"Brown understands well the precariousness of human civilization ...[and] expresses it in patient and telling detail that addresses the intelligence and humanity of the reader." —Bryan Walker on Celsias.com
Chapter 10. Stabilizing Population by Reducing Fertility: Filling the Family Planning Gap
Given the immediate need to slow world population growth, it would be easy to assume that couples everywhere by now have access to family planning services. Unfortunately, despite the pivotal influence of family planning services on the global future, there is still a huge gap between people who want to plan their families and their access to family planning services.
The first step in stabilizing population is to remove the physical and social barriers that prevent women from using family planning services. John Bongaarts of the Population Council reports that 42 percent of all pregnancies in the developing world are unintended. Of these, 23 percent end in abortion. This leads Bongaarts to conclude that one third of projected world population growth will be due to unintended pregnancies. Of all the unmet social needs in the world today, none is more likely to adversely affect the human prospect more than the unmet need for family planning.22
There are several reasons why couples are not planning their families despite their desire for fewer children. In many countries, such as Saudi Arabia and Argentina, government policies restrict access to contraceptives. Geographic accessibility also affects use; in some rural areas of sub-Saharan Africa, it can take two hours or more to reach the nearest contraceptive provider. For those with low incomes, family planning services can be expensive. Even where family planning clinics are accessible, they are often underfunded, leaving them short of supplies and understaffed.23
Women who want fewer children may also be constrained from using family planning by a lack of knowledge, prevailing cultural and religious values, or the disapproval of family members. Studies have shown that a husband's opposition to family planning constrains the efforts to limit family size in numerous countries, including Egypt, Guatemala, India, Nepal, and Pakistan. Moreover, some 14 countries require a woman to obtain her husband's consent before she can receive any contraceptive services, while 60 require spousal authorization for permanent birth control methods. Although it has been argued that these practices lessen conflicts between spouses and health care personnel, they are serious impediments to a woman's ability to control her fertility.24
One way of reducing the unplanned pregnancies that account for a large share of world population growth is through medical abortions. A prescription drug used for many years in France to induce abortion, RU 486 (also known as mifepristone), is now available in several other European countries, the United States, China, India, Pakistan, and several smaller countries in Asia. Another drug, methotrexate, used worldwide in cancer therapy, works well as a "morning after" pill when used in combination with misoprostol. This procedure, prescribed by many U.S. doctors before RU 486 was approved in 2000, typically induces abortion within 72 hours. Although medical abortions are widely used in industrial countries, such as France and the United States, they are of even greater value in developing countries, where many people do not have access to family planning services and, even if they do, where supplies of contraceptives sometimes run out.25
Information about contraceptives and family planning for young men and women facilitates the use of birth control. In Thailand, people of all ages have been educated on the importance of family planning. Mechai Viravidaiya, the charismatic founder of the Thai Population and Community Development Association (PCDA), encouraged familiarity with contraceptives through demonstrations, ads, and witty songs. Math teachers even use population-related examples in their classes. As a result of the efforts of Mechai, the PCDA, and the government, the growth of Thailand's population has slowed from more than 3 percent in 1960 to approximately 1 percent in 2000—the same as that of the United States.26
More recently, Iran has emerged as a leader in population policy. After the Islamic revolution in 1979, when Ayatollah Khomeini came to power, the family planning programs put in place by the Shah were dismantled. Khomeini exhorted women to have more babies to create "soldiers for Islam," pushing annual population growth rates to over 4 percent—some of the highest ever recorded. By the late 1980s, the social and environmental costs of such growth rates were becoming apparent. As a result, policy shifted. Religious leaders argued that having fewer children was a social responsibility. Eighty percent of family planning costs were covered in the budget. Some 15,000 "health houses" were established to provide family planning and health services to Iran's rural population. As literacy levels among rural women climbed from 17 percent in 1976 to nearly 90 percent, fertility dropped to an average of 2.6 children per woman. Within 15 years, Iran's population growth rate has fallen from over 4 percent a year to scarcely 1 percent, making it a model for other developing countries.27
A comparison of population trends in Bangladesh and Pakistan illustrates the importance of acting now. When Bangladesh was created in a split with Pakistan in 1971, the former had 66 million people and the latter 62 million, roughly the same population sizes. Then their demographic trends diverged. Bangladesh's political leaders made a strong commitment to reduce fertility rates, while the leaders in Islamabad wavered over the need to do so. As a result, the average number of children per family in Bangladesh today is 3.3, compared with 5.6 in Pakistan. Each year the gap in the population trajectories of the two countries widens. By putting family planning programs in place sooner rather than later, Bangladesh—the poorer country—is projected to have 79 million fewer people than Pakistan in 2050. (See Figure 10-2.)28
The world now faces a similar choice. The United Nations projects that the number of people on the earth could reach anywhere from 7.9 billion to 10.9 billion by 2050. According to its latest medium-level projections, population in the developing world is projected to rise from 4.9 billion in 2000 to 8.1 billion in 2050. Such an increase would likely lead to organizational overload and ecosystem collapse in dozens of countries.
