Family Planning Programs Research Paper

In the twenty-first century the world will divide along a new socio-economic fault line, also largely driven by differences in birth rates. Countries that achieve replacement level fertility by about 2010 are likely to progress economically. Those that do not will face continued rapid, and in some countries unsustainable, population growth. In much of Africa, for example, half the present population is below the mean age of marriage, and even if the fresh cohorts of young people are able to have smaller families, there will be so many new parents that the population will continue to grow. This phenomenon of population, or demographic, momentum occurred in China in the 1960s and 1970s. As a result of rapid population growth, many more Chinese brides were entering the fertile years than were leaving them by death or reaching the menopause. In 1979 China instituted a one-child policy, but even today the country still has one million more births than deaths each month—and therefore a net growth to China’s population of one million each month. Since the one-child policy began, China has added more people than live in the whole of the USA.

In order to overcome past failures in family planning, countries that are being overtaken by a new wave of demographic momentum will need to adopt bold new policies. This will be difficult.

2. Why Do People Have Children?

Unlike most other animals, human beings have frequent sex; most of it unassociated with ovulation and often taking place thousands of times more frequently than is required for fertilization. This behavior probably evolved as a social bond linking parents in the arduous task of bringing up a family. In preliterate societies, pregnancies were naturally spaced by hidden physiological mechanisms that suppress ovulation during breastfeeding. In such communities, women averaged 4–6 live-born children in a lifetime, of which approximately half died before they could reproduce. In the modern world, family size has increased because (a) women often only breastfeed for a few months or not at all, (b) puberty occurs several years earlier than it used to, and (c) infant mortality has plummeted. These are the factors that drove the twentieth century’s ‘population explosion,’ and these factors will continue to operate in the twenty-first century.

The simple fact that human beings have sexual intercourse much more frequently than most animals is obvious, yet often overlooked by governments when they are setting family planning policies, or specialists analyzing demographic changes. Many policy-makers continue to focus on factors that correlate with family size, such as education or income, instead of those that cause changes in family size, which, in addition to the age when intercourse begins and patterns of breastfeeding, are the use of contraception and abortion.

Economists often speak of people making rational choices over the costs and benefits of a particular act, such as buying a washing machine. However, as a result of frequent sexual relations between couples, human fertility is in effect perpetually turned on, and such rational choices are not possible. We buy a washing machine when we want one, but if this worked like human fertility, the washing machine would arrive whether it was ordered or not. In the modern world it is possible to have a small family only if the couple have access to contraceptives and abortion. Tragically, as the twenty-first century begins, hundreds of millions of people still find contraceptives geographically, socially, or financially inaccessible, and for even more women, abortion is available only in dangerous and commonly financially or sexually exploitative circumstances.

3. Changing Attitudes

In 1900 the world was deeply hostile to the public support of fertility regulation. In the US and parts of Europe, the sale of contraceptives was illegal, while in the UK sales were ‘under the counter.’ Throughout Europe, North and South America, and in all the European colonies, abortion was illegal. Yet doctors and clergymen, who often opposed contraception in public, were beginning to limit the number of children they had. Condoms, spermicides, intrauterine devices (IUDs), and voluntary sterilization were all known in 1900, but were of poor quality and were difficult to acquire. The theory behind the Pill was described in the 1920s, but research in contraception was actively discouraged. When Margaret Sanger opened a family planning clinic in New York in 1916, it was closed by the police. When Marie Stopes started family planning clinics in England in 1921, she had to face stiff criticism and even arson.

The pivotal point in the development of family planning programs came near the middle of the twentieth century. The 1950s saw the introduction of oral contraceptives, the more widespread use of IUDs, and some Scandinavian and eastern European countries introduced liberal abortion laws. Family planning clinics run by non-governmental agencies began to be important in a few developed nations. In 1965, the US Supreme Court struck down the last of the anti-contraceptive laws passed almost 100 years earlier. In 1966 the British reformed their abortion law, and in 1973 the USA Supreme Court (Roe v. Wade) made safe abortion legal throughout the country.

