Sixty years ago, one of the most consequential events of the past century occurred: the first sale of a drug called Enovid. At the time, it was illegal to use any form of contraception in Massachusetts, where Enovid was developed. But soon everyone just called Enovid the Pill.
After a generation of partial neglect, renewed attention is being paid to population and voluntary family planning. Realistic access to family planning is a prerequisite for women's autonomy. For the individual, family, society, and our fragile planet, family planning has great power.
For many developing countries, investments in health have proved a great success. The LancetCommission “Global health 2035: a world converging within a generation”1 and the 2014 Gates annual letter2 envision the possibility of a “grand convergence” by which more countries will have a child mortality rate as low as 15 per 1000 livebirths in 20 years time. We wish to draw attention to the special case of the least developed countries, which on present evidence are likely to be excluded from such a convergence.
Meeting the world’s need for family planning is a human right and a climate imperative. Wherever women have been given information and access to family planning, birth rates have fallen – even in poor, low-literate societies like Bangladesh or conservative religious countries such as Iran.
The population of the least developed countries of the Sahel will more than triple from 100 million to 340 million by 2050, and new research projects that today’s extreme temperatures will become the norm by mid-century. The region is characterized by poverty, illiteracy, weak infrastructure, failed states, widespread conflict, and an abysmal status of women. Scenarios beyond 2050 demonstrate that, without urgent and significant action today, the Sahel could become the first part of planet earth that suffers large-scale starvation and escalating conflict as a growing human population outruns diminishing natural resources. National governments and the international community can do a great deal to ameliorate this unfolding disaster if they put in place immediate policies and investments to help communities adapt to climate change, make family planning realistically available, and improve the status of girls and women. Implementing evidence-based action now will be an order of magnitude more humane and cost-effective than confronting disaster later. However, action will challenge some long held development paradigms of economists, demographers, and humanitarian organizations. If the crisis unfolding in the Sahel can help bridge the current intellectual chasm between the economic commitment to seemingly endless growth and the threat seen by some biologists and ecologists that human activity is bringing about irreversible damage to the biosphere, then it may be possible also to begin to solve this same formidable problem at a global level.
Published in Environmental & Resource Economics 2013: 55(4), 501-512.
Last year a member of the World Bank professional staff gave a lecture on development in Africa on the UC Berkeley campus. His audience asked him about rapid population growth in that continent. He immediately dismissed the question, saying that population growth did not need any special attention. It would look after itself. He was voicing an uncritical interpretation of the demographic transition, a “theory” which has as much evidence to support it as the fictitious Da Vinci Code, and like the Da Vinci Code it remains perennially popular.
Last spring at a Technology, Entertainment, Design (TED) talk in Berlin, Melinda Gates used this phrase, “The most transformative thing you can do is to give people access to birth control.” She expressed similar sentiments at the London Summit on Family Planning on July 11, 2012, as did the British Prime Minister David Cameron, and Andrew Mitchell who was then Secretary of State for the Department for International Development, the British equivalent of United States Agency for International Development. The London Summit represented a new focus on international family planning after nearly 20 years of collapsed budgets. It set the goal of halving the number of women with an unmet need for family planning in the world’s poor counties in the next 8 years — that is, helping 120 million out of an estimated 222 million women worldwide with an unmet need for family planning. Donor governments and foundations pledged US$2625 million dollars over the next 8 years to reach this goal. Governments of the target countries, especially India, committed another US$2 billion. This renaissance in international family planning is exceedingly welcome, but if it is to succeed, it must pay particular attention to the least developed countries (LDCs).
Published in: Contraception (Article In Press)
In 1957, along with many countries in Eastern Europe, Romania liberalised its abortion law. The Soviet model of birth control made surgical abortion easily available, but put restrictions on access to modern contraceptives, leading to an exceptionally high abortion rate. By the mid-1960s there were 1 100 000 abortions performed each year in Romania, a lifetime average of 3.9 per woman, the highest number ever recorded. In October 1966, 1 year after coming to power, in an attempt to boost fertility, Romania’s communist leader Nicolae Ceausescu made abortion broadly illegal, permitting the procedure legally only under a narrow range of circumstances: for women with four or more children, over the age of 45 years, in circumstances where the pregnancy was the result of rape or incest or threatened the life of the women, or in the case of congenital defect.
Published in Journal of Family Planning and Reproductive Health Care 2013: 39(1), 2-4.
A review of “Sex Before the Sexual Revolution: Intimate Life in England 1918–1963” by Simon Szreter and Kate Fisher.
