Malcolm Potts

Cultural debate over harassment is a step in human evolution

Let’s begin not with dreams but by going to the zoo. Penguins are monogamous. Females lay a large egg and then return to the sea to feed. The male incubates the egg for many weeks. When he is nearly dead from hunger and cold, the egg hatches and his mate returns. She regurgitates food to feed the fledgling while he goes to sea to feed. Many bird species are monogamous because the two sexes can share in bringing up the next generation.

Getting family planning and population back on track

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.

Population and climate change: who will the grand convergence leave behind?

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.

"Big issues deserve bold responses" Les grandes questions meritent des responses audacieuses: la population et le changement climatique au Sahel

Parts of Africa have the most rapid population growth in the world. Recent studies by climatologists suggest that, in coming decades, ecologically vulnerable areas of Africa, including the Sahel will be exposed to the harshest adverse effects of global warming. The threat hanging over parts of sub-Saharan Africa is extreme. Fortunately, there are evidence-based achievable policies which can greatly ameliorate what would otherwise be a slowly unfolding catastrophe of stunning magnitude. But to succeed such measures must be taken immediately and on a large scale.

Big issues deserve bold responses: Population and climate change in the Sahel

Parts  of  Africa  have  the  most  rapid  population growth in the world. Recent studies by climatologists  suggest  that,  in  coming  decades, ecologically vulnerable areas of Africa, including the Sahel will be exposed to the harshest adverse effects of global warming. The threat hanging over parts of sub-Saharan Africa is extreme. Fortunately,  there are evidence-based achievable policies which can greatly ameliorate what would otherwise  be  a  slowly  unfolding  catastrophe  of stunning magnitude. But to succeed such measures must be taken immediately and on a large scale.

New hope: community-based misoprostol use to prevent postpartum haemorrhage

The wide gap in maternal mortality ratios worldwide indicates major inequities in the levels of risk women face during pregnancy. Two priority strategies have emerged among safe motherhood advocates: increasing the quality of emergency obstetric care facilities and deploying skilled birth attendants. The training of traditional birth attendants, a strategy employed in the 1970s and 1980s, is no longer considered a best practice. However, inadequate access to emergency obstetric care and skilled birth attendants means women living in remote areas continue to die in large numbers from preventable maternal causes. This paper outlines an intervention to address the leading direct cause of maternal mortality, postpartum haemorrhage. The potential for saving maternal lives might increase if community-based birth attendants, women themselves, or other community members could be trained to use misoprostol to prevent postpartum haemorrhage. The growing body of evidence regarding the safety and efficacy of misoprostol for this indication raises the question: if achievement of the fifth Millennium Development Goal is truly a priority, why can policy makers and women’s health advocates not see that misoprostol distribution at the community level might have life-saving benefits that outweigh risks?

The Sahel: A Malthusian Challenge?

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.

Do Economists Have Frequent Sex?

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.

Crisis in the Sahel: Possible Solutions and the Consequences of Inaction

A report following the OASIS Conference (Organizing to Advance Solutions in the Sahel) hosted by the University of California, Berkeley and African Institute for Development Policy in Berkeley on September 21, 2012.
The goal of this report is to start building a network of scientists and policy makers committed to helping the Sahel address its population, environment, and food security challenges. A compelling body of evidence is needed to inform people in governments and relevant local institutions, humanitarian organizations, foreign aid agencies, philanthropic institutions, and national security agencies concerning the startling challenges facing this neglected and highly vulnerable region.

Why Bold Policies for Family Planning are Needed Now

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) 

The Impact of Freedom on Fertility Decline

Although fertility decline often correlates with improvements in socioeconomic conditions, many demographers have found flaws in demographic transition theories that depend on changes in distal factors such as increased wealth or education. Human beings worldwide engage in sexual intercourse much more frequently than is needed to conceive the number of children they want, and for women who do not have access to the information and means they need to separate sex from childbearing, the default position is a large family. In many societies, male patriarchal drives to control female reproduction give rise to unnecessary medical rules constraining family planning (including safe abortion) or justifying child marriage. Widespread misinformation about contraception makes women afraid to adopt modern family planning. The barriers to family planning can be so deeply infused that for many women the idea of managing their fertility is not considered an option. Conversely, there is evidence that once family planning is introduced into a society, then it is normal consumer behaviour for individuals to welcome a new technology they had not wanted until it became realistically available. We contend that in societies free from child marriage, wherever women have access to a range of contraceptive methods, along with correct information and backed up by safe abortion, family size will always fall. Education and wealth can make the adoption of family planning easier, but they are not prerequisites for fertility decline. By contrast, access to family planning itself can accelerate economic development and the spread of education.

