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In June this year I made a return visit to Ethiopia. I travelled with
representatives from a local family planning group across the highland plateau
to the Sidamo region, in the fertile and densely populated southern lowlands.
My purpose was to see what progress had been made in one of the country’s
first rural, community-based, family planning programmes which was set
up with help from the British development agency Population Concern.

Outsiders commonly assume that there is no widespread demand for modern
contraception in sub-Saharan Africa, where there is a long-standing tradition
of large families and where infant mortality is so high. But what I found
was astonishing evidence of an unmet need for family planning among the
poor subsistence farmers who live in the Sidamo region.

During the 21 months since the programme was launched, use of modern
contraception had increased from 3 per cent of married women of fertile
age to 16 per cent, among a population of some 300 000. This seems to confirm
the views of Malcolm Potts, Bixby Professor of Population and Family Planning
at the University of California. He believes that the demand for family
planning is ‘a moving target’ – the greater the access, the greater the
take-up.

Personal prejudices

Projects such as this show that close collaboration between voluntary
organisations, government departments and local people can quickly reveal
and begin to meet needs for a choice of suitable family planning services.
In this case, each peasant group selected its own family planning worker
– many of whom were men. Talking to some of these farmers, it soon became
clear that their work as educators and service providers, had broken down
many of their personal prejudices and inhibitions. All had become very much
more aware of the health benefits for mothers and children of timing, spacing
and limiting births.

They talked frankly about the changes they had seen in the improved
physical health and fitness of mothers who were no longer subject to two
or three pregnancies every three years. They commented on the more positive
attitude among men towards family planning, and improved sexual relationships
between husbands and wives freed from the fear of unwanted pregnancies.
And they added that with better education, there were now fewer abortions
and infant deaths.

This and similar experiences in countries from Asia and Africa to South
America have convinced me of the validity of findings by the UN-supported
World Fertility Survey in the 1970s, and the more recent Demographic and
Health Surveys funded by the US Agency for International Development. Both
highlighted a very large and fast-growing need for family planning services
in the developing world. And experience shows that such programmes work
best if there is an accompanying investment in education (especially for
girls), healthcare and good communications.

The success, however, of family planning in countries with low incomes
such as Sri Lanka (where the use of contraception is 60 per cent), or in
the Indian states of Kerala and Tamil Nadu where the two-child family is
the norm, is evidence that what is generally regarded as ‘economic development’
does not have to come before the widespread take-up of contraception. The
example of Bangladesh is perhaps the most convincing.

Despite poverty, a high rate of illiteracy, and the low status of women
and girls, there is a strong and consistent demand for family planning services
throughout the country. Though per capita income is less than $1 a day,
and 1 in 10 babies die before their first birthday, use of contraceptives
has risen from 5 to 40 per cent since 1970. Within 20 years, completed family
size has fallen from 7 children to fewer than 5, and desired family size
has fallen from 4 to 3 children in the past 15 years. Yet in other parts
of southern Asia, such as Pakistan, where family planning services remain
largely unobtainable, the use of contraception is below 10 per cent and
women are still having just under 7 surviving children.

The draft Plan of Action, prepared for the International Conference
on Population and Development (ICPD) to be held in Cairo next week, puts
the number of extra women worldwide who would be using a modern method of
contraception ‘if it were available, affordable and acceptable by her husband,
family and community’ at 120 million. It also estimates that a total of
350 million women have access only to an inadequate range of family planning
options. One indication of this is the estimated 50 million abortions that
occur every year.

Perhaps the greatest unmet need is among young people, many of whom
urgently require information and practical help if they are to avoid unwanted,
and often dangerous, pregnancies. In Asia and the Middle East, there are
300 million adolescents. In Latin America there are 100 million young people
aged between 15 and 19, with little access to contraception because clinics
do not normally help unmarried women. Even in a so-called developed country
such as the US there are more than 600 000 unintended pregnancies (more
than half of which end in abortion) among the nation’s 17 million teenagers.

