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This article summarizes the Investment case to end preventable maternal deaths and unmet need for family planning by 2030. The investment case calculated the benefit-cost ratio of accomplishing the goals related to both transformative results for the year 2030 by means of the implementation of a number of interventions prioritized for being critical, effective and high-impact according to evidence. To this end, it was estimated that the necessary investment in prioritized interventions in order to achieve the goals of reducing maternal mortality from a baseline of 85.2 (in 2010) to 41.3 and 33 per 100 000 live births in 2030 sits between 61 and 130 million USD, while the estimated investment to increase the percentage of women1 who employ modern contraceptive methods from 39.3% (in 2019) to 46.5%, 54.5% and 58.8% is 53, 79 and 109 million USD, respectively. In the scenarios of maternal mortality goals, the benefit-cost ratios are 4.8 and 3.3, while in family planning they are 7.5, 5.5 and 4.5 dollars per dollar invested.

Prioritized interventions were chosen from the selection available in the LiST and FamPlan models employed for the development of the investment case, from public policy analysis and management software Spectrum2. The selection was based on the review of evidence, recommendations of specialized organizations, an appraisal of their effectiveness, cost and application in developing countries, and discussion and prioritization by national authorities and other key actors3 in maternal-newborn health and reproductive and sexual health in Peru.

The final report on the investment case was developed by UNFPA as part of the Consultancy for the identification of financing to achieve the Sustainable Development Goals (SDG) related to the transformative results of UNFPA’s Strategic Plan 2018 – 2021.

1. The situation of maternal mortality

Peru has shown one of the most significant advances regarding the reduction of maternal mortality among Latin American countries. Between 1990 and 2018, the ratio of maternal mortality per 100 000 live births (henceforth MMR) saw a significant reduction from 265 in 1990 to 57 in 2019. However, this value is still above the goal of 33 maternal deaths per 100 000 live births established by the Multisectorial National Health Policy for 2030.

Figure 1. Maternal mortality ratio per 100 000 live births (1990-2019)

Sources:
2002-2019: Centro Nacional de Epidemiología, Prevención y Control de Enfermedades – MINSA. 1990-2001: Encuesta Demográfica y de Salud Familiar (ENDES). Note: The data for 2002-2020 takes into account direct and indirect maternal deaths, excluding late maternal death. The values for 2017, 2018 and 2019 are a preliminary estimate, factoring the estimated underreport for 2016.

*For previous values, INEI estimated the maternal mortality ratio in five-year periods4 through ENDES. ENDES’ value for 1996 is assumed for the period 1990-1996 and ENDES’ value for 2000 is assumed for the period 1997-2001. Our elaboration.

Some of the key factors in this improvement were the institutionalization of childbirth, the implementation of budgeting for results geared towards maternal and infant health and an increase in the number of health establishments with Newborn Obstetrics Functions (NOF5) with higher resolution capacity. In spite of these improvements, there is still a pending agenda evidenced by the territorial inequality in the prevalence of maternal deaths in Peru and unequal access to different services such as institutional childbirth, access to qualified providers and prenatal care.

According to regional estimates by the Ministry of Health (MINSA)6, the regions of the Peruvian rainforest bore the highest MMRs and the lowest five-year reductions when compared to regions in the coast and sierra. In some cases, such as Madre de Dios, Moquegua, Ucayali, Tumbes and Callao, the MMR went as far as increasing for the five-year terms 2002-2006 and 2012-2016.

Figure 2: Quinquennial maternal mortality rate by region (2002-2016)

Source: UNFPA-CDC. Estimación de la Razón de Mortalidad Materna en el Perú 2002-2016. Our elaboration.

The distribution of maternal deaths according to age group shows that these are increasingly concentrating around the ages 25-34 range. In 2010, the maternal deaths of women in this range made up for 38.6% of the total, while in 2019 they added up to 43.3%. The same period showed a reduction of maternal deaths in ages below 25 and over 34.

Figure 3. Distribution of maternal deaths according to age group (2010-2018)

Source: Centro Nacional de Epidemiología, Prevención y Control de Enfermedades (2010-2019). Our elaboration.

