Elsevier

The Lancet

Volume 380, Issue 9837, 14–20 July 2012, Pages 111-125
The Lancet

Articles
Maternal deaths averted by contraceptive use: an analysis of 172 countries

https://doi.org/10.1016/S0140-6736(12)60478-4Get rights and content

Summary

Background

Family planning is one of the four pillars of the Safe Motherhood Initiative to reduce maternal death in developing countries. We aimed to estimate the effect of contraceptive use on maternal mortality and the expected reduction in maternal mortality if the unmet need for contraception were met, at country, regional, and world levels.

Method

We extracted relevant data from the Maternal Mortality Estimation Inter-Agency Group (MMEIG) database, the UN World Contraceptive Use 2010 database, and the UN World Population Prospects 2010 database, and applied a counterfactual modelling approach (model I), replicating the MMEIG (WHO) maternal mortality estimation method, to estimate maternal deaths averted by contraceptive use in 172 countries. We used a second model (model II) to make the same estimate for 167 countries and to estimate the effect of satisfying unmet need for contraception. We did sensitivity analyses and compared agreement between the models.

Findings

We estimate, using model I, that 342 203 women died of maternal causes in 2008, but that contraceptive use averted 272 040 (uncertainty interval 127 937–407 134) maternal deaths (44% reduction), so without contraceptive use, the number of maternal deaths would have been 1·8 times higher than the 2008 total. Satisfying unmet need for contraception could prevent another 104 000 maternal deaths per year (29% reduction).

Interpretation

Numbers of unwanted pregnancies and unmet contraceptive need are still high in many developing countries. We provide evidence that use of contraception is a substantial and effective primary prevention strategy to reduce maternal mortality in developing countries.

Funding

Bill and Melinda Gates Foundation.

Introduction

Contraceptive use averts almost 230 million births every year, and family planning is the primary strategy for prevention of unwanted pregnancies.1, 2 Rapid reduction of worldwide fertility rates from a total fertility rate (average number of births per woman) of 4·7 births in the early 1970s to 2·6 births in the late 2000s is predominantly credited to increased contraceptive use. Although organised family planning was first introduced in the 1950s in developing countries to slow rapid population growth, it has emerged as a key public health tactic to improve maternal and child health.3

Contraception and birth spacing have non-contraceptive health benefits in women.4, 5, 6, 7 Contraceptive use has also improved child survival by lengthening birth intervals, thereby reducing sibling competition for scarce family and maternal resources.8, 9, 10, 11

The Safe Motherhood Initiative, a global campaign to reduce maternal mortality, launched in 1987, identified family planning as one of four strategies—with antenatal care, safe delivery, and postnatal care—to reduce maternal mortality in developing countries, where 99% of all maternal deaths occur.12 The 1994 International Conference on Population and Development, held in Cairo, reiterated the importance of family planning for improvement of women's health.13 Increasingly, family planning is being recognised for its direct and indirect effects on maternal mortality.14, 15

Family planning directly reduces the number of maternal deaths because it reduces the chance of pregnancy and the associated complications (exposure reduction), lowers the risk of having an unsafe abortion (vulnerability reduction), delays first pregnancy in young women who might have premature pelvic development, and reduces hazards of frailty from high parity and closely spaced pregnancies. Each year, nearly 50 million of the 190 million women who become pregnant undergo abortions to terminate unwanted pregnancies, and about 13% of maternal deaths are caused by complications of abortion.16 Averted births and abortions contribute to the maternal mortality rate—a measure of maternal mortality risk per woman, defined as the number of maternal deaths in 100 000 reproductive-age women per year.

Contraceptive use also lowers maternal mortality risk per birth, measured by the maternal mortality ratio (defined as the number of maternal deaths in 100 000 livebirths per year), by modification of the excessive hazards associated with pregnancies that are “too early, too late, too many or too frequent”.17, 18 Maternal mortality risk is higher than average in young women (<18 years) because pelvic development is incomplete, and in older women (>40 years) and those of higher parity because their health could be more compromised. Empirical studies from Matlab, Bangladesh, showed that if women younger than 20 years and those older than 39 years avoided having children, maternal mortality would decrease by 34%, and elimination of births in mothers with five or more children could reduce the number of maternal deaths by 58%.19 In the 1970s, Population Council researchers estimated that elimination of births in developing countries in women of the “ages of reproductive inefficiency” (ie, restriction of births to women aged 18–35 years), could reduce maternal mortality by 20%.20 Improved birth spacing as a result of contraceptive use is also likely to contribute to maternal survival because it enables a longer recovery period between pregnancies, allowing more time for mothers to improve their nutritional status.

Studies in the mid-1980s, however, raised concerns that family planning might have little effect on maternal mortality ratio.21, 22 However, assessment of the effect of family planning at that time was probably premature because transitions in fertility rates were just emerging. In the past 2–3 years, three studies14, 15, 23 have examined the effect of the decline in fertility rate between 1990 and 2008 on maternal mortality, but they did not examine the net effect of family planning on maternal death. A major assertion of these studies, however, was that contraceptive use played the predominant part in fertility rate decline.

Although substantial progress has been made in reduction of worldwide maternal mortality—from 546 000 deaths in 1990 to 358 000 in 2008—Millennium Development Goal (MDG) 5A, which was to reduce maternal mortality ratio by three-quarters between 1990 and 2015, looks unlikely to be achieved in many countries.24 An agenda to reduce maternal mortality beyond 2015 that continues to regard family planning as important is needed.

We aimed to estimate the effect of contraceptive use on the reduction of maternal deaths for the same 172 countries assessed by the Maternal Mortality Estimation Inter-Agency Group (MMEIG), composed of WHO, UNICEF, the UN Population Fund, and the World Bank. We also used a simulation analysis to estimate the expected reduction in maternal deaths if unmet needs for contraception were fulfilled.

Section snippets

Data sources

We used data from three sources. The first was the MMEIG (WHO) maternal mortality estimation database used to estimate 2008 levels of maternal mortality.24 We obtained information about maternal deaths, fertility, gross domestic product, and skilled attendance at births from this database. We extracted contraceptive use data and information about the unmet need for family planning from the UN World Contraceptive Use 2010 database,25 which has data for 193 countries and territories from 1950 to

Results

Table 1 summarises model I estimates of worldwide and regional maternal mortality ratios, numbers of maternal deaths, and numbers and proportion of maternal deaths averted by contraceptive use, including the uncertainty range. Our estimated total number of maternal deaths in 2008 (based on the counterfactual model specification [model I]) was 342 203, slightly lower than WHO's reported number of 358 000 for the same year, and very similar to the Institute of Health Metrics and Evaluation's

Discussion

Our results suggest that family planning probably prevents about 272 000 maternal deaths worldwide per year, which is supported by earlier work by Singh and colleagues1 suggesting that 260 000 maternal deaths are averted each year by use of modern contraceptives.

Although our study systematically assessed the effect of births averted by contraception on maternal deaths both for regions and for countries, it is not without limitations. First, our estimates depended on the quality of underlying

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