The U.S. Government and International Family Planning & Reproductive Health Efforts
- Improving access to family planning and reproductive health (FP/RH) services globally can help prevent maternal deaths and reduce unintended pregnancies. Each year, an estimated 303,000 women die from complications during pregnancy and childbirth, almost all in developing countries. Approximately one-third of maternal deaths could be prevented annually if women who did not wish to become pregnant had access to and used effective contraception. Worldwide, 214 million women have an unmet need for modern contraception.
- The U.S. government (U.S.) has supported global FP/RH efforts for 50 years and is the largest donor to FP/RH in the world. It is also one of the largest purchasers and distributors of contraceptives internationally.
- Over time, the U.S. role in global FP/RH has changed, sometimes influenced by differing views and political debates related to FP/RH that have arisen both domestically and internationally. Historically, these debates have concerned both the amount of U.S. funding provided to global FP/RH as well as its use, particularly related to abortion.
- Total U.S. funding for FP/RH, which includes the U.S. contribution to the United Nations Population Fund (UNFPA), was $608 million in FY 2019, up from $425 million in FY 2006; however, the current Administration has withheld the U.S. contribution to UNFPA for FY 2017, FY 2018, and FY 2019 due to the Kemp-Kasten Amendment. Additionally, it proposed eliminating FP/RH funding for FY 2018 (though Congress ultimately held funding level) and, as in FY 2019, has proposed reducing it significantly for FY 2020.
- U.S. funding for FP/RH is governed by several legislative and policy restrictions, including a legal ban on the direct use of U.S. funding overseas for abortion as a method of family planning (which has been in place since 1973) as well as more stringent restrictions in some years, such as President Trump’s January 2017 reinstatement and expansion of the Mexico City Policy.
Access to family planning and reproductive health (FP/RH) services is critical to the health of women and children worldwide. Improving access to FP/RH services globally can help prevent maternal deaths and reduce unintended pregnancies. Each year, approximately 303,000 women die from complications during pregnancy and childbirth, almost all in developing countries.1 It is also estimated that approximately one-third of maternal deaths could be prevented annually if women who did not wish to become pregnant had access to and used effective contraception.2
Family Planning (FP): The ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of births.3
Reproductive Health (RH): The state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive processes, functions, and system at all stages of life.4
Key factors contributing to maternal deaths and unintended pregnancy include:5
- unmet need for FP services;
- high adolescent birth rates, since adolescents (ages 15-19) are more likely to die or face complications during pregnancy and childbirth;
- lack of access to antenatal care, which increases the risk of complications during pregnancy and childbirth; and
- unsafe abortions, which are those performed by individuals without the necessary skills or in an unsanitary environment and often lead to complications and death.
Worldwide, 214 million women have an unmet need for modern contraception (i.e., they do not wish to get pregnant and are using no contraceptive method or a traditional method).6 Access to FP methods, including traditional methods, varies significantly by region (see Table 17). Unmet need for FP is highest in regions like sub-Saharan Africa and Oceania where contraceptive prevalence is low.8 Adolescent fertility rates have declined slowly and remain particularly high in sub-Saharan Africa, where child marriage remains common, and in Latin America and the Caribbean.9 While the percentage of pregnant women receiving the recommended minimum number of four antenatal care visits has been on the rise, it is 52% in developing countries and lower still in sub-Saharan Africa and Southern Asia.10 Each year, approximately 47,000 women die from complications associated with unsafe abortion.11 Access to and use of effective contraception reduces unintended pregnancies and the incidence of abortion.12
Reasons for the lack of access to and, in some cases, utilization of FP/RH services include low awareness of the risks of sexual activity, such as pregnancy and HIV; cost; gender inequality; and laws in some countries that require women and girls to be of a certain age or have third party authorization, typically from their husband, to utilize services.13 See Table 1.