In regards to the causes of death, the ratio of deaths due to direct causes saw a considerable reduction between 2010 and 2019, from 79.0% to 60.9%. This means that abortion and its complications were displaced from being the third most significant cause in 2010 to being the fifth in 2019, surpassed by two indirect causes (cerebrovascular/nervous system disease and infectious and parasitic diseases).

Figure 4. Distribution of maternal deaths according to cause of death (2010-2019)

Source: Centro Nacional de Epidemiología, Prevención y Control de Enfermedades (2010-2019). Our elaboration.

The coverage of some relevant interventions is likewise unequal. Although there is a noteworthy increase in the percentage of institutional childbirths in the rural setting, which went form 57.6% in 2009 to up to 80.8% in 2019, there is a still a pronounced gap with regards to the national average of 92.4% and the urban setting average of 96.3%7, as well as regions such as Loreto, where only 46.8% of women access an institutional childbirth in the rural setting8, followed by other northeastern regions. Finally, there are also gaps in the handling of childbirth by qualified personnel by setting, geographic domain and level of education (Figure 5), with a difference larger than 15 percentage points between coverage for mothers without education or primary education compared to those with high school education or higher.

Figure 5: Childbirths with assistance of qualified personnel by setting, region and education level (2000-2019)

Source: ENDES (2000-2019). Our elaboration.

1.1 Challenges and propositions on maternal death

The challenges in reducing preventable maternal death are presented at different stages in the process of planning and carrying out interventions aimed at improving maternal-newborn health, and are tied to functional aspects of the healthcare system, as well as political, individual and family factors. The investment case reviewed (1) the evolution of trends, (2) geographical distribution and causes of maternal death, (3) nationwide strategies to reduce them and (4) information sourced from key actors in order to determine the main challenges that hinder the achievement of the SDG on maternal mortality, presented in Table 1.

Table 1. National challenges in maternal mortality

Challenges Key points
Politics and management ·   Lack of political capital at all government levels.
·   Relationship between regional and local governments.
·   Lack of strategic planning.
Guidelines ·   Updating attention and procedure protocols.
·   Defining key indicators.
·   Lack of guidelines for generating information.
Budgeting ·   Update the maternal-neonatal budgeting program.
·   The need of regional goals for maternal mortality.
Follow-up and monitoring ·   Monitoring high impact interventions.
·   Monitoring critical supplies for the performance of high impact interventions.
·   Monitoring healthcare establishments.
Access to healthcare services ·   Geographical access to healthcare establishments
·   Establishment distribution according to NOF levels.
·   Quantity and distribution of human resources.
Quality of healthcare services ·   Improving quality in the rendering of high impact interventions in healthcare establishments with ENOF and INOF.
·   Identifying bottlenecks in the rendering of interventions through rapid studies on the intervention production line.
Data handling ·   The official maternal mortality ratio corresponds to the year 2016 and was updated in 2019.
·  The latest official estimates on maternal mortality tendencies and levels at a regional* level were published in September 2019, with information dating back to 2016.
·   There are no numbers according to relevant sociodemographic characteristics such as ethnicity or socioeconomical status.

*http://bvs.minsa.gob.pe/local/MINSA/5181.pdf
Source: MINSA (1990-2019). Our elaboration.

In response to these challenges, the investment case proposes:

  1. The urgent development of a new national strategic plan for the reduction of maternal mortality, with the following characteristics:
    • Engaging and committing main key actors from the health sector and other sectors.
    • Assigning the rectory to a specific State administrative unit.
    • Assessing the actions to perform based on the current situational and evolutionary diagnose of total maternal mortality and by specific causes, not just at a nationwide level but also by regions, settings and age profile.
    • Prioritizing interventions based in robust, scalable evidence.
    • Assessing the actions to improve the coverage and quality of interventions (i.e. building highways, enhancing remote assistance systems or acquiring aerial means of transportation to facilitate assistance and reference in disperse rural areas).
  2. Carrying out a comprehensive update of Budgeting Program 002 Maternal Newborn Health, factoring in the following critical points:
    • Updating differentiated diagnosis according to region and geographical setting.
    • Renewing scientific evidence regarding interventions aimed at reducing maternal mortality.
    • Restructuring products and budgeting activities to align with the prioritization of interventions based on evidence.
    • Elaborating budgeting assignment guidelines taking into account the interventions’ level of evidence and effectiveness, the prevalence of specific causes of maternal death and the performance of specific interventions in terms of coverage indicators.
  3. Creating a national network of NOF establishments, including a selection of healthcare establishments at a national level and assigning NOF levels in function of the establishments’ distance from the population and resolution capacity, with a focus in strengthening ENOF and INOF capacities.
  4. Designing a control dashboard that enables a monitoring of the coverage of key interventions and the availability of critical supplies for their deployment. Another aspect to take into account is enhancing the monitoring of extreme maternal morbidity, whose protocol was published in the first semester of 20219. Once its role in the prevention of maternal mortality is factored in, this monitoring will help in identifying personnel, training and equipment needs, including the establishment of the national network of obstetric ICUs, as well as ambulance transportation (aerial and terrestrial) as part of its reference and counter reference network. This expansion of services must also take into account the equipment, training and registration of remote assistance.
  5. Strengthening the reference system, mainly at the level of BNOF establishments.

