Ending Population Growth: Why Family Planning Is Key To A Sustainable Future
Implications of Personal Fertility-Management Aspirations
History and recent fertility phenomena thus suggest the likelihood that the interest in safely and effectively managing the timing of pregnancy and childbirth may be nearly universal among women. Lack of education, affluence, and equality may simply be barriers--along with others related to patriarchal, pronatalist, and even medical cultural norms--to existing aspirations to avoid unwanted pregnancies.
Data exist for the likely demographic impact of establishing conditions worldwide that would facilitate women's choices about the timing of pregnancy. According to the Guttmacher Institute, a US reproductive health-care research organization, an estimated 215 million women in developing countries have an "unmet need for family planning." This applies to women who are sexually active and express the desire to avoid pregnancy yet are not using contraception. Estimates of their number derive from demographic and health surveys conducted in certain developing countries every few years. Many women in developed countries may be in the same circumstances, but data are insufficient in most cases to suggest their numbers.
In early 2010, researchers with the Futures Group in Washington, DC, estimated the demographic impact of meeting unmet family-planning demand in 99 developing countries and one developed one. The researchers excluded China, on the assumption that government population policies aimed at limiting most families to a single child rule out births from unintended pregnancies. And they supplemented their country list with the United States, the world's most populous developed county and one for which there is some data suggesting the magnitude of unmet need. Using accepted models for the impact of rising contraceptive prevalence on birthrates, the researchers concluded that satisfying unmet need for contraception in these 100 countries--with a cumulative 2005 population of 4.3 billion--would produce a population of 6.3 billion in 2050. Under the United Nations' medium projection, the countries' population would be 400 million higher, at 6.7 billion. Average global fertility at midcentury would be 1.65 children per woman, well below the population replacement fertility level--and would continue to fall.
This conclusion, if backed up by further research, is momentous. By implication, simply providing safe and effective contraceptive options to all sexually active women who do not want to become pregnant would end and then reverse world population growth. The effect is independent of any further fertility reductions that might occur as a result of greater educational attainment for women, improved child survival, women's empowerment, and general economic advancement.
To some experts the idea that simply facilitating women's childbearing intentions would end population growth, without significant demand creation for family planning through cultural shifts and other means, goes against survey findings from many African and some Asian countries. These findings suggest that in parts of these continents women's average desired family size is as high as six or seven children. Wouldn't facilitating these women's childbearing intentions undermine any hope of ending world population growth? Not necessarily. For one thing, women expressing such high desired family sizes are at most a relatively small proportion of the world's population (albeit significant in Africa's). But the more important point is that a high desired family size can easily coexist with high levels of unintended pregnancy that, if prevented, would result in significantly lower birthrates than if not prevented.
The reason for this is not hard to understand: women's individual reproductive decisions arrive at their desired family size, if at all, only cumulatively. Decisions about the desirability of pregnancy are made singly, in individual acts of sexual intercourse in which conception is possible. Whatever one's hopes for an eventual number of children, pregnancy decisions occur in the context of current personal, economic, and social circumstances. Desired family size can be compared to house size and the number of cars owned. We may wish to have a large house and many cars, but our circumstances may not allow for us to have either without endangering our finances and well-being. We decide moment by moment whether working toward that goal makes sense for us. So it is with reproductive intentions; every step of a woman and her partner's reproductive lives is governed by their immediate circumstances.
It seems likely that even in countries where women respond in health surveys that they desire six or seven children, they would end up with fewer, possibly many fewer, if at each step of their reproductive lives they were able to choose precisely when to become pregnant. In some developed countries with low fertility, women express a desire to have two children yet have closer to one on average. With the right partner, the right job, the right apartment, and the right economic and social-support systems, a woman in Japan, for example, might have the two children she desires. But with options to prevent or terminate pregnancies, many Japanese women have one child or none; the national average is 1.3.
All of this suggests the value of developing and testing the hypothesis that meeting the needs of women and their partners for personal control of pregnancy could lead to the end of population growth. Physician and reproductive specialist Malcolm Potts has found that in all countries where women can choose from a range of contraceptive options, backed by access to safe and legal abortion services, total fertility rates are at or below replacement fertility levels.
If these findings can be borne out consistently by additional research, those who worry about the impact of global population growth on environmental and social sustainability might usefully advocate for worldwide universal access to family-planning services. The need for such access is enshrined in the second target of the fifth UN Millennium Development Goal, which calls for developing countries to "achieve, by 2015, universal access to reproductive health." This concept embraces more than family planning, including a holistic state of sexual and reproductive well-being that encompasses maternal and child health, prevention of AIDS and other sexually transmitted infections, access to safe abortion services (where these are legal), and post-abortion care.
A Thought Experiment With Data
The Futures Group study has not yet gained the widespread attention its findings merit. Among the reasons for this may be that the concept of "unmet need" for contraception is not widely understood among the public, news media, and policymakers. Moreover, because of lack of data the study excluded not only China, with a fifth of the world's population, but dozens of other developing countries--and all the world's industrialized countries other than the United States.
Newly available data on unintended pregnancy in many countries, assembled by the Guttmacher Institute, support an alternative research approach to the question of the demographic impacts of births that result from pregnancies women never sought or wanted to have. These data, based on a range of surveys worldwide, provide the basis for beginning to answer an intriguing and valuable question: What would happen to world population growth if every pregnancy worldwide, starting tomorrow, were the outcome of a woman's active intention to become pregnant and bear and help raise a child? If no pregnancies were unintended, in other words, how many births would there be compared to current births, and how would this new birthrate affect the future of human population?
