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World Population and Fertility Planning

Technologies: The Next 20 Years

February 1982

NTIS order #PB82-200338


Library of Congress Catalog Card Number 82-600516

For sale by the Superintendent of Documents,


U.S. Government Printing Office, Washington, D.C. 20402
Foreword
By the year 2 000 the world’s population is projected to increase by between 1.5
)

billion and 2.1 billion people. About 92 percent of this rise will take place in the less de-
veloped countries (LDCs). Birth rates are falling in most of these countries, but be-
cause the largest generation of young people in history is reaching childbearing age,
the annual increase in global numbers is expected to rise from 80 million this year to
95 million annually by 2000.
Rapid population growth in the last 20 years is a result of improvement in health
and agriculture technologies. Increased options for fertility change have also resulted
from advances in science and technology. Because its mission includes foresight on
emerging issues related to science and technology, OTA determined in 1978 that an
objective analysis was timely and appropriate in providing Congress with improved in-
sight in this area. The topic was discussed with Members of Congress and letters en-
dorsing the study were received from the House Committee on Foreign Affairs, the
House Committee on Science and Technology, and the former Subcommittee on Child
and Human Development of the Senate Labor and Human Resources Committee. Per-
mission to undertake the study was granted by OTA’s Technology Assessment Board
in response to a request by the Director.
This report covers the status of current and projected technologies that affect fer-
tility change. It presents current projections for population growth to 2000 and the im-
plications of this growth; identifies the determinants of fertility change; reviews cur-
rent reproductive research and contraceptive R&D; discusses the factors that influ-
ence the acceptance, distribution, and use of fertility planning technologies in LDCs;
and examines past and current U.S. funding arrangements in support of population as-
sistance requests from LDCs.
Issues and options developed for Congress include Federal support of contracep-
tive R&D; product liability and the contraceptive industry; effective patent life; export
of non-FDA approved drugs; levels of funding for international population assistance;
and distribution of population assistance funds.
The Office of Technology Assessment was assisted in the preparation of this study
by an advisory panel of individuals representing a wide range of backgrounds, includ-
ing demographic and family planning research, the pharmaceutical industry, health
policy analysis, ethics and philosophy, and organizations holding differing views on
current reproductive issues. Sixty-six reviewers drawn from universities, nongovern-
mental agencies, and the private sector provided helpful comments on draft reports.
The Office expresses sincere appreciation to each of these individuals. As with all
OTA reports, however, their content is the responsibility of the Office and does not
necessarily constitute the consensus or endorsement of the advisory panel or the
Technology Assessment Board.

W JOHN H. GIBBONS
Director

...
Ill
World Population and Fertility Planning
Technologies Advisory Panel

Philip R. Lee, Chairman


Health Policy Program, School of Medicine, University of California

Leona Baumgartner Nathan Keyfitz


Abel’s Hill, Chilmark, Mass. Harvard University Center for
Population Studies
Kenneth Boulding
Marjory Mecklenburg*
Institute of Behavioral Science
American Citizens Concerned
University of Colorado
for Life

Wilbur J. Cohen Deborah Oakley


LBJ School of Public Affairs School of Nursing
University of Texas University of Michigan

Cyril Crocker Kenneth J. Ryan


Howard University School Boston Hospital for Women
of Medicine
Nafis Sadik
United Nations Fund for
Arthur Dyck Population Activities
Harvard Divinity School
Carol Tauer
William N. Hubbard, Jr. Department of Philosophy
The Upjohn Co. College of St. Catherine

Snehendu B. Kar Faye Wattleton


School of Public Health Planned Parenthood Federation
University of California of America

● Resigned as of February 1981 to assume position at the Department of Health and Human Stm’ices.

iv
OTA Population Assessment Staff

Joyce C. Lashof, Assistant Director, OTA, through November 1981


H. David Banta, Assistant Director, 0TA, from December 1981
Health and Life Sciences Division

Gretchen S. Kolsrud, Program Manager


Leslie Corsa, Project Director through December 1980
Louise A. Williams, Project Director from January 1981
Lawrence Miike, * Senior Analyst

Project Staff
Phyllis Avedon, * Editor
Marya Breznay, Administrative Assistant
David Cantor, Analyst
Susan Clymer, Research Assistant
Emiline Ott, Senior Analyst through 1980

Major Contractors

John G. Stover and Jonathan T. Bye


The Futures Group, Glastonbury, Corm.
S. Bruce Schearer
The
— Pormlation Council, New York
1

OTA Publishing Staff

John C. Holmes, Publishing Officer


John Bergling Kathie S. Boss Debra M. Datcher Joe Henson

“OT.A contract personnel,


Contents

Chapter Page
I. Summary, Issues, and Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2. Population Growth to the Year 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3. Implications of World Population Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4. The Direct Determinants of Fertility Change . . . . . . . . . . . . . . . . . . . . . . . . . . S 7
5. The Technology of Fertility Change: Present Methods and Future
Prospects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
6. Reproductive Research and Contraceptive Development . . . . . . . . . . . . . . . . 105
7. Factors That Affect the Distribution, Acceptance, and Use of Family
Planning in LDCs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
8. Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
9. Financial Support for LDC Population Programs . . . . . . . . . . . . . . . . . . . . . . . 175

Appendixes
A. Evolution of China’s Birth Planning Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
B. Indonesia Looks Toward Continued Fertility Decline . . . . . . . . . . . . . . . . . . . 220
C. Record Population Growth Persists in Kenya . . . . . . . . . . . . . . . . . . . . . . . . . . 225
D. Production and Distribution Capabilities for New Fertility Planning
Technologies Over the Next Two Decades . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
E. Workshop Participants, Contributors, and Acknowledgments . . . . . . . . . . . . 240
F. Commissioned Papers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

vii
Glossary

Abortion rate.—The estimated number of abor- Birth rate (or crude birth rate) .—The number of
tions per 1,000 women aged 14 to 44 in a given births per 1,000 population in a given year. Not
year. to be confused with growth rate.
Age-sex structure.— The composition of a popula- Census.—A canvass of a given area, resulting in an
tion as determined by the number or proportion enumeration of the entire population, and the
of males and females in each age category. The compilation of demographic, social, and eco-
age-sex structure of a population is the cumula- nomic information pertaining to that population
tive result of past trends in fertility, mortality, at a specific time. (See also survey.)
and migration. Information on age-sex compo-
Childbearing years.— The reproductive age span
sition is an essential prerequisite for the descrip-
of women, assumed for statistical purposes to be
tion and analysis of many other types of demo-
15 to 44 in the United States. In other countries,
graphic data. (See also population pyramid.)
the range is often set at 15 to 49.
Amenorrhea.—The absence or suppression of
Cohort.—A group of people sharing a common tem-
menstruation; normal before puberty, after the
poral demographic experience who are observed
menopause, during pregnancy and lactation.
through time. For example, the birth cohort of
Antinatalist policy.– The policy of a government, 1900 would be the people born in that year.
society, or social group to slow population
Completed fertility rate.—The number of chil-
growth through efforts to limit the number of
dren born per woman in a cohort of women by
births.
the end of their childbearing years.
Artificial insemination.—Introduction of semen
into the uterus or oviduct by other than natural Conception.— Generally the beginning of preg-
nancy, but in a theological context sometimes
means.
the point at which a new life, in the sense of a
Baby boom.—The period following World War II new soul, begins. Conception is usually equated
from 1947 to 1961 marked by a dramatic in- with the fertilization of the ovum by the sperm,
crease in fertility rates and in the absolute num- but is sometimes equated with the implantation
ber of births in the United States, Canada, Aus- of the fertilized ovum in the uterine lining. The
tralia, and New Zealand. exact definition is of some significance when at-
tempts are made to classify fertility planning
Barrier method.—A contraceptive method that es- methods as either contraceptive or abortifacient.
tablishes a barrier between the joining of sperm
and ovum; e.g., condom, diaphragm, cervical Consensual union.—Cohabitation by an unmar-
cap. ried couple for an extended period of time.
Basal body temperature method.-See periodic Crude birth rate.—See birth rate.
abstinence methods.
Continuation rate.—The proportion of those
Billings method.–See periodic abstinence meth- adopting a method of contraception who con-
ods. tinue with it for a given period.
Birth interval.—The length of time that has Contraceptive.—An agent or device used to pre-
elapsed between one live birth and the next, or vent conception.
between marriage and the first live birth, or be-
tween the time of last live birth and the time of Contraceptive failure rate.—The ratio of the
number of conceptions occurring during a given
inquiry; normally measured in months. In con-
trast to pregnancy intervals, live birth intervals period to the number of person months lived by
may include pregnancies that did not end in live a group of women or couples during which con-
births; for example, a live birth interval could be traception or a particular contraceptive is used.
a live birth, followed by a stillbirth, followed by Contraceptive prevalence rate.—A measure of
another pregnancy resulting in a live birth. The the extent of contraceptive practice among the
live birth interval would include the entire population at risk of conception, calculated as
period between the two live births. (See pregnan- the ratio of the number of women known or
cy interval.) supposed to be practicing contraception at a

Vlll
0 . .
given time to the total number of eligible women estrogenic hormones estradiol and estrone pro-
(generally those fecund, nonpregnant, married duced by the ovary; the female sex hormones.
women) in that population.
Exponential growth.-A constant rate of growth
Death rate (or crude death rate).—The number applied to a continuously growing base over a
of deaths per 1,000 population in a given year. period of time; for example, a savings account in-
creasing at compound interest; a snowball gath-
Demographic transition.—The historical shift of ering mass; a population growing at 3.0 percent
birth and death rates from high to low levels in a annually,
population. The decline of mortality usually pre-
cedes the decline in fertility, resulting in rapid Failure rate.—See contraceptive failure rate,
population growth during the transition period.
Fallopian tube.—The tube or duct that extends lat-
Demography (Greek, demos [people] graphic erally from the lateral angle of the uterus, ter-
[studyI).–The scientific study of human popula- minating near the ovary. It serves to convey the
tions, including their size, composition, distribu- ovum from the ovary to the uterus and sper-
tion, density, growth, and other demographic matozoa from the uterus towards the overy. .
and socioeconomic characteristics, and the
Family planning.– The conscious effort of
causes and consequences of changes in these fac-
couples to regulate the number and spacing of
tors.
births. Family planning usually connotes the use
Dependency ratio. —The ratio of the economically of contraception to avoid pregnancy, but also in-
dependent part of the population to the produc- cludes efforts of couples to induce pregnancy.
tive part; arbitrarily defined as the ratio of the
Fecundity. —The physiological capacity of a
elderly (those 65 years and over) plus the young
woman, man, or couple to produce a live child.
(those under 15 years of age) to the population in
the “working ages” (those 15 to 64 years of age). Fertility.—The actual reproductive performance of
an individual, a couple, a group, or a population.
Depo-Provera.—See injectable contraceptives.
Fertility rate.– See general fertility rate.
Doubling time. —The number of years required
for a population of an area to double its present Fertilization.—Penetration of an ovum by a sper-
size, given the current rate of population matozoon. Usually occurs in the fallopian tube,
growth. following ovulation in the menstrual cycle, and is
usually considered to be the moment of concep-
Effectiveness.–Clinical or theoretical effec- tion as it is the time when the two sex cells unite.
tiveness is measured by the failure rate of con-
traceptive methods under conditions as close to General fertility rate. (also referred to as fer-
ideal as possible, usually under skilled supervi- tility rate)---The number of live births per 1,000
sion, with care taken to see that they are in- women aged 15 to 44 years in a given year. (see
variably and correctly used. Use effectiveness is also implantation.)
measured by the failure rate of contraceptive Gonadotropin.-A substance having affinity for or
methods when used by the general population, a stimulating effect on the gonads. There are
without careful medical supervision, so that fail- three varieties: anterior pituitary, chorionic
ures may be due to intermittent or incorrect use. from human pregnancy urine, and chorionic
Demographic effectiveness is measured by meas- from the serum of pregnant mares.
uring changes in the fertility of a population
after a particular fertility planning method or Gossypol.-A derivative of the cottonseed plant
program has been introduced. known to induce infertility in males; now being
tested as a male contraceptive in China.
Emigration.- The process of leaving one country
to take up residence in another. Growth rate.—The rate at which a population is in-
creasing (or decreasing) in a given year due to
Emigration rate. —The number of emigrants de- natural increase and net migration, expressed as
parting an area of origin per 1,000 population at a percentage of the base population.
that area of origin in a given year.
Immigration. —The process of entering one coun-
Estrogen.— Any natural or artifical substance that try from another to take up permanent res-
induces estrogenic activity; more specifically the idence.

ix
Implantation .—Process whereby a fertilized ovum stance) of the luteinizing hormone releasing fac-
burrows into the lining of the uterus on its ar- tor (LRF), a hypothalamus-controlled secretion
rival there, and attaches itself firmly. Successful from the anterior pituitary gland, are under
implantation is essential to the future develop- study as contraceptives and agents to treat infer-
ment of the fetus and is sometimes considered as tility. Both long-acting agonists (stimulators) and
the true moment of conception. antagonists involve inhibition of ovulation; lute-
olysis; and inhibition of spermatogenesis and
Infant mortality rate.—The number of deaths to testosterone secretion. Possible routes of ad-
infants under 1 year of age in a given year per ministration include subcutaneous, intramus-
1,000 live births in that year. cular, sublingual, rectal, intravaginal, and in-
Infertility.—Failure, voluntary or involuntary, to tranasal.
produce live born children on the part of an indi- Marital fertility rate.–Number of legitimate live
vidual, a couple, or a population. births per 1,000 married women aged 15 to 44 in
Injectable contraceptives.—The most commonly a given year.
used injectable progestins, given at 3-month in- Maternal mortality rate.—The number of deaths
tervals, are Depo-Provera (DMPA) or medroxy- to women due to pregnancy and childbirth com-
progesterone acetate, and norethindrone enan- plications per 100,000 live births in a given year.
thate.
Menarche.-The beginning of menstruation; i.e.,
integration. —In the family planning context, in-
the first menstrual period. This occurs during
tegration refers to linkage of family planning
puberty but does not signify the beginning of full
services delivery with some other program,
adult fecundity as ovulation may be irregular or
usually health, MCH, or other rural development
absent for some time.
activity (electrification, agriculture, nutrition,
parasite control). The linkage is at either the ad- Menopause. —Cessation of menstruation; i.e., the
ministrative or the service end. At the ad- last menstrual period or the end of a reasonably
ministrative level it is the creation of an umbrella regular menstrual pattern. After the menopause
organization with administrative control over a is completed a woman is permanently sterile.
large array of services; at the service level, spe-
cialized services are linked at the point of service Migration.- The movement of people across a
delivery. specified boundary for the purpose of establish-
ing a new permanent residence. Divided into in-
In vitro.—Outside the living organism and in an ar- ternational migration (migration between coun-
tificial environment. tries) and internal migration (migration within a
Less developed country.—For purposes of this country).
report, all countries, territories, or areas in Latin Mini-laparotomy. —Female sterilization procedure
America and the Caribbean, all in Africa other in which the fallopian tubes are ligated or cau-
than the Republic of South Africa, all in Asia terized through a small abdominal incision.
other than Japan and the U. S. S. R., and all in
Oceania other than Australia and New Zealand. Mini-pill.—Oral contraceptive containing no
LDCs tend to be characterized by low per capita estrogen and generally less than 1 mg of a pro-
gross domestic product (GDP), a low share of gestational agent.
manufacturing in GDP, low rates of annual in-
crease in total GDP, low proportions of people Morbidity. —The frequency of disease and illness in
with basic training or technical skills, and low a population.
literacy rates among those 15 or older. (See more More developed country.—For purposes of this
developed country.) report, all countries of Europe, North America
Life expectancy. —The average number of addi- (Bermuda, Canada, Greenland, St. Pierre and Mi-
tional years a person would live if current mor- quelon, and the United States), Australia, New
tality trends were to continue. Most commtmly Zealand, Japan, and the U.S.S.R. (See less
cited as life expectancy at birth. developed country.)
LRF analogs.- Numerous analogs (chemically dif- Mortality.—Death as a component of population
ferent but reactively similar to the parent sub- change.

x
Natural family planning.–See periodic absti- perature readings to identify the time of ovula-
nence. tion; in the ovulation or Billings method, women
are taught to identify the relationships of
Natural fertility.—The fertility of persons or changes in cervical mucus to fertile and infertile
populations in which deliberate control of child- days; the Sympto-Thermal method charts both
bearing (through use of abstinence, contracep- changes in temperature and cervical mucus and
tion, induced abortion, sterilization, etc.) is not teaches recognition of other symptoms of ovula-
practiced. Sometimes used loosely to signify the tion (i.e., intermenstrual pain).
maximum fertility biologically possible; i.e., that
of a normal healthy person or group of persons The “pill.”—See oral contraceptives.
engaging regularly in sexual intercourse during
Population.— A group of objects or organisms of
the reproductive span with no attempt to re-
the same kind.
strict childbearing. The fertility of such pop-
ulations will be determined by such factors as Population density.– population per unit of land
marriage customs, breastfeeding practices, and area; for example persons per square mile, or
similar social and economic factors, and will persons per square kilometer of arable land.
therefore probably fall short of the biological
maximum of fertility. Population distribution.—The patterns of settle-
ment and dispersal of population.
Natural increase.–The surplus (or deficit) of
births over deaths in a population in a given time Population increase. —The total population in-
period. crease resulting from the interaction of births,
deaths, and migration in a population in a given
Negative population growth.-A net decrease in period of time.
the size of a population.
Population momentum.—The tendency for pop-
Net migration.—The net effect of immigration and ulation growth to continue beyond the time that
emigration on an area’s population in a given replacement level’ fertility has been achieved be-
time period, expressed as increase or decrease. cause of a relatively high concentration of people
Net migration rate. —The net effect of immigra- in the childbearing years.
tion and emigration on an area’s population, ex- Population policy. —Explicit or implicit measures
pressed as increase or decrease per 1,000 popu- instituted by a government to influence popula-
lation of the area in a given year. tion size, growth, distribution, or composition.
Oral contraceptives.— Various progestinlestrogen Population projection.—Computation of future
or progestin compounds in tablet form taken se-
changes in population numbers, given certain as-
quentially by mouth; the ‘(pill.” Estrogenic and
sumptions about future trends in the rates of
progestational agents have contraceptive effects
fertility, mortality, and migration. Demograph-
by influencing normal patterns of ovulation, ers often issue low, medium, and high projec-
ovum transport, implantation, or placental at-
tions of the same population, based on different
tachment.
assumptions of how these rates will change in
Ovulation.—The release of an ovum from the the future,
ovary during the female menstrual cycle.
Population pyramid.— A special type of bar chart
ovulation method.—See periodic abstinence that shows the distribution of a population by
methods. age and sex. Most countries fall into one of three
general types of pyramids: 1) Expansive-a
Parity .–The number of live births a woman has
had; a woman of zero parity has had no live broad base, indicating a high proportion of chil-
dren and a rapid rate of population growth;
births, a woman of parity one has had one live
birth, etc. 2) Constrictive—a base that is narrower than the
middle of the pyramid, usually the result of a re-
Periodic abstinence methods.—Contraceptive cent rapid decline in fertility; and 3) Station-
methods that rely on timing of intercourse to ary—a narrow base and roughly equal numbers
avoid the ovulatory phase of a woman’s men- in each age group, tapering off at the older ages,
strual cycle; Natural Family Planning. The Basal indicating a moderate proportion of children
Body Temperature (BBT) method uses daily tem- and a slow or zero rate of growth.

