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| Splendidly Alive People Within Limited Environmental Resources | |
Part VIII: Learning from Others
"Until recently sociologists overestimated the socioeconomic variables in fertility decline and underestimated the role of family planning services."
South Africa Still Does
"In countries as diverse as Buddhist Thailand, Catholic Colombia and Islamic Indonesia fertility has fallen two to four times as rapidly as it did in the West at a comparable stage."
"The more disadvantaged or ambivalent an individual person is about family planning the more convenience plays a role in contraceptive use. If a woman is a new and uncertain user, or if her husband disapproves of her decisions, then she may find the fact that the fp clinic is open only certain hours an excuse for not going." People and the Planet 17ol 3 No 3
Poor Mexican women have more children in rich America than they did when they were poverty-stricken in Mexico City. Time magazine, June 1994.
The following information is taken from an article in People and the Planet Vol.3, No.3, 1994 by Pouru Bhiwandi, Martha Campbell and Malcolm Potts.
The percentage of married women who say they want no more children varies from under 20% in Senegal to almost 80% in Peru. In addition vast numbers of women want to delay the next birth. The crowded wards in the hospitals that treat botched abortions add reality to the statistics from social surveys.
In countries as diverse as Buddhist Thailand, Catholic Colombia and Islamic Indonesia, fertility has fallen two to four times as rapidly as it did in the West at a comparable stage in the transition from large to small families.
Until recently sociologists overestimated the socioeconomic variables in fertility decline and underestimated the role of family planning services. So ingrained was the conviction that increases in wealth and improvements in education were required for fertility decline that in 1967 Kingsley Davis of the University of California called the family planning programmes that were beginning at that time "either quackery or wishful thinking".
He was wrong: wherever realistic contraceptive choices (including voluntary sterilization) have been offered, fertility has plummeted.
This is not to say that development and family planning are not synergistic. But experience has shown that socioeconomic development is not a prerequisite of fertility change and good family planning services, of themselves, can reduce fertility.
The more disadvantaged or ambivalent an individual person is about family planning the more convenience plays a role in contraceptive use. If a woman is a new and uncertain user, or if her husband disapproves of her decisions, then she may find the fact that the family planning clinic is open only certain hours an excuse for not going.
For the poorest of the world's families, such as those in the rural areas of much of sub-Saharan Africa or South Asia, the only practical way of reducing maternal mortality is to make family planning choices available. Improvements in primary health care and obstetrics are urgently needed but could take a generation to put in place.
Social marketing programmes, which sell subsidized contraceptives through small shops or kiosks and use local promotional skills, can get life-saving contraceptives to the farthest corner of any country in three to five years.
The aggregate effect of hundreds of millions of individual choices about family size gives the planet as a whole a choice. If we have the wisdom and humanity to make family planning universally available by the end of the century, then we will improve the health of millions of families, enhance the status of women around the globe, decrease human suffering and tragedy, and set the world on a significantly lower population trajectory.
The technology, experience and demand exist: do we have the insight and the political will to put the necessary policies in places
The following information on Kenya is taken from the keynote address given to the Western Cape Population Forum by Dr Ayo Ajayi of the World Population Council:
Kenya was the first country in sub-Saharan Africa to articulate a population policy. The findings of the 1962 population census revealed a population growth rate of 3,0 per cent, a total fertility of 6,8 and a high dependency ratio.
Their concern resulted in the formal adoption of family planning as a policy in 1967. The goal of the policy was to provide family planning through an integrated maternal and child health programme, with responsibility under the Ministry of Health whose priority at the time was rural health programmes.
Ajayi quotes from the World Bank report of 1992:
"The first 10-16 years after the policy were devoted to creating the basic MOH network of facilities and staff. Primary health care centres were scattered throughout the countryside to provide MCH/FP services for those who desired them. It was essentially a passive, clinic-based system operated by medical personnel. Efforts to create an outreach programme did not get very far. . . "
Ajayi comments:
1. The programme was targeted at improving the health of mothers and children as a matter of highest priority.
2. The MOH was the sole implementer of the policy.
3. The government did not provide explicit budgetary allocations to the family planning programme.
4. Political support was not adequately accorded to the programmes.
The international agencies, particularly the World Bank, the US Agency for International Development and the United Nations Population Fund (UNFPA) vigorously supported the programme both financially and materially in the hope that the programme would gain acceptance and momentum within a short period of time.
