The Unmet Need for Family Planning by Malcolm Potts

THE UNMET NEED FOR FAMILY PLANNING

Malcolm Potts

Women and men in many countries still lack access to contraceptives. Unless they are given the option of controlling their fertility, severe social and environmental problems loom throughout large parts of the world.

During 1999, the world’s population surged past the 6 billion mark. Such numerical milestones, like a New Year, are of course just arbitrary artifacts of our decimal counting system, yet they offer a suitable occasion for taking stock of important trends.

Worldwide, the average number of children born to each woman—the fertility rate—has declined over the past three decades, from almost 6 to 2.9, prompting some commentators to venture that overpopulation may no longer be a threat. They are mistaken. Global population is still increasing by about 78 million people—a number equivalent to a new Germany—each year. Moreover, because large families were common in most of the world until recently, many countries have very large numbers of young people.

This population structure means that rapid growth is sure to continue for decades to come, almost all of it in developing countries, where family planning services may be deficient or nonexistent. In nations that lack adequate medical, financial and educational institutions, not to mention food and water supplies, the result of a fast-growing population is much human misery. The quality of life of a large proportion of humanity in this century—and the future size of the global population—will depend critically on how quickly the world can satisfy the current unmet demand for family planning.

Every day more than 400,000 conceptions take place around the world. Almost half are deliberate, happy decisions, but half are unintended, and many of these are bitterly regretted. Surveys in over 50 low-income countries have asked more than 300,000 women how many children they want. In nearly every country surveyed, women are bearing more offspring than they intend. When I practiced obstetrics in a London hospital in the 1960’s, I would ask new mothers, “When do you want your next baby?” Many replied, “Doctor, I was just going to ask you about that.” They were glad that I had opened the door to an embarrassing but important topic. My boss in the hospital, however, berated me for discussing birth control. I learned that family planning was wanted but controversial.

During the past 30 years, many countries have greatly improved their provision of family planning services. Contraceptive use in the developing world has risen from one in 10 couples to more than half of all couples. The desire for smaller families is spreading. In 1998 researchers associated with the Asian Development Bank in Laos, one of the world’s poorest countries, invited people there to say what help they wanted most. The men requested jobs, but the women’s #1 priority was family planning.

The unmet need for contraceptives is clearly on a different scale in Ethiopia or West Africa, than in, say, Italy, which has one of the lowest fertility rates in the world—1.2. Yet wherever people have said they want fewer children and family planning has been made available, fertility has fallen. What they need is access to a variety of methods, backed up by safe abortion if they choose it.

Obstacles to Progress
The trouble is that in some parts of the world contraceptives are either too expensive or simply unavailable to the people who most need them. I have seen women in Sri Lanka who were eager to control their fertility but so poor that they had to buy oral contraceptive tablets 5 at a time rather than in a monthly pack of 21. An estimates 120 million couples in developing countries do not want another child soon but have no access to family planning methods. Consequently, pregnancy often brings despair instead of joy.

Limiting family size can be difficult. A healthy woman may be fertile between the ages of 12 and 50, and men produce viable sperm from puberty until death. Many couples engage in intercourse without taking precautions because they cannot find or afford contraception. For others, sex can be a violent act that leaves a woman with no opportunity to protect herself against unwanted pregnancy. A survey conducted in 1998 in the Indian state of Uttar Pradesh found that 43% of wives had been beaten by their husbands. If such women are to be helped, contraceptives have to be very easy to get.

In many countries, laws create hurdles. Japanese women were until 1999 forbidden access to the pill and so had to rely heavily on abortion. Until the early 1990s, condom sales in Ireland were restricted to certain outlets, and even today some pharmacists refuse to sell them. The Indian government does not allow injectable contraceptives to be used, although the method has proved popular in neighboring Bangladesh. The rich typically have ways to get around such obstacles, but the poor do not.

In some nations, contraceptives are available only by medical prescription. This means that they cannot reach the many villages in Asia and Africa where there are no doctors. In Thailand, large numbers of women started to use birth control pills as soon as nurses and midwives were given the authority to distribute them. Restrictive medical practices limit family planning choices and make contraception more expensive, but add nothing to safety. Birth control pills are safer then aspirin. The world would be a healthier place if oral contraceptives were available in every corner store and cigarettes were limited to prescription use.

Changes in South Korea and the Philippines present a stark example of how family size plummets when consumers are offered a range of appropriately priced contraceptive options through convenient channels. In 1960 families in both countries had an average of about 6 children. By 1998 fertility had fallen to 1.7 in South Korea. In the Philippines, though, fertility was still 3.7, because family planning help is harder to get there. Economic research strongly suggests that small family size is a prerequisite to higher per capita income. The difference in fertility rates between South Korea and the Philippines thus probably goes a long way toward explaining why income in South Korea reached $10,550 per person in 1998, whereas in the Philippines it was only $1,200.

In Columbia, fertility fell from 6 to 3.5 in only 15 years, after contraceptives became widely available in 1968. In Thailand the same jump took a mere 8 years. That identical transition took the U.S. almost 60 years, from 1842 to 1900: anti-vice activist Anthony Comstock persuaded Congress to restrict sales of contraceptives in 1873, and it was not until 1965 that the Supreme Court struck down the last laws banning contraception. No surveys of desired family size were conducted in the U.S. in the 19^th century, but I suspect that many couples had more children than they intended.

