Periodic abstinence and withdrawal (the dominant methods in the "traditional methods" category) have been used to prevent pregnancy in both historical and contemporary contexts and, in some countries, continue to be used despite increased availability and use of modern methods. Yet research on family planning programs and contraceptive methods often focuses solely on modern contraceptive methods, thereby overlooking trends and patterns of traditional method use. In this study, we analyze population-level survey data from 1990 to 2020 and find a global decline in the share of overall contraceptive use accounted for by these traditional methods (e.g., withdrawal and periodic abstinence), a slight decline in traditional method prevalence rates, and an overall increase in the absolute number of traditional method users. We then examine geographic and temporal variation in levels and patterns of withdrawal and periodic abstinence method use. Finally, we identify countries that have reached low levels of fertility since 1970 with higher levels of withdrawal or periodic abstinence use, or where these methods account for a substantial portion of overall contraceptive use. We find that while reported use of withdrawal and periodic abstinence is low in many settings, they remain important tools for pregnancy prevention in a number of countries.

The neglect of population in national and international discourses on environment and development has led to a misleading picture of policy options. This article reconstructs the language in which extreme poverty and economic development are discussed by deploying recent advances in our understanding of the population-consumption-biosphere nexus. The new perspective is applied to examine both the global environmental impact and the effects on local ecosystems of individual choices over consumption and reproduction. The analytical apparatus developed here is then used on wide-ranging evidence to explain and measure humanity's ecological overreach. The authors study the pressures people impose on their local ecosystems to show why persistently high population growth in the world's poorest regions is undermining their ecosystems, in some cases trapping communities in poverty.

BACKGROUND Fertility decline in sub-Saharan Africa has been slower than in other regions, with the periods of extremely slow transitions frequently described as stalled. Lack of investment in family planning programs has been proposed as a key contributing factor. However, while there is a large literature on fertility transition stalls, similar phenomena in contraceptive prevalence trends have received less attention. OBJECTIVE We propose a probabilistic method for detecting plateaus in modern contraceptive prevalence (MCP) and in demand for family planning satisfied by modern methods (DS). METHODS We defined a contraceptive prevalence plateau in terms of level, rate, and probability conditions, each with associated thresholds for a plateau to be identified. We used probabilistic annual model -based estimates of family planning indicators and a simple smoothing approach to produce annual estimates of plateau probabilities under a variety of thresholds. RESULTS We applied our method to 48 countries in sub-Saharan Africa over the period 1980-2019 and found plateaus in MCP in ten countries (half in western Africa) and plateaus in DS in two (Niger and Nigeria). We found no indication of a temporal association between MCP plateaus and fertility transition stalls, although we observed that some fertility transition stalls occurred when MCP was low. CONTRIBUTION Our method provides an updated, robust way to identify plateaus in contraceptive prevalence. Moreover, it could feasibly be applied to probabilistic model-based estimates of other demographic indicators, such as total fertility.

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BACKGROUNDContinued rapid population growth in sub-Saharan Africa is driven predominantly by high fertility.Contraceptive use was a key determinant of past fertility transitions.An analysis of this relationship in sub-Saharan Africa can yield a better understanding of the region's prospects for fertility decline. METHODSUsing global estimates and projections, we describe trends in contraceptive use and fertility and analyse the relationship between the two.Timing, pace, and level parameters derived from Bayesian hierarchical models of historic contraceptive and fertility transitions are used to investigate how the experience of sub-Saharan Africa may be distinctive. RESULTSFertility in sub-Saharan Africa fell from 6.4 births per woman in 1990 to 4.6 in 2020, the highest among regions today.Contraceptive use among married/in-union women in sub-Saharan Africa increased from 13% to 33% over the same period, and remains the region with lowest use.At all levels of contraceptive use, countries of sub-Saharan Africa tend towards higher fertility compared to other regions.Transitions in contraceptive use and fertility have occurred later in sub-Saharan Africa, and have been slower in Middle and Western Africa (but not Eastern and Southern Africa), compared to the experience of Asia, Latin America, and the Caribbean.

