Responding to “Fighting Climate Change with Family Planning”

June 4, 2012 • Family Planning, Serial Dramas, Daily Email Recap

You will likely be interested to read Bill Ryerson’s response to the content forwarded by the PMC Daily Email of May 21st (Fighting Climate Change with Family Planning). If you recall, this was a Sierra Club Magazine article dealing with the deleterious effects of rapid population growth and proposing five ways to achieve a global population stabilization. See here for a refresher and to read other comments:

Bill writes:

I’m glad to see the recognition of the link between population growth and climate change.  However, the statement regarding the first proposed solution is demonstrably false.  The statement reads, “The U.N. Population Fund estimates that 215 million women worldwide who desire modern contraceptives are deprived of them. Access to contraceptives would reduce unintended pregnancies by more than two-thirds, from 75 million to 22 million per year, and save $5.1 billion in pre- and postnatal healthcare.”

It is true that over the last 40 years increasing access to contraceptive services has helped reduce fertility rates.  The view of those who subscribe to the “medical model” of solving the population problem is that additional family planning services will complete the job.

This is perhaps the most important issue within the population field.  Of the money spent by developing and developed countries for population-related work in the developing world, the largest share has gone to providing family planning medical services to individuals and couples.  Inherent in this approach is the belief that a large portion of births are unwanted and that contraceptive availability will solve this problem.  Indeed, a significant percentage of births may be unwanted or mistimed, but large family norms and the cultural and informational barriers to use of contraception are now the major impediments to achieving replacement level fertility.

In Kenya, which was the fastest growing country in the world in the 1980s, contraceptives were within reach of nearly 90 percent of the population by the late 1980s.  Yet currently, only 39 percent of married women use them.

Thus, it is clear that providing contraceptive services alone will not solve the population problem.  Since the late 1960s and throughout the 1970s, studies were conducted in numerous countries measuring women’s knowledge of, attitudes toward, and practice of birth control as well as their family size desires.  These knowledge, attitude and practice (or KAP) studies resulted in the term “KAP-gap” – or “unmet need” – to describe those women who wanted to delay their next pregnancy by at least two years but were not using a modern method of contraception.  In the minds of many policy makers and funders, “unmet need” was equated with “lack of access” to contraceptive services.  However, demographers Charles Westoff and Luis Hernando Ochoa, in a review of numerous Demographic and Health Surveys, determined  that about half the women categorized as having an “unmet need” have no intention of using contraceptives even if they were made freely available.

The confusion between the term “unmet need” and “unmet demand” has misled many people in leadership positions to assume  that such “unmet demand” could be overcome by improving family planning services and contraceptive distribution.  The reasoning of these policy makers has been that, if there was a gap between what people want and what they are doing, improving access to contraceptives would close that gap.  The problem is that the discrepancy between attitudes and behavior has had less and less to do with availability in recent decades.

The situation in Kenya is illustrative of findings in numerous countries recently.  In Kenya, according to the 2008-09 Demographic and Health Survey, 96 percent of currently married women and 98 percent of husbands know about modern contraceptives.  Of the married women who are non-users, 40 percent do not intend to ever use contraception.  Among all non-using married women, 8 percent give as their reason the desire for more children.  Among the reasons given for not using contraception by women who are not pregnant and do not want to become pregnant, only 0.8 percent cited lack of availability of contraceptives, and 0.4% cited cost.  The top four reasons among those who are still fecund: 1) concern with the medical side effects of contraceptives (31 percent); 2) religious prohibition (9 percent); 3) personal opposition (8 percent); and 4) opposition from the husbands (6 percent).  These are all issues that are best addressed by information and motivational communications.

Country by country, the Demographic and Health Surveys show a similar pattern.  Lack of access is cited infrequently by those who are categorized as having an unmet need for family planning.

A 1992 paper by Etienne van de Walle showed that another factor is at play for many women and men – fatalism.  Many people have simply not reached the realization that reproductive decisions are a matter of conscious choice.  Many who did not particularly want another pregnancy in the near future still reasoned that God had determined since the beginning of the universe how many children they would have and that it did not matter what they thought or whether they might use a contraceptive, because they could not oppose God’s will.

For example, Pakistan’s 2006-2007 Demographic and Health Survey found that the most common reason for non-use of contraceptives is the belief that God determines family size.  This answer was given by 28% of the respondents.  Since the fertility rate in Pakistan is 4.0 and the mean desired number of children among currently married women is 4.1, it is clear that family size norms are also a major factor in driving high fertility.

The tradition of large families is a deciding factor in fertility rates in most of sub-Saharan Africa.  For example, the 2008 Demographic and Health Survey in Nigeria, Africa’s most populous country with 161 million inhabitants, found that the average ideal number of children for married women was 6.7.  For married men, it was 8.5.  The fertility rate in Nigeria is 5.7 children per woman, which is below what people say they actually want.

Of all births in Nigeria, 87 percent were wanted at the time and another 7 percent were wanted, but not until later.  Only 4 percent were unwanted.  Nationwide, 67% of married women and 89% of married men know of at least one modern method of contraception.  Yet only 10% of married women report they currently use modern family planning methods.

