Monthly Archives: November 2012

The Crucial Distinction between “Unmet Need” and “Unmet Demand” by William N. Ryerson

Proud mother with 6-month-old daughter in Nairobi. She did not want to hear about family planning until a nurse talked to her about child health and education opportunity. Photo from Gates Foundation/Flickr/cc

Motivation to use family planning and to limit family size has been the key missing element in the strategy for population stabilization.

There is a widespread view among many population activists that the top priority in the population field should be focused on providing family planning medical services because of the belief that lack of access to these services is the major barrier to fertility reduction.  It is true that over the last 40 years increasing access to contraceptive services has helped reduce fertility rates.  The view of those who subscribe to the “medical model” of solving the population problem is that additional family planning services will complete the job.

This is perhaps the most important issue within the population field. Of the money spent by developing and developed countries for population-related work in the developing world, the largest share has gone to providing family planning medical services to individuals and couples. Inherent in this approach is the belief that a large portion of births are unwanted and that contraceptive availability will solve this problem. Indeed, a significant percentage of births may be unwanted or mistimed, but large family norms/desires and the cultural and informational barriers to the use of contraception are now the major impediments to achieving replacement level fertility.

In Kenya, which was the fastest growing country in the world in the 1980s, contraceptives were within reach of nearly 90% of the population by the late 1980s.  Yet currently, only 39% of married women use them. That is only one example.

It is clear that providing contraceptive services alone will not solve the population problem. Since the late 1960s and throughout the 1970s, studies were conducted in numerous countries measuring women’s knowledge of, attitudes toward, and practice of birth control as well as their family size desires. These knowledge, attitude and practice studies resulted in the term “unmet need” to describe those women who wanted to delay their next pregnancy by at least two years but were not using a modern method of contraception. In the minds of many policy makers and funders, “unmet need” was equated with “lack of access” to contraceptive services. However, demographers Charles Westoff and Luis Hernando Ochoa, in a review of numerous Demographic and Health Surveys, determined that about half the women categorized as having an “unmet need” have no intention of using contraceptives even if they were made freely available.

The confusion between the term “unmet need” and “unmet demand” has misled many people in leadership positions to assume that such “unmet demand” could be overcome by improving family planning services and contraceptive distribution. The reasoning has been that, if there was a gap between what people want and what they are doing, improving access to contraceptives would close that gap. The problem is that the discrepancy between attitudes and behavior has had less and less to do with availability in recent decades.

The situation in Kenya is illustrative of findings in numerous countries recently. In Kenya, according to the 2008-09 Demographic and Health Survey, 96% of currently married women and 98% of husbands know about modern contraceptives. Of the married women who are non-users, 40% do not intend to ever use contraception. Among all non-using married women, 8% give as their reason the desire for more children. Among the reasons given for not using contraception by women who are not pregnant and do not want to become pregnant, only 0.8% cited lack of availability of contraceptives, and 0.4% cited cost. The top four reasons among those who are still fecund:

  • concern with the medical side effects of contraceptives (31%);
  • religious prohibition (9%);
  • personal opposition (8%);
  • opposition from the husbands (6%).

These are all issues that are best addressed by information and motivational communications. Certainly, counterfeit contraceptives exist, and they may have harmful effects, so improving the availability of reliable methods is important. So is informing women of potential side effects of methods they choose. But much of the fear of health effects is based on intentional misinformation campaigns by those oppoed to contraceptive use.

At a health center in rural Nigeria. Note the percentage of people under age 15.
Photo from DirectReliefInternational/Flickr/cc

Country by country, the Demographic and Health Surveys show a similar pattern to that in Kenya: Lack of access is cited infrequently by those who are categorized as having an unmet need for family planning.

A 1992 paper by Etienne van de Walle showed that another factor is at play for many women and men—fatalism. Many people have simply not reached the realization that reproductive decisions are a matter of conscious choice. Many who did not particularly want another pregnancy in the near future still reasoned that God had determined since the beginning of the universe how many children they would have and that it did not matter what they thought or whether they might use a contraceptive, because they could not oppose God’s will.

