November 13, 2009, Global Footprint Network By: Martha Campbell and Kathleen Bedford

Note: this long but very informative article has lots of footnotes. Please go here to see the entire article and its footnotes



Once it is understood that fertility can be lowered by purely voluntary means, comfort with talking about the population factor in development will rise.



The ability of those concerned with ecological change, resource scarcity, health and educational systems, national security, and other global challenges to look with maximum objectivity at the problems they confront has been hindered by the silence about population growth. This silence has been in place since the 1990s.



The two questions "is population growth a problem?" and "what causes fertility decline?" are often intertwined; if people think the second question implies possible coercion, or fear of upsetting cultures, they can be reluctant to talk about the first.



The classic theories assume that couples want many children and they make decisions to have a smaller family when some socio-economic change occurs. However, this explanation has numerous inconsistencies.



Societal changes are neither necessary nor sufficient for family size to fall. There are many barriers of unscientific restrictive medical rules, cost, misinformation and social traditions that exist between women and the family planning methods and correct information they need to manage their family size. When these barriers are reduced, birth rates tend to decline.



Explanations of fertility should 1) attach more weight to the many barriers to voluntary fertility regulation, 2) recognize that a latent desire to control fertility may be far more prevalent among women than previously understood, and 3) appreciate that women implicitly and rationally make benefit -cost analyses based on the information they have, wanting modern family planning only after they understand it is a safe option.



Darwinian evolution is driven by an unwitting reproductive competition in which those plants and animals who produce the most offspring are the ones that most successfully pass on their genes to future generations and their particular characteristics are perpetuated. From a biological perspective, it is puzzling, then, that rich and powerful people do not have more children than the poor.



Over the millennia, those men who successfully sought the most frequent sex and successfully controlled the most females left the most genes to the next generations, reinforcing these tendencies.



History and the contemporary world are replete with examples of ways men use their power to control women's reproductive lives.



Although most societies throughout history were polygamous and patriarchal. Western Christianity promoted monogamy and a negative framing of carnal pleasures, expressed in the story of Eve in the garden of Eden, who ate the apple of knowledge, and in the process, condemning the human race to mortality and herself to the pains of childbirth. The only justification for sex within marriage was to procreate. The religious and patriarchal hostility held back the acceptance and use of contraception. By the end of the nineteenth century, European powers had colonized much of the rest of the world, disseminating its negative, largely patriarchal views of reproduction and sexuality. The religious and cultural biases were influential at a policy level in many countries.



While European powers introduced basic public health measures and vaccination in their colonies (and the USA did the same for the Philippines), no western ruling power tried to support the introduction of family planning.



Classic theory on demographic transition are based on an assumption that it is natural for couples around the world to want many children and that they change their minds when some change in society occurs, such as the distal factors of improved education, or the education of girls and women in particular, or increased wealth, economic opportunity or reduced infant and child mortality. Increased poverty is also seen as one of these distal factors. Behind these theories is an assumption that when this exogenous change occurs, couples will find a way to achieve their smaller family size, through contraception, abortion, age of marriage or breastfeeding.



However, there are many examples that expose inconsistencies in the classic theory of demographic transition. The Princeton Fertility Project in the 1970s found that consistent patterns of socio-economic change were not always found in European examples of fertility decline in the eighteenth and nineteenth centuries. The report "Population in Twenty-first Century: The Role of the World Bank" recognizes discrepancies between the assumed social and economic bases for couples' decisions to have a smaller family and the actual fertility decline in Bangladesh and Indonesia where these conditions were not present.



The economic model of parents' weighing the costs and benefits of having a child, much as they would weigh the costs and benefits before making purchase decisions for durable consumer goods, such as a major appliance or a car, is not consistent with the biology of human reproduction.



The fact that humans have sexual intercourse many hundreds or even thousands of times more frequently than is needed to achieve the desired number of pregnancies obviates the possibility of applying rational decision-making about when to have a baby. Unlike other mammals, ovulation is concealed in women, and given frequent intercourse, we are forced to take frequent, repeated, persistent and perfect steps 'to separate sexual intercourse from childbearing'. If human reproduction were like purchasing a major appliance for our homes, we would have to take the initiative of asking the store several times a week not to send a new appliance, and if we failed to do this repeatedly, perfectly and persistently, one would be delivered, by default, at our door a few days later (Engelman 2008).



