Our Profound Choice: 7 Billion Reasons to Invest in Family Planning

July 19, 2011 • Daily Email Recap

From the May 2011 issue of Population Connection’s The Reporter.  See http://www.populationconnection.org/site/News2?page=NewsArticle&id=8051 to download the full magazine.

Our Profound Choice: 7 Billion Reasons to Invest in Family Planning

By Martha Campbell and Malcolm Potts

As the global human population reaches 7 billion later this year for the first time in world history, there are several simple things we can (and should) be doing to slow population growth and get on a path toward stabilizing our numbers at 8 billion.

Demographic projections are not predictions. They tell us what can happen if we make a variety of policy choices and investments, most of them pertaining to family planning. The UN high variant projection for the world population in 2050 is 10.5 billion. The low variant is 8 billion. The difference between these two numbers – 2.5 billion – is equivalent to the population of the entire world in 1950. With 2.5 billion more people come farms and factories, mines and ports, and schools and hospitals that must be built and maintained-and energy that must be consumed.

It took nearly 130 years for the world population to grow from 1 to 2 billion, but the recent growth from 6 to 7 billion has occurred in only 12 years. Will the next billion be added so quickly or will we slow the tide toward a more sustainable peak figure?  Since the mid-1990s, international attention has shifted away from family planning. Unless critical changes are made as rapidly as possible, even the high projection of 10.5 billion people in 2050 could be exceeded. In fact, business as usual has us on track to surpass 11 billion in 2050.

Most specialists outside the population field, such as agriculture and climate change experts, assume that world population will reach 9 billion (the UN medium projection) in 2050 and little or nothing can be done to alter this path. This is the wrong approach and every sensible person must ask: Is human population growth some phenomenon beyond our control, or are there policies and  investments that would enable global population to stabilize at the lower projected number?

It is a genuine, dramatic, profound choice. Early in the Second World War, when England stood alone against Nazi Germany, Winston Churchill made his famous “their finest hour” speech. He posed that the world could “move forward into broad, sunlit uplands” or, alternately, that it could “sink into the abyss of a new Dark Age…” Today, Churchill’s stirring words apply not to two nations at war, but to a decision about human population that the whole planet must make. A difference of 2.5 billion will have a huge impact on whether we can feed and employ rising numbers of people while also switching to an ecologically sustainable economy. It is a challenge as formidable as any war and the choices are as stark as those between the broad, sunlit uplands of the civilized world and an abyss of a new Dark Age.

Demography is an unforgiving taskmaster. Many of those who will be parents in the next 40 years are already born and enumerated. Even if they have fewer children than their parents, global population will continue to grow. We can see the consequences of this type of demographic momentum in China. Although the average Chinese couple now has fewer than two children, as a result of rapid population growth in the past, China’s population continues to increase by 7 million every year. Whatever we do, global population will continue to grow for another generation or two. The key issue is, at what rate?

Fortunately, we know a great deal about how to make family planning available without infringing on any human rights. In nearly every setting where couples, and particularly women, have been provided with the means and correct information they need to manage whether or when to have another child, birth rates have fallen rapidly. There is no reason then – other than lack of political will – that the world population should not stabilize at 8 billion.

Half the world’s women have already reached replacement level fertility, which is an average of 2.1 births. (Demographers use 2.1 because some children die before they are able to reproduce.) Another third of the world’s women have between 2.1 and 4 births. These women live mainly in countries where family size has been falling in recent decades. There is reason to believe that they will move to replacement level fertility in a few more decades-provided that population and family planning are given the priority they deserve.

Demographers used to believe that once a country’s fertility rate began to decline, it would continue to do so automatically. For example, Kenya made a modest but consistent investment in voluntary family planning in the 1970s and 1980s and as a result, the average family size fell from 8 to 5. Later, the focus was taken off family planning, and the naïve assumption that birth rates would go on declining proved sadly wrong. In 1998, demographers projected that the population of Kenya in 2050 would be 51 million. As a result of the loss of attention to family planning and a consequent stall in fertility decline, the population in 2050 is now projected to be 85 million.

Forty years ago, population growth caught media attention and inspired scientific endeavors the way climate change does today. Why have media voices grown silent on this issue? Why do many people, including those representing a variety of advocacy groups, avoid talking about population?