Externalities are the unaccounted-for consequences for others of actions taken by one or more persons. They are symptoms of institutional failure, which is why they cannot be eliminated without collective action. When externalities are adverse, the moral directives flowing from them can clash with the exercise of personal rights. In this paper we identify a class of environmental externalities in the contemporary world that accompany procreation. We also identify externalities that are allied to socially embedded preferences for family size. Those preferences can give rise to a heightened demand for children, which exacerbates the adverse environmental externalities present people impose on future generations. Crude but suggestive estimates of the demand humanity currently makes on the biosphere are used to show that adverse environmental externalities accompanying new births are significant. We use data on global economic demography to provide rough estimates of the size of the human population the Earth system can support at a good standard of living. Our analysis, which is designed only to raise questions that have been much neglected in economic demography, allows us to study the sensitivity of sustainable global population to the standard of living.

Expanding access to contraception and ensuring that need for family planning is satisfied are essential for achieving universal access to reproductive healthcare services, as called for in the 2030 Agenda for Sustainable Development. To quantify the gaps that remain in meeting needs among adolescents, this study provides a harmonised data set and global estimates and projections of family planning indicators for adolescents aged 15-19 years. We compiled a comprehensive dataset of family-planning indicators among women aged 15-19 from 754 nationally representative surveys. We used a Bayesian hierarchical model with country-specific annual trends to estimate contraceptive prevalence and unmet need for family planning, with 95% uncertainty intervals (UIs), for 185 countries, taking into account changes in proportions married or in a union and differences in sexual activity among unmarried women across countries. Among 300 million women aged 15-19 years in 2019, 29.8 million (95% UI 24.6-41.7) use any contraception, and 15.0 million (95% UI 12.1-29.2) have unmet need for family planning. Population growth and the postponement of marriage influence trends in the absolute number of adolescents using contraception or experiencing unmet need. Large gaps remain in meeting family-planning needs among adolescents. The proportion of the need satisfied by modern methods, Sustainable Development Goals (SDG) indicator 3.7.1, was 59.2% (95% UI 44.8-67.2) globally among adolescents, lower compared to 75.7% (95% UI 73.2%-78.0%) among all women age 15-49 years. It was less than one half of adolescents in need in Western Asia and Northern Africa (38.7%, 95%UI = 20.9-56.5), Central and Southern Asia (43.5%, 95%UI = 36.6-52.3), and sub-Saharan Africa (45.6%, 95%UI = 42.2-49.0). The main limitations of the study are: (i) the uncertainty surrounding estimates for countries with limited or biased data is large; and (ii) underreporting of contraceptive use and needs is likely, especially among unmarried adolescents.

The Anthropocene can be read as being the era when the demand humanity makes on the biosphere's goods and services-humanity's 'ecological footprint'-vastly exceeds its ability to supply it on a sustainable basis. Because the 'ecological' gap is met by a diminution of the biosphere, the inequality is increasing. We deploy estimates of the ecological gap, global GDP and its growth rates in recent years, and the rate at which natural capital has declined, to study three questions: (1) at what rate must efficiency at which Nature's services are converted into GDP rise if the UN's Sustainable Development Goals for year 2030 are to be sustainable; (2) what would a sustainable figure for world population be if global living standard is to be maintained at an acceptably high level? (3) What living standard could we aspire to if world population was to attain the UN's near lower-end projection for 2100 of 9 billion? While we take a global perspective, the reasoning we deploy may also be applied on a smaller scale. The base year we adopt for our computations is the pre-pandemic 2019.

We consider two aspects of the human enterprise that profoundly affect the global environment: population and consumption. We show that fertility and consumption behavior harbor a class of externalities that have not been much noted in the literature. Both are driven in part by attitudes and preferences that are not egoistic but socially embedded; that is, each household’s decisions are influenced by the decisions made by others. In a famous paper, Garrett Hardin [G. Hardin, Science 162, 1243–1248 (1968)] drew attention to overpopulation and concluded that the solution lay in people “abandoning the freedom to breed.” That human attitudes and practices are socially embedded suggests that it is possible for people to reduce their fertility rates and consumption demands without experiencing a loss in wellbeing. We focus on fertility in sub-Saharan Africa and consumption in the rich world and argue that bottom-up social mechanisms rather than top-down government interventions are better placed to bring about those ecologically desirable changes.