2. The situation of family planning

Despite the increase in the use of contraceptive methods since 2000, the failure to implement an adequate family planning service is still a concern. Only 35% of women of reproductive age (WRA) employ modern contraceptive methods, a number that has remained mostly unchanged over the last years, and adolescent pregnancy is still a public health issue, with 12.6% of adolescents (for the period 2017-2018) having already experienced a pregnancy.10.

Over the last few decades, there has been an increase in the use of contraceptive methods, and the difference in the coverage of said methods between the rural and urban settings has decreased. In 2000, 68.9% of coupled women used some kind of contraceptive method, compared to 75.9% in 2019, and the gap in birth control use between urban and rural areas went down from 12 p.p. at the beginning of said period. Meanwhile, the percentage of coupled women with an unmet demand of family planning11 was reduced from 8.6% in 2014 to 6.1% in 2019, same for the urban-rural gap.

Figure 6. Evolution of the use of contraception by coupled women (2000-2019)

Source: ENDES (2000-2019). Our elaboration.

Compared to other Latin American countries, the total use of contraception in Peru is similar to that of Chile and close to other countries in the region. However, the use percentage of modern contraceptive methods (56%) is considerably lower compared to countries like Chile, Ecuador, Colombia, Argentina, Brazil and Uruguay, which are all above 70%.

Figure 7. Use of contraceptive methods in Peru and LAC (2019)

Source: World Bank Open Data (2019). Our elaboration

According to ENDES (2019), the coverage of modern contraceptive methods in Peru is lower among the female population with less access to education, the lowest income quintiles and women whose mother language is not Spanish. Considering the difficulties in accessing modern contraceptive methods, women with no education or with primary education show a high ratio of non-use of contraceptive methods (33.4% and 25.3% respectively). At the same time, the use of modern contraceptive methods is much lower among these two groups (39.4% and 48.1%) compared to women with secondary or higher education (57.4% and 58.6%). Moreover, among native-speaking women, less than half (45.6%) uses modern contraception, and one in four (25.4%) uses no contraception at all.

Figure 8. Use of contraceptive methods according to mother language (2019)

Source: ENDES (2019). Our elaboration.

Elsewhere, the increase in the coverage of total contraceptive methods (especially between 2000 and 2010) isn’t due mainly to the massification of the use of modern methods, but rather due to the increase in the use of traditional methods. As far as modern methods, the injection (17.2 p.p.) and pills present the largest increase in coverage, while the IUD is the only method that has decreased in use (-5.1 p.p.). The latter fact is striking and concerning, given the method’s effectiveness and long-term duration potential.

Figure 9. Ratio of women of reproductive age that use contraceptive methods, by type of method (2000-2019)

Note: 2004/2006 continuous ENDES Source: ENDES (2000-2019). Our elaboration.

Furthermore, adolescent pregnancy is associated to a lesser development of psychosocial skills and competences, in addition to deficient results in health matters both for them and their children. These factors have negative repercussions in their educational and work opportunities, and contribute to perpetuating intergenerational cycles of poverty12. As can be observed in Figure 10, the Specific Ratio of Adolescent Fertility (SRAF) in children and adolescents ages 15 to 19 has decreased from 59 births per 1000 women in 2006 to 56 in 2018, while the SRAF in children and adolescents ages 10 to 14 has remained invariable with approximately one birth per 1000 women. In percentage terms, the reduction of SRAF in children and adolescents ages 15 to 19 was 5.2% between 2006 and 2018, which is lower than the Global Fertility Rate (GFR) which went down 12% over the same period.