xi
Pregnancy interval.– Length of time that has rate of 1.00. The total fertility rate is also used to
elapsed between the end of one pregnancy and indicate replacement level fertility; in the United
the end of the next, or between marriage and the States today a TFR of 2.12 is considered to be re-
end of the first pregnancy or between the end of placement level. (See zero population growth).
the last pregnancy to occur and the time of in-
Reproductive age.–See childbearing years.
quiry; normally measured in months (See birth
interval). Sex ratio.—The number of males per 100 females in
a population.
Prevalence rate.—See contraceptive prevalence
rate. spermicide.– An agent that kills spermatozoa.
Progesterone.— A steroid hormone obtained from stable population.– A population with an un-
the corpus luteum, adrenals, or placenta. It is re- changing rate of growth and an unchanging age
sponsible for changes in uterine endometrium in composition, because birth and death rates have
the second half of the menstrual cycle prep- remained constant over a sufficiently long pe-
aratory for implantation of the blastocyst, devel- riod of time.
opment of maternal placenta after implantation,
and development of mammary glands. Stationary population.—A stable population with
both a zero growth rate (because the birth rate
Progestin.-A corpus luteum hormone that pre- equals the death rate) and an unchanging age
pares the endometrium for the fertilized ovum. composition.
This word is now used to cover a large group of
synthetic drugs that have a progesterone-like ef- Steroid hormones.— See estrogen, progesterone.
fect on the uterus. Survey.—A canvass of randomly selected persons
Pronatalist policy. —The policy of a government, or households in a population usually used to in-
society, or social group to increase population fer demographic characteristics or trends for a
growth by attempting to raise the number of larger segment or all of the population, (See also
births. census.)

Prosta#andin .—Refers to a group of naturally oc- sympto-thermal method.–See periodic absti-


curring, chemically related long-chain fatty acids nence methods.
that have certain physiological effects (stimulate Total fertility rate (TFR).—The average number
contraction of uterine and other smooth mus- of children that would be born alive to a woman
cles, lower blood pressure, affect action of cer- (or group of women) during her lifetime if she
tain hormones). were to pass through her childbearing years
Rate of natural increase.—The rate at which a conforming to the age-specific fertility rates of a
population is increasing (or decreasing) in a given year.
given year due to a surplus (or deficit) of births Use effectiveness.— See effectiveness.
over deaths, expressed as a percentage of the
base population. Vasectomy.—Surgical sterilization of a male by oc-
clusion of the vas deferens.
Replacement level fertility.—The level of fertil-
ity at which a cohort of women on the average Zero population growth.-A population in equi-
are having only enough daughters to “replace” librium, with a growth rate of zero, achieved
themselves in the population. By definition, re- when births plus immigration equal deaths plus
placement level is equal to a net reproduction emigration.

SOURCES: E. Grebenik and A. Hill,International Demographic Ter- Arther Haupt and Thomas T, Kane, Population Hand-
minology: Fertility, Family Planning and Nuptiality book (Washington, D. C.: Population Reference Bureau,
(Liege, Belgium: International Union for the Scientific Inc., 1978).
Study of Population, 1974), IUSSP Papers No. 4.

xii
Acronyms and Abbreviations

AID — Agency for International IUD — Intrauterine device


Development IUSSP — International Union for the
AVS — Association for Voluntary Scientific Study of Population
Sterilization JHPIEGO — Johns Hopkins Program for
BBT — Basal Body Temperature Method International Education in
(See Glossary) Gynecology and Obstetrics
CBD — Community based distribution (of KAP — Knowledge, attitudes, and practice
contraceptives) (of contraception)
CDB — Contraceptive Development LDC — Less developed country (See
Branch, CPR, NICHD Glossary)
CPR — Center for Population Research, LH — Luteinizing hormone
NICHD LRF(LHRH) — Luteinizing hormone releasing
CPS — Contraceptive Prevalence Survey factor (See Glossary)
CRS — Commercial retail sales (of MCH — Maternal and child health
contraceptives) MDC — More developed country (See
DES — Diethylstilbestrol Glossary)
DHHS — Department of Health and Human MWRA — Married women of reproductive
Services (formerly Health, age
Education and Welfare) NDA — New Drug Application (FDA)
DMPA — Depo-Provera (See Glossary) NFP — Natural family planning (See
FAO — Food and Agricuhure Organization Glossary)
FDA — Food and Drug Administration NGO — Nongovernmental organization
FPIA — Family Planning International NICHD — National Institutes of Child Health
Assistance and Human Development
FSH — Follicle stimulating hormone NIH — National Institutes of Health
GNP – gross national product PARFR — Program for Applied Research on
IBRD — International Bank for Fertility Regulation
Reconstruction and Development PMA — Pharmaceutical Manufacturers
ICCR — International Committee for Association
Contraception Research, Population PIACT — Program for the Introduction and
Council Adaptation of Contraceptive
IDA — International Development Technology
Association PRC — People’s Republic of China
IEC — Information, Education, and R&D — Research and development
Communication TFR — Total fertility rate (See Glossary)
IEM — Information, Education, and UN — United Nations
Motivation (See China report, UNDP — United Nations Development
app. A) Programme
IDRC — International Development UNFPA — United Nations Fund for
Research Center Population Activities
IFRP — International Fertility Research WFS – World Fertility Survey
Program WHO — World Health Organization
ILO — International Labor Organization
IPPF — International Planned Parenthood
Federation

...
X111
Chapter 1

Summary, Issues, and Options


Contents

Page

LIST OF TABLES
Table No. Page
l. Percent Reductions in Crude Birth Rates From 1965 to 1981 for Selected Countries. . . . . . 8
2. Theoretical and Use Effectiveness of Various Means of Contraception. . . . . . . . . . .......10
3. Future Fertility Planning Technologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......11

LIST OF FIGURES
Figure No. Page
I. World Population Growth From 8000 B.C. to 2000A.D.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2A. Age-Sex Composition of More Developed and Less Developed Regions,
1975 and 2000: Medium Series Projections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2B. Population Pyramid of the United States Illustrating the Effects of the Baby Boom. . . . . . 7
3. Channels by Which AID Population Assistance Filters to LDCs, 1979..................13
Chapter 1

Summary, Issues, and Options

Overview
This assessment considers the probable im- birth rates that might be possible. The strengths
pacts of specific fertility planning technologies and weaknesses of present technologies and
on population grotvth. The influence of direct techniques are summarized, and the probable
factors such as age at marriage and contracep- availability of new or improved technologies
tive use on population growth is relatively well within the next 10 to 20 years is estimated. Also
understood. Less well understood are the in- examined are how the U.S. Government sup-
direct influences–the economic, sociocultural, ports international population assistance, both
religious, and political forces—that modify atti- through its international aid programs and
tudes toward family size. Detailed examination through contraceptive research and develop-
of these indirect factors is beyond the scope of ment (R&. D), and how the Food and Drug Ad-
this study. Nevertheless, recognition of their im- ministration’s (FDA) regulatory role in assuring
portance in determining the use of fertility plan- the safety and efficacy of drugs and medical
ning technologies underlies everything that devices affects U.S. international population
follows. assistance efforts. Finally, this report enumer-
ates options that Congress might consider in the
The following pages examine the contribution
areas of reproductive research and contracep-
of fertility planning technologies to reducing
tive R&D and in furthering the aims of its inter-
birth rates, improving maternal and child
national assistance programs, and highlights
health, and enabling couples to choose the num-
issues that could benefit from oversight hear-
ber and spacing of their children. They also ex-
ings,
plore future changes in contraceptive use and

Introduction
Following World War II, the world experi- Rapid population growth in LDCs is a key fac-
enced a sudden sustained drop in death rates tor in limiting the ability of these countries to
which, combined with little change in birth raise their standards of living. Important obsta-
rates, procluced unprecedented growth in the cles to their socioeconomic development include
world)s population. Today, about 80 million peo- limited resources, food distribution problems,
ple, the equivalent of an additional Mexico or high rates of debilitating disease and infant mor-
Nigeria, afre added to the planet every Year. tality, lack of proper sanitation, scarcity of in-
More than 90 percent of this growth is in the vestment capital, and shortages of educational
developing world. In the United States and facilities and work opportunities. But each of
other more developed countries (MDCs), infant these barriers to a better quality of life in LDCs
is intensified by the rapid pace of their popula-
mortality is low and life expectancy exceeds 70
tion growth.
years, yet populations are stable or increasing
only moderately because birth rates are low. In Because LDC governments that once dis-
the less developed countries (LDCs), where in- missed rapid population growth as incidental to
fant mortality, although declining, is high, and their well-being now actively seek help with
life expectancy has not yet reached 5.5 years, their population problems, the United States
birth rates remain high and populations are in- and other MDCs provide population planning
creasing, often at dramatic rates. assistance as part of general developmental aid
4 ● world Popultion and Fertility Planning Technologies: The Next 20 Years

to countries who need and want help in reduc- that the U.S. Government provide assistance for
ing their birth rates. Such assistance has en- population planning, and the governments of a
abled many of these countries to achieve signifi- number of countries began to deal openly with
cant decreases in their population growth rates what they saw as dangers in the sudden dispar-
during the past decade, and there is now an in- ities between their birth and death rates. In its
ternational consensus that access to contracep- 1978 review, the House of Representatives
tive services is a basic human right. through its Select Committee on Population
The issues examined here are not new to Con- issued a series of reports on population and de-
velopmental assistance, and identified areas re-
gress. The United States has been a leader in
quiring additional study. Foremost among these
world population issues since the early 1960’s,
was the area of fertility planning technology.
when the Draper Commission recommended

Findings and conclusions


Fertility is declining in most LDC S) but popula- the reproductive ages (15 to 44) is increasing.
tion growth is continuing at high levels because The pyramid in figure 2A depicts the age struc-
of the momentum for future growth initiated by ture that is typical of most LDCS, where popula-
the high birth rates and rapidly falling infant tions are predominantly youthful because of
mortality rates of the recent past. More than 1 high fertility and declining infant mortality dur-
billion people will be in their peak reproductive ing the past 20 years. If fertility rates were to
years (ages 15 to 29) during the next two dec- fall rapidly, the lower groups of the pyramid
ades. (ages O to 4, 5 to 9, etc.,) would begin to contain
fewer individuals. The older ages (10 to 14, 15 to
Even if growth rates continue their current
19, etc.,) would then form a “bulge,” which
decline, the world’s population is expected to in-
would contribute a disproportionate number of
crease from 4.5 billion in 1981 to between 5.9
people of reproductive age some 5 to 10 years
billion and 6.5 billion in the year 2000 (see fig.
later. This bulge is illustrated in figure 2B by the
1). Almost 92 percent of this growth will occur
U.S. “Baby Boom:” members of this group are
in LDCs. Growth will be greatest, according to now of reproductive age and, although their
current projections, in Africa (76 percent of the
fertility is thus far lower than that of their
1980 population added in 20 years), followed by
parents, the absolute size of this group is
Latin America (65 percent), and Asia (43 per-
already resulting in an increase in the numbers
cent). But more of the increase in absolute
of births per year in the United States.
numbers will occur in Asia (63 percent) than in
Africa (22 percent) or in Latin America (15 per- The same cycle will take place in LDCs during
cent), simply because many more people the next 20 years, but on a more massive scale.
already live in Asia. Three-quarters of all LDC Stationary population growth—the stabilization
growth is expected to occur in just 18 countries: of deaths and births at near equal levels—would
India, China, Brazil, Nigeria, Indonesia, not be achieved until members of the largest age
Bangladesh, Pakistan, Mexico, Philippines, group (those now between O and 4 yeas) reach
Thailand, Vietnam, Turkey, Iran, Egypt, Ethi- old age some 60 years from now. The age struc-
opia, Burma, South Korea, and Zaire, listed here ture of a stationary population illustrated in
in the approximate order of the magnitude of figure 2A describes a typical MDC today.
their projected growth.
Current declines in fertility are unevenly
The striking momentum of world population distributed among LDCs but many of those with
growth means that the number of births ex- the largest populations have achieved the great-
pected each year will increase despite falling est declines. China’s birth rate has declined dra-
fertility rates, because the number of people in matically. Estimates of fertility decline between
Ch.1—Summary, Issues, and Options ● 5

Figure 1 .—Worid Population Growth From 8000 B.C. to 2000 A.D.


.
I
,
A.D. 2000 high variant
projection: 6.5 billion

A.D. 2000 medium variant


■ 1
4
6.5

projection: 6.2 billion 6.0

A.D. 2000 low variant


projection: 5.9 billion P
5.5
. 1

5.0

4.5

4.0

3.5

3.0

Chart shows world population


growth since 8000 B.C. If
2.5
stretched back all the way to
the beginning—300,000 B.C. 2.0
—in this scale, the line would
be an invisibly thin one start-
ing 10 feet 71/2 inches to the 1.5
left of the graph

1.0

0.5

0
7000 6000 5000 4000 3000 2000 1000 A.D. 1 A.D. A.D.
B.C. B.C. B.C. B.C. B.C. B.C. B.C. B.C. 1000 2000

1965 and 1981 range from 17 to 58 percent. ment to population planning by the country’s
South Korea’s fertility has fallen by 34 percent, leaders; 5) a family planning organizational
Colombia’s by 34 percent, and Thailand’s by 36 structure with executive power to mobilize
percent during the same period (table 1). more than one government sector and to coor-
dinate with the private sector; 6) population
Significant fertility declines are usually program funding (usually both external and in-
associated with some or all of the following con- ternal sources); 7) provision of a broad range of
ditions that involve government policy and ac- contraceptive methods; 8) sufficient numbers of
tion with regard to population programs (order- well-trained and motivated family planning pro-
ing does not imply relative importance): 1) gov- gram personnel; 9) population and family plan-
ernmental policies that encourage and promote ning information, education, and communica-
equal status and opportunities for women, tion (IEC) efforts that effectively reach all sec-
higher age at marriage, and more equitable dis- tors of the population; and 10) direct or indirect
tribution of wealth and educational opportuni- incentives that encourage couples to limit the
ties, all of which lead to a higher standard of liv- size of their families. The relative importance of
ing; 2) programs designed to bring about a de- these components is not known because coun-
cline in infant mortality; 3) a government policy try settings differ, and the nature of the coun-
with explicit goals for reduction of birth or try’s developmental process and the level of cer-
population growth rates; 4) a strong commit- tain key indicators (life expectancy, gross na-
6 ● world population and fertility Planning Technologies: The Next 20 Years

1980 and 2 000:

Age

Female 75+
70

60

50

40

30

20

10

0
100 140 180 22-J 260 300
Millions

Less developed regions


Age Age

75+ — 75+ ,

70 — 70

60 — 60

50 — 50

m — 40
40

30 1
— 30

20 — 20

10 — 10

0 — f )
300 260 220 180 140 100 60 20 0 20 60 100 140 180 220 260 300 “
Millions
SOURCE: U.S. Bureau of the Census, Illustrative projections of World Populations to the 21st Century. Special Study Series, table 2, pt. B, p. 23, No. 79,
January 1979.
Ch. l—Summary, Issues, and Options . 7

Figure 2B.—Popuiation Pyramid of the United States If governments decide to take actions to
illustrating the Effects of the Baby Boom reduce population growth in addition to those
Year actions currently planned, the world’s popula-
of birth tion in 2000 will be closer to the lower estimate
Age
1 of 5.9 billion than to the upper estimate of 6.5
75+ 1901-05 billion. Even the low projection, however,
70-74 1906-10 means that today’s 4.5 billion world population
65-69 1911-15 will increase by 1.5 billion in just 20 years. For
60-64 1916-20 the longer term, additional efforts undertaken
55-59 1921-25 now can be still more decisive in terms of the
50-54 1926-30 number of people added to the world’s popula-
45-49 1931-35 tion. The difference between the high and low
40-44 1936-40 projections for 2050 is 4 million people—a
35-39 r 1941-45 number nearly equal to today’s global total.
30-34 1946-50 Countries that wish to reduce their population
25-29 I 1951-55 growth rates have three options: raise mortality
20-24 — 1956-60 rates, encourage emigration (or discourage im-
15-19 — 1961-65 migration), or reduce fertility rates. The first is
10-14 1966-70 morally untenable, and the second is not feasi-
5-9 ., 1971-75 ble over the long term because there are no
0-4 1976-80 countries left to accept vast numbers of immi-
I grants. The only viable solution is to lower fer-
tility rates. Many LDC governments have al-
5 4 3 2 1 0 1 2 3 4 5
ready decided to encourage this latter option; in
the last 20 years, the proportion of the world’s
Percent of population
people who live in countries that provide sup-
SOURCE: U.S. Bureau of the Census, Illustrative Projections of World Popula-
tions to the 21st Century, Special Study Series, p. 23, No. 79, table 2, port for family planning services has risen from
pt. V, January 1979.
about 10 percent to 90 percent.