The COVID-19 crisis could leave significant numbers of women and couples without access to essential sexual and reproductive health care. This research note analyses differences in contraceptive method mix across Sustainable Development Goal regions and applies assumed method-specific declines in use (from 0 per cent to 20 per cent) to produce an illustrative scenario of the potential impact of COVID-19 on contraceptive use and on the proportion of the need for family planning satisfied by modern methods. Globally, it had been estimated that 77 per cent of women of reproductive age (15-49 years) would have their need for family planning satisfied with modern contraceptive methods in 2020. However, taking into account the potential impact of COVID-19 on method-specific use, this could fall to 71 per cent, resulting in around 60 million fewer users of modern contraception worldwide in 2020. Overall declines in contraceptive use will depend on the methods used by women and their partners and on the types of disruptions experienced. The analysis concludes with the recommendation that countries should include family planning and reproductive health services in the package of essential services and develop strategies to ensure that women and couples are able to exercise their reproductive rights during the COVID-19 crisis.

The COVID-19 crisis could leave significant numbers of women and couples without access to essential sexual and reproductive health care. This research note analyses differences in contraceptive method mix across Sustainable Development Goal regions and applies assumed method-specific declines in use (from 0 per cent to 20 per cent) to produce an illustrative scenario of the potential impact of COVID-19 on contraceptive use and on the proportion of the need for family planning satisfied by modern methods. Globally, it had been estimated that 77 per cent of women of reproductive age (15-49 years) would have their need for family planning satisfied with modern contraceptive methods in 2020. However, taking into account the potential impact of COVID-19 on method-specific use, this could fall to 71 per cent, resulting in around 60 million fewer users of modern contraception worldwide in 2020. Overall declines in contraceptive use will depend on the methods used by women and their partners and on the types of disruptions experienced. The analysis concludes with the recommendation that countries should include family planning and reproductive health services in the package of essential services and develop strategies to ensure that women and couples are able to exercise their reproductive rights during the COVID-19 crisis.

Language and metaphors are central mechanisms of the human mind and thought processes, and allow us to draw on existing social or physical experiences to make sense of novel concepts. Metaphors are not simply linguistic tools; they are deeply rooted and structured in cultural backgrounds and can shape our understandings, perceptions and actions. Different cultures can have different views about the life-course, reproduction and preventing pregnancy,2 and these views are reflected in the use of language when talking about contraception. Our hypothesis is that the vernacular language used to refer to contraception in northern Malawi would not correspond to the English terms in content or tone, and that such mismatches in the language of public health initiatives could affect uptake. We propose that the discussion around English terms in reproductive health programming must understand and use the local vernacular in each setting, particularly when trying to promote family planning programmes, where cultural values will shape willingness to use contraception.