Figure 10. Evolution of fertility rate in children and adolescent women (2006-2018)

Source: ENDES (2006-2018). Our elaboration.

2.2. Challenges and propositions in family planning

The panorama of family planning in Peru shows that there is a prevalence of low coverage in modern contraceptive methods, high adolescent pregnancy rates and significant territorial, economical and social inequality. Taking this situation into account, the axes and goals of different national plans on the issue, as well as existing scientific evidence on the matter, the investment case identified the most important challenges in Table 2.

Table 2: Challenges in family planning

Challenges Key points
Political Capital ·   Inclusion of the issue in the political agenda (president, ministries and with aim to the election process).
Guidelines ·   Elaboration and improvement of technical protocols for the application of modern contraceptive methods (LARC in particular).
·   Aligning the guidelines with the feasibility of directives and monitorize their compliance.
·   Expressing reinforcements in a specific manner in National and Regional Plans.
·   Involving the CSE for the case of children inside and outside school.
Budgeting ·   Reformulate the Maternal-Neonatal Budgeting Program for metrics changes to the programming and restructuring of costs according to necessities.
Follow-up and monitoring ·  Installing a control dashboard for the continuous follow-up of coverage of main interventions.
Data handling ·   Change the population used in measurements (Use of WRA and not just coupled WRA).
·   Limited access to administrative records.
Organizational / Logistics ·   Increase in technical capabilities, as well as the elimination of erroneous conceptions and moral conflicts in HR regarding BNOF, ENOF and INOF.
·   Diversifying provision channels through public-private agreements for free provision.
· To warrant that the resolution ability of establishments be permanently supplied with the availability of adequately qualified personnel, including remote assistance according to the predominant morbimortality profile in the area.
·   Innovative communication strategies to reach the population.
·   More community participation to promote the use of modern methods.
Cultural ·   Strategies for the elimination of cultural barriers and generating evidence to this end.
·   The intercultural and ethnic self-identification perspective is undervalued in administrative records.

Our elaboration.

In order to tackle these challenges, the investment case proposes the following measures:

  1. Using WRA to make measurements regarding Family Planning in the future, as they give a better notion of the reality of use and existing needs.
  2. Program the goals of the Maternal Neonatal Budgeting Program in function of WRA numbers and not protected couples or coupled WRA, given that the latter’s use leaves out a significant percentage of women with a need for contraceptive methods.
  3. Ensure that all establishments with BNOF, ENOF and INOF have sufficient resolution ability to implement all modern methods, especially long-acting reversible contraception (LARC), as well as provide sufficiently complete counseling for users to make an informed decision.
  4. Reformulating the Maternal Neonatal Health Budgeting Program to include needs regarding training and continuous monitoring of FP services, in a way that warrants the application of directives, quality of services and the deployment of strategies for increasing the use of modern methods.
  5. Establishing a control dashboard for the continuous follow-up of coverage of the main interventions in FP, whose data must additionally be shared with decision makers in order to generate improvement strategies based on evidence.
  6. Diversify provision channels for family planning counseling through public-private agreements for free provision through pharmacies, private non-for-profit organizations, among others. In this regard, pharmacies can play a crucial role if we take into account that, after MINSA establishments, they are the second largest provider of family planning supplies.

3. Selection of interventions and construction of scenarios

3.1. Maternal mortality

The interventions prioritized to reduce maternal mortality were selected by identifying the two main causes of maternal death in Peru: obstetric hemorrhage (pre, intra and post-partum) and hypertensive pregnancy disorders (HPD) within the LiST model. These interventions were then compared to those addressed at lowering maternal morbimortality in Budgeting Program 002 – Maternal Neonatal (Programa Presupuestal 002 – Materno Neonatal, PPR-002). Nine interventions were prioritized and two scenarios were established in function of their potential impact on maternal mortality and family planning indicators.