tional product (GNP), nonagricultural labor Most LDCs face similar environmental and
force participation, literacy rates, etc.) affect economic problems. In a number of these coun-
the extent to which a program can succeed in tries, the need to increase food and fuel produc-
lowering fertility. But the degree of political will tion to keep pace with population growth has
and commitment and the extent of administra- led to significant environmental degradation
tive capacity play major roles in determining the through denuding of forests, transformation of
magnitude of fertility decline. productive land into desert, and waterlogging
and salinization of irrigated land, The large
Most people in the developing world live in balance-of-payments deficits and increased
countries that now consider their rates of pop- debts confronting most oil-importing LDCs in
ulation growth higher than desirable and want recent years have depressed their rates of
help in achieving lower rates. Recent expe- economic growth, lowering prospects for
rience has shown that growth rates can be meeting basic health care needs, and making
slowed, often with startling success, despite the the provision of jobs a formidable task.
momentum inherent in LDC age structures. Al-
though other development factors influence fer- The collective effects of these continuing en-
tility, both stronger family planning programs vironmental and social problems, exacerbated
and more effective, safer, and easier-to-use con- by rapid population growth, have led 10 in-
traceptive methods can make important contri- creased international migration and political
butions to slowing population growth in the instability. U.S. interests are directly involved,
next two decades. for example, in present immigration pressures
Table 1 .—Percent Reductions in Crude Birth Rates From 1965 to 1981 for
Selected Countries

Asia
China a . . . . . . . . . . . 969 30-40 b 17-58
India a. . . . . . . . . . . . 710 43 16
Indonesia a . . . . . . . 155 46 24
Bangladesh a. . . . . . 91 50 —
Pakistan . . . . . . . . . 85 48 —
Philippines a . . . . . . 53 44 23
Thailand a . . . . . . . . 49 44 36
South Koreaa . . . . . 39 35 34
Sri Lankaa . . . . . . . . 15 33 12
Malaysia a . . . . . . . . 14 42 26
Latin America
Brazil . . . . . . . . . . . . 130 42 32
Mexico a. . . . . . . . . . 72 44 33
Colombia a. . . . . . . . 28 44 29
Venezuela . . . . . . . . 15 42 36
Chile a. . . . . . . . . . . . 11 33 22
Middie East
Turkey . . . . . . . . . . . 46 41 32 22
Egypt . . . . . . . . . . . . 43 42 41 —
Tunisia a. . . . . . . . . . 7 45 33 27
Africa
Nigeria . . . . . . . . .. 80 50 50 —
Zaire . . . . . . . . . . .. 29 47 46 —
Tanzania . . . . . . . .. 19 51 46 10
Kenya . . . . . . . . . .. 17 50 53 —
MDCs
United States . . . . . 224 19 16
Japan . . . . . . . . . . . 117 19 14
United Kingdom . . . 56 18 13
France. . . . . . . . . . . 54 18 14

from Mexico, the Caribbean, South America, Direct fertility determinants


and Southeast Asia.
Rapid population growth is an intensifier of Aside from indirect influences such as levels
current environmental, food, energy, and re- of socioeconomic development, education, and
source pressures in LDCs, and its interaction family size preferences, four factors have a
with these problems is generating a new cat- direct and important impact on the number of
egory of national security concerns. The impli- births that will occur in the next 20 years: age at
cations of this interaction for national security, marriage, prevalence of breastfeeding, preva-
a term that is itself changing, remain largely lence of induced abortion, and–the most signif-
unexplored. icant—use of contraception.
Ch. l—Summary, Issues, and Options ● 9

Young age at marriage and near universality bearing children) from age IS to 45, about 30
of marriage in the absence of widespread con- years. In the absence of contraception and al-
traceptive use are important causes of high lowing for time spent pregnant and infertile
birth rates in many countries. In Europe and the (due to infertility following birth or to breast-
United States, reductions in the proportion mar- feeding), and time not spent in union because of
ried and increases in age at marriage have his- divorce or widowhood, a woman could expect
torically helped reduce growth rates. In many to have an average of about 10 children. If
LDCs, high infant, child, and adult mortality in reduction of fertility rates to those associated
association with the social stigma attached to il- with population stabilization (about 2.2 births to
legitimate births has necessitated very young each woman) is desired, it is necessary that
age at marriage and maximum reproduction to some method of contraception be used for up to
ensure survivral of the family lineage. Increases 25 years.
in age at marriage have contributed to fertility
decline in many LDCs in recent years and may The major methods of contraception cur-
continue to do so in such areas as the Asian sub- rently. in use are:
continent, where age at marriage remains l0w. ● Sterilization—vasectomy in the male, and
Breastfeeding delays the return of ovulation tubal ligation/occlusion in the female.
after childbirth, sometimes for as long as a year ● Steroid hormones—combined (estrogen and
or more. If large numbers of women breastfeed progestin) or low dose progestin oral pills,
for long periods, a natural form of birth-spacing or intramuscular, long-acting progestin in-
occurs that can cause a modest reduction in jections. These synthetic steroids are given
overall fertility rates. But breastfeeding is an im- in different combinations and different
portant influence on fertility only in societies doses, depending on the commercial pro-
with high fertility rates. Breastfeeding is an im- duct, but they act primarily by inhibiting
perfect individual contraceptive because the ovulation through suppression of the hypo-
amount of protection against pregnancy that it thalamic hormones that stimulate the
confers is extremely variable. In LDCs, fewer release of follicle stimulating hormone
women are now choosing to breastfeed, and (FSH) and luteinizing hormone (LH) from
many women are breastfeeding for shorter the anterior pituitary. The synthetic
lengths of time. steroids also cause endometrial changes
that make the uterus inappropriate for im-
The limitations of current contraceptive plantation should breakthrough ovulation
technologies and lack of access to their use and fertilization occur. other changes that
cause many women in all parts of the world to contribute to the contraceptive effect in-
seek induced abortion to terminate unwanted clude scant and thick cervical mucus, re-
pregnancies. Induced abortion is a medically duced sperm transport and penetration in-
safe procedure when performed early in to the uterus, and altered sperm and ovum
pregnancy by skilled personnel. But the risk of transport within the fallopian tubes.
maternal death or serious complications in- ● Intrauterine devices (IUDs)—the insertion
creases greatly when it is performed by less
of a foreign body, made either of an inert
skilled personnel in marginal facilities and when
substance or impregnated with other mate-
it is performed later in pregnancy. Rates of in-
rials (copper, progesterone). Although the
duced abortion are high in LDCs, even though
IUD prevents implantation in some mam-
its legal use is constrained in some countries by mals, its mode of action is unknown in the
religious beliefs. It is rarely a preferred method human being. There are several possible
of fertility planning, but is resorted to when modes of action, from interference w i t h
other means are not available, or fail.
sperm transport, to interference with ovum
Of all the means available, contraceptive use is transport, to interference with implanta-
by far the most important in lowering fertility. tion in the uterus. There is also some evi-
On average, women are fecund (capable of dence that IUDs lead to increased sperm
10 ● World population and Fertility p/arming Technologies: The Next 20 years

damage and affect the motility of the ovum tion—steroid implants (e.g., capsules in the
in the fallopian tube. forearm) and steroid vaginal rings.
● Barrier devices—the condom for the male ● IUDs: three improved types are anticipated.
and the diaphragm and cervical cap for the
female.
● Vaginal spermicides—high viscosity fluids
that both kill sperm and block them from
entering the cervical canal.
● Coitus interruptus-male withdrawal prior
to ejaculation.
● Periodic abstinence (rhythm, natural family
planning)—timed to avoid coitus near the
day of ovulation.
● Postcoital douches-water or spermicidal Table 3.—Future Fertility Planning Technologies
solutions that flush out anci kill sperm in the
vagina, Highly likely before 1990
The effectiveness and order Of effectiveness
of these methods in MDCs are listed in table 2.
Between now and the end of the century,
more than 20 new or significantly improved
technologies for contraception are expected to
become available. The most likely candidates
are identified in table 3. Highly likely to be avail-
induction of menses
able by 1990 are:
● Steroid hormones: safer oral contracep- Monthly steroid-based contraceptive pill
tives, improved long-acting steroid injec- Improved monthly steroid injection
tions, and two new methods of administra- New types of drug releasing IUDs
Mini-dose vaginal rings
Table 2.—Theoretical and Use Effectiveness of Antipregnancy vaccine for women
Improved barrier contraceptives for men
Various Means of Contraception Sperm suppression contraceptives for men
(by pregnancies per 100 woman-years In MDCs)
Reversible female sterilization
Theoretical Use effectiveness Simplified female sterilization techniques
Method effectiveness Rantae Average Simplified male sterilization techniques
Sterilization: LRF analogs for self-administered induction of
Tubal . . . . . . . . . . . . . . . . . — — menses
Vasectomy . . . . . . . . . . . . — —
Steroidal contraceptives:
Uniikely by 1990 but possible by 2000
Injectable progestins (3- Antifertility vaccine for men
month regimen of Antisperm drugs for men
medroxyprogesterone Antisperm maturation drugs for men
acetate). . . . . . . . . . . . . 0.24 –
Orals . . . . . . . . . . . . . . . . . 0.1 0.2-4.5
Lactation-linked oral contraceptives for women
IUDs: Ovulation prediction methods for use with periodic
Lippes loop. . . . . . . . . . . . 1.9 — abstinence
Copper T . . . . . . . . . . . . . . — — New types of antiovulation contraceptive drugs for
Diaphragm and jelly. . . . . . . 3 3.3-33.6 women
Condom . . . . . . . . . . . . . . . . 3 6-30 Contraceptive drugs for women that disrupt ovum
Aerosol foam . . . . . . . . . . . . 3 3.0-35 transport
Jelly or cream . . . . . . . . . . . . 2.0-45
Coitus Interrupts . . . . . . . . 8 10-38
Reversible male sterilization
Periodic abstinence. . . . . . . 2.5 5-40 Pharmacologic or immunologic sterilization for
Suppositories. . . . . . ., . . . . 14 17-27 women
Douche . . . . . . . . . . . . . . . . . 16 21-40.6 Pharmacologic or immunologic sterilization for
men
Agents other than LRF analogs for self-
administered induction of menses
SOURCE: Office of Technology Assessment Survey; S. B. Schearer and M. K.
Harper, 1980.
Ch. l—Summary, Issues, and Options ● 11

of women in LDCs who otherwise might Vialed $10 percent. The U.S. Government is the
lack access to the medical personnel needed major current funder of research on improved
for insertion of other types of IUDs. contraception, providing nearly 60 percent of
● Barrier devices for women: one-size-fits-all worldwide expenditures. Approximately 70 per-
diaphragms, disposable diaphragms, sper- cent of worldwide funds go to basic research,
micide-impregnated diaphragms, vaginal 20 to 25 percent to contraceptive development,
films, vaginal sponges, vaginal rings that and less than 10 percent to safety evaluation.
release spermicides, and cervical caps that
The market approval process of the FDA af-
can be left in place for weeks or months.
fects population planning assistance, because
● Improved ovulation-detection procedures
the U.S. Food, Drug, and Cosmetic Act prohibits
for use with periodic abstinence methods: a
pharmaceutical manufacturers from exporting
wide varietv of biological and biochemical
drugs for uses not approved for marketing in
parameters-are altered when a woman ovu-
the United States. This policy is based primarily
lates, and researchers are endeavoring to
on the premise that one standard of drug ap-
improve or simplify the physical tests that a
proval is necessary, and under this premise, the
woman can use herself to determine when
United States would be promoting a double
she ovulates. Improved methods of evacuat-
standard if it exported drugs not approved for
ing changes in cervical mucus, hormones in
use in the United States.
urine or saliva, and basal body temperature
would enable greater numbers of users of The FDA approval process for all drugs
periodic abstinence to know with certainty averages 7.5 years. FDA requirements for the
when they could safely engage in sexual in- specific types of tests and test animals to be
tercourse during the second half of the used in providing safety and efficacy data for
menstrual cycle without risk of pregnancy, contraceptives usually make the average length
although the prediction of ovulation is like- of the approval process for contraceptive drugs
ly to remain problematic. * longer than for other drugs by about a year.
● New hormonal methods: methods that The reason for these more stringent testing re-
would reversibly inhibit ovulation using quirements for contraceptive drugs over other
synthesized agonists or antagonists to one classes of drugs is that contraceptives are given
of the hormones that controls ovulation, to young, healthy individuals and can potential-
luteinizing-releasing factor (LRF). ly be administered over a period of 30 years,
● Drugs that induce menstruation: pro- whereas other drugs are usually used to treat
staglandin analogs that depend on uterine diseases and/or are often administered only for
muscle contraction for their action. Ad- a few weeks at most.
ministered as vagina] suppositories, these
Drug patents run for 17 years, but effective
drugs can also induce abortion during the
patent life is shortened by the regulatory proc-
first 8 weeks of pregnancy in about 90 per-
ess. For oral contraceptives, however, short.
cent of cases.
ened patent life has not affected the original
Most R&D on contraceptives has been con- manufacturers’ abilities to retain a large share
ducted by MDC governments and the pharma- of the market even when prices were increased
ceutical industry. Prior to 1967, contraceptive after the patent period had expired.
R&D was financed largely through the private
But expanding product liability has escalated
sector. In the 1970’s, however, of funds spent
costs and made the prediction of future costs
worldwide on reproductive research and con-
uncertain for both the pharmaceutical industry
traceptive development, private industry pro-
and its insurers. As in the case of patent life,
vided about 10 percent, and governments and
these difficulties are being experienced by all
philanthropic and nonprofit organizations pro-
drugs (and products in general), but the con-
●Such methods would also benefit couples with infertility}’ prob- traceptive market has been especially affected
lems l)j pinpointing the fertile period. by product liability problems.
12 . world population and Fertility P/arming Technologies: The Next 20 years

Rising product liability costs and the ability of tion (IPPF) and Family Planning International
manufacturers to retain their market share Assistance (FPIA); 2) directly to LDC govern-
even after patents expire signify higher prices ments (bilateral assistance); and 3) through
for contraceptives and reduced purchasing multilateral organizations such as the United
power for family planning programs. Nations Fund for Population Activities (UNFPA).
Private sector donors channel money primarily
International population assistance through NGOs such as IPPF. MDC and private
contributions arrive in LDCs as money, contra-
International population assistance evolved in ceptives, information, and technical assistance
response to growing awareness of the problems in developing and administering family planning
that accompany rapid population growth and to programs and in collecting and analyzing pop-
requests from LDC governments for technical ulation data. Agencies administering the largest
assistance in addressing these problems. The amounts of population assistance are the U.S.
purposes for which population assistance funds Agency for International Development (AID),
are expended include: 1) development of popu- UNFPA, and IPPF (fig. 3).
lation planning policies appropriate to the re-
The United States supports population
cipient country; 2) contraceptive commodities;
assistance through two main channels, AID (Of-
3) systems for contraceptive distribution and
fice of Population) and the World Bank. The
use; 4) information, education, and communica-
World Bank receives moneys in the form of gen-
tion activities; 5) research on the delivery of
eral development appropriations, about 1 per-
family planning services, on the development
cent of which are directed toward population
and application of improved or new contracep- projects. AID, in turn, channels funds bilaterally
tive methods, on the social, economic, and to LDC governments, multilaterally to UNFPA,
cultural conditions that affect their acceptance and through private intermediary orga-
and use, and on those social conditions that nizations, such as IPPF, FPIA, etc. World Bank
directly affect birth rates (e.g., age at marriage); support is exclusively loan assistance; AID pro-
and 6) the gathering, evaluation, analysis, and grams are largely grant assistance but include
dissemination of demographic and other infor- some loans as well.
mation.
The Foreign Assistance Act states that the
Less than 2 percent of official development population planning component is “to increase
assistance from all MDC donors is currently al- the opportunities and motivation for family
located to population activities, a proportion
planning and to reduce the rate of population
that represents a small decline since 1970. The growth.” It authorizes the President “to furnish
United States provides just under 4 percent of
assistance . . . for voluntary population plan-
its total development assistance for interna-
ning. In addition to the provision of family plan-
tional population activities.
ning information and service and the conduct of
In 1980, total resources (excluding China) directly relevant demographic research, popula-
committed to population and family planning tion planning programs shall emphasize motiva-
programs in LDCs amounted to about $1.0 bil- tion for small families.”
lion. Of this total, LDC contributions accounted In recent years this has been translated by
for about $450 million, private sources about AID into program expenditures of about 50 per-
$100 million, and MDC sources about $450 mil- cent for family planning services, 15 percent for
lion. ” Donor governments (including the United
institutional development and training, 10 per-
States) are the principal source of MDC
cent for information and education, 10 percent
assistance; funds are channeled: 1) through for biomedical and operations research, 10 per-
nongovernmental organizations (NGOs) such as cent for demographic analysis, and 5 percent
the International Planned Parenthood Federa- for policy development and research into fac-
● China’s expenditures in 1980 for its intensive birth planning campaign
tors that increase the use and acceptance of
$1.0
are estimated to ha~’e approached billion; see app. A. family planning services.
Ch. l—Summary, Issues, and Options ● 13

Figure 3 .–Channels Through Which AID Population Assistance Arrives in LDCS, 1979
Channel of Number of countries receiving assistance
assistance
o 20 40 60 80 100 120
Direct
Bilateral

100 percent
provided by AID
U.S. intermediaries
and NGOs

About 90 percent
provided by AID

IPPF

28 percent
provided by AID

UNFPA

26 percent
provided by AID
100 120

Middle East

The amount of U.S. population assistance


channeled through AID rose from $5 million in
1965 to $185 million in fiscal year 1979. This
figure remained constant in 1980 and increased
to $190 million in 1981 through continuing
resolutions. The 1982 appropriation has been
increased to $211 million; the authorization for
fiscal year 1983 is $230 million.