Heading off such a prospect depends on filling the family planning gap by ensuring that women everywhere have access to a full complement of family planning services, including the "morning after" pill. The second front in this worldwide effort to stabilize population is to help create the social conditions that will lead to smaller families, specifically by improving the status of women. George Moffett, author of Critical Masses, observes quite rightly that "There's a critical connection between a woman's productive role—the improved legal, educational, and economic opportunities that are the source of empowerment—and a woman's reproductive role."29
In some developing countries, having many children is seen as a matter of survival: children are a vital part of the family economy and a source of security in old age. Institutions such as the Grameen Bank in Bangladesh, which specializes in microenterprise loans, are attempting to change this situation by providing credit to well over a million villagers—mostly impoverished women. These loans are empowering women, helping to end the cycle of poverty, and thus reducing the need for large families.30
Rapid economic growth is not always a prerequisite for reduced fertility rates. Bangladesh has reduced fertility rates from nearly 7 children per woman in the early 1970s to 3.3 children today despite incomes averaging only $200 a year, among the lowest in the world. In the struggle to slow population growth, government leadership, access to family planning services, and improvement in social conditions are proving to be more important than the growth of a nation's economy.31
Slowly, governments are realizing the value of investing in population stabilization. One study found that the government of Bangladesh spends $62 to prevent a birth, but saves $615 on social services expenditures for each birth averted—a 10-fold difference in cost. Based on the study's estimate, the program prevents 890,000 births annually. The net savings to the government total $547 million each year, leaving more to invest in education and health care.32
At the 1994 International Conference on Population and Development in Cairo, the governments of the world agreed to a 20-year population and reproductive health program. The United Nations estimated that $17 billion a year would be needed for this effort by 2000 and $22 billion by 2015. (By comparison, $22 billion is less than is spent every 10 days on military expenditures.) Developing countries and countries in transition agreed to cover two thirds of the price tag, while donor countries promised to pay the rest—$5.7 billion a year by 2000 and $7.2 billion by 2015.33
Unfortunately, while developing countries are largely on track with their part of the expenditures, having covered about two thirds of their allotted payments, donor countries have fallen far behind--honoring only one third of their commitment. As a result of shortfalls following the Cairo conference, the United Nations estimated that there were an additional 122 million unintended pregnancies by 2000. An estimated one third of these were aborted. Moreover, an estimated 65,000 women who did not wish to be pregnant died in childbirth and 844,000 suffered chronic or permanent injury from their pregnancies.34
Slowing population growth depends on simultaneously creating the social conditions for fertility decline and filling the family planning gap. "Global population problems cannot be put on hold while countries reform their health care, rebuild their inner cities, and reduce budget deficit[s]. Avoiding another world population doubling...requires rapid action," notes Sharon Camp, former vice president of Population Action International. The difference between acting today and putting it off until tomorrow is the difference between population stabilizing at a level the earth can support and population expanding until environmental deterioration disrupts economic progress.35
22. John Bongaarts and Charles F. Westoff, The Potential Role of Contraception in Reducing Abortion, Working Paper No. 134 (New York: Population Council, 2000).