Education of women is the most frequently mentioned factor influential in the process of fertility decline. However education is not a reason for fertility decline in itself, instead it functions through its many assets, as 'educated individuals expect lower child mortality, feel more restricted by children, have easier access to reproductive healthcare, are more open to the media, and are more likely to influence others'. It is worth adding that education helps women to distinguish between the common barrier of misinformation about contraception and the correct information they need to manage their childbearing. Women in urban areas generally have easier physical access to contraception than those in rural areas.



While education is clearly beneficial for women themselves, their children's health and education, and their communities -- it is not a prerequisite for high contraceptive use.



In the Philippines, where female literacy is high but access to modern contraceptive methods is low, women in the lowest economic quintile have an average of 6.5 children. By contrast, access to fertility regulation methods in still largely illiterate parts of rural Bangladesh has resulted in replacement level fertility.



Patriarchal barriers to family planning: there are many patriarchal pressures that continue to marginalize women around the world, which women's health advocates have frequently pointed out. Many women lack equal treatment under the law, are subject to domestic violence, have inadequate health services and are separated from educational and economic opportunities. In agrarian societies, women often do most of the agricultural work while not being permitted to hold or control property.



Coercion in family planning: At the 1994 International Conference on Population and Development (ICPD, or Cairo), women's health advocates highlighted coercion in family planning, particularly in India in the 1970s and under China's one-child policy. While there is no question that episodes of coercion in India and China were highly reprehensible, it is odd that there was little attention paid to the coercion involved in forcing women to have pregnancies they did not want, which were and continue to be today. This emphasis on coercion steered international attention to 'reproductive health' and away from the term 'family planning'. The term 'family planning' became politically incorrect to use by itself in the policy and philanthropic communities.



This shift of acceptable language is likely to have led to reduced financial support for family planning budgets -- and more on AIDs funding -- in foreign aid agencies. The term reproductive health was easily adopted in the women's health community and in agencies working in these international areas, it has been less well understood and less easy to identify with in the parliaments of Europe and the US Congress. Population studies experts have found that the term reproductive health was not well defined and not a compelling concept.



The terms 'family planning,' 'population', 'Malthusian', and even 'demographic' became pejorative terms describing those who continued to express interest in population growth. 'Population control', a term that had been virtually unused in the international policy community for well over a decade, became a popularized derogatory label identifying those who continued to be concerned about the population growth factor in development.



Today many young professionals and students on university campuses have been taught that the connection between population growth and the environment is not an acceptable subject for discussion.



Women's health advocates active in the Cairo process tried to draw on funds in existing family planning budgets for the broader goals of improving women's health and empowerment. Unfortunately this shifted attention away from slowing population growth, a counterproductive move, since access to family planning options did not expand with the increase in the number of women who wanted them. In a number of African countries, the disparity in TFR between the richest and poorest economic quintiles has increased since the 1990s.



While the efforts of the women's health advocates did produce some important benefits for women, these have generally been on a small scale, and the expansion of access to family planning has not been among them. The Department for International Development in its report for the 2006 UK Parliamentary hearings on the impact of population growth on the millennium development goals (MDGs) said: 'The ability of women to control their own fertility is absolutely fundamental to women's empowerment and equality'.



Most women's health advocates wanted access to safe abortion, but they only wanted family planning services as part of comprehensive health or reproductive health services. Some of them disliked hormonal contraceptives such as pills and sub-dermal implants. Women's advocates in India caused the government's highest court to outlaw injectable contraception from the government family planning programs. This popular effective method allows women to avoid pregnancy without their partners knowing they are using birth control.



The myth that originated from the Cairo process (and even from the Rio Earth Summit two years before), in its shift towards helping women, labelled everything that happened before Cairo as 'population control'. Any mention of the numerically more common and successful voluntary family planning programs that had been developed between the 1950s and 1990s was suspect.



