Birth Control Choices
Within a decade, women everywhere should have access to quality contraceptive services, argues John Bongaarts.February 24, 2016, Nature magazine By: John Bongaarts
Earth's population is expected to grow by 50% from 7.3 billion today to 11.2 billion in 2100. Most of the growth will be in the least developed regions of south and west Asia (including in India and Pakistan), and Africa. The largest increase is projected in sub-Saharan Africa with a quadrupling of population - from just under a 1 billion today to 3.9 billion by 2100.
Rapid population growth, with attendant consumption and waste, has pervasive adverse effects on societies and the world's ecosystems. Countries with lower population growth, such as the east Asian 'tiger' economies, including South Korea and Taiwan, have seen rapid increases in per capita incomes as birth rates declined.
Programs to provide voluntary family planning education and services, along with investments to improve education and health, have been the main policy response to rapid population growth since the'60s. These programs address the substantial level of unwanted and unplanned pregnancy, as well as an unsatisfied demand for contraception. About 74 million unplanned pregnancies occur each year in the developing world. About half of these end in induced abortions.
Low levels of female education, lack of knowledge about and access to contraception, insufficient supplies and services and cost and fear of side effects are the main reasons for unwanted and unplanned pregnancies. Additional reasons are opposition from spouses and family and traditional gender roles that support a desire for large families. Family planning programs must go beyond simply providing supplies and services; they must also reduce or eliminate these obstacles.
Evidence that such programs work comes from field experiments, such as the one the Matlab region of Bangladesh that began in'77. People in the Matlab experimental area were provided with free services and supplies, home visits by well-trained female family-planning workers, and comprehensive media communication. Outreach to husbands, village leaders and religious leaders addressed potential social and familial objections.
As a result, contraceptive use jumped from 5% to 33% among married women of reproductive age in the experimental area, and fertility declined rapidly. Among the long-term consequences of this reduction in births were that the children in the experimental area being educated to higher levels, families having greater household assets, and the greater use of preventive health services.
Similarly, other countries that have suddenly implemented comprehensive family-planning programs (such as Iran in'89 and Rwanda in the mid-2000s) have seen rapid subsequent changes in reproductive behavior.
Iran's fertility declined from 5.6 births per woman in the late'80s to 2.6 a decade later. In Rwanda, fertility dropped from 6.1 in 2005 to 4.6 in 2010, and the proportion of married women using contraception jumped from 17% to 52%. Both countries' information programs shifted norms by including messages about the benefits of smaller families, raising the demand for family-planning services.
With major investments in family planning, the fertility trajectory could easily be reduced by 0.5 births per woman within a few years after the start of the intervention. This would lead to a population of 2.8 billion in sub-Saharan Africa by 2100. That is around 1 billion fewer people than the current projection.
Education of girls is a powerful brake on fertility. Educated women marry later, tend to want smaller families and are more capable of overcoming obstacles to their use of family planning. However, educated women must have access to contraception to act on their reproductive preferences. Family planning, education (of women and men) and socio-economic development are mutually reinforcing, and should be pursued together.
Support for family planning programs has fluctuated widely over the past 50 years. An initial surge of investment was made in the'60s and early'70s, as the UN and donor countries urged developing countries to address high fertility and rapid population growth.
Several countries accused the industrialized nations of making neo-colonial and imperialistic efforts to keep them weak and impoverished. The Catholic Church, which had long opposed to artificial birth control and abortion, took an aggressive stance in opposition to government-sponsored family planning programs worldwide. And when Republicans have occupied the White House, US lawmakers have also generally been unsupportive of international family-planning programs - reducing funding and adding onerous restrictions.
Despite these obstacles, contraceptive use rose steadily in Asia and Latin America during the'80s. Then, in the'90s, aid for family planning was diverted to fight the AIDS epidemic; also the fertility declines in Asia and Latin America led to optimism that population growth in Africa would soon slow.
Some economists argued that voluntary family-planning programs are ineffective. Parents are thought of as people who choose the number of children that they have in the same way that they might choose how many televisions or bicycles to buy.
The problem with this reasoning is that goods require an active purchase, whereas pregnancies occur unless an effort is made to avoid them. Another fallacy is the assumption that the cost (monetary, social and practical) of contraception is sufficiently low so as not to influence decision-making. From this perspective, the occurrence of unwanted pregnancies should be as rare as people having unwanted new televisions; thus they erroneously conclude that family-planning schemes should not be given priority.
Even women who use relatively effective methods find avoiding unintended pregnancies difficult; total pregnancies resulting from failure of such methods number in the tens of millions each year.
Fortunately the accumulating evidence of plummeting birth rates in a few countries (such as Ethiopia and Rwanda) has largely persuaded policymakers of the cost-effectiveness of these programs.
To reduce high birth rates, each woman, wherever she may be, should have access to quality contraceptive services within a decade. Even in rural areas of poor countries, women should have the choice of multiple contraceptive methods - pills, injectables , barrier methods, even long-acting methods such as intrauterine devices and systems (IUDs and IUSs), implants and sterilization. Where legal, safe abortion services should be made available. Other obstacles to contraceptive use, such as incorrect rumors about side effects and conservative social attitudes, should be addressed by the education of women and men, media campaigns and collaboration with community leaders.
Coercion of any kind should be ruled out. Women and men have the right to decide freely on the number, timing and spacing of children, and on the means to achieve their reproductive goals.
Funding to achieve these goals has been lacking: only 1% of all overseas development assistance (ODA) is allocated to family planning. However, over the past decade, investments in the developing world have risen, especially after the 2012 London Summit on Family Planning, at which many donors and governments renewed or increased their commitments. The proportion of ODA allocated to family planning should be doubled to 2%. Such an increase of funding will be more than repaid by savings in other sectors such as education and health care in future years.
At the international level, development agencies and donors should hire more population experts to write more reports that would include a discussion of the role of demographic shifts in relevant sectors, of the development benefits of reduced birth rates and of the options available to change these trends.
At the national level, ministries of finance or planning commissions should examine alternative population trajectories. Family planning has been ranked by economists at the Copenhagen Consensus Center as one of the most cost-effective development interventions.