed substantial economic advantages to FP investments. The Guttmacher Institute’s 2014 “Adding It Up” report estimated that every $1 (USD) spent on contraception would generate $1.47 in savings from averting unwanted pregnancies
Economic models in Africa have predicted substantial gains if fertility rates can accelerate their decline. One simulation model in Nigeria found that shifting the fertility rate from the UN median fertility projection to the low fertility projection would result in a 5.6% increase in per capita income within 20 years and an 11.2% increase in 50 years
By describing reproductive health challenges and innovative policy strategies in the Zambian context, we present a case for investments in voluntary FP, underpinned by a human rights framework, as a pillar for accelerating development and socio-economic advancement. Through multilevel interventions aimed at averting unintended pregnancies, Zambia – and other low- and middle-income countries – can reduce their age dependency ratios and harness economic growth opportunities awarded by the demographic dividend while improving the health and quality of life of the population.
In 2014, Zambia had a total fertility rate (TFR) of approximately 5.3 births per woman, a substantial drop from 6.5 births in 1992, with rural women having an average of nearly three more children than urban women (6.6 vs. 3.7 births)
Despite these advancements, challenges addressing the demand for FP in Zambia persist. Data from the 2013-14 Zambia Demographic and Health Survey (DHS) reveal that 21% of women of childbearing age have an unmet need for FP, meaning that over 20% of married women of childbearing age wish to prevent or delay childbearing but are not using any form of FP
In addition to having high levels of unmet need, Zambian women commence childbearing early, with more than one-third reporting they gave birth before their 18
th birthday and more than 50% by age 20
The culmination of early childbearing and unmet need for FP contribute to a high birth rate in Zambia, at 40 per 1,000 population per year, by contrast with the worldwide average of 19 per 1,000 and an average of 37 per 1,000 for SSA
At present, the United Nations median estimate for Zambia suggests 553,000 women did not have their FP needs met in 2017; this estimate is projected to increase to 609,000 women by 2030
The Government of the Republic of Zambia (GRZ) has been actively working to generate demand, expand dialogue on FP, and improve FP access and quality in a coordinated effort guided by the national costed implementation plan
Looking ahead to 2030, GRZ has committed to the Sustainable Development Goals (SDGs), which build on the Millennium Development Goals and focus on sustainability and root causes of poverty. Many of the 17 SDGs are linked to key metrics in sexual and reproductive health including FP access, connecting these indicators to improvements in health, gender equality, education, and sustainability
Moving forward with these commitments, it is important to keep a continued focus on the unique opportunities and challenges of FP provision in Zambia. First, GRZ’s focus on adolescents and rural women is critical, since these groups have historically lagged in contraceptive uptake. Strategies to engage adolescents include continued support of comprehensive sexuality education in schools through capacity strengthening of teachers and peer educators, identifying youth-friendly service access points and address existing stigma at health facilities inhibiting youth FP uptake, and clarifying age of consent regulations to improve youth access
In addition to FP demand generation and securing FP commodities for these groups, it is also important to combine FP efforts with other policy interventions, particularly those aimed at reducing early marriage and promoting school retention for girls longer than the current average of 4.3 years
Efforts to address the 21% of women with an unmet need for FP will require not only reaching those who have never used FP previously, but also those who have used at least one FP method but later discontinued use. By expanding the mix of methods available to women, end users can find the method that works best for them throughout their reproductive life courses, thereby minimizing the risk of discontinuation and poor adherence. Additionally, a broader method mix enhances choice, a critical component in a rights-based approach to FP outreach and provision. According to the 2013-14 DHS, Zambian women, on average, desire approximately one fewer child than they currently have
From a public administrative perspective, it is important to both protect FP resources in government budgeting and to increase domestic investment in provision of voluntary FP services. Specifying that allocated funds are for FP supplies and provision helps to improve budgeting transparency; without specification, line item funds risk being absorbed into broader maternal and child health expenses. Increasing domestic investment in voluntary FP services is critical at a time when donor assistance in FP is stagnant or even declining
Decades of research have clearly established the benefits of voluntary FP services as a health, development, and human rights priority. It has a direct impact on women’s health and socio-economic development. There is a pressing need to invest more in voluntary FP services in general and, specific to the Zambian context, to realize the development potential associated with high and sustained contraceptive use. This requires the engagement of diverse stakeholders, economic and planning decision-makers, as well as traditional and religious leaders. With proper planning and investments in FP and related supportive programs, Zambia is at a critical juncture in harnessing the demographic dividend, spurring long-term economic growth and continued improvements in the population’s health, education, and overall quality of life. Unfortunately, this opportunity comes at a time when international resources for FP investments are under threat. Therefore, it is important to also mobilize domestic resources for FP investments and continue to explore innovative strategies to increase FP access for women with current unmet needs. Ensuring a broad contraceptive method mix secures decision-making autonomy over reproductive intentions for women and couples. Ultimately, this will require commitments to FP programs and policies by government officials across line ministries, as well as greater public support.