|Table 1: Key Family Planning/Reproductive Health (FP/RH) Indicators by Region|
|Adolescent Birth Rate
|Women’s SRH Decisionmaking^
|Least Developed Countries||21.0||40.8||91.2||49.0|
|Latin America and the Caribbean||9.6||74.3||61.3||67.7|
|NOTES: # Country classifications are based on SDG regional designations. ^ SRH is sexual and reproductive health; indicator reflects Proportion of Women Who Make Their Own Informed Decisions Regarding Sexual Relations, Contraceptive Use, and Reproductive Health Care. — data not available. * Oceania excluding Australia and New Zealand.|
FP/RH encompasses a wide range of services that have been shown to be effective in decreasing the risk of unintended pregnancies, maternal and child mortality, and other complications. These include:
- birth spacing;
- sexuality education, information and counseling;
- post-abortion care;
- screening/testing for HIV and other sexually transmitted diseases (STDs);
- repair of obstetric fistula;
- antenatal and postnatal care;
- genital human papillomavirus (HPV) vaccine to prevent cervical cancer and genital warts; and
- research into new methods such as microbicides.14
There are several key global goals for expanding access to and improving FP/RH services, including:
SDG 3: Achieving Universal Access to Reproductive Health
This goal, adopted in 2015 as part of Sustainable Development Goal (SDG) 3 – “ensure healthy lives and promote well-being for all at all ages,” is to “ensure universal access to sexual and reproductive health care services, including for family planning, information, and education, and the integration of reproductive health into national strategies and programmes.”15 The SDGs are the successor to the Millennium Development Goals (MDGs), which also included this goal as a specific target under MDG 5 (improve maternal health).16
FP2020: Providing Access to Voluntary FP to an Additional 120 Million Women
In July 2012, the government of the United Kingdom and the Bill & Melinda Gates Foundation – in partnership with the United Nations Population Fund (U.N. Population Fund or UNFPA), civil society organizations, developing countries, donor governments, the private sector, and multilateral organizations – co-sponsored the London Summit on Family Planning, an effort to provide voluntary family planning services to an additional 120 million women and girls in developing countries by 2020 through new commitments. This goal is being monitored by Family Planning 2020 (FP2020), a global partnership created as an outcome of the Summit. In July 2017, the second London Summit on Family Planning reviewed progress made thus far.17
U.S. Government Efforts
The U.S. has a long history of engagement in international family planning and population issues, and today, the U.S. government is the largest donor to global FP/RH efforts and is one of the largest purchasers and distributors of contraceptives internationally.18 Congress first authorized research in this area in the Foreign Assistance Act of 1961.19 In 1965, the U.S. Agency for International Development (USAID) launched its first FP program and, in 1968, began purchasing contraceptives to distribute in developing countries. In the 1980s, USAID programs expanded to address maternal, newborn, and child health as well as the relationship between population, health, and the environment; and in the 1990s, USAID FP/RH programs began to recognize the need for male involvement in FP/RH and focus on the needs of young people.20 More recently, the U.S. adopted a longer term global health goal of ending preventable child and maternal deaths by 2035 and highlighted the important role of FP/RH efforts in achieving this goal.21 U.S. funding for FP/RH is governed by several legislative and policy restrictions, including a legal ban on the direct use of U.S. funding overseas for abortion as a method of family planning (which has been in place since 1973) as well as more stringent restrictions in some years, such as the Mexico City Policy (see below).
USAID has long served as the lead U.S. agency for FP/RH activities, with other agencies also carrying out FP/RH activities.
