AT THE Marie Stopes clinic on the outskirts of Ouagadougou, in Burkina Faso, Juliette, who is about 30 years old, smiles up from the table where she is having an intrauterine contraceptive coil fitted. She says she has three children and does not want any more. Her husband, she admits, does not know she is having the procedure but she thinks he will not mind. To judge by the crowds, nobody minds. The two-storey building is swarming with mothers and children—it gets about 14,000 visits a month, says Sally Hughes, its director. A jeep has just pulled into the courtyard bringing back the doctor, midwife and nurse from their daily tour of the surrounding villages, where they take contraception to many more. Contraception is cheap by rich-country standards—but not for locals. Implants cost Marie Stopes International $25 each, but the charity can charge just $1.50. So donations and government help are needed to keep up with surging demand. Burkina Faso has one of the highest fertility rates in the world, with women likely to bear six children on average in their lifetime. But the number is falling. In 1990 it was seven and in Ouagadougou itself it is below five. Ms Hughes says: “Women use contraception because they want to work and they worry about feeding and educating the children. Men don’t worry about that… but they respond to arguments about their wives’ health and income.” For more than a decade, family planning in developing countries has been carried on in clinics like this without much outside attention. Though national provision has been patchy—contraceptives are encouraged in some places, banned in others—international donors have steered clear of the issue. The last big United Nations conference on family planning took place as long ago as 1994. American politics plays a role. In 1984 Ronald Reagan withdrew American federal aid to groups that performed or advocated abortion. Democratic administrations have rescinded this policy and Republican ones reinstated it. The term “family planning” dropped out of fashion—it was associated with coercive population controls—and was replaced by “sexual and reproductive health”. Many economists have argued that contraception anyway is largely irrelevant: demographic patterns, they claim, do not have much influence on economic growth and the important thing is broader socio-economic development. Others disagree. John Cleland of the London School of Hygiene and Tropical Medicine calls the past 15 years ones of “horrendous neglect”.

So a summit on family planning, held in London on July 11th, represents a big change. The meeting, called by the British government and the Gates Foundation, a charity, won promises of $4.6 billion from donors and developing countries, to provide modern contraception (coils, pills, injectables, implants and condoms) to an extra 120m women by 2020. This would be a hefty increase on the $4 billion spent each year on family planning in those countries.

Back in fashion

If it achieved the hoped-for goals, the new money would more than halve the number of women in poor countries who want or need modern contraceptive methods but cannot get them. According to the Guttmacher Institute, a think-tank in New York, 222m women aged 15 to 49 were in this position in developing countries in 2012 and the number is falling annually by just 0.5%. “After 20 years of neglect,” says John May of the Centre for Global Development, a think-tank in Washington, DC, “family planning is back.”

Not before time. Whereas most of the world, including many developing countries, has seen family size and fertility fall (in part because of the availability of contraception), some places have missed out on the demographic revolution. More than four-fifths of women can get family planning in East Asia. But in the Middle East and most of sub-Saharan Africa the proportion is less than half. In west and central Africa, the share is only a tenth.

This is a substantial group of laggards. About one in seven of the world’s people live in countries where the fertility rate is 4.0 or above. As Mr May points out, most of the 48 poorest countries fall into this category and the UN projects that their population will double from 850m in 2010 to 1.7 billion in 2050. This population growth is not all from choice. In countries where big families are the norm, most parents say they want fewer children. Providing contraception “is about listening to what parents want”, wrote the prime ministers of Ethiopia and Rwanda in the Lancet, a medical journal, on the eve of the summit.

The cost of unwanted children

Lack of family planning holds countries back. As fertility falls from high levels, it brings a demographic dividend: a bulge of working-age adults. So long as contraception is lacking and fertility stays high, countries miss out on the dividend, getting large numbers of dependents instead. In the 1960s the dependency ratio (the ratio of children and pensioners to the whole population) was about ten points higher in Africa than in East Asia. After 50 years of fertility decline, East Asia’s dependency ratio is about 40 points below Africa’s.

Contraception has direct health benefits, too. The Guttmacher Institute calculates that there will be about 80m unintended pregnancies in developing countries this year, resulting in 40m abortions, 10m miscarriages—and 100,000 maternal deaths, 800,000 still births and 600,000 infant deaths. Making contraception universally available, the institute reckons, would cut the number of unwanted pregnancies by two-thirds, resulting in 26m fewer abortions and 21m fewer unplanned births. What vaccinations are to infant mortality, contraception is to maternal mortality. No less important, argues Mr Cleland, is the impact of family planning on the spacing of births. The medical evidence is clear: if a woman conceives within 18 months of bearing a child, the chances of miscarriage or still birth, low birth weight, infant death and stunted physical development are much increased. Spacing births improves child health.

This makes family planning cost-effective. The Guttmacher study reckons that for every $1 spent on modern contraception, developing countries would save $1.40 in maternal and newborn health care—to say nothing of the misery avoided. Family planning, says Mr Cleland, “ought to be one of the priority interventions for maternal health, neonatal survival and child health”. The London summit is a welcome, if shamefully late, start to that.