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I agreed with the first reviewer that this is an excellent, very well written open letter with many clear policy implications. I only have two comments:
While the authors aim to use Zambia to make a case for investments in FP, I am left wanting to know more about Zambia to be convinced that Zambia is such a good example. This is because when the authors describe current efforts in Zambia, they do a very good job in the first half. In the second half, when they start talking about reducing early marriage, promoting education, expanding method mix, etc, it is not clear what the Government of Zambia has done exactly. No specific examples from the country’s programs are provided. The abstract is too heavy on the background, with the first three sentences saying the same key points. Later on, the sentence “Increasing voluntary modern contraceptive use…” in the middle of the abstract is similar to the last sentence of the abstracts as they both talk about socioeconomic outcomes and demographic dividends. Both of these instances give an impression that the abstract could be much more concise and to the point.
Does the article adequately reference differing views and opinions?
Yes
Are all factual statements correct, and are statements and arguments made adequately supported by citations?
Yes
Is the Open Letter written in accessible language?
Yes
Where applicable, are recommendations and next steps explained clearly for others to follow?
Yes
Is the rationale for the Open Letter provided in sufficient detail?
Yes
Reviewer Expertise:
15 years of experience in family planning and reproductive health.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
We thank the reviewer for these thoughtful, detailed comments. In response to the first point about specific policies implemented in Zambia, we have clarified our language in the “Current efforts and recommendations” sub-section (Pgs. 6-7) in hopes of delineated between current FP policies implemented in Zambia and our recommendations. Additionally, at the reviewer’s recommendation, we have supplemented our discussion of policy recommendations with additional detail of existing FP policies in Zambia, particularly those enumerated in the costed implementation plan to support FP scale-up (2013-2020). These include development of a school-based adolescent sexual and reproductive health curriculum and task-shifting FP provision to community-based distributors. With respect to the second comment, we have consolidated some of the language in the abstract (Pg. 2) to more succinctly summarize of the Open Letter’s contents.
This is an excellent open letter: well-written, concise and with clear policy implications. My only issues are with a couple of significant omissions.
First, another benefit of family planning is that it helps countries become more resilient, not only in the face of climate change, but also to other shocks and emergencies.
Second, and more significantly, I was very disappointed that, in a letter full of precise and direct policy recommendations, the authors seemed extremely hesitant to directly address the need for more long-acting methods such as implants and IUDs. Instead, they use roundabout wording to signal this lacuna, citing the problem of early method discontinuation and the need for a broader method mix. If you are serious about improving choice, please be more explicit. You've covered your bases by mentioning "rights" five times and "voluntary" ten times in a single letter; it's okay to say "long-acting" at least once.
Does the article adequately reference differing views and opinions?
Yes
Are all factual statements correct, and are statements and arguments made adequately supported by citations?
Yes
Is the Open Letter written in accessible language?
Yes
Where applicable, are recommendations and next steps explained clearly for others to follow?
Partly
Is the rationale for the Open Letter provided in sufficient detail?
Partly
Reviewer Expertise:
programmatic family planning researcher with >30 years experience
I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
We thank the reviewer for the thorough and thoughtful review of our Open Letter. We agree with the reviewer’s assertion that FP supports women’s resilience to confront climate change, natural disasters, and other destabilizing events. As such, we have added language to the Open Letter’s introduction (Pg. 3) addressing these aforementioned factors as added benefits to investments in FP. Secondly, we also appreciate the reviewer’s attention to the absence of explicit articulation of long-acting methods in our discussion of FP. To correct this oversight, we have weaved discussion of long-acting methods throughout our manuscript, including explicit mention of long-acting methods as a core component of the recommendation for expanding contraceptive method mix.