Prioritized interventions in maternal mortality

  • Parenteral administration of anticonvulsants – severe preeclampsia
  • Supplementation of iron during pregnancy
  • Management of hypertensive disorder
  • Parenteral administration of anticonvulsants – eclampsia
  • Cesarean section
  • Manual removal of placenta
  • Parenteral administration of uterutonics
  • Removal of retained products of conception
  • Blood transfusion

Scenarios of maternal mortality for 2030:

  • MM1 Scenario: Achieve the Pan-American Health Organization’s established goal of 41.3 deaths per 100 000 live births.
  • MM2 scenario: Achieve the Peruvian Government’s established goal of 33 deaths per 100 000 live births.

3.2. Family planning

The high impact goal selected is the increase in the use of modern methods, with an emphasis in LARC, injections and condoms, by women of reproductive age. The prioritization is based on the proven benefits in the rates of continuity of use13 and a higher effectiveness compared to other contraceptive methods14. To reach these goals, the prioritized interventions were grouped into four areas, and three scenarios were laid out, corresponding to three different goals for the prevalence of use of modern contraceptive methods by 2030.

Prioritized interventions in family planning:

  • Promotion of sexual and reproductive health among adolescents
  • Availability and access to sexual and reproductive health counseling
  • Access to methods of family planning
  • Prevention of adolescent pregnancy

Family planning scenarios for 2030:

  • FP1 Scenario – conservative: An increase in the use of modern methods from 38.9% to 46.5% and an exclusive increase of 5% in the use of IUDs, implants and injectables.
  • FP2 Scenario – intermediate: An increase in the use of modern methods from 38.9% to 54.4% and an increase of 7.5% in the prevalence of use of LARCs (IUD and implants) and injectables, as well as a 2% increase for male and female condoms.
  • FP3 Scenario – high: An increase in the use of modern methods from 38.9% to 58.8% and an increase of 7.5% in the prevalence of use of LARCs (IUD and implants), injectables and male and female condoms.

4. Financial resources to achieve the goals of maternal mortality

4.1. Costs and benefits to achieve the goals of maternal mortality

[The costs are presented in current dollars and as a required additional quantity (incremental cost) of financial resources compared to a baseline scenario, where the coverage values for 2020 remain constant for the period 2021-2030. To avoid making a projection on the basis of the values occurred during the pandemic, the baseline scenarios for these estimations correspond to the 2019 values for maternal mortality and 2016 values for family planning.]

The necessary resources to achieve the MM1 scenario (MMR of 41.3) are 61.2 million USD, accumulated in the period 2021-2030. This means investing primarily in parenteral administration of anticonvulsants (29.7 million USD) and cesarean section deliveries (USD 21.6 million USD), in addition to other interventions. Achieving scenario MM2 (MMR 33) requires 129.6 million USD for the same period, out of which 90.4 million USD correspond to the parenteral administration of anticonvulsants and 21.7 million USD to cesarean section deliveries.

Figure 11. Additional annual costs of prioritized investment for the reduction of maternal mortality (in million current USD)

Our elaboration.

The increase in the coverage of prioritized interventions can prevent maternal, newborn and infant deaths, as well as prevent cases of anemia and slowed growth. All these effects translate to years of life and improvements in productivity and income. Considering the above, we can estimate the economical benefit of each scenario in current dollars and assess the benefit-cost of an increase in interventions against maternal mortality.

In scenario MM1, an estimated 366 maternal deaths, 250 newborn and infant deaths, 22 190 cases of anemia and 6730 cases of slowed growth would be prevented between 2021 and 2030. The number of years of life lost (YLL) to maternal, newborn and infant deaths would equal 36 246 years, and the number of disability adjusted life years (DALY) would equal 75 788 years. The benefits associated with the reduction of maternal mortality would be of 293 million USD, which, compared to the cost of 61.2 million USD, means that each dollar invested in interventions to reduce maternal mortality yields an economic return of 4.8 dollars.

In scenario MM2, 693 maternal deaths, 364 newborn and infant deaths, 22 190 cases of anemia and 6730 cases of slowed growth would be prevented between 2021 and 2030. The YLL would equal 61 740 and DALY would equal 101 282. The benefits associated to the accomplishment of this goal would be 427 million USD. Compared to the cost of 129.6 million USD, this means that each dollar invested in interventions to reduce maternal mortality yields and economic benefit equal to 3.3 dollars.