If people think that bringing down average family size involves telling people what to do, or at worst, coercive family planning, then they are unlikely to want to talk about population. In contrast, when people learn that reducing average family size depends on fulfilling an unmet need for family planning, then suddenly they can see that it’s acceptable to talk about population. In short, family planning means listening to what people want, not telling them what to do. The low birth rate in the United States isn’t due to someone telling us to have fewer children; rather, we have achieved small families because we could.

In 1994, the UN International Conference on Population and Development (ICPD) in Cairo drew attention to the many needs of women (some of which had been overshadowed by demographic targets), especially in Africa.  Unfortunately, coming out of that conference, some groups began to view the issue of ‘population’ as politically incorrect.  Family planning budgets collapsed, while HIV/AIDS budgets ballooned. The term ‘family planning’ was replaced by the broader phrase ‘reproductive health,’ triggering numerous pilot projects, few of which were brought to scale. Further hurting the cause, low fertility in countries such as Russia and Japan suggested the ‘population explosion is over.’

In virtually all societies couples have sexual intercourse frequently. This means that women cannot limit family size unless they have access to contraception and accurate information about how to use it. The Demographic and Health Surveys, conducted in nearly every developing country, show that 215 million sexually active women do not want another child in the next two years, or ever, yet they are not using a modern method of contraception.

Holding global population at 8 billion depends on a reasonable level of access to a variety of contraceptive methods made available through a range of distribution channels and backed up with reliable information. Making family planning readily available means changing policies, increasing modest budgets to subsidize the very poor, and overcoming bottlenecks in the supply line.

Family planning is a choice, not a diagnosis, and communities must be empowered to help themselves. In Ethiopia, Venture Strategies and the Bixby Center, working with local leaders, have shown that community volunteers (including, in one case, two Ethiopian priests) can safely dispense the injectable contraceptive Depo-Provera. Such task shifting is key to addressing unmet need for family planning because the demand is so great. There is simply no time to wait for doctors and nurses to tackle the problem single-handedly. Other trained community members must be part of the solution.

Over the decades, family planning has been unnecessarily over-medicalized. In Tanzania, women are refused the Pill if they have five children; in Madagascar, if they have none. There is no scientific justification for either rule. Dispelling misinformation is another necessary step. Some clinic providers give misleading advice or are unwilling to prescribe adolescents contraceptives. Perceived dangers of using contraception are highly prevalent and may be one of the most stubborn barriers to family planning. In many countries, women think the Pill is more dangerous than childbirth, whereas the risks are literally a thousand times in the opposite direction. Reliable ways of dispelling misinformation exist, however, such as the use of community theater and popular radio and television soap operas.

No country has achieved replacement level fertility without access to safe abortion. This is true even of Catholic countries such as the island of Malta, where abortion remains illegal but statistics show many women travel to neighboring countries to terminate unintended pregnancies. The world is most likely to maintain a population of 8 billion if safe abortion is made universally available. This is not because more abortions will be performed, but because those women who have abortions will receive contraceptive counseling. Studies show that after an abortion, a woman is more likely to adopt a method and use it consistently than in any other situation. In Addis Ababa, Ethiopia, the TFR is now 1.6. The most plausible explanation for this uniquely low TFR is that Marie Stopes International provided comprehensive abortion care, including postabortion contraceptive care, for well over a decade before the recent liberalization of the abortion law.

Safe abortion (using manual vacuum aspiration, which can be done in low-resource settings by non-physician providers) and medical abortion (using the drugs mifepristone and misoprostol) are transforming women’s health. In Tigray, a remote part of Ethiopia, 70 percent of the hospital beds were once given to women suffering from botched abortions. Once community health workers were taught how to provide medical abortion, this suffering was virtually eliminated, and women gained from being exposed to modern contraceptive choices.

Without doubt, the greatest challenge of the 21st century will be to move to an ecologically sustainable global economy. If we fail to meet that challenge, then we will irreversibly damage the planet with the most massive extinction of plants and animals since the asteroid that eliminated the dinosaurs.

Some who deny the importance of human numbers point to the Netherlands as a prosperous, small country with almost 17 million people. They ask why the world can’t accommodate a few billion more people at the European standard of living? The problem, as ecologist Mathis Wackernagel points out, is our footprint. The Netherlands imports food, timber, and other resources from around the world. The greenhouse gases it puts into the atmosphere spread from the Arctic to the Antarctic. The footprint of the 17 million people in the Netherlands is eight times the actual area of the country.