BACKGROUND:Expanding access to contraception and ensuring that need for family planning is satisfied are essential for achieving universal access to reproductive healthcare services, as called for in the 2030 Agenda for Sustainable Development. Monitoring progress towards these outcomes is well established for women of reproductive age (15-49 years) who are married or in a union (MWRA). For those who are not, limited data and variability in data sources and indicator definitions make monitoring challenging. To our knowledge, this study is the first to provide data and harmonised estimates that enable monitoring for all women of reproductive age (15-49 years) (WRA), including unmarried women (UWRA). We seek to quantify the gaps that remain in meeting family-planning needs among all WRA. METHODS AND FINDINGS:In a systematic analysis, we compiled a comprehensive dataset of family-planning indicators among WRA from 1,247 nationally representative surveys. We used a Bayesian hierarchical model with country-specific time trends to estimate these indicators, with 95% uncertainty intervals (UIs), for 185 countries. We produced estimates from 1990 to 2019 and projections from 2019 to 2030 of contraceptive prevalence and unmet need for family planning among MWRA, UWRA, and all WRA, taking into account the changing proportions that were married or in a union. The model accounted for differences in the prevalence of sexual activity among UWRA across countries. Among 1.9 billion WRA in 2019, 1.11 billion (95% UI 1.07-1.16) have need for family planning; of those, 842 million (95% UI 800-893) use modern contraception, and 270 million (95% UI 246-301) have unmet need for modern methods. Globally, UWRA represented 15.7% (95% UI 13.4%-19.4%) of all modern contraceptive users and 16.0% (95% UI 12.9%-22.1%) of women with unmet need for modern methods in 2019. The proportion of the need for family planning satisfied by modern methods, Sustainable Development Goals (SDG) indicator 3.7.1, was 75.7% (95% UI 73.2%-78.0%) globally, yet less than half of the need for family planning was met in Middle and Western Africa. Projections to 2030 indicate an increase in the number of women with need for family planning to 1.19 billion (95% UI 1.13-1.26) and in the number of women using modern contraception to 918 million (95% UI 840-1,001). The main limitations of the study are as follows: (i) the uncertainty surrounding estimates for countries with little or no data is large; and (ii) although some adjustments were made, underreporting of contraceptive use and needs is likely, especially among UWRA. CONCLUSIONS:In this study, we observed that large gaps remain in meeting family-planning needs. The projected increase in the number of women with need for family planning will create challenges to expand family-planning services fast enough to fulfil the growing need. Monitoring of family-planning indicators for all women, not just MWRA, is essential for accurately monitoring progress towards universal access to sexual and reproductive healthcare services-including family planning-by 2030 in the SDG era with its emphasis on 'leaving no one behind.'

The COVID-19 crisis could leave significant numbers of women and couples without access to essential sexual and reproductive health care. This research note analyses differences in contraceptive method mix across Sustainable Development Goal regions and applies assumed method-specific declines in use (from 0 per cent to 20 per cent) to produce an illustrative scenario of the potential impact of COVID-19 on contraceptive use and on the proportion of the need for family planning satisfied by modern methods. Globally, it had been estimated that 77 per cent of women of reproductive age (15-49 years) would have their need for family planning satisfied with modern contraceptive methods in 2020. However, taking into account the potential impact of COVID-19 on method-specific use, this could fall to 71 per cent, resulting in around 60 million fewer users of modern contraception worldwide in 2020. Overall declines in contraceptive use will depend on the methods used by women and their partners and on the types of disruptions experienced. The analysis concludes with the recommendation that countries should include family planning and reproductive health services in the package of essential services and develop strategies to ensure that women and couples are able to exercise their reproductive rights during the COVID-19 crisis.

This paper presents an analysis of trends in sexual activity by marital status and age, and their associations with contraceptive use. Understanding levels of, and trends in, sexual activity is important for assessing the needs for family planning services and for analysing commonly used family planning indicators. Data were taken from 220 Demographic and Health Surveys (DHSs) and 62 Multiple Indicator Cluster Surveys (MICSs) to provide insights into sexual activity by marital status and age in a total of 94 countries in different regions of the world. The results show the sensitivity of the indicator with respect to the definition of currently sexually active, based on the timing of last sexual intercourse (during the last 4 weeks, 3 months, or 1 year). Substantial diversity in sexual activity by marital status and age was demonstrated across countries. The proportion of married women reporting recent sexual activity (sexual intercourse during the last 4 weeks) ranged from 50% to 90%. The proportion of unmarried women reporting recent sexual activity did not exceed 50% in any of the 94 countries with available data, but showed substantial regional differences: it appeared to be rare in Asia and extremely varied within Africa, Europe and Latin America and the Caribbean. Among married women, sexual activity did not vary much by age group, while for unmarried women, there was an inverted U-pattern by age, with the youngest age group (15-19 years old) having the lowest proportion sexually active. The proportion of women who reported currently using contraception and reported not being sexually active varied by the contraceptive method used and was overall much greater among unmarried women. The evidence presented in this paper can be used to improve family planning policies and programmes to serve the diverse needs, for example regarding method choice and service provision, of unmarried women.