By 1978, the Kenya Fertility Survey revealed that the total fertility rate had increased to 7,9 with a contraceptive prevalence rate of 7 per cent, and the policy was roundly acknowledged to have failed completely.
Improved access to contraceptives by women and couples in the rural areas, good training schemes and communication programmes brought the total fertility rate down to 6,7 by 1989.
The Fertility Decline in Developing Countries
Family size is decreasing in many Third World countries. The reasons provide the key to slowing population growth. (by Bryant Robey, Shea 0. Rutstein and Leo Morris)
The developing world is under- going a reproductive revolution. Throughout the Third World, women differing vastly In culture, politics, and social and economic status have started to desire smaller families.
Birth rates have declined by one third since the mid-1960s: women formerly had six children on average, but today they have four. Contrary to the expectations of many observers, developing nations are not experiencing the classical demographic transition that took place in many industrialized countries over the past.
BRYANT ROBEY, SHEA O. RUTSTEIN and LEO MORRIS work on various aspects of population studies. Robey is senior writer and coordinator of overseas activities at the Center for Communication Programs at the Johns Hopkins School of Hygiene and Public health Robey, who received his master's from Harvard University, Is founding editor of American Demeographics magazine.
Rustein is technical director at Macro Internationa1, Inc., and deputy director for analysis of the Demographic and Health Surveys Program. He was awarded his doctorate at the University of Michigan. Morris , who also received his doctorate at Michigan, is chief of the behavioural epidemiology and demographic research branch of the U.S. Centers for Disease Control.
He specializes in Latin America, where he has coordinated 29 reproductive health surveys in the past eight years century. In the U.S. and the U.K., for instance, declining birth rates came only after economic growth had brought improvements in health care and education.
The transition took many decades. In contrast, recent evidence suggests that birth rates in the developing world have fallen even in the absence of improved living conditions.
The decrease has also proceeded with remarkable speed. Developing countries appear to have benefited from the growing influence and scope of family-planning programs, from new contraceptive technologies and from the educational power of mass media.
Such findings have extraordinary implications for future efforts to slow population growth. For despite the observed decrease in birth rates, the world's population continues to burgeon: the number of people is expected to double to 10 billion by 2050. It has been estimated that 97 percent of this increase will occur in the developing world, where more than one third of the population is younger than 1 5 years-that is. these individuals are just entering their reproductive years.
By examining the results of recent demographic and family-planning surveys, we have been able to study the direct and indirect causes of falling birthrates in developing countries and to clarify how they differ from the demographic transition of the West. Using these insights, we can pinpoint how most effectively to encourage this unexpected and welcome revolution.
The most recent data about fertility in developing countries are drawn from 44 surveys of more than 300,000 won, en conducted over the past eight years. These surveys were of two types: the Demographic and Health Surveys, carried out by Macro International, Inc.. and the Family Planning Surveys, coordinated by the U.S. Centers for Disease Control.
Both were funded in large part by the U.S. Agency for International. Development and collected nationally representative, comparable information.
The surveys were undertaken in 18 countries in sub-Saharan Africa, 16 in Latin America and the Caribbean, six in the Near East and North Africa, and four in Asia. Independent national surveys provide some data for six additional Asian countries, Including China, India and Bangladesh.
These inquiries continue an international effort that began 20 years ago. Before the 1972 World Fertility Survey, no attempt was made to collect comparable and comprehensive data on fertility and family planning from developing nations. Now more than 30 countries have recorded such material, boil in the World Fertility Survey, which ended in 1984, and in the current round of surveys that began in 1985. Using these records, demographers can chart trends in fertility and family planning over two decades.
Together, these programs represent one of the most comprehensive
Time Magazine: When poor people have fewer children.