Family planning often began with relatively rich women who already enjoyed the privilege of being able to manage their own family size and who were intensely aware that the poor women around them had no such option.



In addition, the vast majority of the successful national family planning programs were designed to make contraception easier for women and men to obtain, not to force them to curtail their childbearing.



Some of the speakers at Rio believed that a focus on population was driven not by humanitarian motives but by neo-colonial interests and a wish to protect and maintain the rich lifestyles of the North. They said that attention to population growth macro-level data was conducive to inhumane approaches in reducing birth rates, and therefore it was best to reduce discussion of the macro-level population concerns, in honor of disadvantaged women.



The ICPD Programme of Action (Cairo) was explicit about the danger of continued rapid population growth and the need to focus on family planning in the short term, writing, 'during the remaining six years of this decade (1994-2000), the world's nations by their actions or inactions will choose from a among a range of alternative demographic futures.' The document emphasized the urgency of slowing rapid population growth by pointing out that the difference between the high and low projections of global population between 1994 and 2015 'exceed the current population of the African continent.' All the nations subscribing to the ICPD should 'meet the family planning needs of their populations as soon as possible and should in all cases by the year 2015, seek to provide universal access to a full range of safe and reliable family planning methods.' 'Governments should unnecessary legal, medical, clinical and regulatory barriers to information and to access to family planning services and methods' (United Nations 1996).



The pervasiveness of barriers to fertility regulation has been so vast and deeply infused into societies and medical structures that some contraceptive options are immediately crossed off in women's minds before they are even tried, owing to widespread misinformation, medical rules and additional barriers that prevent adoption of otherwise effective methods.



Obvious barriers to contraceptive use include laws making abortion and some contraceptive methods illegal, geographical distances from sources of supply or services, unaffordable financial costs, and shortfalls and breaks in commodity supplies. Where contraception is technically available, regulations often make access to contraception difficult to obtain, such as non-evidence-based prescription requirements prior to the use of specific contraceptives or burdensome parity requirements for sterilizations.



Provider biases or medical barriers to contraceptive use take the form of unscientific requirements such as blood tests before hormonal methods can be obtained or providers' refusing contraception unless a woman is menstruating on the day she reaches the clinic.



Pakistan's 10,000 lady health visitors working in rural areas are required to have an eighth grade education in order to distribute oral contraceptives. In many villages there is no female resident with this level of education. When the Kaiser Foundation Health Plan in California removed all co-payments for contraception, the contraceptive prevalence rate rose 18%.



Where the status of women is low, intangible social barriers to accessing family planning can formidable. Afghan refugees in a border town in Pakistan were asked by healthcare workers if they had their husbands' permission to use contraception. In Matlab, Bangladesh (1996), a young woman had to manage any visit to a clinic through conversation with her husband who in turn will talk with his mother.



Fear of side effects of contraception is widespread, and it is one of the most important explanations for non-use of contraception. Some of this fear is due to actual side effects of a method, but a large portion is widespread misinformation, beliefs that contraceptive use will have negative health impacts. Oral contraceptives, which are very safe, are often framed as highly dangerous, while Viagra deaths, which occur relatively often, go largely unnoticed. In many settings, oral contraceptives are perceived to be more dangerous than pregnancy, although in a low resource setting having a baby can actually be up to a thousand times as dangerous as taking the pill.



Some African women believe that pills and injectables can cause infertility and others believe that IUDs can float upward into their stomachs.



Another source of misinformation is the fact that oral contraceptive pills are still unnecessarily sold on prescription in many countries, even though safety is not a problem.



One of the most deep-seated barriers to fertility regulation is the lack of access to safe abortion. In all societies where women on average have the number of children they want, this is achieved through a combination of contraception and abortion, although not every woman resorts to the use of abortion.



Analysis by Tietze and Bongaarts suggested, 'unless there is a major breakthrough in contraceptive technology or major modifications in human sexual behaviour, levels of fertility required for population stabilization cannot be easily obtained without induced abortion'.