In developing nations, non-governmental organizations also took the lead. In 1952 the International Planned Parenthood Foundation (IPPF) was founded to tie these efforts together. In the 1960s, US foundations and the Swedish International Development Agency (SIDA) began to offer money and know-how to help family planning programs in developing nations. The US Agency for International Development (USAID) followed soon afterwards, and finally a number of developed nations joined in offering support.

But there were also problems. Much of the academic community clung too long to outdated paradigms and until1959 the US National Institutes of Health (NIH) was forbidden to conduct contraceptive research. The Vatican State, which is part of the UN system, successfully blocked the World Health organization (WHO) from offering governments help in family planning until the 1960s. The British representative at the WHO Assembly was ordered by the Foreign Office to not discuss family planning, but eventually India, Trinidad and Tobago, and the Netherlands (with British support) did succeed in getting a resolution permitting WHO assistance to respond to requests for family planning technical assistance.

In 1968, many Catholics were stunned when Pope Paul published the Encyclical Humanae vitae and upheld the 1600-year-old tradition of St Augustine that sexual intercourse was sinful unless it was open to the possibility of procreation. (In a clear demonstration of the fact that theological opinions on reproduction are not necessarily constant, Humanae vitae permitted the use of periodic abstinence, or the safe period, which St Augustine in the fourth century had explicitly condemned as immoral.) Today, almost every developed nation, with the exception of the Republic of Ireland and Malta, offers its citizens access to modern family planning. Pills, condoms, safe and effective IUDs, increasing access to voluntary sterilization for either sex, and above all, access to safe abortion has revolutionized the lives of women in developed nations. For the first time in history, they could fit childbearing into a variety of chosen lifestyles and no longer had to spend every month worrying whether they were going to see their next menstrual period. Nearly every developing country has also established some sort of national family planning program. However, the hostility and controversy that had characterized the slow and painful process of family planning in the first half of the twentieth century has not gone away, and many family planning programs in developing nations are deeply flawed and fail to offer the choices required to truly control family size.

4. Family Planning Programs

The development of international family planning movement can be divided conveniently into three phases, each one symbolized by an international population conference organized by the UN.

In the 1950s and 1960s, a few timid, and sometimes frankly unrealistic, efforts at family planning began. In 1951 the WHO responded to a request by the Indian government by advising use of periodic abstinence. (At that time, the Vatican City, as a member of the WHO governing body vetoed more practical methods.) India adopted a formal governmental population family planning program in 1952, but efforts were made to use IUDs on a large scale failed because the health personnel or facilities to support the method were not available. Very different programs began in South Korea (1963) and Taiwan (1959). Here, several methods including voluntary sterilization were offered and safe abortion, although initially illegal, was widely available. New choices were added to the menu of contraceptives as couples showed they wanted them.

These initial efforts were largely brought about by a small number of charismatic, hard-working individuals. They probably had a powerful impact because they were responding to a deep and long-hidden desire for fertility regulation in groups all around the world. In the US William Draper Jr. led the Population Crisis Committee, badgered Congress, and played a key role in putting the UNFPA together. Reimert Ravenholt became an extraordinarily effective leader of the early USAID programs. Alan Guttmacher led Planned Parenthood World Population in the US and changed the face of domestic and international family planning. Ottesen Jensen in Sweden and Madam Kato in Japan moved mountains of opposition. Fernando Tamayo, Jae Mo Yang, Dapne Chung, Lady Rama Rao, L. P. Chow and others appreciated the damage rapid population growth was doing to their societies and economies, and launched family planning programs in their respective developing nations. Those most closely involved in putting programs together, whether from developed or developing nations, were universally impressed by the unmet demand for family planning and the opportunity that family planning provided to meet individual, as well as community needs. Many of these early pioneers were also particularly skilled at turning the controversy, which associated their efforts to their own advantage.

The United Nations Fund for Population Activities (UNFPA) was launched in 1969, and the first UN population conference was held in Bucharest, Romania in 1974. Demographers and economists warned against the dangers of rapid population growth. The Bucharest meeting was dominated by the developed nations who emphasized the need for family planning programs. But a number of developing nations, including India, expressed resentment at what they perceived to be the demographic emphasis of the meeting.