Although the United States continues to pro-


vide the most population assistance to LDCs, its
proportion of the total amount has decreased
over the last 14 years. The United States pro-
vided 50 percent or more of all primary source
assistance until 1974, when this proportion
leveled off to about 40 percent, where it has re-
mained. This decrease is largely due to in-
creased contributions from other MDC donors,
including the Scandinavian countries, Japan,
and West Germany. In addition, the impact of
inflation cut the 1981 funding level, in constant
dollars, to $41 million below that of the peak
year of 1972 ($121 million). The 1982 appropri-
14 . World population and Fertility Planning Technologies: The Next 20 Years

ation is $28 million below the amount required Family planning programs contribute signif-
to maintain the 1972 level. icantly to improved health of women and chil-
dren and have made a substantial difference in
International population programs accelerating the rate at which fertility declines,
as shown in table 1. (The countries noted with
Population assistance has had diverse impacts, asterisks in table 1 are those that have strong-to-
including a heightened awareness of the prob- moderate family planning programs efforts.) In
lems associated with rapid growth. Government countries with strong family planning efforts
officials, scientists, and informed lay people in for which data are available, fertility declined
LDCs and MDCs are working together to devel- an average of 30 percent between 1965 and
op, test, and disseminate new contraceptive 1975. This compares with declines of about 4
methods. Many women of reproductive age in percent in similar countries with weak family
LDCs have at least heard of family planning planning programs and 2 percent in countries
even though some may not fully understand with no programs. On balance, about 15 to 20
what it means or may not yet have convenient percent of the declines in fertility between 1965
access to contraceptive methods. More data of and 1975 in 94 LDCs is attributable to the family
better quality are available to enable govern- planning component of population program
ments to formulate policy, set demographic effort. Thus, although family planning pro-
goals, and monitor program effectiveness. Each grams are not the only factors at work in coun-
of three decennial census rounds from the tries experiencing substantial fertility declines,
1960’s to the present has been characterized by such programs clearly make a difference.
substantial improvements in data collection The use of contraceptive technologies can
techniques and data processing and analysis ca- substantially lower birth rates, but their avail-
pabilities in LDCs. The World Fertility Survey ability and acceptability vary. Delivery systems
and Contraceptive Prevalence Surveys are pro- may be inadequate or culturally inappropriate
viding important data on fertility trends and dif- so that family planning services are in fact not
ferentials, levels of contraceptive knowledge effectively available. The contraceptive methods
and use, and program evaluation. Operations used in a particular country may not be the
research projects are testing innovative ap- ones preferred but the ones available. People
proaches to the delivery of fertility planning in- may become dissatisfied and discontinue the
formation and methods. Social marketing pro- methods used because of side effects, the need
grams have put contraceptives, on the road to for repeated application, costs, medical contra-
being self-financing in some LDCs. And the mass indications, contraceptive failure, and concerns
media campaigns associated with social market- about long-term safety, A realistic goal is for
ing programs have played a major role in en- each country to have enough technologies ap-
hancing public awareness and acceptability of propriate for local conditions so that each in-
family planning. dividual has access to at least one method that
The need for greater sensitivity to and meets his or her current needs. Improved and
knowledge of the role of the sociocultural fac- new technologies could enhance family plan-
tors that motivate people to adopt family plan- ning effectiveness and efficiency by reducing
ning is clear. Social settings that allow women side effects, permitting easier administration,
few options beyond raising large numbers of and simplifying delivery system requirements.
children, and negative attitudes of peer groups, At present, of 374 million couples of repro-
relatives, and spouses can be important con- ductive age in LDCs (excluding China), some
straints to contraceptive use, Thus population one-fifth, or about 74 million, are using contra-
and development programs that are multi- ception. By 2000, there will be at least 638 mil-
faceted and address relevant social, economic, lion couples of reproductive age (889 million
and health needs along with delivery of family couples if China is included). Because about 80
planning services are most likely to be success- percent of these couples would need to use
ful. some form of contraception if fertility were to
Ch. l—Summary, Issues, and Options Ž 15
16 . World population and Fertility Planning Technologies: The Next 20 Years

low variant projection is more likely to be sons—and is equivalent to the addition of three
achieved. The total difference between the high times the current United States population in
and low variants is sizable—650 million per- just 20 years.

Issues and options —-.


The breadth of purpose of international pop- nologies thus can be influenced through Federal
ulation assistance, the range of its activities, and funding of contraceptive R&D, and through
the variety of U.S. governmental involvement in governmental actions that could stimulate or
these activities result in many issues of congres- restrain expanded or renewed interest in con-
sional interest. Not all of these issues require traceptive products by private industry.
legislative action, and many can be examined
through the congressional oversight process. In ISSUE: Federal support of contraceptive
this section, the principal issues and related R&D
legislative options for: 1) Federal involvement in In 1979, governmental agencies throughout
contraceptive R&D, and 2) international popula- the world provided approximately 80 percent of
tion assistance support are addressed. funding for reproductive research and contra-
In the biomedical research area, the issues ceptive development. The United States pro-
center on the U.S. Government’s key role in sup- vided nearly 60 percent of all funds, or about
port of reproductive and contraceptive R&D $89 million. Approximately 70 percent of world-
and on reconciling how the United States regu- wide expenditures were devoted to basic re-
lates the drugs and medical devices industries search, training, and institutional support;
with the need to diffuse these technologies to about 23 percent to contraceptive development;
countries that may have different risks or per- and approximately 7 percent to evaluation of
current methods.
ceptions of risks.
Federal support is provided by the Contracep-
Contraceptive technologies tive Development Branch of the National Insti-
tutes of Child Health and Human Development’s
The U.S. Government’s role in the develop- (NICHD) Center for Population Research and, to
ment and dissemination of contraceptive tech- a lesser extent, by AID. AID is a major funder of
nologies is mediated through two avenues: 1) the Program for Applied Research on Fertility
the R&.D activities of the National Institutes of Regulation (PARFR) and the International Fertil-
Health and AID; and 2) the regulatory policies of ity Research Program (IFRP). Federal funds are
FDA. Peripheral to contraceptive technologies, also provided indirectly through AID’s contribu-
but possibly affecting them, are U.S. patent laws tion to the International Committee for Con-
and their interrelationships with FDA’s regu- traceptive Research (ICCR), to the UNFPA, and
latory process and the direction that product the Program for the Introduction and Adapta-
liability legal doctrines have taken in the United tion of Contraceptive Technology (PIACT).
States.
OPTIONS:
THE ROLE OF THE U.S. GOVERNMENT IN
CONTRACEPTIVE R&D A. Sustain financial support of R&D at current
levels.
The Federal Government not only supports
contraceptive R&D, but also regulates the drug If Congress continues to judge that govern-
and medical devices industries through FDA’s mental action is warranted to continue the de-
market approval process in which efficacy and velopment of improved contraceptives for use
safety requirements must be met. The develop- at home and abroad, the minimum action would
ment and dissemination of contraceptive tech- be to sustain support of existing programs at
Ch. l—Summary, Issues, and Options . 17

current levels. Although the dollar amount for for such development is currently less than $20
reproductive research and contraceptive devel- million annually, present funding levels could
opment increased from $80 million in 1972 to be significantly increased at relatively low cost.
$112 million in 1979, inflation has meant, in An additional $20 million annually in this spe-
terms of constant dollars, a cut of about 20 per- cific field could have a substantial impact.
cent from the 1972 funding level. The budget of AID’s Office of Population also
With limited research dollars, individual could be augmented and earmarked or recom-
investigator-initiated research that may not be mended for contraceptive development, which
part of a larger program might have higher pri- would enable AID to increase funding for both
ority and be more likely to be funded than large, the three U.S.-based international contraceptive
goal-oriented, contract research of the type development programs and other groups that
needed for stimulating contraceptive develop- could contribute to this endeavor,
ment. Increases in NICHD’s budget would need to be
B. Substantially increase financial support. earmarked for the Contraceptive Development
Branch. Such action would greatly increase the
Arguments for increases in contraceptive volume of goal-oriented R&D being conducted
research include the following: Present con- under contract by NICHD. This action would
traceptive development programs may develop contribute directly to the development of new
many useful new and improved contraceptives contraceptives for U.S. use and indirectly to the
over the course of the next two decades if addi- work of international programs seeking to
tional money is available. Because many LDCs develop and introduce new contraceptives in
are actively pursuing policies to reduce popula- LDCs.
tion growth and there is increasing concern in
MDCs about the side effects of current fertility C. Reduce financial support.
planning methods, there is a strong need for im- Although it could be argued that industry in-
proved contraceptive methods both in the vests little in contraceptive R&D because gov-
United States and abroad. The potential impact ernment funds are available, and that one im-
is enormous in terms of improved family plan- pact of this option would thus be increased in-
ning effectiveness, reductions in numbers of un- dustry participation, such factors as product
wanted pregnancies and induced abortions, im- liability are major deterrents to greater in-
proved maternal and family health, alleviation dustrial participation in contraceptive R&D. For
of human suffering, and opportunities for eco- basic reproductive research, the additional fac-
nomic progress. Without such added invest- tors of longer time for return on investment and
ments, emergence of many new contraceptive greater risk further deter industrial participa-
products is likely to be either prevented or very tion in fundamental research.
substantially delayed.
For government research, reduction or
Congress can authorize and appropriate more elimination of Federal funding for basic re-
funds for the entire field of reproductive re- search and contraceptive R&D would produce
search, using the presently available funding different effects depending on how the reduc-
channels, NICHD and AID. This action could tions were carried out.
strengthen this field in a balanced, comprehen-
A reduction exclusively in NICHD’s budget
sive fashion and thereby increase scientific
would rapidly result in a discontinuation of
prospects for discovery and development of im-
research by many U.S. research centers now
proved contraceptives in the future.
working in this field under NICHD support.
Alternatively, Congress may wish to increase Much of the Nation’s safety research on con-
funding only for contraceptive development. traceptive methods currently in use would also
Added investments in this specific area are be eliminated. At least initially, the direct effect
highly likely to produce payoffs in the form of on the U.S.-based contraceptive development
useful new technologies. As total public funding programs to which AID contributes (IFRP,
18 ● World Population and Fertility Planning Technologies: The Next 20 years

PARFR, and ICCR) would be minimal, as they are ary effect is the adverse publicity accruing to
not funded by NICHD. But because these other the product and its manufacturer. Because of
programs utilize basic research and goal- increasing frequency of claims and escalating
oriented research findings that emerge from size of successful judgments against contracep-
NICHD-funded projects, over the long term tive manufacturers, pricing of liability insur-
their prospects for successful development of ance has become so uncertain that insurers are
new methods could be reduced significantly. either withdrawing from the field, mandating
that manufacturers self-insure larger and larger
A reduction exclusively in AID’s contraceptive
amounts of first-dollar costs, or placing con-
development program likely would be detri-
traceptive drugs and devices in special cat-
mental for at least three of the four nongovern-
egories of risk separate from product liability in-
mental contraceptive development and dissem-
surance for the manufacturer’s other products.
ination programs, Three programs—IFRP,
PARFR, and ICCR—are highly dependent on As liability costs are business expenses that
AID funding, and any substantial reductions in are incorporated into the price of the affected
their budgets would essentially put them out of product, manufacturers may be increasingly re-
business. While PIACT might continue its work luctant to devote research and development ef-
independently if its budget were maintained forts to products such as IUDS. Once the sale is
under such circumstances, it could not replace made, there is less opportunity to recoup liabil-
the clinical research and applied R&D work of ity costs, as sales are not as frequent and con-
the other three organizations as PIACT concen- tinuous as they would be for oral contracep-
trates largely on providing product information tives. With the latter, liability costs can be
to LDCs. passed on, which may explain in part the large
price increases of oral contraceptives (discussed
STIMULATE THE INTEREST OF PRIVATE
next) in comparison with other drugs. Thus,
INDUSTRY IN CONTRACEPTIVE R&D
product liability may be affecting not only the
Most of the numerous factors that might propensity of private industry to develop new
stimulate more private industry interest in con- contraceptives but also the kinds of contracep-
traceptive R&D concern removing apparent dis- tives to be developed in the future.
incentives against developing and marketing of
Because the product liability problem is of
contraceptive products. But as these factors also
concern for products in general, the contracep-
involve major issues in their own right, trying to
tive field may well be an inappropriate forum
change these factors to promote contraceptive
for congressional consideration of this larger
R&D quickly impinges on other substantial in-
liability issue. But recognition by the Congress
terests. Hence, although options for some fac-
of liability problems with contraceptives might
tors are discussed here, it should be kept in
encourage the congressional committees that
mind that the effects of these changes would
have jurisdiction over laws governing commer-
reach beyond contraceptives to other drugs and
cial products to consider changes in these laws,
other products.
ISSUE 2: Effective Patent Life
ISSUE 1: product Liability and the
Contraceptive Industry The current process through which drugs and
medical devices are cleared for commercial dis-
According to representatives of companies ac-
tribution and sales takes a number of years.
tively researching new contraceptive products,
However, in order to protect its interest in the
product liability is as great a negative factor in
potential new product, a company must apply
making a business decision regarding new con-
for and be granted a patent long before the
traceptives as meeting the FDA requirements
product has been approved by FDA. Drug
for safety and efficacy.
patents run for 17 years, but it takes an average
The primary effect on a manufacturer from of 8.5 years for a contraceptive drug to clear the
product liability is financial; i.e., compensation regulatory process, cutting its effective patent
for claimants and defense of claims. A second- life to less than 9 years. Whether this situation
Ch. l—Summary, Issues, and Options . 19

inhibits the development of new drugs and med- Changes in the export provision of non-
ical devices is not clear. FDA approved drugs have been considered by
Congress. In the 96th Congress a bill adopting
Wyeth Laboratories and Ortho Pharma-
the medical devices export law for drugs was
ceutical share approximately 70 to 80 percent of
passed by the Senate but died in the House of
the U.S. market for oral contraceptives. Wyeth’s Representatives.
patent on norgestrel is still in effect, but the
patent on norethindrone expired in 1973. Since OPTIONS
the patent expiration, only Mead-Johnson and A. Keep the status quo, where drugs not approved
Lederle have entered the market, and Lederle
for marketing in the United States cannot be ex-
no longer markets its oral contraceptive. No
ported to other countries but medical devices
generics (nonbrand name drugs) have entered can be exported under certain conditions.
the market. The Pharmaceutical Manufacturers
Association also reported in August 1980 that By keeping the status quo, Congress prevents
oral contraceptives had the greatest price in- the foreign marketing of drugs that have not
creases of all classes of pharmaceuticals in the been adequately tested or whose safety has not
periods 1969 to 1979 (187 percent) and 1978 to been established by U.S. standards.
1979 (23.7 percent), as compared to only a 37.4 Current law does not affect the foreign pro-
percent increase in price during 1969 to 1979 duction and use of contraceptives that are not
and a 6.5 percent increase in 1978 to 1979 for a approved for use in the United States. For exam-
sample of over 1,000 drugs. Although other fac- ple, medroxyprogesterone acetate (Depo-Pro-
tors (e.g., product liability) may be at work, vera) is manufactured and used as a contracep-
shortened patent life has not had a significant tive abroad, although approved only for the
effect on the oral contraceptive market. After treatment of endometrial and renal cancer in
patents have expired, prices have remained the United States.
high and new firms have not been able to enter
the market on a competitive basis. Keeping the status quo helps to avoid the
danger of “unsafe” drugs being manufactured in
ISSUE 3: Export of Non-FDA Approved the United States and then “dumped” on other
Drugs countries as some critics have charged. Existing
law protects the United States from being criti-
The market for U.S. manufacturers of contra- cized for subjecting other people to risks to
ceptives could be expanded if the law on the ex- which it does not allow U.S. citizens to be ex-
port of non-FDA approved drugs were changed. posed.
Current law prohibits the export of drugs for However, the relative risks and benefits of a
uses that are prohibited in the United States. drug are not the same for people in LDCs,
Two categories of drugs are at issue: 1) drugs where health conditions, including the risks of
unevaluated for use; and 2) drugs evaluated but pregnancy and childbearing, are quite different
not approved for use. There are some excep- from those in the United States. Further, the
tions to the drug exportation ban; e.g., investiga- wide range of contraceptives available to U.S.
tional drugs can be exported for investigational women may not be available to women in LDCs,
purposes, provided that the importing country’s a factor that affects the risldbenefit assessment
government has approved such imports. In ad- of a particular contraceptive. Thus, the United
dition, medical devices not approved for mar- States may be depriving women in LDCs of
keting in the United States can be exported if: 1) drugs that would have a greater benefit than
they conform to the laws and specifications of risk for them.
the importing country; and 2) their export is not
considered by the Secretary of Health and Hu-
B. Adopt the medical devices export law for drugs.
man Services to be contrary to the public health As in the case of medical devices, non-FDA ap-
and safety of the importing country. proved drugs could be exported, provided that
20 . Wor/d population and Fertility Planning Technologies: The Next 20 years