Essay (Eugene Lindon)
Population: The Awkward Truth
WHY DO MEXICAN IMMIGRANTS IN LOS ANGELES tend to have more children than impoverished peasants living in Mexico City? The answer helps explain why the international community has so far failed to slow the population explosion, and why it will probably fail when delegates from 180 nations meet in Cairo this year to address the issue. But first a little background.
Twenty years ago in Bucharest the United Nations World Population Conference produced a wish list of things governments might do to get a grip on population: improve the status of women, expand access to health care, alleviate poverty.
With the notable exception of Africa, the world has made progress in these areas: infant mortality has declined, as has the percentage of people who live in abject poverty, and the Green Revolution has improved the diet of hundreds of millions of people.
Despite this progress, the global population situation is far more dire than it was back then. In 1974 the world had roughly 3.9 billion people and was growing by 80 million a year. Since then the world's population has grown nearly 1.7 billion, and it now increases 90 million annually.
Today the Green Revolution falters, ecosystems are badly degraded and fresh-water supplies continue to shrink. It is open to question whether the world can feed the 3 billion to 5 billion mouths that will be added during the next 50 years. Refugees produced by population pressures in Africa and Asia already threaten to destabilize nations.
And so delegates from 180 nations will meet in Cairo for another go at the population problem. Advocacy groups and bureaucrats alike trumpet this conference as a breakthrough because it will focus on women's issues.
In U.N. -speak, however, that translates into a catalog of desiderata ranging from appeals to eliminate sexual stereotypes to calls for men to do more housework-nice-sounding proposals that are irrelevant to population control in many of the traditional cultures of the Third World.
In fact, this effort is unlikely to be any more effective than the agenda that came out of Bucharest 20 years ago. Reason: the principal assumption underlying decades of efforts to halt the population explosion turns out to be questionable at best. This is the 'demographic transition," the notion that people will have fewer children as their sense of well-being increases.
It has been embraced in the U.S. by such strange bedfellows as the offers the bland assurance that people have more children as their sense of well-being increases, particularly when technological advance or government largesse give them the idea that the old limits no longer apply.
Conversely, it seems that countries often show a dramatic drop in their birthrate not because of prosperity but because of a decrease in people's sense of well-being.
For instance, a study of Nigerian communities revealed that bad economic times in recent years caused young Yoruba families to turn contraception even though infant mortality was rising - a development that directly contradicts conventional wisdom about the demographic transition.
This is not to argue that poverty is the way to control population but to point out that policymakers, in their eagerness to embrace a politically correct approach to a sensitive issue, frequently ignore what determines family size. This brings us back to the question of the Mexican mothers.
Conventional wisdom holds that poor women in Mexico City should have more children than their counterparts in the U.S. who have better health care and a higher standard of living. But peasant families tend to have two or three children in Mexico City, while those who immigrate to the U.S. average four or five children.
In crowded Mexico City each child imposes steep costs on a family, while in the U.S. welfare payments and other social safety nets buffer those costs. These skewed incentives convey similar signals to poor young women in America's inner cities, who in many cases see no reason to defer having children.
Delegates going to Cairo should keep these subtle signals in mind and scale back their ambitions to reform the world as they formulate their action plan. Government programs that subsidize jobs or housing can spur population growth by giving people false confidence in the future, while a tiny loan that enables a woman in Bangladesh to buy a sewing machine to start a business may give her an incentive to limit the number of children she bears.
Such empowerment is more achievable in the developing world than paid maternal leave, day care and other high-minded calls that characterize population summits.
Finally, 120 million couples who would like to limit their family size still lack easy access to contraception. We must help them get it. Promoting the use of condoms also helps impede the spread of AIDS.
If governments continue to fiddle while human numbers explode, it becomes ever more likely the horse-men of famine, disease and anarchy will have their day, train people such as shopkeepers or village headmen's wives to distribute condoms and birth control Pills, charging the consumer a small amount and making a small profit, as in Thailand or Mexico.
Payment may not cover the whole cost but it gives the consumer a lever on quality assurance. Patient payment is also a guarantee of freedom of choice, particularly in the all-important area of sterilization: people rarely pay for what they do not want, especially poor people.
In many parts of the world the most direct way to reach burgeoning numbers of underprivileged groups is to focus on robust, easy to manage projects that can be replicated rapidly.