However, when it comes to sex and reproduction, people do not always say what they mean, or mean what they say. Although India and China adopted the rhetoric that ‘development is the best contraceptive,’ almost as soon as the meeting ended China introduced the one-child family and India embarked on a top-down family planning campaign that ended with episodes of coercive sterilization, which brought down the government of Indira Gandhi. The problem in China was that Chairman Mao had denied there was such a thing as a population problem, and this delayed the introduction of a realistic family planning program. As noted, China ended up with an enormous imbalance of young people. No one in China liked the one-child policy but neither has anyone ever come up with a plausible alternative strategy. Had China started a voluntary family planning program just a few years earlier, there is every reason to believe it would have been as successful as Korea, which saw the TFR fall from 6.0 in 1960 to 1.7 in 1990. Indeed, during the 1970s a number of countries, such as Colombia and Thailand, followed the example of Taiwan and South Korea. They forged ahead offering several methods of contraception, they developed non-medical channels of distribution and they confronted the public health issues of unsafe abortion. Whereas it had taken the USA almost 60 years (from 1842 to 1900) for the total fertility rate (TFR) to fall from 6.0 to 3.5, Taiwan, Columbia, and Thailand all made the same transition in a few years. In 1984 the world community met for a second population conference, this time in Mexico City. Whereas the US had been criticized in 1974 for emphasizing population problems, in1984 the Reagan administration asserted that population growth was not a serious problem and followed this up with policies in the US. It was now the turn of the developing nations to call for more support of family planning programs.

At the Cairo International Conference on Population and Development in 1994, yet another set of political forces surfaced. Population issues had fractured into five different schools of thought. Women’s advocates focused on the needs of the individual, emphasized broader aspects of reproductive health as well as access to family planning, and downplayed demographic forces, often portraying family planning programs as coercive. Those emphasizing socioeconomic development focused on the inequalities between North and South and the need to redistribute the world’s wealth more equally. Voices from the South harked back to the Bucharest conference, and again used the slogan that ‘development is the best contraceptive’ to diminish any role for purely population issues. The Vatican continued its hard-line stand against any form of ‘artificial contraception’ and condemned the use of condoms, even by monogamous couples where a man might have acquired HIV through a blood transfusion. The group who had launched family planning in the 1960s were reduced in numbers, but they maintained a traditional concern about rapid population growth and emphasized that if the unmet need for family planning was met in a respectful way then fertility would fall rapidly. Most groups at Cairo (other than the Vatican) considered the meeting a considerable success because consensus appeared to have been achieved on so broad a range of issues.

The program of action that came out of Cairo underscored the heavy burden of social and cultural injustice that falls on many women in the world. The conference looked at sexually transmitted diseases and AIDS, it condemned female genital mutilation, and it set family planning in a broad context of reproductive health care. With the passage of time, however, the Cairo Program appears more blurred and less satisfactory. One of the weakest parts of the Cairo document were the targets set for finance, which were much too low. A broad agenda not backed up by the necessary budget is a dangerous situation. It is a sad fact that since the Cairo conference, the sum total of human suffering in the reproductive health field has significantly increased. The WHO has raised the estimates of women dying from pregnancy, childbirth, and abortion from 500,000 to 575,000 a year—more than one a minute. In the countries most heavily affected by HIV-AIDS, reproductive health has deteriorated more in the past five years than in any similar period during the twentieth century.

5. Meeting Individual Family Planning Needs

A great deal is known about how family planning choices can be made available in a poor country. Experience suggests that a 15 percent rise in contraceptive prevalence is associated with approximately one birth less per family. The wider the choice of contraceptive methods and the greater the variety of distribution channels the more rapidly contraceptive prevalence rises. In many countries prevalence has been going up at more than 2 percent per annum. Family planning is a choice and not a therapy, and therefore contraceptives can be distributed responsibly within a community, often outside any clinic-based health system. Unfortunately, the expansion of family planning also continues to be limited by restrictive medical policies. For example, injectable contraceptives could perfectly well be distributed at a subsidized cost by traditional practitioners, injection doctors, and others who provide medicines in rural and shantytown communities. The subsidized sale of contraceptives has proved an effective way of distributing pills and condoms and is almost always more cost-effective than distribution through medical clinics.