USAID operates FP/RH programs in more than 30 countries, with a focused effort in 24 priority countries that are mostly in Africa and Southern Asia.22 The agency’s stated FP/RH objective is to help countries meet the FP/RH needs of their people.23 It does this by expanding sustainable access to quality voluntary FP/RH services, commodities, and information (see Table 224) that enhance efforts to reduce high-risk pregnancies; allow sufficient time between pregnancies; provide information, counseling, and access to condoms to prevent HIV transmission; reduce the number of abortions; support women’s rights; and stabilize population growth.25 These efforts aim to contribute to the global goal of reaching more than 120 million more women and girls in the world’s poorest countries with access to voluntary FP information, contraceptives, and services by 2020.26
|Table 2: U.S. Government-Funded Family Planning/Reproductive Health (FP/RH) Interventions|
|· Addressing child marriage|
|· Addressing gender-based violence|
|· Biomedical and contraceptive research and development|
|· Contraceptive supplies and their distribution|
|· Contributions to UNFPA*|
|· Counseling and services such as birth spacing|
|· Eliminating female genital mutilation|
|· Financial management|
|· Linking FP with HIV/AIDS & STD information/services|
|· Linking FP with maternity services|
|· Post-abortion care|
|· Prevention and repair of obstetric fistula|
|· Public education and marketing|
|· Sexuality & reproductive health education|
|· Training of health workers|
|NOTES: * means U.S. support for UNFPA has been withheld during FY 2017 and FY 2018 due to the Kemp-Kasten Amendment.|
Other U.S. FP/RH Efforts
Also carrying out FP/RH efforts are the Centers for Disease Control and Prevention (CDC) (research, surveillance, technical assistance, and a designated World Health Organization Collaborating Center for Reproductive Health);27 the Department of State (diplomatic and humanitarian efforts); the National Institutes of Health (NIH) (research); and the Peace Corps (volunteer activities).
Additionally, USAID’s FP/RH and maternal and child health (MCH) efforts are closely linked, although Congress directs funding to and USAID operates these programs separately. Recent years have also seen greater emphasis on coordinating FP/RH investments with global HIV efforts through the President’s Emergency Plan for AIDS Relief (PEPFAR).28 See the KFF fact sheet on U.S. MCH efforts and the KFF fact sheet on U.S. PEPFAR efforts.
The U.S. works with several international institutions, partnerships, and other donors to carry out FP/RH efforts. Among them are the U.N. Population Fund (UNFPA, the largest purchaser and distributor of contraceptives worldwide – though the current Administration. has determined the U.S. will withhold its contribution to UNFPA in FY 2017 and FY 2018; see below); Family Planning 2020 (FP2020, an international partnership to expand access to family planning services in which the U.S. is a core partner); and the Global Financing Facility (GFF, a partnership to improve the health of women, children, and adolescents through innovative financing in which the U.S. is an investor).29
Total U.S. funding for FP/RH, which includes the U.S. contribution to UNFPA, has increased from $425 million in FY 2006 to $608 million in FY 2019 (see Figure 1). However, the current Administration has withheld the U.S. contribution to UNFPA for FY 2017, FY 2018, and FY 2019 due to the Kemp-Kasten Amendment.31 Additionally, it proposed eliminating FP/RH funding for FY 2018,32 though Congress ultimately held funding level, and, as in FY 2019, has proposed significantly reducing FP/RH funding for FY 2020.
Most U.S. funding for FP/RH is part of the Global Health Programs account at USAID, with additional funding provided through the Economic Support Fund account. FP/RH funding is also provided through the International Organizations & Programs account at the Department of State for the U.S. contribution to UNFPA. Under current U.S. law, any U.S. funding withheld from UNFPA is to be made available to other family planning, maternal health, and reproductive health activities.33
Requirements in Law and Policy34
Legal, policy, and programmatic requirements for U.S. funding for international FP include (also see the KFF fact sheet on these and other requirements):
Since 1973, through the Helms Amendment, U.S. law has prohibited the use of foreign assistance to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion.
Mexico City Policy
First instituted by President Reagan in 1984 through executive order, the Mexico City Policy (the “Global Gag Rule”) required foreign non-governmental organizations (NGOs) to certify that they would not perform or promote abortion as a method of family planning using funds from any source as a condition for receiving U.S. funding. A highly debated issue, this policy was rescinded by President Clinton, reinstated by President Bush, rescinded by President Obama, and reinstated – in an expanded form – by President Trump in January 2017. The current Administration’s application of the policy extends to the vast majority of U.S. bilateral global health assistance, including funding for FP/RH, HIV under PEPFAR, maternal and child health, malaria, nutrition, and other programs; in past iterations, it applied to family planning assistance only. Under the current administration, the policy has been renamed “Protecting Life in Global Health Assistance.” See the KFF explainer on the Mexico City Policy.