Is it better to reach 500 teenagers through a structured outreach programme at $50 a couple year of protection (CYP), or to serve 3,000 at $8 per CYP, through a less labour-intensive project? It is estimated that for about 360 million couples in the developing world, even the choice of family planning is not there.
One of the problems is that individual agencies often expect the 'other agency' to do the work: the IPPF affiliate focuses on sexuality education for young people because it believes there are other sources of large-scale service but can the young people really get the Pill or an abortion when they need it? UNFPA focuses on communications because it believes the government should provide large scale services but are they really providing condoms and can any woman who wants one get a tubal ligation? Often not.
For the poorest of the world's families, such as those in the rural areas of much of sub-Saharan Africa or South Asia, the only practical way of reducing maternal mortality (the majority of the half million women dying each year from pregnancy, childbirth and abortion come from exactly these areas) is to make family planning choices available.
Improvements in primary health care and obstetrics are urgently needed but could take a generation to put in place. Social marketing programmes, which sell subsidized contraceptives through small shops or kiosks and use local promotional skills, can get life saving contraceptives to the farthest corner of any country in three to five years.
As a result of continued high fertility, more women than ever before are entering the fertile years. As a consequence, while the rate of global population growth is falling, the absolute increase in human numbers each year continues to rise.
The bad news is that whatever we do, global population is going to grow hugely before it stabilizes; the good news is that rapid action today can have a considerable impact on that stable final population. If we fail to take action now, many countries will face the same predicament as China, requiring forceful implementation of the one child family.
The demand for family planning is so strong that universal access to family planning could well shift population projections much below the 8.5 billion currently quoted as the median UN projection for 2025. We have an opportunity to double the number of couples using contraception in the developing world in a decade.
If we meet this challenge, then the final stable population of the world will be several billion lower than if we allow innumerate people to continue to de-emphasize large scale family planning services.
The aggregate effect of hundreds of millions of individual choices about family size gives the planet as a whole a choice. If we have the wisdom and humanity to make family planning universally available by the end of the century, then we will improve the health of millions of families, enhance the status of women around the globe, decrease human suffering and tragedy, and set the world on a significantly lower population trajectory. The technology, experience and demand exist: do we have the insight and the political will to put the necessary policies in place?
Dr Martha Campbell is a public policy specialist 1 and Visiting Scholar
at the University of California at Berkeley. Dr Pouru Bhiwandi trained as a physician in Bombay, worked as Medical Director of family Health International, North Carolina and now practices as an obstetrician. Dr Malcolm Potts is Bixby Professor of Population and Family Planning at the University of California, Berkeley.
Ingredients of family planning success (by Jay Parsons)
Widespread recognition and acceptance by governments, especially ministries of health and/or national family planning coordinating agencies, that high levels of contraceptive prevalence cannot be achieved in the absence of the provision of adequate family planning information and services.
But programmes must be culturally sensitive, offer a range of services, be voluntary and tailored to the needs of acceptors.
Commitment by governments measured primarily. in terms of allocation of domestic financial and manpower resources - to make such information and services available to all sectors of society regardless of economic or social status or geographical location.
Recognition by programme managers, both government and non- government, that satisfying existing demand for family planning is far easier and has a greater multiplier effect than tackling the more difficult issue of setting out, in situations of low prevalence or widespread resistance to family planning, to gain rapid and widespread acceptance of "the small family norm" or "the two child family".
Flexibility and sensitivity of governments with regard to the need for different family planning strategies to fit particular local needs and conditions.
Ability of governments to obtain international donor support for family planning by demonstrating commitment, ability to plan and implement national family planning programmes and strategies, and to co-ordinate - not be coordinated by international donor agencies.
Allocating national and donor resources to concrete programmes which empower women - from education for girls, literacy and skills development programmes for school dropouts to the full involvement of women in all aspects of development.
The author has served as Country Director for UNFPA in Indonesia, Thailand and Bangladesh. He is presently serving as Deputy Director of the Asia and Pacific Division in UNFPA headquarters in New York. The opinions expressed in this article are solely those of the author.