other constraints to adoption and continued use, and sterilization as a contraceptive option that is not always appropriate. This focus also encompasses the implications of the sexually transmitted diseases for contraceptive technology and their relevance for the contraceptive market.

The third perspective has to do with consumer preferences, with particular attention to the content and character of the "woman-centered agenda" and the issues it raises.

The fourth perspective is quantitative: a look at today's market for contraceptives in terms of numbers of actual and potential users and dollar values; lessons to be learned from the world vaccine market, with which the contraceptives market is in some ways analogous; and subsidized procurement as a market factor.

The chapter closes with a discussion of the cost-effectiveness of contraception and what that might mean as an incentive to investment in contraceptive R&D and the intimate and necessary relationship of that investment with the market for contraceptive technologies.

Current Contraceptive Use

Contraceptive Use Worldwide

Contraceptive prevalence2 among women currently married or in union (a group designated by the abbreviation MWRA, or "married women of reproductive age") increased worldwide from 30 percent during 1960-1965 to 57 percent in 1990. The increase was much more dramatic in the developing countries, where prevalence rose from 9 percent to 53 percent in that same period (UN 1994, cited in WHO/HRP 1995). The increase was especially dramatic in eastern Asia and Latin America, slightly less so in other parts of Asia and in North Africa, least of all in Sub-Saharan Africa. The range is wide: Contraceptive use prevalence in Africa is currently estimated at 17 percent, quite a difference from Latin America, for example, where prevalence is almost 65 percent (see Table 5-1 and Table 5-2 for data for developing countries).

There is also great variability within regions. While overall prevalence in the Arab States and Europe averages 44 percent, the range is from almost zero in some Persian Gulf countries to 68 percent in Turkey. And, in Asia, where the overall prevalence is 62.5 percent, the range is from 10 percent in Afghanistan to a use prevalence of 80 percent or more in China. Variability in contraceptive use prevalence among the industrial countries is much narrower (Guttmacher Institute 1995a; WHO/HRP 1995).

The overwhelming majority—90 percent-—of women using contraception in the developing countries are using modern methods. Globally, the most used method is female sterilization (tubectomy or tubal ligation). Thirty percent of all contracepting couples worldwide relied on female sterilization as of 1990; in the



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