For example, Pakistan’s 2006-2007 Demographic and Health Survey found that the most common reason for non-use of contraceptives is the belief that God determines family size. This answer was given by 28% of the respondents. Since the fertility rate in Pakistan is 3.6 and the mean desired number of children among currently married women is 4.1, it is clear that family size norms are also a major factor in driving high fertility.

The tradition of large families is a deciding factor in fertility rates in most of sub-Saharan Africa. For example, the 2008 Demographic and Health Survey in Nigeria, Africa’s most populous country with 170 million inhabitants, found that the average ideal number of children for married women was 6.7.  For married men, it was 8.5.  The fertility rate in Nigeria is 5.6 children per woman, which is below what people say they actually want.

Of all births in Nigeria, 87% were wanted at the time and another 7% were wanted, but not until later. Only 4% were unwanted. Nationwide, 67% of married women and 89% of married men know of at least one modern method of contraception. Yet only 10% of married women report they currently use modern family planning methods.

Changing this situation takes more than provision of family planning services. It requires helping people understand the personal benefits of limiting and spacing births—in health and wealth for them and their children. It also involves overcoming fear that contraceptives are dangerous or that planning one’s family is unacceptable. It requires getting husbands and wives to talk to each other about use of family planning—a key step in the process of using contraceptives.

In Afghanaistan, Ghulam, age 11, is married to Faiz, age 40. She had hoped to be a teacher, but was forced to quit classes. About 58% of Afghan girls get married before age sixteen. Photo from Splintergroup/Flickr/cc

Delaying marriage and childbearing until adulthood, and educating girls are critical components. According to a 2003 report by the Nigerian Population Commission, in northern Nigeria the mean age at first conception is 15 years.  Teen births increased 50% between 1980 and 2003 in Nigeria, mostly attributable to adolescents in the northern regions.

The above should not be interpreted as suggesting that the level of effort in providing contraceptive services be reduced. High quality, low cost reproductive health care services are an essential element of fertility planning. Both quality and quantity of contraceptive choices and services are in dire need of improvement throughout much of the developing world. And “stockouts” of certain methods are a problem in many countries. But access to family planning methods is not sufficient if men can prevent their partners from using them, if women don’t understand the relative safety of contraception compared with early and repeated childbearing, or if women feel they cannot take control of their own lives.

Many population planners measure progress on the basis of contraceptive prevalence rates. Use of effective family planning methods is critical, but will not result in population stabilization if desired family size is five, six or seven children.

Motivation to use family planning and to limit family size has been the key missing element in the strategy for population stabilization.  While the percentage of non-users of contraceptives has declined, various studies indicate that the actual number of adults not using contraceptives is greater than it was in 1960, a fact stemming from the enormous increase in world population over the past 50 years. Approximately 44% of the roughly 2.3 billion people of reproductive age who are married or in long-term unions currently use no modern method of contraception. This means there are about 1 billion adult non-users of contraceptive methods. It’s time to focus significant effort on motivating this group to use contraception for the purpose of achieving small family size.

In reality, there are about 600 million adults in marriages or long-term unions who are non-users of contraception specifically because they want additional children or as many children as possible. This group is more numerous than the 430 million men and women classified as having an unmet need for family planning, and they deserve a lot of attention via programs that role model the benefits of smaller family norms.

Nearly as important are the desired family sizes of the 1.3 billion users of contraception. In many countries, those who do use contraceptives still want more than enough children to replace themselves. Their goals, if achieved, will lead to continued high rates of growth.

Japan has achieved below-replacement-level fertility (1.5 children per woman) in a country where the oral contraceptive pill was illegal until recently. The United States achieved below-replacement-level fertility in the Great Depression, before the invention of most modern contraceptives. Similarly, fertility dropped to near-replacement level in the 19th century in Western Europe and the United States.