UNFPA & the Kemp-Kasten Amendment
Although the U.S. government helped create the U.N. Population Fund (UNFPA) in 1969 and was a leading contributor for many years, there have been several years in which funding has been withheld due to executive branch determinations that UNFPA’s activities in China violated the Kemp-Kasten Amendment, which prohibits funding any organization or program, as determined by the President, that supports or participates in the management of a program of coercive abortion or involuntary sterilization.35 In January 2017, President Trump directed the U.S. Secretary of State to “take all necessary actions” to implement the Kemp-Kasten Amendment, and for three years now (FY 2017, FY 2018, and FY 2019), the Administration has withheld funding for UNFPA by citing the Kemp-Kasten Amendment.36 See the KFF explainer on UNFPA funding and the Kemp-Kasten Amendment.
Voluntarism and Informed Choice
The principles of ensuring voluntary use of FP/RH services as well as informed choice of FP/RH options are specified in legislative language and program guidance.
Key Issues for the U.S.
In recent years, growing global attention has highlighted the need to augment FP/RH services worldwide and increase coverage and access. As the global community endeavors to support and fund efforts to achieve SDG 3’s FP/RH targets, the future of U.S. FP/RH efforts is more uncertain, with questions about the extent to which the current Administration will support FP/RH efforts (given the Jan. 2017 reinstatement and expansion of the Mexico City Policy, its Kemp-Kasten determinations regarding UNFPA, and recent budget requests to eliminate or significantly reduce FP/RH funding), and the strength of bipartisan support in Congress for FP/RH. Policy debates and discussions within and among Congress and the current Administration regarding the U.S. role in FP/RH (such as its role in fostering progress toward global goals related to providing access to FP/RH services) and the amount and use of U.S. funding (including legal and policy requirements) are likely to continue. Other key issues and challenges for U.S. efforts include:
- continuing support for FP/RH efforts in order to expand access to and ensure the quality of FP/RH services;
- reaching the most vulnerable;
- supporting advances in research and uptake of new technologies;
- further integration of FP/RH efforts with other U.S. global health programs (such as maternal and child health and global HIV under PEPFAR) and broader U.S. development efforts (including education); and
- coordinating these efforts with the activities of other donors and partner countries in order to maximize the impact of available resources.
WHO, et al., Trends in maternal mortality: 1990 to 2015, 2015.
S. Ahmed, et al., “Maternal deaths averted by contraceptive use: an analysis of 172 countries,” The Lancet, July 14, 2012 (Vol. 30, no. 9837: 111-125).
World Health Organization (WHO), Family Planning website, http://www.who.int/topics/family_planning/en/.
WHO, Reproductive Health website, http://www.who.int/topics/reproductive_health/en/; International Conference on Population and Development (ICPD), Programme of Action, Cairo, 1994.
WHO, “Maternal mortality,” fact sheet, Feb. 2018; United Nations (UN), The Millennium Development Goals Report 2009, 2009; WHO, World Health Report 2005 – Making Every Mother and Child Count, 2005; Guttmacher Institute, “Induced Abortion Worldwide,” fact sheet, March 2018; WHO, “Preventing unsafe abortion,” fact sheet, Feb. 2018.
Guttmacher Institute, Adding It Up: Investing in Contraception and Maternal and Newborn Health, 2017, fact sheet, Dec. 2017.
UN, Progress towards the Sustainable Development Goals, Report of the Secretary-General, Supplementary Information, E/2018/64*, statistical annex, revised June 20, 2018; U.N. Department of Economic and Social Affairs, Population Division, Estimates and Projections of Family Planning Indicators 2018: Regions, 2018.
U.N. Department of Economic and Social Affairs, Population Division, Estimates and Projections of Family Planning Indicators 2018: Regions, 2018.
UN, Progress towards the Sustainable Development Goals, Report of the Secretary-General, Supplementary Information, E/2018/64*, statistical annex, revised June 20, 2018.