The exact worldwide figures are open to debate, but there is legitimate concern that by 2050 the planet’s water, land, and atmosphere will no longer be able to support the population’s needs in a sustainable way. Given time and a great deal of scientific ingenuity, we might still be able to reduce our consumption and create an ecologically sustainable economy. But the more we impoverish the earth in the short term, the more difficult the task will be.

Well over 95 percent of the population growth between now and 2050 will be in the least developed countries-those that are also the least able to feed, educate and employ their burgeoning numbers. The poorest 2 billion people on the planet contribute 3 percent of the greenhouse gases responsible for global warming. Cruelly, the adverse impacts of global warming will be greatest on those who have contributed least to the problem. Global warming will increase the number of people exposed to malaria. In a country such as Bangladesh, a small rise in sea level could inundate vast areas of rich agricultural land.

Even at a population of 8 billion, it will be difficult to feed everyone, as nearly all the good agricultural land in the world is already farmed at moderate intensity. As the emerging economies in Asia and Latin America consume more animal protein, that livestock will be fed the same grain that will be needed for African villages facing starvation. The absurdity of converting grain to ethanol will be responsible for leaving more children malnourished in the least developed countries.

Some of the countries in sub-Saharan Africa, especially those making up the Sahel, face particularly grave challenges. They have average family sizes of 5 or more. In Niger, the rate of population growth exceeds the rate of economic growth. More than one quarter of women over age 40 have 10 or more children, and only 1 in 1,000 women completes secondary school. Approximately 10 percent of children under five in Niger suffer from acute malnutrition and 44 percent of children suffer from chronic malnutrition. If the TFR falls from the current 7.4 to 3.8 by 2050, the population will still expand from 16 million today to 58 million by 2050. If the TFR does not fall so fast, then the population could reach a totally unsustainable 80 million.

The history of family planning is one of missed opportunities. When the World Health Organization (WHO) was established in 1948, the first Director General, a Canadian named Brock Chisholm, saw reducing mortality and slowing population growth as synergistic goals. However, the Vatican and some Catholic countries ferociously opposed giving any assistance for family planning to countries such as India and Ceylon (now Sri Lanka), which requested it in the 1950s. The Catholic minority went as far as to threaten to destroy the fledgling WHO and create a new world organization. Chisholm was forced to back down at a time when death rates were falling in a spectacular way. Vaccination, DDT to control malaria, and relative peace in much of the world had a tremendous impact on death rates. It was at this time that a small but sensible investment in family planning in countries such as those lining the Sahara would have had the greatest leverage.

From the 1970s to the 1990s considerable progress was made in making voluntary family planning available in East Asia and Latin America, but a highly reprehensible episode of coercive family planning in India in the 1970s, the Chinese one-child policy that was initiated in 1980, and Peru’s forced sterilizations in the 1990s set progress back a second time. And, as we have mentioned, the ICPD often focused on women’s empowerment at the expense of population and family planning.

To keep world population at 8 billion we need a sense of scale and a sense of urgency; the confidence that population growth can be slowed within a human rights framework; the political will to make it happen; the investments necessary to make family planning options universally available; the courage to fight patriarchy so that women are free to make the best decisions for themselves; and a burning desire to bequeath our children and grandchildren a sustainable, peaceful and prosperous world rather than a hungry, angry world riven by conflict over resources and a slew of failed states-some perhaps armed with nuclear weapons. Stabilizing the population at 8 billion requires adopting win-win policies that benefit women and their families and help make the world a safer, less divided, more sustainable place.

Population is only one factor among many in health and development outcomes, educational attainment, food and water security, and political stability. It is only one factor, but it’s a critical one. Attention to population will not solve the world’s problems alone, but without it, the world’s problems will not be solved.

Martha Campbell is a Lecturer in the School of Public Health, University of California, Berkeley. In the 1990s she directed the population program at the David and Lucile Packard Foundation. In 2000 she founded and became President and CEO of Venture Strategies for Health and Development, a nonprofit organization that works to help facilitate large-scale health and reproductive health change where it is wanted in low resource countries.

Malcolm Potts is an obstetrician and reproductive scientist. He is the first Fred H. Bixby Chair of the Population and Family Planning program in the School of Public Health, University of California, Berkeley and has developed the Bixby Center with a team of young experts. He was the first Medical Director of the International Planned Parenthood Federation, a position he held for a decade. He has published ten books and over 200 scientific papers.


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