World Bank economist Lant Pritchett, in a 1994 article in Population and Development Review, concluded that family size desire is the overwhelming determinant of actual fertility rates. “The conclusion that follows from the evidence and analysis we presented,” he wrote, “is that because fertility is principally determined by the desire for children, contraceptive access (or cost) or family planning effort more generally is not a dominant, or typically even a major, factor in determining fertility differences.” According to Pritchett, desired levels of fertility account for roughly 90% of differences among countries in total fertility rates.

Reducing the demand for children—for instance, by giving girls more education—is vastly more important to reducing fertility than providing more contraceptives or family planning services.

 Bill Ryerson is founder and president of the Population Media Center (PMC). He has worked for more than 38 years in the fields of reproductive health and behavior change. To read about PMC and its exciting programs, go to <www.populationmedia.org/>

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Planet and Population by Sir David Attenborough

“Fifty years ago, when the WWF was founded there were about three billion people on earth. Now there are almost seven billion. Over twice as many—and every one of them needing space.”

“It is all getting too serious for fastidious niceties.”

Fifty years ago, a group of far-sighted people in this country [Great Britain] got together to warn the world of an impending disaster. Among them were a distinguished scientist, Sir Julian Huxley; a bird-loving painter, Peter Scott; an advertising executive, Guy Mountford; and a powerful and astonishingly effective civil servant, Max Nicholson. They were all, in addition to their individual professions, dedicated naturalists, fascinated by the natural world not just in this country but internationally.  And they noticed what few others had done—that all over the world, charismatic animals that were once numerous were beginning to disappear. The Arabian Oryx , which once had been widespread all over the peninsula had now been reduced to a few hundred. In Spain, there were less than a hundred imperial eagles. The Californian condor was down to about sixty. In Hawaii, a goose that had lived in flocks on the lava fields around the great volcanoes were reduced to fifty. The strange little rhinoceros that lived in the dwindling forests of Java—to about forty. Wherever you looked there were examples of animals whose populations were falling rapidly. This planet was in danger of losing a significant number of its inhabitants—both animals and plants.

Something had to be done. And that group determined to do it. They would need scientific advice to discover the causes of these impending disasters and to devise ways of slowing them and hopefully, stopping them.  They would have to raise the awareness of the threat to get the support of people everywhere;  and—like all such enterprises—they would need money to take practical action. They set about raising all three. Since the problem was an international one, they based themselves, not here, but in the heart of Europe in Switzerland. And they called the organisation they created the World Wildlife Fund.

The methods WWF used to save these endangered species were several.  Some, like the Hawaiian goose and the oryx, were taken into captivity in zoos, bred up into a significant population and then taken back to their original home and released.  Elsewhere, in Africa for example, great areas of unspoilt country were set aside as National Parks where the animals could be protected from poachers and encroaching human settlement.  In the Galapagos Islands and in the home of the mountain gorillas in Rwanda, ways were found of ensuring that local people who also had claims on the land where such animals lived, were able to benefit financially from the creatures they were protecting by attracting visitors.  Eco-tourism was born.

The world awoke to conservation.  Millions—billions of dollars were raised.  And now fifty years on, conservationists who have worked so hard and with such foresight can justifiably congratulate themselves on having responded magnificently to the challenge.

Yet now, in spite of a great number of individual successes, the problem remains.  True, thanks to the vigour and wisdom of conservationists, no major charismatic species has yet disappeared.  Many are still trembling on the brink, but are still hanging on.  But overall, today there are more problems not less, more species at risk of disappearance than ever before. Why?

Fifty years ago, when the WWF was founded there were about three billion people on earth. Now there are almost seven billion. Over twice as many—and every one of them needing space. Space for their homes, space to grow their food (or to get others to grow it for them), space to build schools and roads and airfields. A little of that space might be taken from land occupied by other people but most of it could only come from the land which, for millions of years, animals and plants have to themselves.

