Fertility rates worldwide have been on the decline for many years, the result of a steady decrease in desired family size. But more often than not, fertility rates have not fallen as quickly as desired family size, as access to contraceptives has not kept pace with increasing demand. Consequently, more than 75 million pregnancies each year are unintended, finds “Fertility Regulation Behaviors and Their Costs: Contraception and Unintended Pregnancies in Africa and Eastern Europe & Central Asia,” a World Bank discussion paper surveying decades of research from Africa, Eastern Europe, and Central Asia. One fifth of these pregnancies end in induced abortion, fully half of which are classified as unsafe, meaning they are not attended by a properly trained health care worker or in an environment that conforms to minimum medical standards.

The costs of unsafe abortion are tremendous, financially and in terms of human lives. Approximately 67,000 women die annually from complications resulting from unsafe abortion, leaving more than 200,000 children motherless. Sexual and reproductive health issues constitute 20 percent of the global disease burden, and produce additional “direct and indirect costs to the individual woman, the woman’s household, the country’s health system and society as a whole.”

In Africa, post-abortion care can consume up to half of obstetrics and gynecology department budgets. The cost of this care is often much higher than the patient’s monthly salary. The authors report that “comprehensive family planning services to prevent unwanted pregnancy and reduce unsafe abortion in Nigeria would cost only a quarter of what is being spent in direct costs to treat post-abortion complications.” This point is taken up by author Margaret E. Greene is the latest issue of FOCUS, ECSP’s series of occasional papers featuring Wilson Center speakers. She writes that “[r]obust, compelling evidence linking good reproductive health to poverty reduction,” as is offered in the World Bank report, will “support efforts to include it in country-level poverty reduction strategies and in the allocation of international poverty reduction funding.”

This situation repeats itself across the globe. In Central Asia and Eastern Europe, induced abortion is “the principal method of birth control,” due to the expense of importing Western contraceptives, the medical community’s stigma against oral contraceptives, and the availability of abortion result. In Russia, government concerns about low fertility led the government to dismantle its sex-education curriculum and to carry out widespread layoffs in the government-controlled offices of contraceptive manufacturers.

Without exception, the case studies in this discussion paper find significant financial benefit to increasing modern contraceptive availability. Inadequate access is “an important barrier,” the authors write, discounting the argument that the contraceptives are there and people simply don’t use them. DHS surveys worldwide find that cost has prohibited contraceptive use for fewer than 2 percent of the estimated 137 million women with an unmet need. Women have decided, it seems, that the costs of childbearing far outweigh those of contraceptives.

“It is imperative,” the authors write, “that policies and programs address the need for contraception globally – for all population groups but with special emphasis on those who are most disadvantaged.” Community insurance schemes to reduce out-of-pocket payments can help accomplish this. Other ideas include increased subsidies for basic health services and adjusted user fee policies. The report also urges expanded and improved provision of contraceptive information and services, as well as improved training for health care providers. The problem is not a lack of good ideas and policies, but a lack of political will.