The contrasting cases of Bangladesh and Pakistan illustrate particularly well how family planning can help women escape centuries of obedience to their mothers-in-law and of subservience to their husbands. Until a civil war in 1971, these two countries were a single political unit, and women had an average of seven births. Over the past 20 years, Bangladesh has made a systematic effort to provide a variety of fertility regulation methods, including the pill and injectables. With these, women can control whether or not they become pregnant—an advantage they may lack if they rely on their husband’s use of a condom. As a consequence, in spite of appalling poverty, fertility has fallen to 3.3 as contraceptive use among Bangladeshi women has risen from 5% in the 1970s to 42% today. Similar changes have not occurred in Pakistan, where most of the population still does not have access to fertility regulation, and women there bear an average of 5.3 children. These differences will have consequences that will last well into the 21^st century. Although Bangladesh will increase its numbers by 65% by 2050, Pakistan will probably by then have over 200% more people than it has today.

Offering Choices
My lifetime has seen the most far-reaching demographic changes in history. Global population has almost tripled since I was born in 1935; it has quadrupled during the past century. The primary reason is a welcome decline in infant and child mortality brought about by the spread of public health measures such as vaccination. Unfortunately, this progress has not been accompanied by a parallel spread of modern contraception.

It is only since the 19^th century that families have routinely seen more than two children survive to the next generation—otherwise there would have been a population explosion centuries ago. Large families are a recent, and temporary, anomaly. Small families reduce stress on the environment, benefit economies—and gain directly themselves. Research in Thailand has shown that children born into families with two or fewer offspring are more likely to enter and stay in school than are children from larger families with four or more youngsters. When pregnancies are spaced at least two years apart, both mother and baby are significantly more likely to survive.

When Paul Ehrlich wrote his well-known book The Population Bomb in 1968, Western governments were just beginning to support family planning in countries such as South Korea. At the time, demographers and politicians spoke about “population control,” giving the impression that rich countries were telling others how their people should live. Today we know that the surest way to bring down the birth rate is to listen to what people are asking for and to offer them a range of choices. Adults are capable of making up their own minds about what they want.

Many people in the developing world can afford a small payment for modern contraceptives, but poor countries cannot meet the full cost of manufacturing, distributing and promoting them. A few governments, such as those of India and Indonesia, provide contraception free or at subsidized prices. Yet many nations are too impoverished or too corrupt to make family planning a priority. For many of the hundreds of millions of people around the world who live on a dollar a day or less, donations from the rich countries are essential—and wanted.

This consensus achieved public prominence in 1994, when the United Nations organized the International Conference on Population and Development in Cairo. Its Program of Action broadened the traditional scope of population activities to include not only family planning but also efforts to reduce maternal mortality, to treat sexually transmitted infection and to slow the spread of AIDS. The price tag foreseen for the year 2000 was $17 billion, of which $6.5 billion (in 1998 dollars) was to come from rich developed nations.

Will that money be available? Not on present showing. In 1998 the total flow of foreign aid from rich to poor countries was the lowest in 30 years. Of this amount, only about 3% was allocated to assist family planning and reproductive health. Indeed the U.S. has cut its funding for international family planning programs over the past few years.

Counting the Unborn
Many of the parents of the 21^st century’s children are already born, so credible estimates of the future world population can be made to about 2050. The latest projections from the UN Population Division, envisages a global total between 7.3 billion and 10.7 billion in 2050, with 8.9 billion considered the most likely figure.

It is crucial to realize, however, that this “most likely” number assumes a continuing rise in the rate of use of contraceptives and consequent widespread decline in birth rates. Specifically, it supposes that fertility in developing countries will reach 2.1 by 2050. With current rends, this actually seems unlikely. Large regions of Africa and southern Asia have fertility rates far above 2.1, and unless more funds for family planning become available, I see no reason to think fertility will fall as much as the UN’s “most likely” figure assumes.

The success or failure of national family planning efforts in this millennium will divide the world along a new geopolitical fault line. These newly industrialized nations of Asia and Latin America that see family size settle at two or fewer children by about 2010 will join the club of rich Western nations. They will have a slowly aging population, and the number of their citizens older than 60 will double by 2050.

The other set of countries, in Africa and the Indian subcontinent, will be overwhelmed by burgeoning population growth. Vast cohorts of young people will grow up with little education and even fewer job opportunities. Some may form gangs in politically unstable, exploding city slums; others may try to eke out a living by cutting down the remaining forests.

The Cairo conference recognized “the crucial contribution that early stabilization of the world population would make toward the achievement of sustainable development.” Transforming the global economy into a biologically sustainable one may well prove the greatest challenge humanity faces. Ultimately, we have to construct a world in which we take no more from the environment than it can replace and put out no more pollution than it can absorb.

If this transformation is to succeed, societies will have to reduce both levels of consumption and population size. Even today it would impossible for the planet to sustain a Western standard of living for everyone. Many experts predict that a billion people will be facing severe water shortages by 2025.

Fortunately, much expertise has accumulated about how to make family planning available. The cost to developed nations of meeting this vital need is less than $5 per person per year. That amount is trivial in comparison with the financial, environmental and human costs of inaction.

Malcolm Potts is a British physician who also holds a PhD in embryology from the University of Cambridge. For the past 30 years, he has worked with many organizations to implement family planning services worldwide. Presently, he is Bixby Professor in the School of Public Health at the University of California, Berkeley.