ELSEVIER European Journal of Obstetrics & Gynecology

and Reproductive Biology 57 (1994) 63-64

Editorial

Family planning investing in the future

Rolf Korte

Deuische Gesellschaft ftir Techhnische Zusammenarbeit, Healrh Population Nutrition Division, Postfach 5180, 65726 Eschborn, Germany

As long ago as 1798, Thomas Malthus dealt with the problem of population growth in his ‘Essay on the Prin- ciple of Population’, the most famous work ever to be written on this issue. In view of the rapid urbanization, spreading poverty and severe famines that afflicted En- gland during the late eighteenth century, his situational analysis was largely correct. However, Malthus was not good at predicting what was to come. He painted an overwhelmingly repugnant scenario of horror that had the effect of causing many people to repress the issue. His forecasts failed to anticipate either the enormous ad- vances that would later be made in food production and technology, or the possibility of large-scale emigration from Europe to North America, Australia and South Africa. As a result of all this, in spite of fast population growth the situation in the following decades not only remained stable, but even improved substantially. Since then, however, the factors Malthus had failed to con- sider have been fully exploited, leaving today’s popula- tions no more room to expand.

As long ago as the 196Os, the topic of population poli- cy was repeatedly addressed at the international level as a priority issue. But this time, in contrast to Malthus, the possibilities for influencing population growth were regarded as being too complex. Many expressed the opinion that development was the best contraceptive. Others asserted that the population explosion could pri- marily be combated by educating women and alleviating poverty. Consequently, the issue of population growth and family planning remained in public view but was consistently relegated to second or third place behind other development priorities. In view of the scarce re- sources available for development programs and the numerous acute problems that had to be dealt with on an everyday basis, this effectively resulted in too little at- tention being devoted to population issues including family planning.

Although the world’s population has continued to grow at an alarming rate, by providing family planning services today we are able to exert an influence on

whether there will be 7.27 or 7.92 billion people in the world in the year 2015. At first glance, this difference may not appear to be very large. But it amounts to 660 million persons, which is equivalent to the present popu-

lation of the African continent. Depending on how suc- cessful our efforts are, we will either be able to stabilize the population in the year 2050 at 7.8 billion or wind up with a population of 12.5 billion. The difference between these two extremes is as large as the world’s population today.

Public opinion continues to sway back and forth, alternately moved by a scenario of impending cata- strophe and news of successes curbing population growth that make it seem unnecessary to be very con- cerned. In some developing countries the percentage of couples that practice contraception has increased from 10% to 50% over the last 30 years. At the same time, the average number of children born to each couple has diminished at a faster rate than Europe has ever ex- perienced. To a large extent, this is due to successful family planning programs. If such programs had never been offered, then in the year 1990 there probably would have been 412 million more people in the developing countries.

Yet we must not let these reports of success entice us to relax our efforts. The United Nations Fund for Popu- lation Activities (UNFPA) estimates that there is an unmet need for family planning for some 300 million couples. As numerous studies have confirmed, in Africa contraceptives are only used by about one in four women who do not wish to have any more children. In Asia, by comparison, 43% of such women take preven- tive measures, and the corresponding figure in Latin America is 57%. In 48 surveyed population groups, parents had more children than they really wanted. The proportion of unwanted births amounted to 22% on average. It can be concluded from this that many women would like better access to family planning services.

It is estimated that 50 million abortions are performed

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64 R. Kotte / Eur. J. Obstet. Gynecol. Reprod. tliol. 57 (1994) 63-64

each year, half of them illegally. Between 60 000 and 100 000 women die from complications of unsafe abor- tion. This is probably the most compelling and dramatic evidence of an unsatisfied demand for more and better advice on family planning.

In some countries, improperly performed abortions are responsible for half of the deaths of pregnant women. A large number of studies have shown that when women have no access to family planning advice their lives are endangered. The average maternal mortal- ity in the developing countries is about 420 deaths for every 100 000 live births. In the developed parts of the world, it is only between 8 and 30 deaths per 100 000 live births.

Proper use of generally accepted contraceptives is one of the most cost-effective methods for improving the health of women and also, indirectly, of their children. Where family planning is readily available, a number of other health indicators for women and children also rise. For example, it has been demonstrated that there is a correlation between effective family planning and great- er weight at birth of children, an improved nutritional situation of families, declining abortion rates, and reduced maternal mortality. Other benefits, which can- not be easily quantified but appear to be thoroughly plausible, include improved educational opportunities when new pregnancies are prevented while children are attending school and when births are spaced further apart.

Even now, excessive population densities in many poor regions are having a devastating impact on the en- vironment. The steadily diminishing fertility of soils is already prompting involuntary migratory movements. Violent conflicts over vital resources like water and land are occurring with increasing frequency. At the same time industrialized countries should not try to distract attention from their own responsibility: every one of their inhabitants consumes many times more resources than their counterparts in the developing countries.

It is imperative to remind oneself again and again of the following fact: many developing countries are ex- periencing such rapid population growth that their populations will double within 20 years.

It is often claimed, mainly by representatives of in- dustrialized countries, that family planning is an ex- tremely delicate topic that can only be approached with great caution. All too often, they are merely projecting their own problems in dealing with this issue onto the situation in the developing countries. Many traditional forms of family planning have been practiced in the

past, although today we would regard some of them as unethical. More than 100 years ago, explorers like Liv- ingstone reported with amazement on the small sizes of families in Africa. Abstinence, coitus interruptus, con- traceptive mixtures, and also abortion and infanticide - especially when women gave birth to twins - were all practiced to avoid endangering the lives of children who had already been born. The turning point came with the start of the colonial era. In order to ensure the availabili- ty of enough manpower to work the plantations, many types of traditional family planning were systematically suppressed, in some cases even by passing laws against them. Because of this fact alone, today the erstwhile col- onial masters are morally obligated to support family planning.

In the same way that a pro-birth policy was imposed during the colonial era, today we are once again running the risk of projecting our problems in connection with population policy and sexuality onto the developing countries. This could lead us to refrain from providing urgently needed help. Yet, the right to family planning is also a right to self-determination, which today is inter- nationally acknowledged as a basic human right. Unhindered access to family planning facilities pro- motes the development of this right to self-determin- ation and furnishes an opportunity to exercise it.

Today there is no longer any question as to whether family planning should be the first, second or third de- velopment priority. Practical population policies and family planning services must be an integral part of all development planning.

According to estimates of the UNFPA, the number of couples practicing contraception can be increased to 830 million by the year 2015 by reducing the unsatisfied de- mand for family planning facilities and providing appro- priate information and services.

This would signify a rise in the proportion of couples practicing contraception from 58% at present to 69% in the year 2015. The required yearly expenditures for basic services in the family planning sector would amount to less than 3 dollars per capita. It is likely that two-thirds of these costs could continue to be met by the develop- ing countries themselves. That means that roughly ten billion dollars annually would have to be additionally raised by the international community in order to make family planning available to most of humanity by the end of this century. Access to family planning and safe abortion must not remain limited to the industrialised world.