The impact of these extra millions of people has spread even beyond the space they physically occupy. Their industries have changed the chemical constituency of the atmosphere. The oceans that cover most of the surface of the planet have been polluted and increasingly acidified. We now realise that the disasters that continue increasingly to afflict the natural world have one element that connects them all the unprecedented increase in the number of human beings on the planet.

There have been prophets who have warned us of this impending disaster, of course.  One of the first was Thomas Malthus.  His surname – Malthus – leads some to think that he was some continental European savant, a German perhaps.  But he was not.  He was an Englishman, born in Guildford in Surrey in the middle of the eighteenth century.  His most important book, An Essay on the Principle of Population was published over two hundred years ago in 1798.  In it, he argued that the human population would increase inexorably until it was halted by what he termed ‘misery and vice’.  Today, for some reason, that prophecy seems to be largely ignored—or at any rate, disregarded. It is true that he did not foresee the so-called ‘Green Revolution’ which greatly increased the amount of food that could be produced in any given area of arable land. But that great advance only delayed things. And there may be other advances in our food producing skills that we ourselves still cannot foresee. But the fundamental truth that Malthus proclaimed remains the truth. There cannot be more people on this earth than can be fed.

Many people would like to deny this.  They would like to believe in that oxymoron  ‘sustainable growth.’  Kenneth Boulding, President Kennedy’s environmental advisor forty-five years ago said something about this.  ‘Anyone who believes in indefinite growth in anything physical, on a physically finite planet,’ he said,’ is either mad – or an economist.’

The population of the world is now growing by nearly 80 million a year. One and a half million a week.  A quarter of a million a day.  Ten thousand an hour.

In this country [England] population is projected to grow by ten million in the next twenty-two years.  That is equivalent to ten more Birminghams.  Not only that, but every one of us in this country consumes far more of the earth’s resources than an average African.

All these people, in this country and worldwide, rich or poor, need and deserve food, water, energy and space. Will they be able to get it?  I don’t know.  I hope so. But the Government’s Chief Scientist and the last President of the Royal Society have both referred to the approaching ‘perfect storm’ of population growth, climate change and peak oil production, leading inexorably to more and more insecurity in the supply of food, water and energy.

Consider food. Very few of us here, I suspect have ever experienced real hunger.  For animals, of course, it is a regular feature of their lives. The stoical desperation of the cheetah cubs whose mother failed in her last few attempts to kill prey for them and who consequently face starvation is very touching.  But that happens to human beings too.  All of us who have travelled in poor countries have met people for whom hunger is a daily background ache in their lives. There are about a billion such people today—that is four times as many as the entire human population of this planet a mere two thousand years ago at the time of Christ.

You may have seen the Government’s “Foresight Report on the Future of Food and Farming”.  It shows how hard it is to feed the seven billion of us who are alive today.  It lists the many obstacles that are already making this harder to achieve—soil erosion, salinization, the depletion of aquifers, over grazing, the spread of plant diseases as a result of globalisation, the absurd growing of food crops to turn into biofuels to feed motor cars instead of people—and so on. So it underlines how desperately difficult it is going to be to feed a population that is projected to stabilise in the range of eight to ten billion people by the year 2050. It recommends the widest possible range of measures across all disciplines to tackle this. And it makes a number of eminently sensible recommendations, including a second ‘green revolution’.

But surprisingly there are some things that the report does not say. It doesn’t state the obvious fact that it would be much easier to feed eight billion people than ten.  Nor does it suggest that the measures to achieve such a number—such as family planning and the education and empowerment of women—should be a central part of any program of active food security.  It doesn’t refer to the prescient statement forty years ago by Norman Borlaug, the Nobel  Laureate and father of the first Green Revolution, who produced a strain of high-yielding, short-stemmed, disease resistant wheat, that all he had done was to give us a ‘breathing space’ in which to stabilize our numbers. It anticipates that food prices may rise with oil prices and so on and makes it clear that this will affect poorest people worst and discusses various way to help them. But it doesn’t mention what every mother subsisting on the equivalent of a dollar a day already knows—that her children would be better fed if there were four of them around the table instead of ten. These are strange omissions.