23. Nada Chaya, Contraceptive Choice: Worldwide Access to Family Planning, wall chart (Washington, DC: Population Action International, 1997); Macro International, Contraceptive Knowledge, Use, and Sources: Comparative Studies Number 19 (Calverton, MD: 1996).
24. John B. Casterline, Zeba A Sathar, and Minhaj ul Haque, Obstacles to Contraceptive Use in Pakistan: A Study in Punjab, Working Paper No. 145 (New York: Population Council, 2001); John A. Ross, W. Parker Mauldin, and Vincent C. Miller, Family Planning and Population: A Compendium of International Statistics (New York: Population Council, 1993).
25. Mark Kaufman, "Abortion Pill Deliveries Begin Soon," Washington Post, 16 November 2000; Susan Okie, "RU-486 Joining Methotrexate in Reshaping Abortion," Washington Post, 13 October 2000; Craig S. Smith, "Chinese Factory to Soon Begin Exporting Recently Approved Abortion Pills to U.S.," New York Times, 13 October 2000; Susan Toner, "U.S. Approves Abortion Pill; Drug Offers More Privacy and Could Reshape Debate," New York Times, 29 September 2000.
26. G. Tyler Miller, "Copps and Rubbers Day in Thailand," in Living in the Environment, 8th ed. (Belmont, CA: Wadsworth Publishing Company, 1994).
27. Farzaneh Roudi, "Iran's Revolutionary Approach to Family Planning," Population Today, July/August 1999; Abubakar Dungus, "Iran's Other Revolution," Populi, September 2000; Akbar Aghajanian and Amir H. Mehryar, "Fertility Transition in the Islamic Republic of Iran: 1976-1996," Asia-Pacific Population Journal, vol. 14, no. 1 (1999), pp. 21-42; total fertility rate (the average number of children born to a woman) from Population Reference Bureau (PRB), 2001 World Population Data Sheet, wall chart (Washington, DC: 2001).
28. Figure 10-2 from United Nations, op. cit. note 1; total fertility rate from PRB, op. cit. note 27.
29. George D. Moffett, Critical Masses (New York: Penguin Books, 1994), cited in Laurent Belsie, "How Many People Does it Take to Change the World?" Christian Science Monitor, 22 June 2000.
30. Gary Gardner, "Microcredit Expanding Rapidly," in Worldwatch Institute, Vital Signs 2001 (New York: W.W. Norton & Company, 2001), pp. 110-11.
31. Bruce Caldwell and Barkat-e-Khuda, "The First Generation to Control Family Size: A Microstudy of the Causes of Fertility Decline in a Rural Area of Bangladesh," Studies in Family Planning, September 2000, pp. 239-51.
32. "Bangladesh: National Family Planning Program," Family Planning Programs: Diverse Solutions for a Global Challenge (Washington, DC: PRB, February 1994).
33. U.N. Population Fund (UNFPA), "Meeting the Goals of the ICPD: Consequences of Resource Shortfalls up to the Year 2000," paper presented to the Executive Board of the U.N. Development Programme and the UNFPA, New York, 12-23 May 1997; military expenditures calculated from U.S. Department of State, Bureau of Verification and Compliance, World Military Expenditures and Arms Transfers 1998 (Washington, DC: U.S. Government Printing Office, April 2000), p. 61.
34. UNFPA, op. cit. note 33; UNFPA, Population Issues Briefing Kit (New York: Prographics, Inc., 2001), p. 23.
35. Sharon L. Camp, "Population: The Critical Decade," Foreign Policy, spring 1993.
Copyright © 2001 Earth Policy Institute