WHO, World Health Statistics 2014, 2014; UN, The Millennium Development Goals Report 2015, 2015.
WHO, Unsafe abortion: global & regional estimates of the incidence of unsafe abortion and associated mortality in 2008, 2011.
Eric Zuehlke, “Reducing Unintended Pregnancy and Unsafely Performed Abortion Through Contraceptive Use,” PRB, 2009.
WHO, World Health Report 2005 – Making Every Mother and Child Count, 2005. See also Guttmacher Institute, Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method, June 2016, and Guttmacher Institute, “Reasons for Unmet Need For Contraception in Developing Countries,” fact sheet, June 2016..
USAID, “Family Planning & Reproductive Health Programs - Saving Lives, Protecting the Environment, Advancing U.S. Interests,” fact sheet, undated; USAID, “Fast Facts: Family Planning,” fact sheet, Dec. 2009; WHO, Johns Hopkins, and USAID, Family Planning: A Global Handbook for Providers, 2007; USAID, Report to Congress: Global Health and Child Survival Progress Report – FY 2008, 2009; UNESCO, International Technical Guidance on Sexuality Education, Dec. 2009.
UN, Transforming our world: the 2030 Agenda for Sustainable Development, 2015.
This goal was originally specified in the 1994 Cairo International Conference on Population and Development’s (ICPD) Programme of Action and was added in 2007 as a specific target of Millennium Development Goal 5 (MDG 5), which aims to improve maternal health. This addition to MDG 5 was a recognition by governments and world leaders of the need to address challenges related to access and utilization of RH services. The world did not reach this target, but some progress was made, with more women attending a health provider four times or more during pregnancy and using contraceptives, though these indicators still vary widely across regions. ICPD, Programme of Action, Cairo, 1994; UN, The Millennium Development Goals Report 2009, 2009; UN, The Millennium Development Goals Report 2015, 2015.
Family Planning Summit, July 11, 2017 – London website, http://summit2017.familyplanning2020.org/about-us.html.
KFF, Mapping the Donor Landscape in Global Health: Family Planning and Reproductive Health, 2014; KFF, Donor Government Assistance for Family Planning, report series; UNFPA, Contraceptives and Condoms for Family Planning and STI & HIV Prevention (2014), 2015.
Congressional Research Service (CRS), U.S. International Family Planning Programs: Issues for Congress, Jan. 2016.
USAID, USAID Family Planning Program Timeline, undated.
USAID, “What We Do - Global Health,” webpage, https://www.usaid.gov/what-we-do/global-health; USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014. See also USAID, Acting on the Call 2018: A Focus on the Journey to Self-Reliance for Preventing Child and Maternal Deaths, 2018.
KFF analysis of data from the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. See also USAID, “Family Planning Countries,” webpage, https://www.usaid.gov/what-we-do/global-health/family-planning/countries. Countries are selected based on high rates of unmet need for FP, prevalence of high-risk births, low contraceptive use, and significant population pressures on land and water resources (per KFF personal communication with USAID, April 2, 2010).
USAID, “Family Planning and Reproductive Health Program Overview,” fact sheet, Nov. 2017.
U.S. Government, FY 2019 Congressional Budget Justification - Department of State, Foreign Operations, and Related Programs, 2018; USAID, “Family Planning and Reproductive Health Program Overview,” fact sheet, Nov. 2017; USAID: “Family Planning and Reproductive Health,” webpage, http://www.usaid.gov/what-we-do/global-health/family-planning; USAID, “Family Planning Resources,” webpage, https://www.usaid.gov/what-we-do/global-health/family-planning/family-planning-resources; USAID, “Reproductive Health,” webpage, https://www.usaid.gov/what-we-do/global-health/cross-cutting-areas/reproductive-health; USAID, “Family Planning & Reproductive Health Programs - Saving Lives, Protecting the Environment, Advancing U.S. Interests,” fact sheet, undated; USAID, “Fast Facts: Family Planning,” fact sheet, Dec. 2009.