As a young obstetrician in London in the 1960s, who had just moved into a house built in the 1920s, I began talking to my two neighbors, literally over the garden fence. They were both widows in their 80s and we soon wandered into conversations about the role of contraception in their married lives half a century earlier. Looking out on the sexual revolution of the 1960s, they were almost eager to talk about intimate details of their younger lives.
Niger—with the world’s fastest growing population, its highest total fertility rate (TFR), a small and diminishing amount of arable land, low annual rainfall, a high level of malnutrition, extremely low levels of education, gross gen- der inequities and an uncertain future in the face of climate change—is the most extreme example of a catastrophe that is likely to overtake the Sahel. The policies chosen by Niger’s government and the international community to reduce rapid population growth and the speed with which they are implemented are of the utmost importance. In this comment, we review the problems posed by Niger’s rapid population growth and the policy options proposed to confront it.
Although maternal mortality is a significant global health issue, achievements in mortality decline to date have been inadequate. A review of the interventions targeted at maternal mortality reduction demonstrates that most developing countries face tremendous challenges in the implementation of these interventions, including the availability of unreliable data and the shortage in human and financial resources, as well as limited political commitment. Examples from developing countries, such as Sri Lanka, Malaysia and Honduras, demonstrate that maternal mortality will decline when appropriate strategies are in place. Such achievable strategies need to include redoubled commitments on the part of local, national and global political bodies, concrete investments in high-yield and cost-effective interventions and the delegation of some clinical tasks from higher-level healthcare providers to mid- or lower-level healthcare providers, as well as improved health-management information systems.
Objective: Guide policy-makers in prioritizing safe motherhood interventions.
Methods: Three models (LOW, MED, HIGH) were constructed based on 34 sub-Saharan African countries to assess the relative cost-effectiveness of available safe motherhood interventions. Cost and effectiveness data were compiled and inserted into the WHO Mother Baby Package Costing Spreadsheet. For each model we assessed the percentage in maternal mortality reduction after implementing all interventions, and optimal combinations of interventions given restricted budgets of US$ 0.50, US$ 1.00, US$ 1.50 per capital maternal health expenditures respectively for LOW, MED, and HIGH models.
Results: The most cost-effective interventions were family planning and safe abortion (fpsa), antenatal care including misoprostol distribution for postpartum hemorrhage prevention at home deliveries (anc-miso), followed by sepsis treatment (sepsis) and facility-based postpartum hemorrhage management (pph).
In the 1970s, policy-makers in both India and China, convinced that reducing population growth was critical for ending poverty, instituted coercive population policies. Yet fertility had already been declining in both countries before the population policies were instituted. In China, the total fertility rate (TFR) had already fallen to 2.9 before the institution of the One-Child Policy. In India, fertility continued to decline at roughly the same rate before, during and after ‘The Emergency’. Regardless of government mandates, couples in both countries before the policies and since have shown a desire to reduce their family size and when given access to family planning, have voluntarily limited the number of children they chose to have.
This comment in the explores the role of policy and research in using the prevention of postpartum hemorrhage and suggest a joint meeting by WHO and FIGO to revisit the 2009 statement by WHO which does not recommend the use of misoprostol at the community level.
This paper provides a personal perspective on the rich discussions at the Bixby Forum. The size, rate of growth and age structure of the human population interact with many other key factors, from environmental change to governance. While the details of future interactions are sometimes difficult to predict, taken together they pose sombre threats to a socially and economically sustainable future for the rich and to any realistic possibility of lifting the world’s bottom two billion people out of poverty. Adaptive changes will be needed to cope with an ageing population in countries with low fertility or below, but these are achievable. More worrying, continued rapid population growth in many of the least developed countries could lead to hunger, a failure of education to keep pace with growing numbers, and conflict. The assumption that the demographic transition from high to low birth rates occurs as a result of exogenous social and economic forces is being replaced by a clearer understanding of the many barriers that separate women from the knowledge and technologies they need to manage their childbearing within a human rights framework. The forum ended with a clear consensus that much more emphasis needs to be given to meeting the need for family planning and to investing in education.