Averaged over the 73 countries for which data exist, and comprising 83 percent of the world's births, just under ten percent of births result from pregnancies occurring among women who never wanted to have another child. Even under the most conservative scenario--extrapolated globally, with all births from pregnancies that are merely mistimed considered equivalent to births from intended pregnancies--a hypothetical world population in which women only become pregnant when they want to would reduce today's global total fertility rate to 2.29 births per woman. That figure is slightly below today's global replacement fertility rate--placing world population on a direct path toward future decline, albeit at a very slow pace given population momentum (and assuming neither future fertility decline nor improvement in mortality among young people). Under the less conservative assumption that one-quarter of births from mistimed pregnancies are equivalent to unwanted pregnancies, the total fertility rate sinks lower, to 2.22 births per woman--resulting in a somewhat faster track toward a human population peak, even with no future fertility decline. These calculations are, at best, first-order analyses of the impact on world population growth of an idealized scenario in which all births are the outcomes from intended pregnancies. As noted, they do not take into account the possibility that global fertility would continue its decline once all births resulted from intended pregnancies. More survey research and data on pregnancy intention among individual women in all countries would be needed to make a more robust determination of demographic impacts.
But the essence of research on this question remains hopeful--and little known: a successful global effort that assured all women the capacity to decide for themselves whether and when to become pregnant would also place world population on a path toward a reasonably imminent peak followed by slow demographic decrease. Additional efforts to see that women have the educational, economic, legal, and political opportunities they deserve would accelerate this transition.
Toward a World of Intended Pregnancies and Wanted Children
Given the feasibility of such a transition, why isn't it happening today? Why aren't higher proportions of births the result of intended pregnancies? And what might we do to overcome the obstacles and actually bring that world about?
Popular as it is with women and couples, contraception remains a deeply sensitive issue for much of the public. Vehemently opposed by the Catholic Church and regarded with suspicion by many other Christian, Islamic, and even some Jewish religious leaders, open advocacy for contraceptive availability and use inevitably risks stoking religious opposition. Influence of the Catholic Church hierarchy has blocked efforts in the Philippines, for example, to include access to modern contraception in the country's government health system. Opposition from the Holy See, which has permanent observer status within the UN system, led to silence on reproductive health in the UN Millennium Development Goals when they were forged in 2000--even though representatives of the world's governments had pledged to achieve universal access to reproductive health by 2015 at the UN conference in Cairo in 1994. Only in 2007 was language aiming at that reproductive health access target added to Millennium Development Goal number five. Seven years of opportunities to achieve the target had been squandered.
Perhaps more destructive than religious opposition is a relative denigration in most cultures of concerns that lie principally in the sphere of women. Access to contraception is clearly one such concern, since women bear the babies and undergo most of the risks to life and health associated with reproduction. At least since the rise of agricultural, urban, and hierarchical societies, male interests in reproduction have differed markedly from those of women. Men are often anxious to produce a multitude of future heirs, soldiers, laborers, farmers, and followers. Women tend to be strategically concerned with the survival and well-being of each of their children.13 These gender differences are anything but ironclad, and in many cultures the gender gap in attitudes has narrowed in recent decades, especially as women's status has risen relative to men's. In other cultures, however, the gap not only remains wide, it demands the subjugation of women, sex, and reproduction to male needs.
Beyond male reproductive dominance lies the conviction among neoclassical economists that endless economic growth is possible and that it requires endless population growth. Politicians often measure their self-worth based on the size of their electorates. They happily side with economists on the idea that endless economic and demographic growth is both possible and desirable.
With all these factors in play, it is not surprising that the world's governments are nowhere close to allocating the resources the Cairo conference had estimated would be needed for all women in developing countries to have reasonable access to decent family-planning services. This was roughly $18 billion for the year 2010, a third of which was to be contributed by industrialized-country governments (the 1993 dollars in the UN document are here converted to current dollars). Despite that commitment--and an increase in the population of reproductive-age people in developing countries, from 2.3 to 2.9 billion--actual expenditures from these governments on international family-planning assistance fell from $723 million in 1995 to $338 million in 2007. Assistance has changed little since the latter year.
A global social movement is needed to pressure policymakers and influential cultural and thought leaders to reverse this dismal trend. Raising $9 billion a year from wealthy governments that currently spend just a few hundred million on international family-planning assistance shouldn't be as difficult as it is. As much money is allocated for a few days worth of military activities worldwide. A comparable or greater amount probably would be needed to assure that the vast majority of pregnancies in wealthy countries are intentional, but this sum has never been estimated. Significant investments in all countries in education on sexuality and reproduction are also needed, but what these should be is unknown as well.
Still, the point undoubtedly still holds: a world in which almost all births result from intended conceptions would not be prohibitively expensive or difficult, aside from cultural barriers, to bring about. Yet due to contraception's sensitivity--complicated by a history pockmarked with episodes of contraceptive coercion in China, India, Peru, and a few other countries--environmentalists and advocates for women's rights and health have never succeeded in forging an activist alliance capable of raising the modest sums needed for all to have access to family planning.
Several elements are needed if a global social movement to promote family planning and intentional pregnancy is ever to have its own birth. One is more research about the likely population and environmental outcomes of a world of fully intended pregnancies--and the policies, programs, and costs that could lead to such a world. Another is agreement that any such policies and programs must be based on reproductive rights rather than on coercion, and therefore on the intentions of women and their partners rather than on those of anyone else. And a third is the creativity to shape--or the courage to stand up to--the religious, economic, and other cultural forces that promote population growth and oppose the gender and reproductive health conditions that undermine it.
There is nothing fated about a world of 9 billion people--in 2050, or ever. While true control of population is beyond our aspirations and capacities, policy choices are available that will nudge our numbers closer to environmentally and socially sustainable levels. The choices are rooted in human development and human rights, specifically the right of all, and most directly of women, to decide for themselves when it is the right time to bring a new child into the world.
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