Population and the Millennium Development Goals

Population and the Millennium Development Goals

Malcolm Potts, MB, BChir, PhD, FRCOG

School of Public Health

University of California, Berkeley

March 11, 2006

I am a Cambridge trained biologist and obstetrician, and was the first medical director of the International Planned Parenthood Federation (IPPF) from 1967 to 1977. For most of my professional life I have worked in family planning, safe motherhood and HIV prevention in developing countries for most of my professional life. This work has included projects for DIFD, KfW, USAID, the World Bank, UNFPA, and Marie Stopes International. I have been a board member of Population Services International (PSI) since it was founded in 1970. For 12 years I was the president and CEO of Family Health International in North Carolina. I now hold the Bixby Endowed Chair in Population and Family Planning at Berkeley.

I have worked in 100 countries including most of the world’s developing countries. I have witnessed success in Thailand, Colombia, Mexico and Sri Lanka, where family size has fallen from 5 or 6 children to between 2 and 3; and in Iran, where family size has recently declined from 6 to 2 faster than any country on earth. I have also seen first hand the suffering of women and adverse consequences for society when family planning is not made available, as in Afghanistan or Palestine, or is still offered in less than optimal ways, as in Egypt, Pakistan, Tanzania and Uganda.

While the central question in these hearings specifies population growth, I am going to focus on the importance of reducing high fertility and the central mechanism that achieves this, family planning. I have decided to do this because without realistically easy access to family planning methods and the correct information needed to enable couples – and particularly women – to use them, low income people simply do not have the power to decide whether or when to have a child. Frequent sexual intercourse is ubiquitous, it is a biological reality among humans in all societies on this planet, regardless of culture. The use of family planning is the only way to separate frequent sex from procreation.

The world’s rapid population growth over the past 200 years was caused primarily by a dramatic reduction in mortality, particularly of children. These declines have been tribute to human ingenuity, and they were achieved with the introduction of technologies and their associated information, leading to cleaner water, better hygiene, vaccines, and improved nutrition – the latter including new modes of transportation to move food around. Saving children’s lives is a priority for most people, and taking the many steps to this triumphal achievement has generated little controversy. For example, in Afghanistan prior to 2001, the Taliban and the northern opposition alliance regularly cooperated with the United Nations and aid groups for anti-polio campaigns, agreeing to cease fire to facilitate vaccinations. In contrast, allowing women to have the technologies and correct information they need in order to manage their own reproductive lives, and to reduce their own chances of an early death, is often controversial and debated. This is completely consistent with the behaviour of males seen from the perspective of evolutionary biology. Over the 200,000 years of early human existence, evolution favored males who best controlled females by leaving more of their particular genes to the next generation. It does not seem unrelated that the easy availability of fertility regulation methods giving women the freedom to manage their own reproduction has been hard won in many countries and continues to be severely delayed in many others.

My current research focuses on (i) the role played by lack of access to family planning in exacerbating civil unrest and terrorism; (ii) the many kinds of barriers to family planning around the world – and in particular the regulatory barriers and non-evidence based medical barriers that could easily be eliminated once they are more widely understood; (iii) cost-effective and culturally appropriate ways for donors to support family planning in resource-scarce settings; and (iv) reducing maternal mortality among women living on $2 a day or less.

Forty years of experience in family planning in Britain and around the world tells me that improved access to family planning and slower rates of population growth are required for achieving most of the Millennium Development Goals.

• Universal primary education: Research in Thailand has shown that even when other socio-economic variables are carefully controlled, children from families with one or two children are more likely to enter school and more likely to stay in school than children from families with four or more children. As family size in Iran rapidly declined to two children, more women than men entered Iran’s universities.

It is often said that when people become more educated, and particularly women, they decide to have fewer children. The reality is the other way around. In high fertility countries, governments cannot provide education to its population because each year’s children are more than the previous year – it is impossible to keep up with this growth. It is true, though, that women are greatly helped by education: an educated woman is better able to climb over the many barriers to fertility regulation methods, including misinformation which is extremely common, and take control of her own childbearing. However, in countries where family planning is easy to obtain (e.g. Thailand), women with no education use family planning at the same rate as women who are educated.