Figure 12. Benefits and costs of each scenario of maternal mortality (in million USD)

Our elaboration

4.2 Financial resources to accomplish the goals of family planning

Accomplishing the different family planning scenarios requires investment amounts above 50 million USD. To accomplish scenario FP1, an additional investment of 53.2 million USD is necessary for the period 2021-2030, scenario FP2 entails an investment of 79.3 million USD and scenario FP3 requires 109.3 million USD. In all cases, the sum invested in 3-month injectables and 3-years implants represent more than half the total investment. In scenario FP3, the investment in female condoms displaces the 3-year implant as the second most significant investment.

Figure 13: Annual additional costs of prioritized investments for the improvement of family planning (in million current USD)

Our elaboration.

The benefits of increasing the coverage of modern methods of family planning can materialize in the reduction of maternal and infant/newborn deaths, as well as social benefits derived from a reduction in the rate of unintended pregnancies. Furthermore, the benefits associated with prevented pregnancies that don’t result in deaths imply social benefits through other channels: i) an increase in the level of professionalization in women, as there is empirical evidence that pregnancy and adolescent maternity are tied to higher levels of school dropout and less access to higher education, and ii) an increase in women’s participation in the work market, since empirical evidence shows that women who have children in adolescence face bigger challenges in securing a job and are usually more predisposed to accept jobs with poorer conditions15.

Analyzed in terms of its impact in GDP per capita, early fertility affects two of its elements. In the first place, early fertility affects women’s productivity and their ability to work (especially in the formal market) because early school dropout reduces the likelihood of labor qualification. Secondly, early fertility alters the rate of dependency by increasing the number of people who are economically dependent on people of working age. This can be aggravated by the fact that the younger the mother is at the time of her first childbirth, the higher the likelihood that she will have another before turning 20, which supposes a shorter interval between them, and therefore a higher risk of low birth weight, malnutrition and anemia at the time of birth.

In scenario FP1, an estimated 18 664 pregnancies, 10 maternal deaths, 90 newborn and infant deaths and 68 253 abortions would be prevented between 2021 and 2030. The YLL would equal 6230 years and DALY would equal 12 564 years. Finally, 41 609 women will have access to higher education and 25 138 will have access to employment. The benefits associated to the accomplishment of this scenario are 398.2 million USD, which, compared to a cost of 53.2 million USD, mean that every dollar invested in interventions to reduce maternal mortality yields an economic return equal to 7.5 dollars.

To accomplish scenario FP2 would mean preventing 8664 pregnancies, 23 maternal deaths, 110 newborn and infant deaths and 68 253 abortions between 2021 and 2030. YLL would equal 8218 and DALY would equal 16 559 years. 43 690 women would have access to higher education and 26 395 women would have access to employment. The accomplishment of scenario FP2 would generate a benefit of 439 million USD, which means a return of 5.5 dollars per dollar invested.

To accomplish scenario FP2 would mean preventing 8664 pregnancies, 23 maternal deaths, 110 newborn and infant deaths and 68 253 abortions between 2021 and 2030. YLL would equal 8218 and DALY would equal 16 559 years. 43 690 women would have access to higher education and 26 395 women would have access to employment. The accomplishment of scenario FP2 would generate a benefit of 439 million USD, which means a return of 5.5 dollars per dollar invested.

In the three family planning scenarios, prevented abortions represent more than 37% of the benefits and the increase in years of education represents more than 31%, followed by an increase in the labor force and prevented newborn and infant deaths.

Figure 14. Costs and benefits of each family planning scenario (in million USD)

Our elaboration.

5. Conclusions

Despite the advances in the reduction of maternal deaths and improvements in family planning, Peru still has a long path to tread in regards to both aspects. To achieve the goals proposed in the different scenarios for maternal mortality and family planning for 2030, it is necessary to deploy a number of high impact interventions. Interventions addressed accomplishing the scenarios for maternal mortality entail additional investments of 61.2 million and 129.6 million USD, while family planning scenarios require additional costs of 53.2, 79.3 and 109.3 million USD. The benefits derived from these investments (quantified based on prevented maternal, newborn and infant deaths16, abortions and the increase in years of education and labor force) largely exceed their costs. Therefore, the necessary investment to achieve the different goals for 2030 proposed here is profitable for the country.




