"It is the most interesting book I have ever read and inspires me to do something immediate to save our civilization." —Hanh Lien, translator for the Vietnamese edition of World on the Edge
Female sterilization is the world's most popular method of birth prevention. A global survey of reproductive health among married couples by the United Nations found that one fifth rely on female sterilization (tubal ligation) to control their fertility. In Brazil, India, and China, a third or more of all married women have been sterilized.
Even though male sterilization (vasectomy) is safer, quicker, and less expensive, it is much less common, used by just 4 percent of married couples. In only a few countries, including New Zealand, the United Kingdom, the Netherlands, and Bhutan, do more couples choose male over female sterilization.
Out of the world's 1 billion married couples, some 650 million plan their families. It is the other 350 million couples who either do not have access to family planning services or do not want to plan their families who contribute a disproportionately large share of the near 80 million people added to the world's population each year. It is also couples in this group who seek out more abortions and who are most at risk from higher maternal mortality.
Among the world's married couples who do practice modern contraception, the next most popular methods after female sterilization, which is used by 36 percent, are intrauterine devices (IUDs), at 27 percent, and the pill, at 14 percent. An additional 6 percent choose other modern female methods.
Just 17 percent of modern contraception is in the hands of men. In addition to the 7 percent of couples relying on male sterilization, 9 percent use condoms. But male methods are used by only 12 percent of couples in the developing world, compared with 38 percent in the industrial world. Among traditional methods, withdrawal—perhaps the oldest method of birth control—is practiced by more than 32 million married couples worldwide. It is the leading method for couples in several East European countries, including Yugoslavia, Bulgaria, and Romania.
New Zealand boasts the world's highest vasectomy rate; there, nearly one in five married men has been sterilized. The method is just slightly less popular than the pill. Family planning researchers from Bangladesh, the world's eighth most populous country, are examining New Zealand's high vasectomy rates for clues on how to promote this method in their own densely populated country.
More men assume responsibility for family planning in Japan than in any other country, no doubt because the pill became available only recently. In 2000, condoms accounted for almost 78 percent of modern contraceptive use there. This is down from at least 86 percent in 1994. Condom use has fallen in recent years as some couples switched to the pill, which was finally approved by the Japanese government in 1999.
The condom is becoming somewhat less popular in Japan just when its use elsewhere is increasing as a means of protection against sexually transmitted infections, importantly HIV. Among all American contraceptive users, for instance, pill use dropped from 31 percent in 1988 to 27 percent in 1995, while condom use climbed from 15 to 20 percent. Similar shifts have been observed in Canada, France, and Australia.
In the United States, 38 percent of married modern contraceptive users depend on male methods, split between condoms and vasectomy, but female sterilization remains the single most popular method, chosen by 34 percent of couples. Twenty-two percent rely on the pill. Less than 1 percent choose IUDs—one of the world's lowest rates.
In China and India, home to the world's two largest populations, female contraceptive measures predominate. In China, 44 percent of married women using modern contraceptives rely on the IUD and 40 percent on sterilization. In India, female sterilization is the overwhelming choice, accounting for a full four fifths of contraceptive use.
Government encouragement, a high female literacy rate, and low infant mortality have helped raise China's modern contraceptive use among married couples to 83 percent—the world's highest. As a result, population growth has slowed to less than 1 percent annually, roughly the same as in the United States. Chinese women on average have fewer than two children.
By contrast, fewer than half of India's married couples use any form of birth control. Low literacy levels, high infant mortality, and a lack of access to affordable and reliable contraceptives have kept the annual population growth rate at 1.7 percent. On average, women in India give birth to more than three children.
Lowering fertility to replacement level (roughly two children per couple) sets the stage for population stabilization—the ultimate goal of most population policies. This is typically achieved when at least 70 percent of reproductive-age women practice some form of family planning. Unfortunately, more than half of the world's women live in countries where regular birth control use is much lower. Many of these women do not have any access to affordable and reliable reproductive health services, or do not have the support of their husbands, extended families, or communities to try to plan their families.
Much of the family planning shortfall occurs in the developing world, although this varies widely among countries. Though contraceptive use among women in developing countries has increased dramatically—from 24 percent in 1970 to 60 percent in the late 1990s (but 49 percent if China is excluded)—it still lags behind the industrial world's rate of 68 percent. (See figure).
African countries have the lowest levels of contraceptive use, suffering from a lack of reproductive health funding. In some 30 African countries, less than 20 percent of married couples use contraception. The Democratic Republic of the Congo, Eritrea, Rwanda, Angola, and Somalia are among the dozen or so countries where less than 5 percent of couples plan their families. Making condoms available there would both prevent births and the surging spread of HIV.
Partly as a result of the continuing family planning gap, at least one fourth of the 133 million babies born worldwide each year are unplanned. When family planning needs are not met, women's health is compromised. Some women turn to abortion as a last option, simply because they may not have enough food for another child.
The 1994 International Conference on Population and Development held in Cairo set goals for funding a 20-year population and reproductive health program, but donor countries—mostly industrial nations—have fallen short on their funding commitments by some two thirds. Few funding shortfalls have such a high social toll. The United Nations Population Fund (UNFPA) estimates that each $1 million shortfall in contraceptive spending translates into 360,000 additional unwanted pregnancies, 150,000 additional induced abortions, 800 maternal deaths, 11,000 infant deaths, and 14,000 additional deaths of children under the age of 5—all preventable.
Now that the United States has ignored the recommendations of its own State Department and withdrawn a promised $34 million in funding for UNFPA, other donor countries and individuals are scrambling to try to make up the difference so that women will not lose access to vital services. With the world's largest generation of young people entering their reproductive years, this is not the time to cut family planning funds.
Copyright © 2002 Earth Policy Institute