• Poverty and hunger: No country has escaped from widespread poverty while still maintaining a high birth rate. We cannot find any exceptions to this. Countries that have made great economic strides, such as S. Korea, often explicitly understood the need to slow population growth before economic growth could take off.

• Gender equality and empowerment of women: No woman can be free unless she has the technologies and correct information required to enable her to decide whether and when to when to have a child. Women need to have many opportunities opened to them – education, fair treatment in labor, income, property and divorce, and voice in civic matters. But all of these are exceedingly difficult to achieve before first escaping the tyranny of unintended pregnancy.

• Child mortality: There is a strong relationship between pregnancy intervals and infant survival. A child born within 18 months of the birth of the previous sibling will have three times the chance of dying than the child born 36 months after the preceding birth. And as in the situation with education, governments in countries with high fertility – and thus significant population growth – cannot keep up with the demand for health services that would help save children’s lives. When each year’s cohort of children is larger than the one before, it is impossible to expand health services as fast as the growth in the number of children for whom medical care is needed.

• Maternal mortality: In Africa, little or no progress has been made towards the MDG of reducing maternal mortality by 75% between 1990 and 2015. Many women die from unintended pregnancies and especially from those unintended pregnancies that end in unsafe abortions. The most straightforward evidence for the role of family planning in reducing maternal mortality is the counterfactual argument: if Swedish women in 1990 had the age and parity maternal mortality of that year but age specific fertility observed in 1900 there would have been approximately one third more deaths – i.e. two thirds of the remarkable fall in maternal mortality in Europe over the past 100 years has been due to improved obstetric care one third the result of improved access to family planning . Improvements in family planning and access to safe abortion along with more widespread access to technologies that save mothers lives during childbirth are essential, mutually supportive strategies, for reducing maternal mortality.

• HIV/AIDS: In regions with a high prevalence of HIV, improving access to family planning will prevent many cased of maternal to child transmission of HIV, because, tragically, many pregnancies (although obviously not all) among HIV positive women are unintended. Voluntary counseling and testing (VCT) has a role to play in preventing maternal to child transmission of HIV. But family planning should not be overlooked because new research has shown it is more cost effective than VCT, and thus, in the context of always-strained financial resources, can reach women on a larger scale.

• Environmental sustainability: Environmental sustainability cannot be achieved by conservation efforts alone, for these efforts will be overtaken by the multiplier of population growth. Low birth rates cannot be achieved without family planning. The hills surrounding the Gombe Stream National Park in western Tanzania, where Dr. Jane Goodall has studied her chimpanzees for over 40 years, have been deforested purely because the families averaging seven children need the wood for cooking. In these villages, family planning is exceedingly difficult to obtain. Jane Goodall is worried about this situation, and she is well aware that couples welcome family planning when it is available.

The availability of family planning is necessary, although not sufficient, for meeting most of the MDGs.

Unfortunately, the motivation for family planning is sometimes misunderstood by the donor community, and the implementation of family planning assistance is not always well managed. It is increasingly under-funded.

There is a large, well measured and growing need for voluntary family planning. This means that by meeting this need population growth becomes a variable open to change. When women are offered the ability to decide whether or when to have a child, the birth rate always falls, and when this happens the average desired family size falls ahead of the actual family size as more couples, or women, learn that they have a safe, realistic option.

Wherever the birth rate has reached replacement level, fertility regulation methods and correct information for taking advantage of them are widely available, and few or no non-evidence based barriers exist between the woman wishing to limit the size of her family and the information and technology she needs to achieve her fertility goals.

Freedom to control family size correlates more closely and consistently with fertility decline than other factors such as education or wealth.

The Unmet Need

The number of fertile women is increasing rapidly, and if population growth is to be slowed then contraceptive prevalence must increase also. While there is a large unmet need for family planning among the world’s poor (e.g. those living on $2 a day per capita or less) the majority of these individuals cannot afford the full cost of modern family planning. Currently, the resources going into international family planning are one tenth of those estimated at the time of Cairo as necessary to meet the goal of widespread access to family planning by 2015. Unless this shortfall is made good then both population growth will be higher than it need be and the number of unsafe abortions will expand.