the specifications and laws of the importing D. Develop international standard-setting mech-
country were met, and the Secretary of HHS anisms on the use, safety, and effectiveness of
determined that the importing country’s public contraceptive drugs and devices.
health and safety were not compromised.
If modifications of existing export laws on
C. Adopt the medical devices export law for drugs along the lines of the current medical de-
drugs, and add one or more of the following vices export law (options 2 and 3) are adopted,
provisions: such international standards would be helpful
to the Secretary of HHS in determining whether
1, Require that the risk/benefit analysis for an
or not the importing country’s public health and
unapproved drug take into consideration
safety are compromised.
conditions of the drug's use (and other health
risks) to individuals in the importing country WHO could be encouraged to develop interna-
This provision is based on the assumption that tional standards for safety and efficacy and/or
the risks and benefits of a given drug can for labeling and promotion standards for con-
change from country to country. Some advo- traceptive drugs and devices. These standards
cates of this provision believe that a risk/benefit —in conjunction with safety data specific to the
analysis of a drug should be based on data ac- importing country—could provide the basis for
tually obtained in the importing country and in the Secretary’s decision.
response to requests from that country, Deter- INTERNATIONAL POPULATION ASSISTANCE
mination of a drug’s benefits would be based on
Because the momentum for large increases in
the prevalence and severity of the target
the world’s population is clearly present and
medical condition, and safety assessments could
recognized, many LDCs now actively seek pop-
consider such items as the extent to which the
ulation assistance. They recognize the implica-
drug user could be monitored for adverse reac-
tions of their high growth rates, and their re-
tions. Other user conditions—e.g., nutritional
quests for population assistance have risen to
status—that could affect a drug’s safety and ef-
the point that donor agencies can meet only a
ficacy could also be studied,
fraction of current requests for such aid. Fur-
Instead of actually collecting data from clinical ther, the people who will contribute to the an-
trials conducted in the importing country, it ticipated surge in world population gorwth in
may be more feasible to adjust data collected the next few decades have already been born
from other countries to reflect user conditions (see fig. 2A), and a very substantial increase in
and disease prevalence in the importing coun- the use of fertility planning methods is required
try. It is very difficult to collect data from a suf- in LDCs in order to slow population growth.
ficient number of women within any given
There are two issues to be addressed in U.S.
country when low-incidence, but very impor-
international population assistance efforts—
tant, medical events are to be assessed. Many
level of funding, and the distribution channels
importing countries would lack the capacity to
through which U.S. funds are dispensed.
conduct such assessments.
ISSUE 1: Level of Funding
Z. Establish industrial standards of conduct.
Because there are many competing demands
Procedures could be developed in which of-
on Federal funds, careful examination of the im-
ficials–and perhaps the public–in importing
pact of various funding levels is essential.
countries could be informed of the risks, ben-
efits, and costs of the drugs they wish to import. OPTIONS:
Written verification of such an informed con-
A. Reduce financial support.
sent process, signed jointly by company ex-
ecutives and importing country officials, could Reduced support from the United States for
be filed with the Secretary of Health and Human population programs would force LDCs to re-
Services (HHS). Violation of that document could duce their programs, cut back on supplies that
serve as a basis for withdrawal of approval. require foreign exchange, eliminate training
Ch. l—Summary, Issues, and Options ● 21

programs, and probably decrease program out- assistance funds would reduce U.S. influence on
reach to rural and other hard-to-reach areas, program strategies and design.
Because the momentum for population growth B. Increase financial support,
already exists, spending for population pro-
grams deferred now would still be necessary at population and family planning programs
higher funding levels because of inflation, loss have been a key factor in recent fertility
of trained personnel, and duplication of start-up declines. The needs of many LDCs for popula-
costs. The capability of LDCs to finance their tion assistance and the current shortfall of
own family planning programs through such funds for these purposes are well-documented.
promising avenues as commercial retail sales Congress has in fact increased its appropria-
(CRS) programs would be postponed. (CRS pro- tion from $190 million in fiscal year 1981 to
grams provide oral contraceptives, condoms, $211 million in 1982; $230 million has been au-
and spermicides at low cost and can effectively thorized for 1983. These current and potential
extend to hard-to-reach areas. However, they increases represent a significant step and un-
require substantial initial funding for bulk pro- derscore the importance of population assist-
curement of contraceptives, subsidizing of retail ance at a time when many high priority social
prices, and technical assistance in the establish- programs are being cut. However, inflation has
ment of backup medical services, ) Also, if the reduced the purchasing power of these funds to
U.S. level of support were to be decreased now, below that of the total amount provided for pop-
self-sufficiency of LDCs in population planning ulation funding in the peak year of 1972 ($121
and progress in economic development might million, or about $239 million in 1982 dollars).
be further delayed, resulting in: 1) deteriorating At a time of rising requests for assistance, the
social and economic conditions including in- AID population commitment is decreasing in
creased death rates in LDCs; 2) need for signifi- purchasing power.
cant future increases in general economic AID’s fiscal 1982 budget is about $200 million
developmental assistance from MDCs to LDCs; below levels of documented need and insuffi-
or 3) if the United States were to abstain from cient to the point that: 1) most AID-supported
future increases in economic developmental projects and programs will receive less than the
assistance, widening of the economic chasm be- funds needed to satisfy demand for family plan-
tween MDCs and LDCs, with all of the political ning services or otherwise function optimally
implications that are associated with these dif- (this includes inability to meet shortfalls at
ferences. UNFPA, IPPF, and other major private voluntary
Overall, U.S. cuts would disrupt the current organizations); 2) there will be few new initia-
working balance among private organizations, tives in Africa (where governments are now be-
intergovernmental agencies, and government ginning to ask for assistance) and the Near East;
donors, with particularly adverse effect on the and 3) projects are being terminated premature-
private agencies that are likely to suffer major ly, before recipient countries become self-suffi-
reductions yet are often the most cost effective. cient.
Under current budgets, AID and the multi- UNFPA’s 1982 calendar year budget of $135
lateral donors cannot meet current commit- million represents a shortfall of $40 million to
ments. With further cuts, many countries and $100 million. ” The $40 million represents the
agencies would have to reconsider their ability
to implement effective programs. ‘on the basis of its 1979-80 projections of 15 percent per year
gro~~h in contributions from hlLX: donors, LJNFPA set up multi.
The U.S. Government, as the largest single year commitments for various LDC and international progran15,
both new and ongoing. AS 1980-81 unfolded, a plateau in the U.S.
donor to international population assistance, contribution occurred, and the l], S. dollar strengt Iwned in for~~ig[l
has been able, to some degree, to coordinate markets, making other currencies relati~’elj’ weaker. These etrents
population assistance efforts and influence the combined with inflation to gi~re NIDC donations less actual value
direction of funding. A reduction in population (Footnote continued on p. 22)
22 . World population and Fertility Planning Technologies: The Next 20 Years

gap between available funds and established tion of the International Conference of Parlia-
needs for ongoing programs and commitments mentarians on Population and Development
previously made. The $100 million includes new held in Colombo, Sri Lanka in 1979. Delegates
programs that have been requested and merit representing 58 countries unanimously called
funding, but for which funds are not available. for a total annual allocation of $1 billion in inter-
However, a much larger number of countries national population assistance (exclusive of LDC
now wish populaiton assistance, and there has commitments) by 1984.
been a 20 percent increase in couples of child-
More recently, at the International Con-
bearing age in LDCs since 1972. This argues for ference on Family Planning in the 1980’s held in
an even greater increase in assistance com- April 1981 in Jakarta, Indonesia, participants
mitments in the coming years. from 76 African, Asian (including China), Latin
Excluding China, only 20 percent of couples of American, and Middle Eastern countries joined
reproductive age are currently using contracep- representatives of major international agencies
tion in LDCs. Efficient programs cost an average in calling for a rapid increase in overall national
of $15 per user annually (new programs can and international expenditures for population
cost as much as $100 per user). Many countries and family planning programs to $3 billion an-
are only beginning to implement family plan- nually. LDC representatives stressed the urgen-
ning programs so start-up costs are very high. If cy of reducing high fertility rates, slowing the
fertility is to fall to replacement levels, con- momentum for further growth, raising
traceptives must be used by about 80 percent of women’s status and economic opportunities,
couples in the childbearing ages. The growth in and providing family planning services as a
the population, the need for increased use of basic human right.
fertility planning methods, and higher costs of
Assuming that the United States wishes to
programs that cannot be fully implemented
maintain its 40 percent share of the total assis-
until LDCs themselves can contribute more sup-
tance budget and that other MDCs and private
port all argue for major incremental increases
sources increase their contributions, the goals
in population assistance in the coming years.
set by these international representatives might
One approach to steady incremental increases be attained, although the timing is likely to be
in funding would be to meet the recommenda- delayed. If the United States were to increase its
contributions by 30 percent per year (assuming
an annual inflation rate of 15 percent), its con-
tributions could keep pace with inflation and in-
cremental funding would be available for in-
creasing needs. The United States would there-
by maintain its leadership position in population
assistance and would contribute significantly to
meeting requests from LDCs for assistance with
a problem most of these countries now view as
high priority.

ISSUE 2: Distribution of Population


Assistance Funds.
Present channels and content of population
assistance programs reflect both the priorities
of the assistance agencies and the needs of
Ch. l—Summary, Issues, and Options ● 23

LDCs. A change in the present distribution sys- planning services and improvements in ma-
tem would affect the type of aid available and ternal and child health.
hence would have different impacts on dif-
There is thus a major difference between
ferent regions,
Asia, for example, where governmental pro-
Because of differences among regions, vary- grams are established but where support is
ing approaches are required. In general, Asia’s needed to make them comprehensive and effec-
primary needs are for efficient and effective tive, and Africa, where there is much less ap-
services delivery to very large rural popula- preciation of the implications of rapid popula-
tions, a large volume of supplies, and additional tion growth and less governmental commitment
training in health care and program manage- to extend family planning services widely.
ment.
However, these broad generalizations mask
In Latin America, some governments are the variability that exists among countries,
reluctant in the face of religious and conser- which is at least as great as that among regions.
vative opposition to give rigorous support to Different countries have different cultural
family planning programs, but public demand values and development goals and thus require
for family planning services is growing rapidly. different forms of assistance. Different forms of
As a consequence, support for private agencies government and different political alliances also
and expansion of family planning within health make some forms of assistance more appropri-
care systems are increasing. ate to one country than another.
In the Middle East, the limitation of oppor- Technical assistance and commodities for
tunities beyond childbearing for women is a ma- population planning and family planning pro-
jor barrier to fertility change. Expansion of grams are currently channeled through several
government and private services, and of broad major international agencies and many private
social programs, is needed. The continuation of nongovernmental agencies. The largest agen-
innovative efforts by private population and cies, AID, UNFPA, IPPF, and the World Bank
family planning agencies to change perceptions provide technical assistance in varying degrees
of the role of women is crucial. in the areas of family planning services (in-
cluding commodities); information, education,
Birth rates in some countries in Africa are the
and communication; institutions and training;
highest in the world, but few African countries
research and evaluation; policy development;
have formulated policies that make a direct con-
and data collection.
nection between their serious economic and so-
cial problems and rapid population growth. As Each agency tends to have different emphases
most of these countries do, however, favor the and priorities within a broad range of support
provision of family planning services in the con- activities. For example, UNFPA provides tech-
text of maternal and child health activities, em- nical assistance for basic population data collec-
phasis should be on support for family planning tion, and channels assistance for family plan-
as a component of health programs. Improved ning services primarily through health minis-
collection and analysis of demographic and tries incorporated into maternal and child
other data would make an important contribu- health programs. AID is the largest supplier of
tion to increased understanding of the magni- commodities and places strong emphasis on
tude of population growth and its impact on family planning services delivery. IPPF empha-
economic development and the environment. sizes family planning services delivery in private
Expansion of the role of existing private volun- sector clinic settings. Because each agency has
tary agencies would facilitate delivery of family different emphases and countries have differ-
24 . world populatjon and Fertility Planning Technologies: The Next 20 Years

ent priorities, the agencies can cooperatively levels of funding and of the current appor-
tailor their support to individual country needs. tioning of aid between multilateral and
other channels through which assistance is
About 28 percent of AID funds are currently
funneled.
dispensed to the multilateral agencies (UNFPA
and IPPF), 26 percent are dispensed bilaterally, ● As summarized earlier in looking at the dif-
and 46 percent dispensed to and through pri- ferences among Asia, Latin America, the
vate intermediaries and organizations, Changes Middle East, and Africa, the pace of popula-
in present proportions of assistance would have tion change in different regions of the
uncertain effects on the balance that has been world varies greatly. Each region requires
achieved among these agencies and there are no different types of assistance and runs on
compelling reasons for considering changes at different timetables, and in some settings
this time. Given current shortfalls, duplication immediate results cannot be expected. Pri-
of efforts is not an issue, but if funds are in- orities and restrictions in addressing these
creased, efforts to promote greater coordina- various aspects of global population growth
tion among agencies at administrative and coun- require clarification. For example, current
try levels would need to be examined more restrictions prohibit aid to China. The
closely. result of this action toward the country
which contributes the largest proportion of
Additional issues for global growth may be that U.S. population
assistance is oriented less toward having
congressional oversight
the greatest impact on total world popula-
Several additional issues that Congress may tion growth than to slowing population
wish to consider for oversight are as follows: growth in those regions of the world and in
those countries where the United States has
● Although population issues are the jurisdic- a strong interest. Congress may want more
tion of several congressional committees, extensive reviews of these priorities and the
there is no single congressional mechanism reasons behind them.
for continued oversight of international
population assistance. A prime issue, there-
● If governmental support for social pro-
fore, is whether population growth in LDCs grams, including economic aid to LDCs, is
and its implications for their progress reduced, there will be a need to accelerate
toward economic self-sufficiency should the pace of self-sufficiency of LDCs, and for
continue to be addressed within the general additional support from the private sector
subject of international economic develop- in both LDCs and MDCs. Congress may
mental assistance, or whether a committee therefore wish to explore the extent to
or subcommittee should be formed to focus which this support can be encouraged, and
directly on issues related to national, re- how governmental actions can facilitate
gional, and world population growth. greater activity by the private sector in
● Present criteria for determining which LDCs.
countries receive population assistance are ● Factors that may be inhibiting the develop-
established by AID, except for-the following ment, manufacturing, and marketing of
provisions: limitation of assistance to the medical products—e.g., product liability
poorest countries (currently interpreted as suits, shortened patent life, and FDA’s ex-
yearly income below approximately $300 port provisions on drugs–are not unique to
per capita), prohibition of aid to Communist the contraceptive market, but are represen-
bloc countries, and prohibition of funding tative of problems that have arisen gener-
of abortion services. A review of Congress’s ally for all types of consumer products. Ad-
legislative guidelines and the ways in which dressing these generic consumer product
AID has interpreted them would be a neces- problems through the issue of fertility plan-
sary corollary of changing the current ning technology may be inappropriate, but
Ch. l—Summary, Issues, and Options • 25
Chapter 2

Population Growth
to the year 2000
Contents

Page

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Trends in Population Growth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......29
The Demographic Transition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......31
Projections of World Population Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....33
Sources and Bases of Population Projections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......34
The Built-in Momentum of Population Growth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .....36
Technical Note A: Projections of Populaticn Growth. . . . . . . . . . . . . . . . . . . . . . . . . . .. .....39
Technical Note B: Exponential Growth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......39
Chapter 2 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......40

LIST OF TABLES
Table No. Page
4. Selected Population Data for the 25 Most Populous LDCs. . . . . . . . . . . . . . . . . . . . . .......30
5. Selected Socioeconomic and Quality of Life Indicators for the 25 Most Populous
LDCs and Selected MDCs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......30
6. Alternative Projections of Population in 2000. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ....34

LIST OF FIGURES
Figure No. Page
4. Comparisons of the Demographic Transition in LDCs and MDCs. . . . . . . . . . . . . . .......32
5. World Population Growth From 8000 B.C. to 2000 A. D. . . . . . . . . . . . . . . . . . . . . . . .......36
6A. Age-Sex Composition of More Developed and Less Developed Regions, 1980
and 2000: Medium Series Projection. . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
6B. Estimated World Population Growth, 1981-2000-2050. . . . . . . . . . . . . . . . . . . . . .......38
Chapter 2

Population Growth to the Year 2000

Abstract

Rapidly declining death rates combined with continuing high birth rates are
producing unprecedented world population growth, some 92 percent of which is
occurring in less developed countries (LDCs). The current world population of
4.4 billion is projected to reach about 6.2 billion (range: 5.9 billion to 6.5 billion) in
2000. Eighty million people are being added to the world annually; this number is
expected to rise to 9S million per year by 2OOO [range: TO million to 120 million).
Growth will be greatest in Africa, Latin America, and Asia. Three quarters of this
growth is expected to take place in 18 countries (listed by the magnitude of their
projected growth): India, China, Brazil, Nigeria, Indonesia, Bangladesh, Pakistan,
Mexico, Philippines, Thailand, Vietnam, Turkey, Iran, E~pt, Ethiopia, Burma,
South Africa, and Zaire. At current rates of growth, many LDCs will double their
populations within 25 years. The difference between the low and high projec-
tions for the year 2000 is roughly three times the size of the current U.S. popula-
tion. The United States is expected to grow from today’s 226 million to 260 million
in 2000, and 290 million in 2050, but to fall from 4.9 percent of the world’s popu-
lation today to 4.0 percent in 2000, and 3.5 percent in 2050. The impact of global
population growth on the united States will thus be greatest from beyond its
borders.
The demographic transition from high to low birthrates experienced earlier by
more developed countries (MDCs) is taking place in LDCs under very different
conditions: death rates have declined at a more rapid pace; LDCs have far greater
momentum of population growth because large proportions of their populations
are reaching reproductive age; international migration Can no longer serve as an
outlet for rapidly growing populations; LDCs have more limited development op-
portunities than did MDCs in the past, and LDCs have higher levels of unemploy-
ment that were experienced earlier in MDCs. LDCs do have three major new ad-
vantages, however: many LDC governments are taking direct actions to reduce
birth rates; highly effective fertility planning methods are now available; and the
international transfer of appropriate knowledge and technology is now orga-
nized.