And how can we ignore the chilling statistics on arable land? In 1960 there was half a hectare of good cropland per person in the worldenough to sustain a reasonable European diet.  Today, there is only 0.2 of a hectare each.  In China, it is only 0.1 of a hectare, because of their dramatic problems of soil degradation.

Another impressive Government report on biodiversity published this year, “Making Space for Nature in a Changing World”, is rather similar. It discusses all the rising pressure on wildlife in the United Kingdom, but it doesn’t mention our growing population as being one of them—which is particularly odd when you consider that England is already the most densely populated country in Europe.

Most bizarre of all was a recent report by a Royal Commission on the environmental impact of demographic change in this country which denied that population size was a problem at all—as though twenty million extra people more or less would have no real impact. Of course it is not our only or even our main environmental problem; but it is absurd to deny, as a multiplier of all the others, that it is a problem.

I suspect that you could read a score of reports by bodies concerned with global problems—and see that population is clearly one of the drivers that underlies all of them—and yet find no reference to this obvious fact in any of them.

Climate change tops the environmental agenda at present.  We all know that every additional person will need to use some carbon energy, if only firewood for cooking and will therefore create more carbon dioxide—though of course a rich person will produce vastly more than a poor one. Similarly, we can all see that every extra person is—or will be—an extra victim of climate change—though the poor will undoubtedly suffer more than the rich.  Yet not a word of it appeared in the voluminous documents emerging from the Copenhagen and Cancun Climate Summits.

Why this strange silence? I meet no one who privately disagrees that population growth is a problem. No oneexcept flat-eartherscan deny that the planet is finite. We can all see it in that beautiful picture of our earth taken from the Apollo mission. So why does hardly anyone say so publicly? There seems to be some bizarre taboo around the subject. “It’s not quite nice, not PC, possibly even racist to mention it.” And this taboo doesn’t just inhibit politicians and civil servants who attend the big conferences. It even affects the people who claim to care most passionately about a sustainable and prosperous future for our children, the environmental and developmental  Non-Government Organisations. Their silence implies that their admirable goals can be achieved regardless of how many people there are in the world, even though they all know that they can’t. 

“The sooner we stabilise our numbers, the sooner we stop running up the ‘down’ escalator. Stop population increase—stop the escalator—and we have some chance of reaching the top—that is to say a decent life for all.”

I simply don’t understand it.  It is all getting too serious for such fastidious niceties. It remains an obvious and brutal fact that on a finite planet human population will quite definitely stop at some point. And that can only happen in one of two ways. It can happen sooner, by fewer human birthsin a word by contraception.  This is the humane way, the powerful option which allows all of us to deal with the problem, if we collectively choose to do so. The alternative is an increased death ratethe way which all other creatures must suffer, through famine or disease or predation. That translated into human terms means famine or disease or warover oil or water or food or minerals or grazing rights or just living space. There is, alas, no third alternative of indefinite growth.

The sooner we stabilise our numbers, the sooner we stop running up the  ‘down’ escalator.  Stop population increase—stop the escalator—and we have some chance of reaching the top—that is to say a decent life for all.

To do that requires several things. First and foremost it needs a much wider understanding of the problem and that will not happen while the absurd taboo on discussing it retains such a powerful grip on the minds of so many worthy and intelligent people. Then it needs a change in our culture so that while everyone retains the right to have as many children as they like, they understand that having large families means compounding the problems their children and everyone else’s children will face in the future.

It needs action by Governments.  In my view all countries should develop a population policy—some 70 countries already have them in one form or another—and give it priority.  The essential common factor is to make family planning and other reproductive health services freely available to every one and empower and encourage them to use it—though of course without any kind of coercion.

