MARCH 2025

Politicization of reproductive rights, and concerns over falling birth rates, are preventing women and girls from accessing the education and care they need

Despite widespread efforts to demonstrate and emphasize the critical role that family planning and reproductive health play in health outcomes, economic development, educational attainment, and more, religious and political objections continue to block access to services including modern contraception and abortion. The Mexico City Policy is a prominent example of this backlash against reproductive health services, and it has been linked in multiple studies to an increase in pregnancies, abortions, and unplanned births, and a reduction in the use of contraceptives due to its impact on broader family planning services.

More broadly, interviewees reported widespread backlash against providers of reproductive health and family planning care, including vandalism of clinics and health facilities, and attacks on health care workers and clinic staff. In many cases, narratives and action against SRHR services are funded and coordinated by foreign actors, including religious groups. The criminalization of groups including LGBTQ+ people, sex workers, and seekers of abortion and contraception represent a worrying trend that can impact wider reproductive health services. As Alvaro Bermejo, Director General of the International Planned Parenthood Federation (IPPF), noted in an interview with FP Analytics, “In this current environment, every sexual and reproductive health service, every contraceptive service, every abortion service has become a political act. We need both the provider and the client to understand that, and to understand that they’re going to have to fight for the right to continue to provide and receive those services.”

A related trend in the backlash against family planning and reproductive health services is connected to the demographic transition. As populations in high-income countries shift toward falling birth rates and longer life expectancies, the trend toward aging societies is leading some to call for a rollback of family planning interventions such as contraception, in order to increase birth rates. A cross-section of FP Analytics interviewees noted this trend and highlighted concerns that it would undo significant wins and progress on reproductive health and family planning outcomes achieved to-date, while potentially causing a return to coercive and pro-natalist reproductive health policies. As Kathleen Mogelgaard, President and CEO of the Population Institute explained, “We’re seeing emerging rhetoric and alarmism around population decline. It raises the specter that once again, governments may be thinking about population trends in ways that would lead them to seek control of people’s reproductive lives.” Mogelgaard emphasized the importance of rights-based approaches—in which all have the right to choose the timing, spacing, and number of births, and the methods by which to control them—rather than focusing specifically on population growth and size, as the best way to maintain commitments to reproductive health and family planning.

Similarly, Hassan Mohtashami, UNFPA Representative in Indonesia, underscored that fertility decisions are complex, shaped by a range of considerations and not simply linked to the availability of certain contraceptive methods, noting, “Fertility is a socioeconomic construct. The decision around having a child or not is based on a very complicated set of parameters, and contraception is only a tool of prevention of pregnancy. It’s not the reason for pregnancy or the lack of it.” Instead, Mohtashami recommended that governments seeking to promote childbearing and increase birth rates should continue the provision of contraceptives and adopt policies that support parents in any decision, including “child benefit, paid maternity leave, free childcare and the like, only if women decide to have children.” However, despite concerns shared by almost all interviewees regarding politicization of reproductive health and family planning services and rights, many noted that this backlash can catalyze political mobilization and coalition-building to protect these rights. Indeed, as Kathleen Mogelgaard, of the Population Institute, noted “the backlash on reproductive rights and the idea of reproductive autonomy is very much an energizing force for our work.”

Conflict and crisis disrupt the safe and effective provision of services and commodities

Conflict presents a twofold challenge to adequate family planning and reproductive health care delivery, as it disrupts existing services while exacerbating need. Over twenty percent of women and girls in humanitarian settings experience sexual and gender-based violence, leading to injury, transmission of STIs, psychological trauma, and death. In addition, individuals’ regular SRHR needs such as pre- and post-natal care, safe and sanitary menstrual hygiene and birth conditions, and contraceptive use continue. As Alvaro Bermejo, Director-General of IPPF, noted in an interview with FP Analytics, “Pregnancies still take nine months,” regardless of the conditions in which women and girls are living. Those in need of SRH services in conflict zones may not trust or feel safe seeking them from NGOs and aid workers parachuted in to address the immediate crisis. As Bermejo noted, “It requires so much trust and confidence for the most at-risk populations to come out—that’s an area in which it will be difficult for mainstream humanitarian actors to intervene, unless they do so through local women-led organizations that already have that trust.” Local grassroots organizations—alongside international organizations with a historical and trusted presence within the community—are therefore key to ensuring that individuals in need of care feel safe and confident seeking it.

Humanitarian settings typically lack, or are in short supply of, the necessary tools, commodities, and facilities to ensure safe and sanitary conditions for women and girls—and men and boys—with reproductive health and family planning needs. Indeed, in a 2023 study of 63 health facilities in conflict zones across Africa, only five were deemed to have “adequate” obstetric and newborn care facilities. Aid and health guidelines such as the UNFPA’s Minimum Initial Service Package (MISP) for sexual and reproductive health are critical to establishing a baseline level of care in conflict- and disaster-affected regions. The MISP lays out clear guidance and steps for health aid workers to reduce and prevent mortality, morbidity, and disability due to sexual and reproductive health needs, including establishing a private space in which individuals can seek contraceptives or report instances of sexual violence. However, the MISP is only the first step in providing adequate care in humanitarian settings, describing itself as a “starting point” for SRH programming. Staying on track to meet reproductive health and family planning goals will require greater intervention in conflict settings to be possible, especially in a time when armed conflicts are at an unprecedented level, in addition to ensuring that supply chain gaps and disruptions are minimized.