  1. Factoring in coupled women as well as non-coupled or non-sexually active women.↩︎

  2. Spectrum is a set of analysis tools for the elaboration of policy models. The LiST module (Lives Saved Tools), developed by Avenir Health and supported by the John Hopkins Bloomberg School of Public Health’s Institute for International Programs allows to estimate and make projections for the impact of changes in the coverage of a set of interventions based in evidence on maternal and infant health in medium and low income countries. The Family Planning module (FamPlan) allows to estimate and project the necessary family planning requirements to accomplish national goals regarding the increase in use of contraceptive methods, the reduction of unmet needs and the desired scope of fertility.↩︎

  3. United Nations Population Fund, Centro Nacional de Epidemiología, Prevención y Control de Enfermedades (National Center of Epidemiology. Prevention and Disease Control); Dirección General de Salud Sexual y Reproductiva (General Directorate of Sexual and Reproductive Health), Dirección General de Promoción de la Salud – PROMSA (General Directorate for the Promotion of Health), Seguro Integral de Salud (Comprehensive Health Insurance - SIS), Instituto Nacional de Estadística e Informática (National Institute of Statistics and Informatics), Colegio de Obstetras del Perú (Obstetrics Association of Peru), Instituto Nacional Materno Perinatal (National Maternal-Perinatal Institute), Oficina General de Tecnología de la Información (Bureau of Information Technology)↩︎

  4. According to Padilla in Relevancia y perspectiva para el desarrollo de los sistemas de información en población y salud sexual y reproductiva en Perú. Revista Peruana Experimental Salud Pública 2007;24(1):67–80↩︎

  5. Facilities with Obstetric and Newborn Functions, classified as: Primary NOF (PNOF), Basic NOF (BNOF), Essential NOF I (ENOF-I), Essential NOF II (ENOF-II) and Intensive NOF (INOF).↩︎

  6. http://bvs.minsa.gob.pe/local/MINSA/5181.pdf↩︎

  7. ENDES (2019). Perú - Encuesta Demográfica y de Salud Familiar - ENDES - 2019 - INEI. https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Endes2019/↩︎

  8. ENDES (2019). Loreto - Encuesta Demográfica y de Salud Familiar - ENDES - 2019 - INEI. https://proyectos.inei.gob.pe/endes/2019/departamentales/Endes16/pdf/Loreto.pdf↩︎

  9. https://www.dge.gob.pe/epipublic/uploads/normas/normas_20215.pdf↩︎

  10. MINSA (2020). Plan Estratégico Institucional - PEI 2019 - 2023 ampliado del MINSA. https://cdn.www.gob.pe/uploads/document/file/1199035/resolucion-ministerial-n-546-2020-minsa.pdf↩︎

  11. INEI estimates the unmet demand for family planning taking into account women who don’t belong to the following groups: (i) women that are not currently coupled, (ii) women who are practicing family planning, (iii) currently pregnant women or amenorrheic women who were employing some form of contraception when they got pregnant, (iv) currently pregnant women or amenorrheic women whose last pregnancy was planned, (v) sterile women, meaning women with no live births in the last five years, despite being coupled and not having used contraception, and fertile women who wish to bear children in the following two years.↩︎

  12. Mendoza W, Subiría G. (2013). Adolescent pregnancy in Peru: its current situation and implications for public policies. Revista Peruana de Medicina Experimental y Salud Pública, 3, 471-479.↩︎

  13. Diedrich JT, Klein DA, Peipert JF. (2017). Long-acting reversible contraception in adolescents: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology, 4, 364.↩︎

  14. Mansour D, Inki P, Gemzell-Danielsson K. (2010). Efficacy of contraceptive methods: A review of the literature. European Journal of Contraception and Reproductive Health Care, 1, 4-16↩︎

  15. Instituto Nacional de Estadística e Informática. (2015). Las adolescentes y su comportamiento reproductivo, 2013. https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1199/libro.pdf
    Mendoza W, Subiría G. (2013). Adolescent pregnancy in Peru: its current situation and implications for public policies. Revista Peruana de Medicina Experimental y Salud Pública, 3, 471-479.↩︎

  16. The avoided maternal deaths should not be confused with preventable maternal deaths.↩︎