According to the Global Footprint Network there are already over a hundred countries whose combination of numbers and affluence have already pushed them past the sustainable level.  They include almost all developed countries. The UK is one of the worst.  There the aim should be to reduce over time both the consumption of natural resources per person and the number of people, while needless to say, using the best technology to help maintain living standards.  It is tragic that the only current population policies in developed countries are, perversely, attempting to increase their birth-rate in order to look after the growing number of old people. The notion of ever more old people needing ever more young people, who will in turn grow old and need ever more young people and so on ad infinitum, is an obvious ecological Ponzi scheme.

I am not an economist, nor a sociologist nor a politician, and it is their disciplines that should provide the solutions. I am a naturalist. But being one means that I do know something of the factors that keep populations of different species of animals within bounds. I am aware that every pair of blue tits nesting in my garden is able to lay over twenty eggs a year but as a result of predation or lack of food, only one or two will, at best, survive.  I have seen how lions ravage the hundreds of wildebeest fawns that are born each year on the plains of Africa. I have seen how increasing populations of elephants can devastate their environment until, one year when the rains fail on the already over-grazed land, they die in hundreds.

But we are human beings. We have ways of escaping such brutalities. We have medicines that prevent our children from dying of disease. We have developed ways of growing increasing amounts of food. That has been a huge and continuing advance that started several thousand years ago, a consequence of our intelligence, our increasing skills and our ability to look ahead.  But none of these great achievements will be of any avail if we do not control our numbers.

And we can do so. Wherever women have the vote, wherever they are literate, and have the medical facilities to control the number of children they bear, the birth rate falls.  All those civilised conditions exist in the southern Indian state of Kerala. The total fertility rate there in 2007 was 1.7 births per woman.  In India as a whole it is 2.8 per woman.  In Thailand in 2010, it was 1.8 per woman, similar to that in Kerala.  But compare that with the Catholic Philippines where it is 3.3.

Here and there, at last, there are signs of a recognition of the problem.  The Save the Children Fund mentioned it in their last report [printed in Population Press, vol. 16, #3].

But what can each of us do—you and I?  Well, there is just one thing that I would ask.  Break the taboo, in private and in public—as best you can, as you judge right. Until it is broken there is no hope of the action we need.  Wherever and whenever we speak of the environmentadd a few words to ensure that the population element is not ignored.  If you are a member of a relevant NGO, invite them to acknowledge it.  If you belong to a Church—and especially if you are a Catholic because its doctrine on contraception is a major factor in this problem—suggest they consider the ethical issues involved.  I see the Anglican bishops in Australia have dared to do so. If you have contacts in Government, ask why the growth of our population, which affects every Department, is yet no one’s responsibility.  Big empty Australia has appointed a Sustainable Population Minister so why can’t small crowded Britain [or large crowded USA]?

Make a list of all the environmental and social problems that today afflict us and our poor battered planetnot just the extinction of animals and plants that fifty years ago was the first signs of impending global disaster, but traffic congestion, oil prices, pressure on health services, the growth of mega-cities, migration patterns, immigration policies, unemployment, the loss of arable land, desertification, famine, increasingly violent weather, the acidification of the oceans, the collapse of fish stocks, rising sea temperatures, the loss of rain forests. The list goes on and on. But they all share an underlying cause. Every one of these global problems, environmental as well as social,  becomes more difficultand ultimately impossibleto solve with ever more people.

 This speech was given by broadcaster and naturalist Sir David Attenborough at the 2011 RSA President’s Lecture,  March 10, 2011. The event was chaired by His Royal Highness, Prince Phillip, The Duke of Edinburgh.  Attenborough is one of the world’s pre-eminent  naturalists.  His career as the respected face and voice of natural history programs has endured for more than 50 years.  To see the lecture, go to http://rsafellowship.com/group/digitalengagement/forum/topics/live-streaming-presidents

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