Global warming and reproductive health

The largest absolute numbers of maternal deaths occur among the 40–50 million women who deliver annually without a skilled birth attendant. Most of these deaths occur in countries with a total fertility rate of greater than 4. The combination of global warming and rapid population growth in the Sahel and parts of the Middle East poses a serious threat to reproductive health and to food security. Poverty, lack of resources, and rapid population growth make it unlikely that most women in these countries will have access to skilled birth attendants or emergency obstetric care in the foreseeable future. Three strategies can be implemented to improve women’s health and reproductive rights in high-fertility, low-resource settings: (1) make family planning accessible and remove non-evidenced-based barriers to contraception; (2) scale up community distribution of misoprostol for prevention of postpartum hemorrhage and, where it is legal, for medical abortion; and (3) eliminate child marriage and invest in girls and young women, thereby reducing early childbearing.

The remarkable story of Romanian women’s struggle to manage their fertility

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.

Book Review of “Sex Before the Sexual Revolution: Intimate Life in England 1918–1963”

A review of “Sex Before the Sexual Revolution: Intimate Life in England 1918–1963” by  Simon Szreter and Kate Fisher.

Brief Excerpt:

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.

A Woman Cannot Die from a Pregnancy She Does Not Have

The fifth Millennium Development Goal has brought critical attention to the unacceptably high burden of maternal mortality and the need to improve antenatal health care. However, many of the approaches to reducing maternal mortality (e.g., increasing the number of deliveries at health facilities with skilled attendants or improving access to emergency obstetric care) are complex and will take time to implement. In the meantime, maternal mortality can be reduced relatively inexpensively by preventing unwanted pregnancy through family planning. The decision to practice family planning is personal and private, and it need not require professionals or health clinics. Although inexpensive at the program level, however, family planning may be difficult for individuals to afford. Thus, women face barriers, including cost, lack of transportation and the fear of side effects (real or rumored). In developing countries, making contraceptives available and accessible may be the most important, cost-effective and easily accomplished primary health care goal. Reducing barriers to family planning may lessen the burden of maternal death in low-resource settings.

A new hope for women: medical abortion in a low-resource setting in Ethiopia

Between February 2002 and January 2004 in the Adigrat Zonal Hospital, covering one-fifth of the large Tigray region of North West Ethiopia, there were 907 admissions with a diagnosis of abortion. Among these, 521 were induced by traditional, unsafe methods. Unsafe abortion was the leading cause of admission, accounting for 12.6% of all bed occupancy throughout this general hospital and 60.6% of the gynecological admissions. About 57% of patients admitted with unsafe abortions had serious complications, including tubo-ovarian abscess, vaginal laceration, uterine perforation, generalised peritonitis and renal failure. Three women died from complications of unsafe abortion. Five years later in the same hospital, between July 2009 and September 2010 unsafe abortion cases had declined, becoming the tenth cause of hospital admission. There were no deaths and no severe complications.

Niger: Too Little, Too Late

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.

The impact of vouchers on the use and quality of health care in developing countries: a systematic review

One approach to delivering healthcare in developing countries is through voucher programmes, where vouchers are distributed to a targeted population for free or subsidised health care. Using inclusion/exclusion criteria, a search of databases, key journals and websites review was conducted in October 2010. A narrative synthesis approach was taken to summarise and analyse five outcome categories: targeting, utilisation, cost efficiency, quality and health outcomes. Sub-group and sensitivity analyses were also performed. A total of 24 studies evaluating 16 health voucher programmes were identified. The findings from 64 outcome variables indicates: modest evidence that vouchers effectively target specific populations; insufficient evidence to determine whether vouchers deliver healthcare efficiently; robust evidence that vouchers increase utilisation; modest evidence that vouchers improve quality; no evidence that vouchers have an impact on health outcomes; however, this last conclusion was found to be unstable in a sensitivity analysis. The results in the areas of targeting, utilisation and quality indicate that vouchers have a positive effect on health service delivery. The subsequent link that they improve health was found to be unstable from the data analysed; another finding of a positive effect would result in robust evidence. Vouchers are still new and the number of published studies is limiting.

Setting priorities for safe motherhood interventions in resource-scarce settings

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).