Phil. Trans. R. Soc. B October 27, 2009 364:3115-3124;
The silence about population growth in recent decades has hindered the ability of those concerned with ecological change, resource scarcity, health and educational systems, national security, and other global challenges to look with maximum objectivity at the problems they confront. Two central questions about population—(i) is population growth a problem? and (2) what causes fertility decline?—are often intertwined; if people think the second question implies possible coercion, or fear of upsetting cultures, they can be reluctant to talk about the first. The classic and economic theories explaining the demographic transition assume that couples want many children and they make decisions to have a smaller family when some socio-economic change occurs. However, there are numerous anomalies to this explanation. This paper suggests that the societal changes are neither necessary nor sufficient for family size to fall. Many barriers of non-evidence-based restrictive medical rules, cost, misinformation and social traditions exist between women and the fertility regulation methods and correct information they need to manage their family size. When these barriers are reduced, birth rates tend to decline. Many of the barriers reflect a patriarchal desire to control women, which can be largely explained by evolutionary biology. The theoretical explanations of fertility should (i) attach more weight to the many barriers to voluntary fertility regulation, (ii) recognize that a latent desire to control fertility may be far more prevalent among women than previously understood, and (iii) appreciate that women implicitly and rationally make benefit–cost analyses based on the information they have, wanting modern family planning only after they understand it is a safe option. Once it is understood that fertility can be lowered by purely voluntary means, comfort with talking about the population factor in development will rise.
Published in: Phil. Trans. R. Soc. B October 27, 2009 364:3101-3113;
We found ourselves strongly disagreeing with a recent editorial in Contraception by Wells et al. when they asserted, “Thirty years ago, our approach to uncontrolled population growth in developing countries was to flood them with contraceptives. After millions of dollars without making an appreciable dent, we have come to understand that improving contraceptive practice is more dependent on women’s literacy and education than on the actual access to contraceptives”. We also asked why those who are often warm friends and who work together with a common enthusiasm to improve all aspects of family planning can also end up adopting profoundly different explanations of why family size falls. We all accept that modern contraception improves the health of women and their families and that it is central to the autonomy of women in modern societies, yet for half a century, family planning has been riven by this deep and sometimes counterproductive fault line. On one side are those who emphasize that easy access to modern contraception, backed by honest information, helps drive up the contraceptive prevalence rate. On the other side are those who assert that changes in socio-economic factors are a prerequisite for greater contraceptive use.
Printed in Contraception. 77: 389-390. 2008
Literature review to identify interventions that require minimal treatment/infrastructure and are not dependent on skilled providers. Simulations were run to assess the potential number of maternal lives that could be saved through intervention implementation according to potential program impact. Regional and country level estimates are provided as examples of settings that would most benefit from proposed interventions.
Three interventions were identified: (i) improve access to contraception; (ii) increase efforts to reduce deaths from unsafe abortion; and (iii) increase access to misoprostol to control postpartum hemorrhage (including for home births). The combined effect of postpartum hemorrhage and unsafe abortion prevention would result in the greatest gains in maternal deaths averted. Bold new initiatives are needed to achieve the Millennium Development Goal of reducing maternal mortality by three-quarters. Ninety-nine percent of maternal deaths occur in developing countries and the majority of thes ewomen deliver alone, or with a traditional birth attendant. It is time for maternal health program planners to reprioritize interventions in the face of human and financial resource constraints. The three proposed interventions address the largest part of the maternal health burden.
© 2008 Elsevier Ireland
published in Health Policy 2009
Letter in response to the Perspective “REPRODUCING IN CITIES” by Mace published in Science February 2008 in Science
In her Perspective “Reproducing in cities” (8 February, p. 764), R. Mace assumes that differences in birth rates between rural and urban areas largely represent the wishes of parents. Human beings in all societies have sexual intercourse hundreds or even thousands of times more often than is needed to conceive the number of children they want. Once individuals have access to the means and information to separate sex from childbearing, family size often falls rapidly (1). For rural women there are an astonishing number of barriers to access to modern contraception (2), while urban women are often better placed to overcome these barriers.
We suggest that birth rates fall in cities primarily because contraception and safe abortion are easier to obtain than in the countryside. For example, in rural Ethiopia only doctors and nurses are permitted to give contraceptive injections, so this popular method is denied to rural women. The total fertility rate (TFR) in Ethiopia as a whole is 5.4, while in Addis Ababa it is now thought to be below 2.0 children. Addis is unusual among African capitals in that safe abortion was available for several years before the recent liberalization of the abortion law. Tens of thousands of operations were performed annually and linked to effective post-abortion contraceptive advice.
We posit that fertility will fall in rural Ethiopia as contraception and safe abortion become more easily available. In Bangladesh, where many women now have access to modern contraception and reasonably safe abortion, two large predominantly rural areas (Khulna and Rajhashi) now have replacement-level fertility (3).
Published in Science, May 16 2008, 874
Letter to the Lancet
Published in Lancet, 9 25 1993, 342(8874):808