The case for investing in family planning in the Pacific: Costs and benefits of reducing unmet need for contraception in Vanuatu and the Solomon Islands

Background: Unmet need for family planning in the Pacific is among the highest in the world. Better understanding of required investments and associated benefits of increased access to family planning in the Pacific may assist prioritisation and funding. Methods. We modelled the costs and associated health, demographic and economic impacts of reducing unmet need for family planning between 2010-2025 in Vanuatu and the Solomon Islands. Baseline data were obtained from census reports, Demographic and Health Surveys, and UN agency reports. Using a demographic modelling program we compared a scenario of “no change in unmet need” with two distinct scenarios: 1) all family planning needs met by 2020; and, 2) all needs met by 2050. Results: Meeting family planning needs by 2020 would increase prevalence of modern contraception in 2025 from 36.8 to 65.5% in Vanuatu and 28.5 to 37.6% in the Solomon Islands. Between 2010-2025 the average annual number of unintended pregnancies would decline by 68% in Vanuatu and 50% in the Solomon Islands, and high-risk births would fall by more than 20%, averting 2,573 maternal and infant deaths. Total fertility rates would fall from 4.1 to 2.2 in Vanuatu and 3.5 in the Solomon Islands, contributing to slowed population growth and lower dependency ratios. The direct cost of reducing unmet need by 2020 was estimated to be $5.19 million for Vanuatu and $3.36 million for the Solomon Islands between 2010-2025. Preventing unintended pregnancies would save $112 million in health and education expenditure. Conclusions: In small island developing states such as Vanuatu and the Solomon Islands, increasing investment in family planning would contribute to improved maternal and infant outcomes and substantial public sector savings. © 2013 Kennedy et al.; licensee BioMed Central Ltd. We used the demographic modelling software Spectrum 4.391 (Futures Institute, Glastonbury, CT, USA) to examine health, demographic and economic consequences of reducing unmet need for family planning in Vanuatu and the Solomon Islands. A detailed description of the program methodology and assumptions has been published elsewhere [14-17]. In brief, the program is based on a standard demographic cohort-component model and uses the proximate determinants of fertility framework to relate contraceptive use to total fertility rate (TFR) [18]. Baseline population projections (assuming no change in unmet need for family planning) were generated for Vanuatu and the Solomon Islands for the period 2010–2054. This projection period was chosen as both countries are predicted to reach replacement fertility by 2054 [19,20]. Two additional projections were generated separately for each country based on two hypothetical family planning scenarios: all needs met by 2020 (scenario one) and all needs met by 2050 (scenario two). Neither country is likely to achieve universal access to family planning by 2015 [12], so a target of 2020 was considered to be a best-case scenario. The additional target of 2050 was included to examine the impact of slower progress. A panel of Pacific and international family planning and population experts and representatives from Ministries of Health (MOH) in both countries provided guidance concerning data and key assumptions. The projections required base-year data for over 40 indicators of demography, health, determinants of fertility, family planning usage and costs, economy, and education. Definitions and estimates for key indicators are detailed in Table 1. The most recent estimates available were obtained from a range of sources including census reports, Demographic and Health Surveys (DHS), UN agency reports, and through consultation with MOH and key informants in each country. Key population, reproductive health, and economic estimates for the base year (2010) for Vanuatu and the Solomon Islands † Births to women aged <18 or >34 years; births spaced <24 months apart; birth order 4 or more. For this analysis, unmet need for family planning was defined as the percentage of fecund women of reproductive age (15–49 years) who are married or in consensual union, who want no more children or want to delay pregnancy by two years or more, and are not using any method of family planning (including traditional methods). This includes pregnant or amenorrhoeic women whose last pregnancy was mistimed or unwanted [27]. The estimate of unmet need for the Solomon Islands (11% (95% confidence interval (95% CI): 10-12%)) was sourced from the 2006–2007 DHS [9]. Data for unmet need in Vanuatu are limited. Following recommendation from the expert panel, a 1995 UNFPA estimate of unmet need for birth limiting was included (30% (95% CI: 28-33%)) [8]. Base year estimates of contraceptive method mix (including oral contraceptive pill, injectable, implant, intrauterine device, male and female sterilisation, male condom, female condom and other vaginal methods, and traditional methods) were obtained from DHS data and the 2007 UNICEF Vanuatu Multiple Cluster Indicator Survey [10]. Contraceptive effectiveness was based on estimates of first-year unintended pregnancy rates for each method as