Supply chain disruption and gaps can prevent reliable access to new and proven contraceptives, diagnostics, and therapeutics for reproductive health threats

Delivery of reproductive health and family planning commodities to all who need them—including marginalized or vulnerable populations, rural and remote communities, and those living in extreme poverty—is the critical final step in ensuring the rights and health of all. However, ensuring that the necessary products reach users is a goal rife with challenges. Poor transit and health care infrastructure can make it difficult to deliver a range of health care services to rural and remote communities, making last-mile delivery an important priority for family planning and reproductive health, including through the proliferation of skilled and adequately trained health care workers.

Indeed, large countries like Nigeria, Indonesia, and India face an additional challenge in the delivery of reproductive health commodities and services: fragmentation. In many large countries, health care delivery is the responsibility of state or provincial governments, which can lead to uneven health care outcomes. While the state-led approach can be an opportunity to pilot new approaches and new commodities before expanding their adoption throughout the country—or to target the districts and states with the highest unmet need, as in India’s Mission Parivar Vikas program—coordination between state- and national-level governments can be difficult. In an interview with FP Analytics, Andrea M. Wojnar, UNFPA India Country Representative, noted that multilateral stakeholders such as the UN can play a critical role in supporting “knowledge management and exchange of best practices and evidence to really help stimulate action across states.” As part of this facilitation role, well-resourced and well-respected actors can assist in data collection—or building capacity for better domestic data collection—and identification of the necessary factors for state-level authorities to adopt or adapt successful practices and policies. Multistakeholder partnerships such as the Reproductive Health Supplies Coalition (RHSC) can draw upon the expertise and insights of their cross-sectoral membership base to develop high-quality, accurate datasets to that end. The RHSC’s LEAP reports, for example, provide an annual snapshot of the coverage of essential reproductive health commodities, including contraceptive methods and medicines important for maternal health care.

Among the delivery policies necessary for national and state governments to consider is how best to service marginalized, vulnerable, and criminalized populations, including adolescents, members of the LGBTQ+ community, indigenous people, and sex workers. These communities represent some of the most vulnerable to sexual violence, contraction of STIs, and maternal and infant mortality, and can be distrustful of government-delivered reproductive health and family planning services, because of past discrimination. According to Alvaro Bermejo of the IPPF, a cross-sectoral approach—where government services are augmented by affordable private, NGO- and CSO-led health care—can support the provision of high-quality services to marginalized or vulnerable groups on a confidential basis. Cost is a key factor in ensuring that these groups can access care via their preferred means: contraceptive supplies used by women and girls in LMICs, for example, cost around USD 5.48 billion in 2023, of which 87 percent derived from the private sector. Government subsidies and creative financing partnerships will be key to facilitating access to contraceptives and other family planning services even among groups who prefer to make use of the private sector.

The development of self-administered contraceptives and diagnostics can assist in ensuring that marginalized groups’ health does not suffer due to an inability or fear of accessing public-sector services. These include at-home STI tests, which the WHO recommends should be globally available for chlamydia and gonorrhea, and self-administered contraceptives such as the pill or the DMPA-SC injectable, which is now available in countries including Nigeria, Uganda, Senegal, and the DRC. Telehealth services, which increased during the COVID-19 pandemic, are another avenue to ensure privacy—as Alvaro Bermejo noted, “There are a number of countries where 50 percent of our clients never go into the clinic or see a provider face-to-face, it’s all done through digital means.”

Cultural expectations and stigmatization of certain behaviors or reproductive health services can act as a deterrent against health-seeking behaviors, and undermine quality caregiving

Cultural expectations and taboos around sex outside of marriage, the number and timing of pregnancies, son preference, certain types of contraception, and abortion all create barriers to access to high-quality family planning and reproductive health services. Adolescent marriage and pregnancy, for example, can be linked to an expectation that women will begin childrearing at a young age, and have large numbers of children, despite the health risks that such behavior is linked to, and despite the demonstrated benefits of girls’ higher education and delayed pregnancy. Stigma can both deter health-seeking behaviors—for example, by reducing contraceptive use among girls and unmarried women for fear of judgement by family and peers—and undermine trust in health providers, if health care workers perpetuate traditional cultural beliefs. As Kayode Afolabi, former director of reproductive health at the Nigerian Ministry of Health, acknowledged in an interview with FP Analytics, “The attitude of service providers can sometimes put off women of reproductive age who want access to family planning, and that can cause a lot of reputational damage to service delivery.”

