Where next? Conclusion for ‘The impact of population growth on tomorrow’s world’

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 theoretical and political framing of the population factor in development

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;

Editoral for ‘The impact of population growth on tomorrow’s world'

An international group of 42 scientists met at the University of California, Berkeley on 23–24 January 2009 to discuss The World in 2050, and how global changes in the human population might change our future.

The papers prepared for the Forum are published as a theme issue of the Philosophical Transactions of the Royal Society B.

Published in Phil. Trans. R. Soc. B 2009 364, 2975-2976

Freedom Closes the Gap

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

Prevention of Postpartum Hemorrhage: Options for Home Births in Rural Ethiopia

This paper sought to determine the safety and feasibility of home-based prophylaxis of postpartum hemorrhage (PPH) with misoprostol, including assessment of the need for referrals and additional interventions. In rural Tigray, Ethiopia, traditional birth attendants (TBAs) in intervention areas were trained to administer 600mcg of oral misoprostol. In non-intervention areas women were referred to the nearest health facility. Of the 966 vaginal deliveries attended by TBAs, only 8.9% of those who took misoprostol prophylactically (n=485) needed additional intervention due to excessive bleeding compared to 18.9% of those who did not take misoprostol (n=481).The experience of symptoms among those who used misoprostol can be considered of minor relevance and self-contained. This study found that prophylactic use of misoprostol in home births is a safe and feasible intervention. Community health care workers trained in its use can correctly and effectively administer misoprostol and be a champion in reducing PPH morbidity and mortality (Afr J Reprod Health 2009; 13[2]:87-95)

Saving maternal lives in resource-poor settings: Facing reality

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