commonly used, provided by the World Health Organisation (WHO) [28]. We assumed a service-delivery perspective for this analysis. The direct costs (government and non-government) of providing family planning per contraceptive method (per couple-year of protection for short-acting methods and per acceptor for long acting methods) were calculated from cost estimates of: commodities, supplies and equipment procurement; shipping, storage and distribution; and staff costs for counselling, method provision and follow-up. Commodity, equipment, transport and storage costs were obtained directly from the Pacific Sub-Regional Office of UNFPA (the major supplier of family planning commodities in Vanuatu and the Solomon Islands), International Planned Parenthood Federation (IPPF) East and Southeast Asia and Oceania Region (the major non-government provider) and MOH of each country. Staff costs were based on estimates of average staff salaries and time spent per client per method obtained from MOH and IPPF clinics. Other non-government and private providers as well as out-of-pocket family planning expenditure were not included due to lack of reliable data. All costs were converted to US dollars based on the official nominal exchange rate and adjusted to a 2010 price year [23]. Thirty of the 40 model inputs required yearly estimates for the entire projection period. All base year inputs and assumptions (except for the proportion of women with unmet need) were the same for the baseline and two hypothetical projections for each country. Unmet need remained constant for the baseline projection. In the other two projections the reduction in unmet need was ‘front loaded’ commencing in 2010, assuming a more rapid initial increase in contraceptive prevalence [29], with all needs met by 2020 (scenario one) and by 2050 (scenario two). Due to the lack of age-disaggregated data, the reduction in unmet need was assumed to be evenly distributed across all age groups. Estimates for proximate determinants of fertility remained constant. Projected contraceptive method mix for both countries was adjusted to take into account the planned introduction of contraceptive implants and to adjust for the current high reliance on oral contraceptives in Vanuatu and female sterilisation in the Solomon Islands. The adjusted method mix was estimated from global trend data, the average method mix for the Pacific region, and following consultation with regional and international family planning experts [29-31]. In brief, the prevalence of long-acting and permanent methods of contraception was increased in Vanuatu, while the current low prevalence of traditional methods remained constant. In the Solomon Islands the prevalence of traditional methods was projected to halve by 2054, while other methods were adjusted to the Pacific average. In both countries the prevalence of intrauterine devices and condoms remained constant. Source mix and direct costs per method also remained constant. Age-specific fertility rates were projected to reach the average of Australia, New Zealand, France and USA by 2054 as per the methodology used by the Statistics and Demography Programme of the Secretariat of the Pacific Community. Future life expectancy was calculated using the UN models for mortality improvement assuming medium gains [32]. Economic growth, health and education expenditure were assumed to reach the average for East Asia and the Pacific by 2054 based on the most recent data from the World Bank [23], UNESCO [33], WHO [26] and the International Monetary Fund [34,35]. Primary outcomes included contraceptive prevalence and number of users per method, family planning costs, health outcomes (unintended pregnancies, induced abortions, total births, births with any avoidable risk, and maternal and infant deaths), TFR, population growth, dependency ratio, and annual public sector health and education expenditure. The program was used to project these outcomes, with analysis restricted to the time period 2010–2025. The program methodology has been described elsewhere [15-17], however, in brief, unintended pregnancies are calculated from pregnancies due to contraceptive failure and those to women of reproductive age (married or in union) with unmet need for contraception. Maternal deaths per year are calculated from the number of deaths associated with both wanted and unwanted pregnancies: where BW is the number of wanted births and BNW the number of unwanted births. Infant deaths are calculated using an adjusted infant mortality rate (IMR) related to risky births: where t is the target year and 0 base year. Avoidable high-risk births are defined as those that occur at extremes of maternal age (younger than 18 and more than 34 years), are spaced less than 24 months apart, or are high parity (birth order 4 and higher) [27]. Infant deaths are then calculated by multiplying the total number of births by the adjusted IMR. Projected outcome data for each model for the period 2010–2025 were extracted and analysed using Microsoft Excel (Microsoft Corp, Redmond, WA, USA). Future costs and health effects were discounted by 3% per year [36]. The impact of reducing unmet need by 2020 and 2050 was compared to the baseline model for each outcome of interest. All costs are reported in US dollars.