Objective Some beneficial reproductive health interventions affect who will be born and how many people will be born (e.g., providing contraception, treating avoidable causes of infertility like chlamydia). In order to decide whether these interventions should be included in health benefits packages a consistent methodology is needed for assessing their costs and benefits within a population. Such a methodology should enable cost-effectiveness analyses of interventions that affect birth rates so they can be compared with other health interventions. At present the health economic analyses of these interventions use apparently inconsistent methods. This presentation provides a taxonomy and ethical analysis of current methodologies used to assess the effects of interventions that affect birth rates.

Methods We reviewed the studies cited in two recent literature reviews of economic evaluations of interventions that affect fertility and childbearing. On the basis of this review, we developed a taxonomy of methods used for assessing the effects of interventions that affect birth rates. These methods were then evaluated for logical consistency, utility, and fit with defensible ethical principles.

Results and Discussion A number of the methodologies used appear to treat the benefits and costs of interventions that affect birth rates in inconsistent ways—for example, contraception is sometimes treated as averting infant deaths by preventing the infants from coming into existence but not as averting the creation of other individuals who would live long, healthy lives. Other methodologies are ethically indefensible—for example, putting a positive value on the reduction of fertility independent of whether the reduction is desired by the people who would otherwise reproduce. Consistent and ethically defensible methodologies fall into three categories: those measuring intermediate outcomes; those measuring total effects; and those focused on reproductive autonomy. Each has pros and cons for policy-makers designing health benefits packages.