If abortion is accessible in a country the TFR is likely to be one child lower than if abortion is not accessible. No country has reached replacement-level fertility without widespread access to safe abortion for poor women as well as the rich, who tend to have this access everywhere.



Barriers to accessibility for safe abortion for low-income women in developing countries can include price, sexual exploitation and threat of imprisonment. Those women for whom unsafe abortion is the only option, risk extreme pain, debilitating injuries that often last a lifetime, and death.



None of the classic or economic theoretical explanations for fertility decline predicted or could explain the below replacement level fertility now found Europe and Japan. Leading demographers doubted that the early efforts to make family planning more accessible would work. The standard theoretical framework did not explain the fall in Iran's TFR from 5.2 to 2 in the 12 years between 1988 and 2000.



The timing of fertility decline is dependent on the degree to which women have freedom from barriers to fertility regulation and are able to obtain both the technologies and the supporting information they need to manage whether or when to bear a child. This model has now been dubbed as the 'opportunity' model.



The reduction of patriarchal barriers to fertility regulation methods and information is necessary for replacement-level fertility to be achieved in any society. Disappearance of the barriers may be sufficient as well, regardless of women's or couples' education or wealth.



One possibility is that latent desire of women to control fertility is more widespread than is commonly recognized and that most women in all societies, if they had the means and understood that safe options were available, would choose not to bear many children. The direct threat of pregnancy and childbirth to the life of the mother is no small consideration.



Freedman (1997) wrote that availability of contraceptives can crystallize latent demand. The concept of latent desire to control one's fertility is illustrated in published studies where women who had not expressed any desire for using family planning have nevertheless welcomed it once the opportunity arose. In Africa, providing general as well as specific information through the broadcast media has had positive influence on contraceptive use.



One analysis in Morocco observed that 'women in societies where contraceptive use is widespread, may find it easier to act on their contraceptive intentions than women in societies or communities in which contraceptive use is less common.'



In analysing patterns of contraceptive use in Matlab, Bangladesh, Phillips et al.observed that latent demand for contraception was activated by appropriately delivered, socially sensitive supply in an impoverished society, and this new opportunity also influenced desired family size.



Items such as garage door openers, Post-its, or TV remotes, IPods and the Internet were not particularly desired until the opportunities they showed up were realistic options.



Ultimately the decision-making power needs to be in the hands of woman, because biologically she invests far more than a man in each child she conceives and carries.



The fertility decline in a number of the developing countries and in most developed nations has taken a sense of urgency out of the problem, and below replacement-level fertility, with special concerns about the ageing of populations in Europe and Japan has received much attention.



Global warming has focused well justified attention on the impact of high levels of western consumption on the environment. Thinking rationally about the population factor in development has been hindered by a millennium of cultural and religious opposition to a woman's ability to make decisions about the size of her family.



Finally, the assumption that couples naturally want many children has made it difficult to see the many barriers blocking women's options to manage their own childbearing.



Once women have the opportunity to decide whether and when to have a child, then birth rates can be lowered in a human rights framework. An emphasis on opportunities to access family planning places female decision-making centre stage, respecting and empowering women to decide whether and when to have a child.



When it was thought that social and economic changes as prerequisites for the demographic transition to take place, then the question about whether population growth is a problem has tended to be pushed aside by the media and policy-makers, because if needed socio-economic changes are not occurring then the inference is that either that the situation is hopeless or coercion is needed.



If it is understood that birth rates can be lowered by purely voluntary means, then the question 'is population growth a problem?' can be addressed squarely.



Health and education systems in countries with high fertility cannot keep up with their rapidly growing populations. The developing world needs to meet the challenge of training and deploying two million new teachers every year just to stand still, without any increase in the percentage of children in school.



The number of people living in abject poverty in sub-Saharan Africa has hardly changed in percentage terms but has grown substantially in absolute numbers.



As it becomes increasingly apparent that birth rates can be slowed within a human rights framework, then those concerned with ecological change, resource scarcity, climate change, national security and other global problems can begin to look objectivity and creatively at the role of the population factor in the problems they confront.