A new trend has been visible recently where the birth rate in some countries (e.g. Nigeria) is rising and in others (e.g. Tanzania, Mozambique, Kenya, Cameroon, Burkina Faso, Benin) the disparity in family size between the uppermost and lowest economic quintiles in increasing. In my opinion, this is the result of a loss of focus on family planning, which has occurred over the past decade.

Any effort to reverse this unfortunate situation should include establishing realistic budgets. The MDGs have the advantage of presenting quantitative targets, and in a number of cases the cost of meeting the family planning goals necessary to meet these objectives, can be calculated.

Closing the Family Planning Gap

In the case of family planning, the first priority must be to help those who wish to have fewer children but are too poor to afford the modern contraceptives or the choice of voluntary male or female sterilization. This need, along with the willingness of the poorest families to make a co-payment, can be estimated with some accuracy using existing data.

Contraceptive prevalence tends to rise most rapidly when a range of family planning choices are offered, backed up by correct information about their advantages and disadvantages. (Misinformation is a major barrier to contraceptive use.) Improvements in the quality of care are maintained when consumers are empowered to choose the provider they trust most.

The poorer people are, the more likely they are to turn to the private/informal sector for health care (in the absence of government health services), and the higher the percentage of their disposable income they devote to health. International assistance to family planning must find ways to carry the work beyond the ministry health (important as their work can be) and into the private informal sector. In Africa this will include the excellent work of many medical missions.

The poorest and most vulnerable women will continue to require a large degree of subsidy towards the cost of family planning. DFID and other donor agencies should establish and review annually the budgets needed by countries, “to meet the family planning needs of their populations as soon as possible and should, in all cases, by the year 2015, seek to provide universal access to a full range of safe and reliable family planning methods.” (ICPD Programme of Action 7.16)

“The international community needs to work with local leaders to strengthen the evidence base and implement the policies needed to ensure that contraceptives and voluntary sterilization are made freely accessible those wishing to use them without unnecessary medical constraints or provider biases. In this area WHO has shown important leadership.

Practical Approaches Towards Achieving MDGs 4 and 5

(This section can be used for testimony or not, as appropriate)

In order to reduce maternal mortality, reducing maternal mortality, including improving women’s reproductive health, and reducing child mortality, the first priority is to understand the important contribution family planning makes to reducing infant and maternal mortality.

The second priority is to ensure that those aspects of safe motherhood, cancer detection and treatment and STI therapy which are currently understood and achievable, even in the presence of a weak heath infrastructure, are funded to the extent possible. Particular attention needs to be given to the needs of the three poorest economic quintiles, especially in Africa and South Asia. .

The failure to date, and the area where donors must devote greater attention, is that of rolling out proven interventions on a large scale. Given a sufficient budget and professional inputs, practically any pilot project can be made to work; scaling up is far more difficult.

To achieve these life saving goals, donors must review objectively the available data on budgets and set evidence-based priorities for distributing scarce resources by

• choosing the most cost-effective ways of reducing the burden of disease in resource-scarce settings;
• recognizing the shortcomings in the health infrastructure; and
• using the resources of the government, NGOs, faith-based and private sector providers in complementary ways.

With the German Credit Bank (KfW), we have been designing a new way of spending foreign aid budgets for health. Input-based funding to governments and NGOs have a role, although in many cases only a small proportion of the funds provided actually ends up subsidizing those essential reproductive health services that the poorest and most vulnerable need. Output-based assistance where lifesaving interventions, such as long acting contraception or safe delivery, are subsidized by item of service payments or giving (or selling at an affordable cost) coupons to the poor proved superbly successful at an early stage of the family planning and reproductive health programs in S. Korea and Taiwan, and are being revived in Kenya, Uganda, Tanzania, and several other countries by Marie Stopes International (MSI) and by the German Credit Bank (KfW). OBA ensures a much higher proportion of the money provided by donors goes to subsidize essential services the poor need. Commonly, it is also less open to corruption and wastage.

The research community should:

• devote more attention to estimating required budgets;
• the donor community should agree on evidence-based ways of setting priorities when the available budgets fall below those estimated; and
• the opportunity should be taken to build on the metrics already present in the MDGs to measure progress.

1