Of the non-users, 55% report that they never intend to use family planning.  The top reasons given are the desire for as many children as possible (17%), opposition to family planning (39%), fear of health effects (11%), and not knowing a method (8%).  Lack of access and cost were cited by only 0.2% each.  Only about a third of women have discussed family planning use with their husband.

Changing this situation takes more than provision of family planning services.  It requires helping people understand the personal benefits in health and wealth for them and their children of limiting and spacing births.  It also involves role modeling family planning use and overcoming fear that contraceptives are dangerous or that planning one’s family is unacceptable.  It requires getting husbands and wives to talk to each other about use of family planning – a key step in the process to begin using contraceptives.

Delaying marriage and childbearing until adulthood and educating girls are critical.  According to a 2003 report by the Nigerian Population Commission, in northern Nigeria, the mean age at first conception is 15 years.  Teen births increased 50% between 1980 and 2003 in Nigeria, mostly attributable to adolescents in the northern regions.

The above should not be interpreted as suggesting that the level of effort in providing contraceptive services be reduced.  High quality, low cost reproductive health care services are an essential element of fertility planning.  Both quality and quantity of contraceptive choices and services are in dire need of improvement throughout much of the developing world.  But access to family planning methods is not sufficient if men prevent their partners from using them, if women don’t understand the relative safety of contraception compared with early and repeated childbearing throughout the reproductive years, or if women feel they cannot take control of their own lives.

Many population planners measure progress on the basis of contraceptive prevalence rates.  Use of effective family planning methods is critical, but will not result in population stabilization if desired family size is five, six or seven children.

Motivation to use family planning and to limit family size has been the key missing element in the strategy for population stabilization.  While the percentage of non-users of contraceptives has declined, various studies indicate that the number of adults not using contraceptives is greater than it was in 1960, a fact stemming from the enormous increase in world population over the past 50 years.  Approximately 44 percent of the roughly 2.3 billion people of reproductive age who are married or in long-term unions currently use no modern method of contraception.  This means there are about 1 billion adult non-users of contraceptive methods.  It’s time to focus some significant effort on motivating this group to use contraception for the purpose of achieving small family size.

Of the non-users, there are about 215 million women (or 430 million men and women) who want to delay or limit childbearing but are not using a modern method of family planning.  The top reasons for their non-use are cultural and informational issues, namely, fear of health effects, male opposition, religious opposition, and fatalism.  A lot of effort has been focused on providing contraceptives to this group (classified as those with an “unmet need” for contraception), but, in reality, less than 1% in most countries cite cost or lack of access to services as their reasons for non-use.  There are about 600 million adults in marriages or long-term unions who are non-users of contraception specifically because they want additional children or as many children as possible.  This group is more numerous than the group classified as having an unmet need for family planning and deserves a lot of attention via programs that role model the benefits of smaller family norms.

Nearly as important are the desired family sizes of the 1.3 billion users of contraception.  In many countries, those who do use contraceptives still want more than enough children to replace themselves.  Their goals, if achieved, will lead to continued high rates of growth.

Japan has achieved below-replacement-level fertility (1.5 children per woman) in a country where the oral contraceptive pill was illegal until recently.  The United States achieved below-replacement-level fertility in the Great Depression, before the invention of most modern contraceptives.  Similarly, fertility dropped to near-replacement level in the 19th century in Western Europe and the United States.

Demographer Charles Westoff, in a 1988 paper, concludes that, “By and large, contraceptive behavior…is not grossly inconsistent with reproductive intention.”  Only one to two percent of the women failed to use contraception in a manner consistent with their family size preference in Brazil, the Dominican Republic, Peru, and Liberia.  According to Westoff, “The overwhelming majority of women who want no more children or want to postpone fertility, at least in the four countries discussed here, are behaving in a manner consistent with that goal.”

World Bank economist Lant Pritchett, in a 1994 article in Population and Development Review, concluded that family size desire is the overwhelming determinant of actual fertility rates.  “The conclusion that follows from the evidence and analysis we presented,” he wrote, “is that because fertility is principally determined by the desire for children, contraceptive access (or cost) or family planning effort more generally is not a dominant, or typically even a major, factor in determining fertility differences.”  According to Pritchett, desired levels of fertility account for roughly 90 percent of differences among countries in total fertility rates.  He argues that reducing the demand for children – for instance, by giving girls more education – is vastly more important to reducing fertility than providing more contraceptives or family planning services.

An illustration of the importance of motivation is the fact that the contraceptive prevalence rate in Malawi (38 percent) is four times higher than it is in Macedonia (10 percent), but the total fertility rate in Malawi (6.0 children born during a woman’s lifetime) is quadruple the rate in Macedonia (1.5).

Not enough is known about family size preferences of the men and women of the world – particularly among those who are not using any method of contraception.  Papers on family size preferences by demographers John Bongaarts, Charles Westoff, and Warren Miller and David Pasta point to the need for much more in-depth, interdisciplinary research on the relationships among ideal family size as viewed by men and women at each age level, fertility intentions and actual achieved fertility.

More research is needed to measure the effects of non-medical interventions, such as efforts to raise women’s status, mandatory education for children and mass media communications designed to affect desired family size.

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