Cultural norms and historical precedent can also contribute to the proliferation of long-term permanent contraceptive methods such as sterilization, which can undermine individuals’ right to choose the timing and number of their pregnancies. Sterilization has a long, complicated history within LMICs where high birth rates were addressed with government-driven, sometimes forced, sterilization programs, despite the emergence of reversible contraceptive methods such as the pill, IUDs, or injectables. As a result, stigma and cultural norms need to be addressed through as many channels as possible, to reach as many individuals as possible, whether teachers, health care workers, community elders, media, or more.

The mobilization of community-based health care workers, for example, is a common tactic in resource-scarce settings to ensure that information and services are reaching women in rural and remote regions, as they can quickly deploy when needed and build long-term trust with community members. Community health workers are key to building an accurate picture of demographic trends and reproductive health and family planning needs across LMICs. In India, for example, community health care workers help to register births and deaths and connect women to vital reproductive health services such as pre- and post-natal appointments and cancer screening. Training for these vital workers needs to cover comprehensive sexuality education—most commonly deployed in schools and other educational settings to educate children and adolescents on SRHR. This is key to ensure that community health workers do not perpetuate negative cultural norms and stigma, such as by refusing to treat or provide contraceptives to unmarried women or failing to fully inform reproductive-aged men and women seeking family planning support of the full range of products and approaches they can choose from.

Similarly, influential community members such as religious leaders, elders, and particularly mothers-in-law, especially in inter-generational households, can be critical to unlearning harmful beliefs and practices, and disseminating a rights-based approach to family planning and reproductive health. Interviewees operating in India and Nigeria, for example, highlighted programs in which SRHR actors educate mothers-in-law about the benefits of well-spaced pregnancies. As highly influential members of the family unit, mothers-in-law can then support their daughters-in-law to make informed, empowered decisions regarding the timing, spacing, and number of pregnancies they have, including by helping them to access contraceptive and pre-natal services. A similar group to whom outreach could be targeted is men and boys of reproductive age. However, while reduction of stigma is key to supporting health-seeking behaviors, family planning and reproductive health care can only be provided if the health workforce is adequately sized in comparison to the population in need, well-trained to address SRH-specific needs, and able to reach their target population.

Shortages in the health care workforce reduce stakeholders’ ability to provide care to all in need, but addressing this challenge will require ensuring that skills and education gaps are additionally addressed

The WHO predicts that there will be a global health care workforce shortage of over 10 million by the year 2030, undermining global health goals and targets, including those relating to reproductive health and family planning. The need to increase the SRHR workforce, and to reduce brain drain in resource-scarce contexts, is reflected in the international development strategies of several of the major bilateral funders of family planning and reproductive health, including the U.S. and the Netherlands, and is similarly present in the strategic planning of national governments such as India and Indonesia.

In addition to the overall shortfall, family planning and reproductive health services can suffer due to skills and education gaps among health care workers, which can lead to poor health outcomes and reduce confidence in SRHR services. As Kayode Afolabi noted in an interview with FP Analytics, “If a long-acting contraceptive like an implant or IUD is wrongly inserted or poorly removed, it could cause a lot of complications, and once a woman has complications, she can discourage a hundred women and young girls from accessing family planning.” The answer, he suggests, is that “the skill of the provider should reflect the quality of care expected for that particular contraceptive method mix.” Taken more broadly, it is critical to train health workers who are responsible for delivering reproductive health and family planning services in all necessary skills and activities for a given context. For example, in countries where long-term contraception such as IUDs is becoming more common, ensuring that any health worker who is responsible for their insertion and removal is up to date in the correct procedures will be key, as is the case for health workers conducting communicable and non-communicable disease diagnostics.

However, training and upskilling health care workers can be a challenge in resource-scarce settings. Stakeholders in high-quality family planning and reproductive health care therefore need to incentivize and facilitate opportunities for upskilling and further training to ensure that the workforce is fit-for-purpose. For example, in response to very high maternal mortality rates in Benin, in 2020 the WHO supported the integration of targeted SRHR training and information into all education programs for health care workers, with the aim of providing specialized care all the way to the last mile, and reducing the maternal mortality rate. Similarly, many institutions are implementing online and remote skills training for reproductive health and family planning, to reduce transit- and time-related attendance barriers.

Given the critical that role health workers play in delivering necessary family planning and reproductive health services, including contraceptives, reducing cost barriers to their continued education and upskilling can help increase uptake. Cross-sectoral collaboration and public-private partnerships can reduce training costs for individuals and governments through resource-sharing and catalytic investment. The European Union’s Pact for Skills initiative, for example, launched a vertical aimed specifically at health care workers in 2023, co-funded by the European Commission and a range of non-governmental actors including pharmaceutical companies and universities. Training pathways include adapting to technology advancements, quality assurance, and regulatory compliance. Initiatives like this could be adapted to respond to the specific challenges facing SRH workers, such as providing training to deliver the full range of contraceptive methods available, with support from actors working within the family planning ecosystem.