USAID, “Family Planning and Reproductive Health Program Overview,” fact sheet, Nov. 2017; USAID: “Family Planning and Reproductive Health,” webpage, http://www.usaid.gov/what-we-do/global-health/family-planning; USAID, Report to Congress: Global Health and Child Survival Progress Report – FY 2008, 2009.
USAID, “Family Planning and Reproductive Health Program Overview,” fact sheet, Nov. 2017; USAID: “Family Planning and Reproductive Health,” webpage, http://www.usaid.gov/what-we-do/global-health/family-planning; USAID, “USAID Global Health Programs: FY 2016 President’s Budget Request, Ending Preventable Child and Maternal Deaths,” fact sheet, March 2015.
CDC, Global Reproductive Health website, http://www.cdc.gov/reproductivehealth/Global/index.htm.
For example: OGAC, PEPFAR 2018 Country Operational Plan Guidance for Standard Process Countries, Jan. 28, 2018; OGAC, PEPFAR Fiscal Year 2014 Country Operational Plan (COP) Guidance, Version 2, Nov. 8, 2013; OGAC, PEPFAR Blueprint:Creating An AIDS-free Generation, Nov. 2012; OGAC, U.S. PEPFAR: Five-Year Strategy, Dec. 2009.
The GFF was launched in 2015 as “a multi-stakeholder partnership that supports country-led efforts to improve the health of women, children, and adolescents,” and the U.S. is as a member of the Investors Group that oversees the partnership’s overall activities; see https://www.globalfinancingfacility.org/introduction.
KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. For an in-depth discussion of U.S. government FP/RH funding, including trends, see KFF, U.S. Funding for International Family Planning & Reproductive Health, April 2016.
For several years, including FY 2017 and FY 2018, Congress has required that funding withheld from UNFPA be reallocated to USAID’s family planning, maternal, and reproductive health activities. See KFF, UNFPA Funding & Kemp-Kasten: An Explainer.
While the FY 2018 Request eliminated funding for the FP/RH program under the Global Health Programs (GHP) account, it did note in proposed legislative language that GHP funds could be used for "reproductive health activities, such as fistula repair, prevention and response to gender-based violence, and ending child marriage and female genital cutting or mutilation."
KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet; KFF, Statutory Requirements & Policies Governing U.S. Global Family Planning and Reproductive Health Efforts, brief, 2012; USAID, USAID's Family Planning Guiding Principles and U.S. Legislative and Policy Requirements webpage, http://www.usaid.gov/what-we-do/global-health/family-planning/usaids-family-planning-guiding-principles-and-us-0.
CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, Feb. 2010.
White House, “Subject: The Mexico City Policy,” Memorandum for the Secretary of State[,] the Secretary of Health and Human Services[, and] the Administrator of the United States Agency for International Development, Jan. 23, 2017, https://www.whitehouse.gov/the-press-office/2017/01/23/presidential-memorandum-regarding-mexico-city-policy. FY 2017 Determination: State Department: Letter to Bob Corker, Chairman, Committee on Foreign Relations, from Joseph E Macmanus, Bureau of Legislative Affairs, State Department, dated April 3, 2017, and accompanying “Determination Regarding the ‘Kemp-Kasten Amendment,’” dated March 30, 2017, and “Memorandum of Justification for the Determination Regarding the "Kemp-Kasten Amendment,” undated. Available online (follows the article) at: https://www.buzzfeed.com/jinamoore/the-us-wont-give-any-more-money-to-the-un-population-fund. The FY 2018 determination was made on March 8, 2018, at the six-month mark after the passage of the initial continuing resolution for FY 2018 appropriations. FY 2019 Determination: State Department: Letter to Eliot Engel, Chairman, Committee on Foreign Affairs, from Mary Elizabeth Taylor, Assistant Secretary, Bureau of Legislative Affairs, State Department, dated July 12, 2019, and accompanying “Determination Regarding the ‘Kemp-Kasten Amendment,’” dated July 8, 2019, and “Memorandum of Justification for the Determination Regarding the "Kemp-Kasten Amendment,” undated.