Family planning methods vary in their cost-effectiveness. Condoms are relatively expensive, while voluntary sterilization and intrauterine devices often cost the least per couple-year of protection. Probably the most realistic and acceptable way of satisfying the community’s need for family planning would be as follows. The government health services would focus on IUDs and voluntary sterilization. Pills, condoms, and injectables would be available in government clinics, but the primary mode of distribution would be through the commercial sector or through subsidized marketing, involving a variety of outlets, from kiosks on the pavement, through chemical sellers and pharmacies, to traditional practitioners and finally trained physicians. Private physicians could offer sterilization and IUDs. The consumers would pay what they can afford and the government would make up the shortfall. Such a scheme has worked exceedingly well in South Korea and Taiwan and needs to be repeated in countries like India or Nigeria.

6. Abortion

The Cairo conference was the first UN meeting to mention the health consequences of unsafe abortion. It concluded that ‘prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion.’ These are goals that most reasonable people support, but it will take a long time to achieve them given the current low levels of funding.

No country has achieved a low birth rate without a considerable number of abortions—whether legal or illegal. Conversely, wherever women have access to safe abortion, fertility has declined to a lower level than where such a choice is not available. Indeed, nearly all countries that have access to safe abortion have reached or passed below replacement-level fertility. Technically, abortion in the first 3 months of pregnancy can be safely preformed in any clean room. Manual vacuum aspiration (MVA) using hand-held plastic equipment costing less than $20 has proved an appropriate technology in locations from rural Vietnam to urban San Diego, California. The technique can be used to treat patients with botched abortions as well as to terminate an early pregnancy. In Bangladesh, MVA is available for menstrual regulation, approved by the government as a family planning method through approximately 12,000 providers, and it is one reason why the TFR has fallen from almost 7 in 1960 to 3.3 in 1998.

Abortion is an ethical problem, and all modern democratic societies that separate church and state have to find ways to accommodate a variety of sincerely held views on this critically important topic. Some groups may have to learn the hard lesson that toleration is preferable to confrontation.

7. HIV/AIDS

By the early decades of the twenty-first century, AIDS will have killed 30 to 40 million people—more than died as civilians and combatants in World War II. Current UN population projections assume that the global population in the twenty-first century will be 400 million less than it would otherwise have been as a result of the spread of HIV/AIDS. This does not imply that 400 million people will die from this disease, but that the approximately 30 million projected to die early in the next millennium will not themselves have children, and the downstream effects of these deaths will be considerable. In most of the worst hit countries of Africa AIDS will slow population growth but it will not halt it.

8. The Future

The developing world is approximately halfway through the demographic transition that began in the 1960s. Family planning programs have played a significant, (and some would argue, a major) role in this important change. As the twenty-first century opens, the largest cohort of young women in history is entering the fertile years. Contraceptive prevalence is rising. Unfortunately, at this time of unprecedented need, attention is being taken away from family planning. There is an increasing demand for subsidized contraceptives to meet the needs of many millions of very poor people, but there is no clear strategy in the donor community to provide the essential commodities required to fulfill this need.

In 1998 the UN population division issued new projections for global population. Demographic projections are ‘what if’ statements. The UN projections assume a continued fall in fertility, and in regions such as Africa, these are based on the assumption that the needed contraceptives and services will be available. This may not happen, in which case there will either be a 4-fold rise in abortions, or else millions of unintended pregnancies, in which case even the high UN projections will be exceeded. Of the small amount transferred from rich nations to the poor in overseas aid, only between 1 and 2 percent goes to international family planning. With the added burden of AIDS and lack of a coordinated global policy to ensure that essential commodities are available, the world faces a genuine crisis in family planning and reproductive health.

9. Summary

A great deal is known about how to provide effective family planning choices. When people are offered several methods of contraception and access to safe abortion, fertility always falls. However, family planning has a controversial history. Currently, poor countries sometimes lack the will to make realistic services available and rich countries are reluctant to put enough money into needed programs. As a result the world looks destined to become increasingly divided between high fertility and low fertility countries.

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