Estimates of the potential impacts of contraceptive use on averting unintended pregnancies, total and unsafe abortions, maternal deaths, and newborn, infant, and child deaths provide evidence of the value of investments in family planning programs and thus are critically important for policy makers, donors, and advocates alike. Several research teams have independently developed mathematical models that estimate the number of adverse health outcomes averted due to contraceptive use. However, each modeling approach was designed for different purposes, and as such the methodological assumptions, data inputs, and mathematical algorithms initially used in each model differed; consequently, the models did not produce comparable estimates for the same outcome indicators. To address this, a series of expert group meetings took place in which 5 models-Adding it Up, Impact 2, ImpactNow, Reality Check, and FamPlan/Lives Saved Tool (LiST)-were reviewed and harmonized where possible. The group identified the main reasons for the inconsistencies in the estimates generated by the models for each of the adverse health outcome indicators. The group then worked together to align the methodologies for estimating numbers of unintended pregnancies, abortions, and maternal deaths averted due to contraceptive use, and reviewed the challenges with estimating the impact of contraceptive use on newborn, infant, and child deaths, including the lack of a conceptually clear pathway and rigorous evidence. The assumption that most influenced harmonization was the comparison pregnancy rate used by the models to estimate the counterfactual scenario-that is, if women who are currently using contraception were not using a method, how many would become pregnant? All the models now base this on the number of unintended pregnancies among women with unmet contraceptive need, bringing the estimates for unintended pregnancies, total and unsafe abortion, and maternal deaths much closer together. The agreed approaches have already been adopted by the Family Planning 2020 (FP2020) initiative and Track20, a project that supports FP2020. The experts will continue to update their models collaboratively to ensure that the most current estimation methodologies and data available are used. Valid and reliable methodologies for estimating these impacts from family planning are critically important, not only for advocacy to sustain resource allocation commitments but also to enable measurement and tracking of global development indicators. Conflicting estimates can be counterproductive to generating support for family planning programs, and this harmonization process has created a more unified voice for quantifying the benefits of family planning.

From 2001 to 2011, modern contraceptive prevalence in Uganda increased from 18% to 26%. However, modern method use, in particular use of long-acting reversible contraceptives (LARCs) and permanent methods (PMs), remained low. In the 2011 Uganda Demographic and Health Survey, only 1 of 5 married women used a LARC or PM even though 34% indicated an unmet need for contraception. Between 2011 and 2014, a social franchise and family planning voucher program, supporting 400 private facilities to provide family planning counseling and broaden contraceptive choice by adding LARCs and PMs to the service mix, offered a voucher to enable poor women to access family planning services at franchised facilities. This study analyzes service trends and voucher client demographics and estimates the contribution of the program to increasing contraceptive prevalence in Uganda, using the Impact 2 model developed by Marie Stopes International. Between March 2011 and December 2014, 330,826 women received a family planning service using the voucher, of which 70% of voucher clients chose an implant and 25% chose an intrauterine device. The median age of voucher users was 28 years; 79% had no education or only a primary education; and 48% reported they were unemployed or a housewife. We estimated that by 2014, 280,000 of the approximately 8,600,000 women of reproductive age in Uganda were using a contraceptive method provided by the program and that 120,000 of the clients were "additional users" of contraception, contributing 1.4 percentage points to the national modern contraceptive prevalence rate. The combination of family planning vouchers and a franchise-based quality improvement initiative can leverage existing private health infrastructure to substantially expand family planning access and choice for disadvantaged populations and potentially improve contraceptive prevalence when scaled nationally.

FP2020's overarching goal is framed around the new metric of “additional users.” This measure inherently captures population-level change but has been conflated with other ambiguous metrics, such as “new users.” Therefore, we propose a standard set of terms to provide more consistent measurement. Although commonly used service-level metrics cannot be directly compared to the population-level metric of additional users, we describe 2 modeling approaches that can allow service-level data to inform estimates of additional users. FP2020's overarching goal is framed around the new metric of “additional users.” This measure inherently captures population-level change but has been conflated with other ambiguous metrics, such as “new users.” Therefore, we propose a standard set of terms to provide more consistent measurement. Although commonly used service-level metrics cannot be directly compared to the population-level metric of additional users, we describe 2 modeling approaches that can allow service-level data to inform estimates of additional users.