Trends in population growth

29
30 • World Population and Fertility Planning Technologies: The Next 20 Years

ized nations. This historic transition from high Table 5.—Selected Socioeconomic and Quality of
to low rates, which began in western Europe Life indicators for the 25 Most Populous LDCs and
some 200 years ago, combined with the indus- Selected MDCs
trial revolution to sharply divide the world into 1975
adult 1981
one-quarter rich and three-quarters poor. A 1978 literacy life 1981
number of terms—more and less developed; de- GNP rate expectancy infant
Country (dollars) (percent) (years) mortality
veloped and developing; North and South; First,
China . . . . . . . . . 230 68
Second, and Third Worlds; industrialized and India . . . . . . . . . 180 52
underdeveloped—describe this division. This Indonesia . . . . . 360 50
Brazil . . . . . . . . . 1,570
report uses those terms most commonly used by Bangladesh . . . 90
international agencies: more developed coun- Pakistan . . . . . . 230
tries and less developed countries. Nigeria . . . . . . . 560
Mexico. . . . . . . . 1.290
Although the dichotomy is real, the terms Vietnam. . . . . . . ’170
Philippines . . . . 510
oversimplify. The two groups of nations are
vastly different in terms of income, health, edu- Thailand . . . . . . 490
Turkey . . . . . . . . 1,210
cation, and rates of natural increase, but dif- Egypt . . . . . . . . . 400
Iran . . . . . . . . . . 2,160 b
ferences within each group are also wide, as South Korea . . . 1,160
shown in tables 4 and 5. Awareness of the het- Burma . . . . . . . . 150
erogeneity and individuality of LDCs is vital to Ethiopia. . . . . . . 120
South Africa . . . 1,480
understanding their levels of development and Zaire . . . . . . . . . 210
population growth. Colombia . . . . . 850
Argentina . . . . . 1,910
Table 4.—Selected Population Data for Afghanistan . . . 240
Morocco . . . . . . 670 55 133
the 25 Most Populous LDCs Algeria. . . . . . . . 1,260 56 127
(Medium variant) Sudan . . . . . . . . 320 46
population 1981 1981 United States . . 9,590 74
(millions) rate of doubling Japan . . . . . . . . 7,280 76
Country 1981 2000 natural increase time
a
UnitedKingdom 5,030 73
China . . . . . . . 969 1,190 0.8 59 ........ 8,260 73
India . . . . . . . . . . 710 1,040 2.1 33
Indonesia . . . . . . 155 221 2.0 35
Brazil . . . . . . . . . 130 212 2.4 29
Bangladesh . . . . 91 153 2.6 27

Pakistan . . . . . . . 85 145 2.8 25


Nigeria . . 80 149 3.2 22
Mexico . . . . . . . . 72 132 2.5 28
Vietnam . . . . . . . 54 79 2.8 25
Philippines. . . . . 53 83 2.4 29

Thailand . . . . . . . 49 76 2.0 35
Turkey. . . . . . . . . 46 69 2.2 32
Egypt . . . . . . . . . 43 65 3.0 23
Iran . . . . . . . . . . . 39 65 3.0 23
South Korea. . . . 39 51 1.7 41

Burma. . . . . . . . 36 55 2.4 29
Ethiopia . . . . . . . 33 55 2.5 28
South Africa. . 30 48 2.4 29
Zaire . . . . . . . . . . 29 46 2.8 25
Colombia . . . . . . 28 42 2.3 33

Argentina . . . . . . 27 33 1.6 43
Afghanistan . . . . 23 37 2.7 26
Morocco . . . . . . . 21 36 3.0 23
Algeria . . . . . . . . 19 36 3.2 22
Sudan . . . . . . . . . 19 31 3.1 22

All LDCs . . . . . . . 3,357 4,926 2.1 34


All MDCs . . . . . . 1,138 1,272 0.6 113
World . . . . . . . . . 4,495 6,199 1.7 41
a
Numbe r of y
ears to double population (at current growth rate)
SOURCE: U. N., 1979-World Population Trends and Prospects by Country,
1950-2000: Summary Report of the 1978 Assessment for 1981 and
2030 population figures; Population Reference Bureau 1981 World
Population Data Sheet for rate of natural Increase and doubling time
figures.
Ch. 2—Popu/ation Growth to the Year 2000 . 31

Following World War 11 the world experi- their ability to raise living standards, the neg-
enced a sudden, sustained drop in deaths ative consequences of population growth are
which, combined with little change in births, not confined to these countries. MDCs are in-
produced unprecedented growth in numbers of creasingly concerned about their own popula-
people. Today, about 80 million persons—the tion growth. The congressionally established
equivalent of an additional Mexico or Nigeria— Commission on Population Growth and the
are added to the planet every year (7). By the American Future concluded in 1972 that: “the
end of the century, despite reduced birth rates, stabilization of our population could contribute
this annual increase is expected to reach 95 significantly to the Nation’s ability to solve its
million. Most of this increase in numbers is tak- problems.” National assessments in Great Brit-
ing place in the LDCs, where expectations of a ain and Japan have reached similar conclusions.
better life are also rising. A few countries in Europe are worried about
their s1OW population growth, but overall there
The timing, intensity, and effects of popula-
is growing concern that world population is
tion changes have varied greatly among LDCs)
pushing against the Earth’s carrying capacity.
but, beginning with India in the early 1950’s,
The Independent (Brandt) Commission on Inter-
more than 40 percent of LDC governments have
national Development (4) warned of the global
become concerned about their rapid growth
consequences of population growth and its in-
and its detrimental impact on national develop-
creasingly severe pressure on many basic
ment, and have sought means to reduce their
resources.
birth rates.
Although the most immediate effect of rapid
population growth in LDCs has been to limit

The demographic transition


Although the timing of the transition from annual death rates from 30 to 15 per 1,000
high to low birth and death rates varies among population that took 150 years in Great Brit-
countries, the chronology of the phases is ain, Sweden, and the United States, took
similar: only about 35 years in India. Declines in
LDC death rates from major causes such as
1. an early phase of rising growth as death
cholera, malaria, and smallpox have been
rates fall and birth rates do not;
facilitated by new large-scale international
2. a peak growth phase as death rates con-
transfers of health and agricultural tech-
tinue to fall and birth rates begin to fall;
nologies from MDCs.
3. a falling growth phase as death rates stabi-
lize at lower levels and birth rates continue ● As a result, population growth has been much
to decline; and more rapid in LDCs in both rates and ab-
4. a stabilization phase of low, nearly equal, solute numbers than it was in MDCs. Great
death and birth rates. (See Tech. Note A, ch. Britain’s growth rate fell slowly from 1.4 to
4) 0.4 percent between 1800 and 1921; the an-
Differences in timing have produced much nual increase in numbers did not deviate
higher growth rates at the beginning of the greatly from 200,000. By contrast, India’s
transition in LDCs than those experienced by annual growth rate rose from about 1.5 to
M D CS (fig. 4). Conditions in Africa, Asia, and 2.5 percent between 1950 and 1970 as its
Latin America today therefore differ from those annual increase in numbers soared from
of the MDC demographic transition in several about 5 to 11 million in just 20 years.
very important ways: ● LDCs have greater momentum of population
● Death rates declined much faster in LDCs growth built into their age structures than
than they did earlier in MDCs. The decline in MDCs had earlier. Sustained higher birth
32 • World Population and Fertility Planning Technologies: The Next 20 Years

Figure 4.—Comparisons of the Demographic rates have produced large proportions of


children who will soon reach reproductive
age. Thus, even if average family size is
50
reduced dramatically in this generation, na-
MDCS
tional birth rates will fall more slowly
because such a large proportion of people
40
are of reproductive age.
● International migration can no longer serve as
an outlet for rapidly growing populations as it
30 did for much of Europe. There are no more
‘(empty” lands to colonize or to accept great
numbers of immigrants. Nevertheless, pop-
20 ulation pressures in LDCs and income op-
portunities in MDCs are likely to result in
sizable illegal migration and its attendant
10 problems as long as rapid population
--- Assumed trend in the absence of growth in LDCs continues.
World Wars I and II ● LDCs have far fewer opportunities for
0 1 1 I I development than did MDCs. Most LDCs
1750 1800 1850 1900 1950 2000 have little unutilized arable land, are
unevenly endowed with natural resources,
In MDCs death rates declined slowly beginning in the late
and face stiff competition from MDCs in in-
18th century. Birth rates followed closely. - P o p u l a t i o n
growth rates rarely exceeded 1.5 percent per year. ternational markets for industrial products.
● LDCs face higher levels of unemployment
than were experienced earlier in MCs. The
opportunities for employment (or migra-
tion) that were available earlier in MDCs
LDCs are not available in LDCs, where unemploy-
Birth rate
ment and underemployment are wide-
spread.
In sum, LDCs have not only encountered pop-
ulation growth unlike anything in MDC experi-
ence, but have fewer opportunities for accom-
modating this growth than were available to
MDCs a century earlier. They do, however,
have three major new developments in their
favor:
1. Many LDC governments, unlike MDCs earli-
er, are taking direct actions to reduce birth
rates by utilizing new fertility planning tech-
nologies and by other means. Although fam-
ily planning programs vary greatly in effort
and effects and most governments allocate
In LDCs birth and death rates remained high through the less than 1 percent of governmental ex-
first decades of the 20th century. Then death rates began to penditures to them, more than 92 percent
drop. Birth rates stayed high and populations grew at 2.5, of the world’s population live in countries
3.0, and 3.5 percent or higher a year. Since the mid-1960’s
some countries’ birth rates have begun to decline. whose governments provide some form of
family planning services for their people.
SOURCE: State Department Bulletin, “The Silent Explosion,” fall 1978. (See ch. 7.)
Ch. 2—Popu/ation Growth to the Year 2000 ● 33

Z. There are more effective technologies for the tion activities rose from virtually none in
planning of births than existed in 1800 or 1960 to 2 percent in 1979. MDCs now pro-
even 1950. These technologies—the pill, vide about $450 million annually for popu-
IUD, and new voluntary sterilization tech- lation assistance. (See ch. 9.)
niques–have replaced less effective meth-
ods in MDCs and are beginning to be used This assessment focuses on policies of the U.S.
in LDCs. (Technological development is Government now and during the next 20 years,
now lagging, however; although concerted which will be a pivotal period in global popula-
research efforts to develop better con- tion history. LDCs receive greatest considera-
traceptive technologies increased appre- tion because problems arising from rapid pop-
ciably during the 1960’s, financial support ulation growth are particularly acute in these
for such efforts has fallen in real purchasing countries and because their population growth
power since 1970.) (See ch. 6.) between 1980 and 2000 will account for more
3. international transfer of knowledge and tech- than 90 percent of the rise in world numbers.
nologies to reduce birth rates is now orga- How fertility can be changed takes precedence
nized. The proportion of total international because it is the most viable option for countries
development assistance devoted to popula- that wish to lower population growth rates.

Projections of world population growth


The size of world population during the next percent in 1980 to 21 percent in 2000 (and the
20 years can be predicted with greater certainty U.S. proportion from 4.9 to 4.0 percent).
than most future events because about 60 per-
cent of the people who will be on Earth in 2000 The LDCs differ greatly in population size and
A.D. are already here, and—barring a possible growth both by individual countries and by geo-
global nuclear catastrophe or unexpected great graphic regions. Growth will be greatest, ac-
epidemic or famine—experts differ little on how cording to current projections, in Africa (76 per-
many will die in the coming two decades. The cent of the 1980 population added in 20 years),
uncertainties lie in how many people will be Latin America (65 percent), and Asia (43 per-
born. Their numbers will depend to a great ex- cent), However, more of the increase in absolute
tent on what the LDCs do to modify their na- numbers will occur in Asia (63 percent) than in
tional birth rates. There is a consensus that Africa (22 percent) or in Latin America (15 per-
population growth has such a powerful, built-in cent), simply because many more people al-
momentum that actions taken or not taken now ready live in Asia. Three-quarters of all
will determine the size of world populations far 1980-2000 LDC growth is expected to occur in
into the future. just 18 countries: India, China, Brazil, Nigeria,
Indonesia, Bangladesh, Pakistan, Mexico, Philip-
World population is projected to grow from pines, Thailand, Vietnam, Turkey, Iran, Egypt,
an estimated 4.5 billion in mid-1981 to 6.2 billion Ethiopia, Burma, South Africa, and Zaire, listed
(between 5.9 and 6.5 billion; much will depend here by the magnitude of their projected
upon the rates at which fertility declines) in growth. Much of future world population
mid-2000. Despite decreasing growth rates, the growth thus depends upon what happens in
total number of persons added to the world’s these few large countries.
population each year is expected to increase
from some 80 million in 1981 to about 95 million The interval during which some of these
(between 70 and 120 million) in 2000. This countries will double their populations, if pres-
growth will be distributed very unevenly among ent fertility trends continue, is very brief: Kenya
different regions and countries. Close to 92 per- may double the numbers of its people in 18
cent is expected to occur in LDCs, cutting the years, India in 33, Bangladesh in 27, and Egvpt
MDC proportion of world population from 26 in 23 (table 4). (See Tech. Note B.)
Sources and bases of population projections
The projections used here are those of the The U.N. projections are similar to those pro-
United Nations (U.N.), the principal source of in- duced by five other major sources (table 6).
formation about world population. Its Popula- Each set of projections starts from estimated
tion and Statistical Divisions publish current 1975 base populations, fertility rates, and life
population, birth, and death data annually and expectancies. Each uses similar assumptions
prepare periodic global assessments and projec- about death rates and assumes no major wars,
tions. famines, or epidemics, and all except the U.N.
exclude international migration. All depend on
data from individual nations—sources whose
Projections based upon a 1978 assessment
frequency, accuracy, and completeness of infor-
were published in 1979; revised projections mation vary greatly. (See Tech. Note A.)
based upon a 1980 assessment were published
in 1981. The projections include high, medium, The projections prepared by the U.S. Bureau
and low variants. The medium variant is de- of the Census also include high, medium, and
signed to represent likely demographic trends low series, and are based on current levels of
based on past demographic changes, expected fertility, development, and family planning; gov-
social and economic progress, ongoing govern- ernment policy on population matters; and ex-
ment population policies, and prevailing public perience in countries with similar social, eco-
attitudes toward population issues. The high nomic, and political settings. These projections
and low variants are intended to represent the assume that fertility will decline more or less
effects of plausible variations in these factors. continuously throughout the period, that all

Table 6.—Alternative Projections of Population in 2000 (millions)

Source
U.S. Bureau United World University of Harvard Population
of the Census Nations Bank Chicago (6) University (5) Councilc
Region 1980 1979 1979 1977 1977 1981
World:
High . . . . . . . . . 6,520 6,508 – 5,974 — 6,353
Medium . . . . . . 6,175 6,199 6,004 5,883 5,882 —
Low . . . . . . . . . 5,799 5,855 – 5,752 — 6,046
MDCs
High . . . . . . . . . 1,324 1,319 – 1,266 — 1,135
Medium . . . . . . 1,272 1,272 1,261a 1,263 1,275a —
Low . . . . . . . . . 1,225 1,229 – 1,250 — 1,054
LDCs
High . . . . . . . . . 5,196 5,189 – 4,706 — 5,218
Medium . . . . . . 4,903 4,926 4,743 4,620 4,807 —
Low . . . . . . . . . 4,574 4,626 — 4,501 — 4,992
China:
High . . . . . . . . . 1,425 1,228 — 1,135 — —
Medium . . . . . . 1,284 1,189 1,210 b 1,131 1,129 NA
Low . . . . . . . . . 1,141 1,132 — 1,109 — —
India
High . . . . . . . . . 995 1,105 971 — —
Medium . . . . . . 959 1,037 973 951 1,009 NA
Low . . . . . . . . . 922 983 – 923 —
Ch. 2—Population Growth to the Year 2000 ● 35

countries will have adopted some kind of family Much of the uncertainty about China should
planning program by 2000, and that the effec- be resolved by its 1982 census and pending im-
tiveness and coverage of such programs will in- provements in and availability of its birth,
crease. death, and birth planning program data. Mean-
while, special population projections for China
The World Bank’s single population projection (l)—based upon China’s new emphasis on the
was prepared by estimating, for each country, one-child family to achieve population stabiliza-
the year in which fertility would reach replace- tion by 20()()-come close to the low estimates in
ment level. For all countries except those in sub- table 6.
Saharan Africa, fertility decline toward the re- The U.N. projections have been used as stand-
placement level is assumed to have started in ard reference figures in most of this report but
1975 if not before. For the sub-Saharan coun- have been supplemented by new national data
tries, the declines are expected to begin in where available and relevant.
1980-85.
For policy makers concerned with modififying
The University of Chicago projections also in- population growth, the most meaningful popu-
lation information is the difference in numbers
clude high, medium, and low variants. The pro-
jected fertility rates are based On specified rela- of people added to the world’s population if
tionships between the rate of fertility decline governments do or do not take feasible actions
and the strength of family planning efforts. The to reduce birth rates in addition to those
high projection assumes that each country already under way. The actual amount attribut-
maintains its present level of family planning ef- able to additional governmental actions that
fort. The medium projection assumes that reduce birth rates is neither accurately’ known
strong family planning efforts eventually are im- nor explicitly stated by most demographic ex-
plemented in all nations by the year 2000. The perts who make projections. There is general
low projection assumes that all countries have agreement, however, that if gotvernments inten-
sify current actions to reduce growth rates, the
strong family planning programs by 1995.
low variant projection is more Iikely to be
achieved. The total difference between the high
The Harvard University projections assume and low variants is sizable-650 million per-
that fertility will decline to replacement levels sons—and is equivalent to the addition of three
by 1990-95 in MDCs and by 2000-05 in LDCs. times the current U.S. population in just 20
The Population Council projections assume at- years (table 6 and fig. 5).
tainment of replacement level fertility at vary-
ing times from 1980-85 to 2040-45. Differences The tendency of demographers to follow past
among the six sets of projections summarized in trends and to underestimate changes in birth
table 6 are mainly in base data used, in assump- rates means that the low variant projections for
tions about future LDC birth rates, and in inter- 2000 are probably not low’ enough. New infor-
pretations of incomplete data about China and mation has already led to downward revisions
central Africa. Despite these differences, the of these low variants. The 1980 Census Bureau
outcomes in world, LDC, and MDC population low series projection for lvorld population i n
estimates for 2000 are quite similar among the 2000 was 2-percent lower than in 1977. Some of
first five. The university scholars and the World this change in predictions can be attributed to
Bank expect slightly less growth in LDCs than governmental actions.
do the U.S. Census Bureau and the U.N. Popula-
tion Division.
36 . World Population and Fertility Planning Technologies: The Next 20 Years

Figure 5.–World Population Growth From 8000 B.C. to 2000 A.D.