Every year, 15 million teenage girls – married and unmarried – become
pregnant, sometimes at a very young age. In Nigeria, for example, nearly
1 in 5 of all 15-year-old girls has already given birth, and abortion accounts
for 70 per cent of all deaths of girls under 19. Globally, older women and
those who have already had repeated pregnancies also face high risks if
they become pregnant. Yet surveys indicate that some 20 million in these
groups have no way of avoiding unwanted pregnancies. Other research shows
that as many as half of those who start to use the Pill, IUDs or condoms
stop because of poor or inappropriate services.

China and India provide telling examples. In China – where birth rates
fell from an average of 6 per family to 3.5 in the first half of the 1970s,
before the one-child policy was introduced – the main temporary contraceptive
method had been the steel ring IUD, which has a very high failure rate.
In India, the heavy reliance on sterilisation in many states means that
thousands of women have no temporary method of birth control.

And the scale of the need for appropriate contraception is growing rapidly.
It has been estimated that if the UN’s medium projection for population
growth (6.25 billion by the end of the century) is to be met, the use of
contraceptives in developing countries will have to increase from 51 per
cent of couples at the beginning of the decade to 59 per cent. This will
mean an increase from 387 million to 567 million during the 1990s.

This is not an impossible goal, and one which would have a tremendous
payoff in terms of health, family wellbeing and population growth. Steven
Sinding of the Rockefeller Foundation has calculated that by meeting the
need for contraceptive services, average family size worldwide could fall
from 4 to as little as 2.8 by the end of the century. Another demographer,
Parker Mauldin of the Population Council, estimates that just by meeting
85 per cent of that need, family size could achieve the UN’s low projection
of 2.855 children per family by 2000. This would put the world on course
for a population of 8 billion by 2050 rather than the UN’s high projection
of 12.5 billion.

But first there must be greater political commitment to family planning
and reproductive healthcare. While it is true that birth rates are falling
fast without government intervention in one or two countries – Colombia,
for example, where there is a powerful private sector family planning programme
– the big successes have nearly all involved a determined government policy.
And two surveys, one commissioned by the Australian government and another
by the Population Council, suggest that family planning is responsible for
between 20 and 50 per cent of the decline in birth rate globally. A successful
and sustainable population development policy also requires investment
in other social sectors such as the education of girls, primary healthcare,
work opportunities for women.

Pressing problems

In a country like Pakistan, where less than 6 per cent of the national
budget is spent on health and education (compared with 20 per cent in Tamil
Nadu in India), there are huge hurdles to be overcome. The government shows
little commitment to family planning, foreign aid from non-government initiatives
has been hit by the withdrawal of US aid for political reasons, and women
remain isolated and discriminated against. Yet anyone who has worked in
Pakistan will know that when services are provided, with a genuine choice
of method and local involvement, the demand for family planning is overwhelming.

In Africa too, women will have to be given more say. And men will have
to be involved. I recall a visit to a remote village in Sierra Leone where
the children were dying of TB, measles, diarrhoea and whooping cough and
many of the women were exhausted by their triple workload in the field,
in the home and as mothers. One woman of 28 wept and said: ‘I bore my first
child when I was 15. I have had 11 pregnancies and only three surviving
children. I know I am going to lose this one in my arms too. I am tired
of childbearing but the decision to have children is my husband’s. I have
no charge over my body.’

The hope from Cairo is that an overwhelming majority of countries will
back the targets for a total of $17 billion to be spent on family planning
and reproductive healthcare by the year 2000 and that the goals for improving
the education and opportunities for girls will be met. Several of the major
donors seem ready to increase their investment in population and related
public health programmes.

In early drafts of the Plan of Action, there was even talk of developed
countries devoting 20 per cent of their aid budgets to the social programmes.
At present the average is 7 per cent. The developing countries currently
allocate an average of 13 per cent of their national budgets to these programmes.
If, as Gustave Speth of the UN Development Programme has suggested, they
devote 20 per cent of their government spending to health and family planning,
education and water supplies and spend less on arms, an extra $50 billion
a year could be generated. The dream of stabilising world population at
a manageable level would then look as if it was within our grasp.

Rajamani Rowley was Director of Population Concern from 1988 to 1994.
She now works as a consultant to various overseas development programmes.