Is population growth a factor amenable to change?
The principal driver of population growth in the past century has been the reduction in mortality due to improvements in nutrition, cleaner water, improved hygiene and vaccines. Developments in transportation were important factors in nutrition, as they made possible the shipment of farm products out of their immediate localities. All of these factors can be classified as technologies and information. And about virtually all of these technologies there has been little controversy. Nearly everyone is in favor of saving children’s lives.
With the much welcome reduction in deaths, the difference between births and deaths rose dramatically, as most babies survived to reproduce children of their own. As it happens, having a small family in balance with reduced mortality rates is not easy to do, as it requires technologies (fertility regulation methods) and correct information to make these technologies useful.
Unlike the technologies and information that so dramatically reduced mortality, the technologies and information required to choose whether and when to have a child are often highly controversial and hard to obtain, particularly for poor women in many countries of the developing world. Every country that has reached replacement level fertility on average (approximately 2 children, the number of children that simply replaces the two parents who produced them) has widespread, easy access to fertility regulation methods. (It is also of interest to us that, in our examination of 170 countries, every one of the countries with an average of 2 or fewer children has widespread availability of abortion. We have not found any exceptions. Contraception is used imperfectly and often with significant failure rates, and also, contraception is often difficult to obtain. In countries where family planning is made exceedingly easy to obtain and use, such as the Netherlands and Belgium, abortion is still available but the rates of its use are the lowest in the world.)
For the following explanation, please note that the word “fertility” has different meanings. In biology fertility is the ability to reproduce, while the demographic sense means how many children born. In these paragraphs we adopt the latter meaning.
The standard paradigm for understanding the fertility decline of countries is that couples who previously had many children because they wanted many are influenced by societal or economic factors and change their minds, deciding to have a small family. This is an over-simplified description, but the principle of exogenous influence on decision-making by couples has been widely accepted by most demographers since the 1960s. More recent work on the dynamics of diffusion of the ideas and technology of contraception has been developed to help explain situations that the previous model could not account for, including important examples of dramatic fertility decline in certain countries of Europe in the 18 th and 19 th centuries.
We recognize the importance of diffusion wherever fertility decline occurs, as a necessary factor. But from our observations around the world it is clear to us that influence of societal or economic factors, including education, do not adequately explain fertility decline. In Thailand, where fertility regulation (FR) technology and information is easy to obtain, women with no education use contraception at the same rate as educated women. In Italy when family planning and abortion became legal and easy to obtain, birth rates among the poor and rich became similar. Korea’s birth rate fell after family planning and abortion were made available, and many people attribute this decline to the growing economy, but Cuba’s fell in the same way with the opposite economic conditions. What they had in common was the ease of access to FR methods and information. And we find that what the countries that have continued to have high fertility rates (for example, Uganda, 6.9; Ethiopia, 5.9, and many more) are all beset with a wide range of barriers to family planning.
Evidence including studies reported in the references in the sections below on this page has led us to recognize that the population growth factor is amenable to change – a fact not well understood by many people who are studying and writing about the impact of population and the environment. We are impressed when the removal of barriers to FR has led to rapid fertility decline, which implies that realistic availability of methods and correct information are a recognized benefit to large numbers of couples, and often to women in particular. Iran’s recent fertility decline from nearly 6 children to 2 between 1987 and year 2000, after the religious leaders agreed to allow the use of all family planning methods, is a very good example of the impact of making family planning easier to obtain.
Barriers to Family Planning
Developing the Ease model of fertility decline is one project of the Bixby Program in the School of Public Health. We have been inviting scholars to join us in quantifying this model to test its strength. The former, standard models of fertility decline are based on large, easily obtained databases on economic advancement, poverty, and education levels. The Ease model depends to a considerable degree on compelling evidence that is not reflected in large databases. For example, in our study of barriers to FR methods we commonly encounter “provider bias” – widespread habits of health providers, ranging from medical associations to individual health workers in rural areas who actually make family planning hard for poor women to obtain. These biases usually can be explained only qualitatively. In addition, databases reporting in sensitive areas, including abortion, are by their nature usually incomplete by reasons of confidentiality for both providers and clients. We welcome academic efforts to construct ways to contribute to these findings additional quantitative validity.
The 1994 Cairo Programme of Action explicitly recognizes the importance of barriers to family planning.
7.19. As part of the effort to meet unmet needs, all countries should seek to identify and remove all the major remaining barriers to the utilization of family-planning services… It should be the goal of public, private and non-governmental family-planning organizations to remove all programme-related barriers to family-planning use by the year 2005 through the redesign or expansion of information and services and other ways to increase the ability of couples and individuals to make free and informed decisions about the number, spacing and timing of births and protect themselves from sexually transmitted diseases (United Nations, 1994)
7.20. Specifically, Governments should make it easier for couples and individuals to take responsibility for their own reproductive health, by removing unnecessary legal, medical, clinical and regulatory barriers to information and to access to family-planning services and methods (United Nations, 1994).
The following references provide information about many of the types of barriers to fertility regulation methods and information in developing countries. Most of these papers have made good use of the Demographic and Health Surveys (DHS), the excellent database of 44 developing countries to which we have provided a link under the Population Growth page of this web site. These are good sources – but we would like to add one type of barrier that has not been highlighted in most of these papers because it is often subsumed under a commonly measured barriers “side effects of family planning”. In describing side effects, women, and sometimes men, refer to concerns about deleterious health impacts of using contraception. For example, uneducated people often believe that birth control pills cause illness or will make a woman infertile later, or that IUDs will float up their bodies and do great damage. In our view nearly all health concerns should ideally be classified as incorrect information – and we have observed that incorrect information about family planning is common everywhere (even in the United States). A woman who believes that family planning can be bad for her health is making a perfectly rational decision not to use it, given the best information she has. We believe that incorrect information may be one of the most important reasons for low contraceptive use in many countries, and until it is replaced with correct information many women are unlikely to desire small families – because they do not see it within the options they have in their calculus of conscious choice.
References for " Barriers to Family Planning"
The Power of Realistic Options
In addition to assembling examples of the wide range of barriers to FR methods, we have identified a series of studies describing situations where women who had not planned to use family planning changed their minds when family planning opportunities actually arrived. In reading these studies we are conscious that the decision-making occurring is no different from normal consumer behavior. There are many things we have wanted in our lives only after they arrived – the Internet, Palm Pilots, garage door openers, cars – the examples are endless. It is perfectly reasonable for a woman to want family planning only after the option is realistically available for her – including correct information – and she recognizes that its use will not be more costly (burdensome, dangerous) than having another child. We feel the decision-making around family planning and family size is reasonably like the behavior of humans as consumers in all societies around the world, where people make sensible, smart decisions base on the options available to them.
References for "The Power of Realistic Options"