A.D. 2000 high variant


projection: 6.5 billion ‘ 6.5
m
A.D. 2000 medium variant A \
projection: 6.2 billion 6.0

A.D. 2000 low variant


projection: 5.9 billlon I 5.5

1 5.0
The difference in numbers of people added to the world’s popula-
tion by 2000 will depend to a significant extent on the actions
taken by governments to modify birth rates. The difference be- 4.5
tween the high and low projections—about 650 million persons
—is equivalent to the addition of three times the current U.S.
W ; 4.0
population within 20 years. Close to 92 percent of population
growth projected by 2000 is expected to occur in LDCs.
3.5

3.0

Chart shows world population 2.5


growth since 8000 B.C. If
stretched back all the way to
the beginning—300,000 B.C.
—in this scale, the line would
L 1945
2 .3 billion
2.0

be an invisibly thin one start-


ing 10 feet 71/2 inches to the
r 1850
I 1 billion I I
1 1.5
left of the graph
1.0

6000 B.C. 0.5


5 million
0

The built-in momentum of population growth


Population growth in the next 20 years has age groups will be so much larger than the older
enormous momentum that will affect later pop- age groups, the number of people being born
ulation size. This momentum comes from the each year will be much greater than the num-
combination of high fertility and rapidly declin- ber of people dying. Even when fertility ap-
ing infant mortality in LDCs that followed proaches replacement levels, the number of
World War II. The result is a subtle, very pow- deaths will not equal births until the largest co-
erful built-in inertia, resulting from the age hort of births reaches old age, some 60 years
structure of LDC populations (fig. 6A). later.
In LDCs, far more people are in the younger In contrast to the LDCs, by 2000 the MDCs
age groups than in the older ones. Because the will have a very even distribution of population
number of people entering the reproductive by age (fig. 6A). The number of people in each
ages each year will be more than 150-percent 5-year age group between birth and 50 years
greater that the number leaving them, the num- will be between 87 and 93 million. Each year
ber of births will be greater each year, even if fer- just as many people will move out of their repro-
tility rates fall dramatically. Because the younger ductive years as will enter them. With births at
Ch. 2—Popu/ation Growth to the Year 2000 ● 37

.g=—.6A.—Aae.Sex
Fiaure – Composition
. of More Developed and Less Developed Regions, 1980 and 2000:
Medium Series Projections
A _ - More developed regions Age

75+ Male Female 75+

70 — 70

60 — 60

50 — 50

[
— 40

— 30

— 20

— 10

I I I 1 I I I 0
w
300 260 220 180 140 100 60 20 020 60 100 140 180 220 260 300

Age

— 75+
— 70

— 60

— 50

— 40

— 30

“ 20

— 10

— o
300 260 220 180 140 100 60 20 0 20 60 100 140 180 220 260 300 -
Millions
SOURCE: U.S. Bureau of the Census, Illustrative Projections of World Populations to the 21st Century, Special Study Series, table 2, pt. B, p. 23, No. 79,
January 1979.
38 ● World Population and Fertility Planning Technologies: The Next 20 Years

replacement level, approximately the same had become a part of the built-in growth projec-
number of children will be born each year. Fur- tion.
thermore, because the size of the older age
groups will be about the same as the younger How actions taken now can affect the future
age groups, the number of children born each size of world population is shown in figure 6B.
year will be about the same as the number of Despite all feasible efforts to reduce birth rates,
persons dying each year. By 2000, many MDCs the world’s population will almost certainly dou-
are expected to have achieved population ble from 4.4 billion to well over 8 billion persons
stabilization—or zero population growth—with in the next 70 years. But if the world instead
low birth rates equal to low death rates, if their chooses a path of high growth by doing nothing
immigration is in balance with their emigration, further to change trends, an additional popula-
tion roughly equivalent to that of the entire world
One effect of the population momentum in in 1981 will be on Earth in 2050. Most of these
LDCs is to foreclose future options if actions are people would be born in the LDCs, where the
not taken in time. Frejka and Mauldin (2) con- initial direct impact of their numbers would be
clude that the range between the high and low most keenly felt.
variants, and thus the range for plausible gov-
ernment options for the eventual size of world The United States is expected to grow from
population toward the end of the next century, 226 million in 1980 to about 260 million in 2000,
was narrowed by 3 billion people in a single and to about 290 million in 2050, while at the
decade. Taking certain actions to reduce birth same time dropping from 4.9 to 4.0 to 3.5 per-
rates lowered the plausible upper level; not tak- cent of the world’s population. The impact of
ing other actions raised the plausible lower global population growth on the United States
limit, because by 1980 population momentum will thus be greatest from beyond its borders.

Figure 6B.–Estimated World Population Growth, 1981-2000-2050


(in billions)
1981 2000 2050

6,508 12,403

5,855 8,384

SOURCE: United Nations, 1979, World Population Trends and Prospects by Country, 1950-2000; Summary Report of the 1978
Assessment for 1981 and 2000 population figures,
Ch. 2—Popu/arion Growth to the Year 2000 39 ●

The magnitude of growth in many LDCs will capacity and stability of the entire world will be
almost certainly be disruptive within those felt everywhere. What some of those impacts
countries but the challenge to the carrying are likely to be is examined next.

Technical Note A: Projections of population growth


and on birth and death rates for the base year. If the
size estimate is in error, the projection will be inac-
curate by the amount of error from the beginning.
Inaccuracies will be compounded to the extent that
birth and death rate data are inaccurate. This factor
is the most serious problem in projecting population
growth rates in LDCs) where data are often of poor
quality.
Projections made in prior decades for the year
1980 illustrate this problem of poor quality baseline
data. The U.N.’S most recent projection estimates
world population at 4.43 billion in 1980. In 1973 this
projection was 4.37 billion (1.3 percent less than the
1980 estimate); in 1963 it was 4.33 billion (2.2 percent
less); and in 1957 it was 4.22 billion (4.7 percent less).
The major factor affecting these projections was the
inaccuracy of base data on death rates. The death
rate for 1960-65 was estimated in 1963 to be 15.9 per
1 )000 for the world and 19.2 for LDCs. Today the
respective rates for 1960-65 are estimated to have
been 14.4 (10 percent less) and 16.8 (12.5 percent
less). The decline in death rates was projected fairly
accurately, but the higher base figures led to low
overall growth rates. Birth rates were estimated
more accurately for the base years but were pro-
jected to decline more slowly than they actually did,
which compensated to some extent for the high
death rate projections. Based on calculations of error
and estimates of quality of current baseline data, pro-
jections for 2000 have an uncertainty range of 10 to
20 percent.

Technical Note B: Exponential growth


The concept of exponential growth can be illus- males each woman has since women bear children
trated by observing, during a certain length of time, and the ratio of males to females is usually close to
a theoretical population in which the rate of repro- 1:1). The two females leave four females in the next
duction per individual remains constant. Each female generation, the four leave eight, the eight leave six-
on average leaves two females in the next generation. teen, and so forth. If this were a population with an
(Population grolvth is measured by the number of fe- age at marriage (generation length) of 20, the popula-
tion would double every 20 years. Because individ- growth were to continue unchecked, the world
uals in this population are reproducing at a constant would soon contain more living organisms than
rate, the rate at which the population increases de- atoms in the universe. The factors that keep this
pends on the number of people at the beginning. A growth in check are the number of deaths in a popu-
population with 10 females at the beginning in- lation (growth rates slow if death rates rise), the time
creases faster than a population with two females at between generations (age at marriage in human pop-
the beginning even though each is reproducing at ulations), and the number of offspring each couple
the same rate. This kind of population increase, has (fertility). (Migration is a factor only for individ-
known as exponential growth, is also referred to as ual countries.)
geometric or logarithmic growth. If exponential

Chapter 2 References
1. Chen, P., contractor’s report to OTA, 1980. 8. U.S. Commission on Population Growth and the
2. Frejka, T., “~$~orld Population Projections: A Con- American Future, “Population Growth and the
cise History, ” Population Council Center for Anlerican Future” M’ashington, D. C.: Govern-
Policy Studies, Working Paper No. 66, Ne\v York, ment Printing Office, 1972).
1981. 9. IJ.S. Council on Environmental Quality and De-
~. F u t u r e s (h’OUp, “The Impacts of Population partment of State (G. O. Barney, Study Director),
(;rowth on Less Developed Countries,” (ITA The Global 2000 Report to the President
working paper, 1980. (Washington, D. C.: Government Printing office,
4. Independent Commission on International Devel- 1980).
opment Issues (Winy Brandt, Chairman), Norfh- lo. tJ. S. Department of Commerce, Bureau of the
South: A Program for Sur\~iva/ (Cambridge, Mass.: Census, illustrative Projections of world Popula-
NI. I.T. Press, 1980). tion in the 21st Centurey, Current Population
5. I.ittman, (;., and Key fitz, N., The Next 100 Years, Report, Special Study Series P-23, No. 79
(Mter for Population Studies Working Paper NO. (Washington, DC.: Goiernrnent Printing Office,
1 0 1 ( C a m b r i d g e , itlass.: Har\’ard LJni\’ersity, 1979).
1980). 11. , 1980. Re\~ised table to above.
6. Tsui, A. ()., and Bogue, D. J., Population Projec- 12. World Bank Development Economics Depart-
tions .fbr the World, 1975-2000: Summary Report ment, prepared by K, C. Zachariah and Aly Thi
of the 1978 Assessment, New York, 1979. V Ll , Popu lat ion Pro ject ions, 1975-
7. United Nations, World Population Trends and 2000 and Lon~ Term (Stationary Population)
Prospects by Country, 1950-2000: Summary Re- (Jt’ashington, D. C.: ~ToI.]C~ Bank, 1979).
port cf the 1978 Assessment, Ne\v York, 1979.
Chapter 3

Implications of World
Population Growth
Contents

Page

LIST OF TABLES
Chapter 3

Implications of World
Population Growth

Abstract

Less developed countries (LDCs) are experiencing severe environmental and resource
pressures to which more developed countries (MDCs) substantially contribute because
their fewer numbers consume the greater proportion of the world’s resources. Lower con-
sumption levels in MDCs plus agricultural and other developmental aid to LDCs would ease
many of these pressures. The continuation of traditional land-use patterns by rapidly rising
numbers of people has significantly weakened the resource base of many LDCs, whose gov-
ernments must achieve huge future increases in agricultural production to keep pace with
unprecedented population growth. Food resources are expected to be adequate to the year
2000, but distribution will remain a serious problem, and the burden of increased produc-
tion will fall largely on marginal lands. Most LDCs are in one of four situations: 1) those
with severely limited resources and heavy population pressures, 2) those with resource po-
tential that are slow to exploit it, 3) those with periodic food surpluses, and 4 those with
food shortages but the ability to import. World aquatic yield has declined slightly since
1970. Global water supplies, now about 10 times demand, are projected to fall to 3.5 times
demand by 2000. Water supplies are already critical in some areas and international dis-
putes over water rights are likely to intensify. International energy demands indicate a dif-
ficult future for LDCs; high oil prices, dwindling fuelwood supplies, and use of needed fer-
tilizers (dung, crop residues) as fuels have contributed to decreasing rates of economic
growth. Continuation of today’s rate of deforestation, with its concomitant large-scale soil
erosion and decreased soil productivity, could reduce the world’s forests by18 to 20 per-
cent by 2000. Human intervention has so far altered some 15 to 17 percent of the Earth’s
land area; of the world’s land surface, only 30 to 36 percent has significant life-support ca-
pability with present technology. The outcome of human impact on the global temperature
is uncertain. less rapid population growth would reduce pressures to provide health care,
education, and employment opportunities in LDCs. The impact of population growth on po-
litical stability depends on its interaction with the social, economic, and political structure
of the society involved. Because rapidly rising numbers of people can limit the ability of gov-
ernments to meet the expectations of their people, conflicts can have demographic roots.
Growing populations of rural landless, explosive urbanization, and large-scale migration
can exacerbate socioeconomic burdens in LDCs and influence stability in MDCs. High popu-
lation growth rates influence the social, economic, and political factors that threaten the
stability of many LDCs in which the United States has vital security interests; many contain
such tangible commodities as oil, chromium, and vanadium. Less tangible but probably far
more important is the significance of some of these countries to regional stability and the
balance of global power. Rapid population growth is intensifying current environmental,
food, energy, and resource pressures in LDCs. Its interaction with these problems has gen-
erated a new category of national security concerns, the implications of which remain
largely unexplored.

43
LDCS are experiencing selrere entironrnenta] d i s t r i b u t i o n p r o b l e m s . NIDCS presentl:r ha\re
and resource pressures. hlDCs contribute Sub- sLlfficient SLlt-plUS production to be able to exp-
stantially to these pressures because their far ort to 1,DCS, but clistribution s~stenls in these
fe~ter numbers consume the greatest propor- countries are inadequate to ensure the receipt
tion of’ the ~i’orld’s resources. Effective efforts to of food t]}’ those in greatest need. In the future,
c u r b c o n s u m p t i o n lelre]s in NIDCS combined some of the ~~wilthier I.D[;s \\’ill be able to inl-
\\’ith agricultural and other det’elopmental aici port food, but nlan~r poor LDCS t~rill hale insuffic-
to LDCS ~vould ease some of the most serious ient financial resources and are Iikel}’ to expe-
stresses faced by the det’eloping }vorlci. * rience continued food c~eficits.

In man~~ LDCS, farmers suilsist ily c l e a r i n g F o o d prociuction to 2000is projected to in-


forestland that has marginal productit~it~~, 3.0 per-
crease bv. 2.8 percent per ~’ea r in Africa,
quickly \%’earing out the soil, and mo~ring on to cent per year in Latin America, and 2.6 percent
clear more forest. The traditional use of wood per year in Asia (6). 11’hether LD(;s can t]~~ thf311
and charcoal for cooking cuts further into the be relatitwl~f self-sufficient ~iill depend to a
tree co~~er, and forested areas rapidly disap- great extent on the IIKi#litLldC of their pO]3Ll]a-
pear. The Philippines lose an estimated 200,000 t i o n gro~$rth. In ,~frica, domestic food produc-
hectares of forest each ~ear and Thailand’s for- tion can currently meet 86 percent of calorie re-
ests are i’anishing at the rate of 2s0,000 hec- (~ LliI’enleIlt S. Depending on \\ fhether the high or
tares annually. Droughts hai’e become mor[? fre- loLIr p o p u l a t i o n p r o j e c t i o n b e c o m e s realit}r b)r
quent and sei’ere; floods are unmoderated by ~0()(), this proportion f?ith[?r decreases to 80 pCl’-
forest buffers; erosion is extensile; irrigation cent or increases to 92 percent. In I,at in Amer-
and hydroelectric sJ~stems are silting in. India, ica, domestic p r o d u c t i o n , CllI’I’(?llt]J’ Lit 84 per-
Brazil, Indonesia, Costa Rica, Burundi, the I\JOI’}r cent of food liec~Llir’(?IlleIltsl ~1’ould i n c r e a s e i n
coast, Burma, Haiti, HOndUI’aS, and Nepal are either the high or ]mtr Population projections,
among the nations facing similar problems. }’et bLlt the d i f f e r e n c e \l’OLlld be b[?tll’e(?ll Ill[X?tillg
these countries must achim’e huge increases in 87 or 101 percent of food I’[;[ltlil’(trllf?rlts. In Asia,
agI’ iCLl h L1l’al ~l’Od LICt iOI~ i II the )’~~a I’s ahead to the increase L\rOLlld be from9.5 percent todi~~’ to
keep pace \~’ith their rapid popLllation gro\~th. either 110 or 120 percent b~’ 2000.
AlthoLlgh its most direct effect is se(?n in the E\ Fen ~%hen total production approaches 100
pressures exertecl on agricultLlral systems, rapid percent of food I“(?[]llil’etllellts, caloric intake is
pOpLlhitiOIl gro~~th eXaCtS a hea\r} toll on OtheI’ often insufficient among large s(?gments of the
important resources. It also points to complex ~O~LdatiOIl t)eCaLIS(? Of k)sses iIl StoI’:ig(? :111(] t l’all-
interrelationships bet~~’een the demands on sit and the proportion of thos(? Lt’hose intake is
food, ~$rater, and fuel resources and their result- at)o\’e a\’erage. ~]thOLlgh food production Illti)’
ing impacts on the en\rironment, on the social rise suffic ientl~’ to meet minimum calori~? rc-
and economic p regress of delwloping nations, cluirements in sonx? p o o r ” IJD(~s, Smrerc ])rob-
and on the political stabil itf’ of the ~$rorld at Iems of distribution are likel~~ to continue.
kWge.
Nlost L[](k are in one of fOur situations:

Food 1. C o u n t r i e s \\rith se\’er[?l\~ limited r e s o u r c e s


(land and technology) t;) increase food” pro-
hlost e x p e r t s e s t i m a t e t h a t \troI’ld food re-
dLICt ion, most of Lf’h ich face heavy ])op Llk I-
s o u r c e s \\’ill be aclecluate to 2000, t)ut many
tiOIl pI’eSSLII’eS :iIld ha\’e Iitt](? UIILIS(X] ;I1’at)l[?
countries ~~’ill ha\’e setrere p r o d u c t i o n ancl kind (e.g., Bangladesh, Pakistan, ~;gjrpt).
Countries that ha\’e potential l)ut are sIOLI”
+ I’tl(’ I)l[)j(’{li{)lls 011 ItIt’ iIll])ii[’l S ()! IX)[)llldtloll gl’(n$’111 Ill 1,[)(’s

Irl(’lll(k’(1 Ill 11)1s (’llaplcl’ \ \ t)l’t’ })1’t’l)ii 1’(>(1 !01” ( ) [ \ t ) \ ‘ 1 111> t’ 111111’[’S to exploit it. ‘rh(;~’ ha\’C ]aIKi a\’aiklbk? [01”
(;r(wp (!)}, I\ h(h(I t(lll report is pul)listled as a lt [Jrhing })apt’1’ agricultural dekwlopment, good” cl i ma t r,
Ch. 3—/mp/ications of World Population Growth . 45

solid infrastructure, and an abundance of


other natural resources (e.g., the majority
of Latin American countries).
3. Countries with periodic food surpluses
(e.g., Thailand, Brazil).
4, Countries that have food shortages but are
able to import (e.g., South Korea, Saudi
Arabia).
Food production increases are achieved by in-
creasing yields of lands now under cultivation
and by opening new lands. Because the most
productive lands have already been brought
into production in most areas, pressures to in-
crease production will fall on marginal lands,
with consequent need for far-higher use of irri-
gation, fertilizers, pesticides, herbicides, and
higher yielding crop strains than for productive
lands.
Production from another important source of
food, the Worlds oceans, lakes, and rivers, has
declined since the peak year of 1970 (3). The
contribution of the aquatic yield to global food
requirements is about 25 percent of required
protein. Even if the total aquatic yield could be
increased from its present 70 million to 100 mil-
lion metric tons by 2000, through the exploita-
tion of new species and the emergence of a
large marine-culture industry, the world’s pop-
ulation will increase at a slightly higher rate.

Water

An adequate supply of water is the most im-


portant factor in raising agricultural production
in large areas of the world, Global water sup-
plies are now about 10 times demand. Projected
growth of irrigation and domestic water use
would reduce these supplies to about 3.5 times
demand by 2000. Irrigation for food production
is the major use of water, accounting for 70 per-
cent of total water use in Africa, 88 percent in
Asia, and 60 percent in South America.
The water supply is already critical in various
areas of the world for different reasons. In
areas such as the Middle East, population den-
sities are low (the Nile River valley is an excep- Photo credit Agency for International Development

tion), but water is very scarce because people Haitian farmers plant tree seedlings in efforts to
are crowded close to the few available water restore eroded hillside
46 . World Population and Fertility Planning Technologies: The Next 20 Years

Table 7.—Projected per Capita Water Avaliability in the Year 2000


(thousand cubic meters per capita per year)

Per capita Sub-Saharan North Africa


water availability Africa Asia Latin America and Middle East

Medium availability Mali Nepal Argentina


(5 to 10) Philippines Guatemala
Low availability Ethiopia Afghanistan Cuba Iran
(1 to 5) Ghana China Dominican Iraq
Kenya india Republic
Mozambique South Korea El Saivador Sudan
Niger Sri Lanka Mexico Turkey
Senegal Thailand
Tanzania
Uganda
Upper Volta
Very low Malawi Bangladesh Haiti Algeria
availability Morocco Pakistan Egypt
(o to 1) Saudi Arabia
Tunisia
SOURCE: Futures Group, 1980; contractors report to Office of Technology Assessment.

Energy Wood can be a renewable resource, but en-


croachment on forests for farming and fuel has
The global energy situation signifies a difficult resulted in widespread shortages. Charcoal is
future for much of the developing world. While frequently adopted as a fuel when deforestation
many of the industrialized countries have raised extends beyond distances from which fuelwood
the prices of their exported goods, thereby buf- can be economically transported, because char-
fering the impact of higher costs for oil imports, coal contains about four times the energy per
most LDCs have not been able to effectively do unit weight as wood. But because much of the
so. They have suffered a double hardship by energy value of wood is lost in the process of
paying higher prices for both oil and other im- charcoal manufacture, intensified charcoal use
ports. will accelerate the problem of deforestation.
Consumption of commercial energy (oil, gas,
coal, etc.) is more closely tied to economic Rising commercial fuel costs and diminishing
growth and level of development than to popu- supplies of fuelwood are forcing many people in
lation growth. But the demand for “noncommer- LDCs either to greatly reduce fuel consumption
cial” fuels is directly related to population or to find alternative fuel sources. Among these
growth. are dried dung and crop residues. Because of
fuel shortages, increasing numbers of people
Wood is the most widely used noncommercial have only these materials to burn. Yet they are
fuel and supplies the majority of all energy used needed to maintain soil productivity, as subsist-
in many LDCs. Worldwide, wood burned for ence farmers can rarely afford commercial fer-
fuel provides energy equal to that derived from tilizers, and when they are burned, energy is
all hydroelectric sources. LDCs consumed about gained at the expense of land productivity.
90 percent of all fuelwood used in 1974, which
provided between 30 and 60 percent of their Burning of dung and crop residues is already
total energy (l). extensive in India, Nepal, other parts of Asia,
Ch. 3—lmp/ications of World Population Growth . 47

and in the Andes of South America. Worldwide,


between 150 million and 400 million metric tons
of dung are burned for fuel every year. As
about 50 kilograms of additional food grain can
be produced from land fertilized by a ton of
dung, this burning represents a potential loss of
between 8 million and 22 million metric tons of
food grain.
Population growth can make a substantial dif-
ference in the “affordability” of commercial
energy on the economy. Although supply-price
constraints are likely to depress economic
growth and gains in living standards, at a given
level of economic growth, gains in living stand-
ards can be much higher when population
growth rates are lower. A higher population
growth rate means that roughly the same
amount of gross national product (GNP) must be
divided among a larger number of people.
Photo credit; Agency for /nternat/ona/ Developrnenf
Commercial energy requirements have histor-
ically been closely linked with growth in GNP. A Makeshift housing characterizes the outlying areas
of most cities in LDCs
l-percent increase in GNP is associated with a
0.95-percent increase in commercial energy re-
quirements. The tremendous oil price increases duras, and over 90 percent of those in Haiti. The
that most oil-importing LDCs have had to pay removal of the forest canopy results in large-
have meant large balance-of-payment deficits scale soil erosion, decreased soil fertility, land-
and increased debts to finance decreasing, slides, silting-in of reservoirs and irrigation
rather than increasing, rates of economic channels, drought, desertification, and the ex-
growth. The World Bank has estimated that tinction of forest plant and animal species.
GNP growth rates collectively fell by more than Direct human intervention has caused the
60 percent in LDCs between 1973 and 1975, transformation of some 9 million square kilo-
from an annual growth rate of 7.6 to 3 percent. meters (kmz) of savanna to desert; 600).00 km2
Higher rates of population growth require more of forest to fields, grassland, or salvanna; and 1
commercial energy, necessitating more rapid million km z of fields or forests to paved areas
growth in GNP-growth that cannot always b e and urban buildings-a total alteration of some
assured and that appears unlikely to occur in 15 to 17 percent of the Earth’s land area (8).
some countries. Much of the best agricultural land lies near ur-
ban centers and is being used for urban and in-
Environmental effects dustrial development. These alterations are im-
portant because only 30 to 36 percent of the
Forests now cover about one-fifth of the
Earth’s total land area is fit for agricultural ac-
world’s land surface but are being depleted at a
tivities or has significant life support capabilities
rate of 18 million to 20 million hectares per with present technologies.
year, a reduction rate of about eight-tenths of 1
percent per year. If this rate were to persist to The U.S. Department of Agriculture estimates
2000,” forests would be reduced by 18 to 20 per- that the rapidly rising growth of cities in the
cent, or to one-sixth of the world’s land surface. developing world is cutting arable land in LDCs
very little forested area remains in such heavily by 0.03 hectare per capita per year (1 hectare
populated countries as India and Pakistan. equals 2.47 acres). If the most likely population
Deforestation has razed about 10 percent of projection becomes reality, this rate ivoulcd lead
Brazil’s forests, 30 percent of those in H o n - to a loss of 49 million hectares of arable l a n d
48 ● Wor/d population and Ferti/ity p/arming Technologies: The Next 20 years

from food production by 2000, an amount pres- The leading cause of the transformation of
ently calculated to feed some 165 million people. productive land into deserts is overgrazing.
If the low projection is achieved, the quantity of Overgrazing and overcropping, combined with
land lost would fall to 41 million hectares, but if drought, are rapidly expanding deserts in the
population totals rise to the high projection, this Sudan and Sahelian regions of Africa.
loss would reach 56 million hectares by 2000 ) an
Irrigation often causes long-term problems of
amount that could have fed 188 million people.
loss of soil productivity through waterlogging,
The impact of converting arable land is graph- salinization, and alkalinization. These problems
ically illustrated by the case of Egypt, where the occur when irrigation systems provide poor
current total of 25)000 hectares of cultivable drainage or where there is improper use of fer-
land lost each year is expected to rise as the tilizer. Evaporation of water from soil surfaces
pace of urbanization quickens. Despite large in- leaves residues of salt that form a mineral crust
vestments to expand the country’s irrigated land on the surface that can kill plants or inhibit
area with water from the Aswan Dam, irrigated their growth.
land totals remain essentially unchanged be-
Anthropogenic land-use changes are said to
cause old producing lands are lost at about the
have played a role in depressing the global tem-
same rate that new hectares are irrigated. If
perature by about 0.20 C over the past 25 years,
its present population growth rate continues,
and this temperature could fall by another full
Egypt’s goal of food self-sufficiency will be dif-
degree by the end of the century (8). Other
ficult to achieve.
studies suggest that the release of chemicals,
The increased pollution that accompanies particulate) and carbon dioxide into the
rapid urbanization has overwhelmed the ability air—the most serious human-induced threat to
of many LDC governments to provide sanitation climatic stability—could instead result in a
and other public services. In 1976, fewer than gradual warming trend (7). Still others project
one-third of LDC city dwellers lived in housing little or no effect on global temperatures. There
connected to sewer systems and less than 4 per- is no doubt that humans have caused significant
cent of this housing was connected to some changes in the environment, but whether these
form of sewage treatment facility. Air pollution changes extend beyond the microclimates of
problems have become critical in the urban cen- specific regions is still being debated.
ters of such cities as Mexico City, Sao Paulo, and
Bombay.

Economic and social impacts


The numerous pregnancies, closely spaced When women are malnourished during preg-
pregnancies, and additional pregnancies at com- nancy, they are likely to develop maternal de-
paratively late ages that are associated with pletion syndrome, * and while infants derive im-
rapid population growth are also associated portant benefits from breastfeeding, the prac-
with higher rates of illness and death for both tice further compromises the nutritional status
mothers and infants. of malnourished mothers. There is a high in-
cidence of infant mortality and low birth
An important health side effect of high fertil-
weights in almost every part of the world where
ity is nutritional deficiency. Each additional
child in a poor family may be believed by the * Klaternal depletion syndrome is characterize~i b}r smwral dis-
family to provide greater social security for the ease states including anemia, osteonudacia, and iodine-deficiency
goiter. It is caused hy multiple repregnancies occurring while the
parents’ old age, but available food must also be woman is suffering protein/calorie ciepri~~ation, Its effects are
divided among a larger number of people. Mal- cumulatit’e and contribute to lo\4’ birth \i’eight infants, failure to
nourished children are more vulnerable to dis- gain sufficient l~x?ight during pregtMncy, and a drrreaw in sub-
cutaneous fat and muscle tissue. The process undouhtedl!’ plays a
ease and their physical and mental growth may part in the premature aging and early death often seen among
be retarded. women in LDCS.
Ch. 3—/mp/ications of World Population Growth 49 ●

the population is under age 15. This group of 1.4


billion people will enter their economically ac-
tive years during the next 15 years. But the In-
ternational Labor Organization estimates that
the underemployed already account for almost
30 percent of the labor force in Latin America
and 36 to 38 percent in Asia and Africa. Reduc-
tions in fertility and mortality for the African
countries will be particularly significant be-
cause of the difference between the high and
low projections of population growth (table 8).
In Kenya, for example, annual new job require-
ments in 1975 were about 170,000. By 2010, the
number of new jobs needed annually, prinmrily
for young people just entering the job market,
would rise more than fivefold under the high
projection—to 900,000—as compared with
530,000 under the low projection of population
growth.
Per capita income increases only to the extent
that gross domestic product (GDP) growth ex-
ceeds the rate of population growth. But rapid
population growth requires high rates of invest-
ment at the same time that it makes domestic
savings more difficult.

Table 8.—Average Annual Growth of Labor Force for


Selected Countries

2000-2025
Low Medium High
1970-77 variant variant variant

Sub-Saharan Africa:
Ethiopia. . . . . . . . . . . 1.8 1.9 2.7 3.1
Kenya . . . . . . . . . . . . 2.8 2.7 3.4 3.9
Nigeria. . . . . . . . . . . . 2.0 2.8 3.4 3.7
Tanzania . . . . . . . . . . 2.3 2.5 3.2 3.5
Zaire. . . . . . . . . . . . . . 1.9 2.1 2.4 2.9
Asia:
Bangladesh. . . . . . . . 2.3 2.2 2.6 3.0
India. . . . . . . . . . . . . . 1.7 1.3 1.6 1.9
Indonesia . . . . . . . . . 2.0 1.3 1.7 2.0
Malaysia . . . . . . . . . . 3.6 1.1 1.3 1.6
Pakistan . . . . . . . . . . 2.4 2.2 2.6 2.9
Philippines . . . . . . . . 2.1 1.6 1.9 2.3
Sri Lanka . . . . . . . . . . 2.1 0.7 0.8 1.1
Latin America:
Argentina . . . . . . . . . 1.2 0.5 0.7 0.9
Brazil . . . . . . . . . . . . . 2.8 1.6 2.3 2.9
Colombia. . . . . . . . . . 3.5 1.2 1.9 2.4
Mexico, . . . . . . . . . . . 3.3 2.5 2.9 3.2
Venezuela . . . . . . . . . 3.3 1.7 2.1 2.6
North Africa and
Middle East:
Egypt ., . . . . . . . . . . . 2.2 1.6 1.8 2.2
Iran. . . . . . . . . . . . . . . 2.5 2.0 2.3 2.6
Morocco . . . . . . . . . . 2.7 2.3 2.6 3.0
SOURCE: The Futures Group, “The Impacts of Population Growth on Less
Developed Countries, ” report prepared for the Office of Technology
Assessment, 1980.
50 • World Population and Fertility Planning Technologies: The Next 20 Years

The extraordinary period of the 1960’s and vent significant and even very high rates of per
1970’s illustrates this point. World population capita income gain. But to overcome the eco-
growth, at an average annual rate of 1.9 per- nomic burden of rapid population growth re-
cent, was greater during these two decades quires rates of economic advance that exceed
than at any other period of human history, and the rate of natural population increase by a sub-
the economic growth rate of more than 5 per- stantial margin. Given the demands for services,
cent per year was also unparalleled in human employment, etc., by constantly rising numbers
history. World income per capita grew rapidly, of people in the next two decades, declines in
averaging about 3.2 percent per year. rates of economic growth are likely. Thus, pop-
ulation growth aggravates the economic prob-
Although economic performance in terms of lem of many countries that have had to borrow
aggregate growth of output was about the same from outside sources, and their increasing debts
for LDCs and MDCs, a substantial difference in are now becoming a hindrance to development.
demographic growth gave MDCs a marked ad-
vantage in per capita income. The LDC popula-
The combined benefits of slowing population
tion grew by 1.2 billion people during this
growth–on health, education, and the eco-
period, at an annual rate of more than 2 per-
nomy—are all interrelated. A smaller child pop-
cent, while MDC numbers rose by fewer than
ulation makes it easier to provide quality educa-
200 million, at a rate of less than 1 percent. MDC
tion and health care to young children. It also
per capita income growth exceeded 4 percent
reduces dependency ratios, which can lead to
annually, but LDC growth remained below an increased savings. A healthier, better educated
annual rate of 3 percent. The absolute income
work force is more productive. Increased sav-
g a p b e t w e e n LDCs and MDCs widened
ings can lead to more investment, more capital
significantly between 1960 and 1978, but the
per worker, and, again, higher worker produc-
relative gap—as measured by per capita in-
tivity. The resulting higher output and income
come—widened to a far greater degree (4). can, in turn, make it possible to provide still bet-
Thus, population growth, even when rapid by ter health care and education to the young pop-
historical standards, does not necessarily pre- ulation.

Political consequences
The impact of population growth on political demographic roots (2). Religious, social, and
stability depends on its interaction with the racial differences are important contributors to
social, economic, and political structure of the violence and conflict, and differential rates of
society involved. The ability of any government population growth among separate ethnic, lin-
to meet the needs and demands of its people is guistic, or religious groups can generate serious
clearly a critical element in that government’s political strains.
medium- and long-term survival. There is gen-
Rapid population growth in rural areas can
eral agreement that political stability is jeopard-
jeopardize political stability in several ways. As
ized when the expectations of individuals and
rural population densities rise, existing agricul-
groups are not fulfilled. Resultant frustrations
tural acreage must either be divided into ever
can then lead to political and social unrest as in-
smaller parcels or an increasing proportion of
creasing numbers of people place ever greater
the rural populace must be left landless. Either
demands on the limited capacity of national gov-
result can lead to political unrest as living stand-
ernments and economies to provide desired
ards decline and frustrations grow. Rural pop-
goods and services.
ulation growth also stimulates migration from
Although demographic factors such as rapid rural to urban areas, as people search for the
population growth do not act alone or directly better economic and educational opportunities
cause conflicts, conflicts that have been viewed that urban centers are more likely to provide.
as primarily due to political causes can have Explosive urbanization in turn strains service
Ch. 3—/replications of World Population Growth ● 51

----
52 . World Population and Fertility Planning Technologies: The Next 20 Years

Table 9.—Population Trends in Selected Countries Involving U.S. Security Interests


Total Annual Urban
Total Annual population Population urban population
population population doubling under population doubling
mid-1981 increase a time age 15 increase time
Country (millions) (percent) (years) (percent) (percent) (years)
All MDCs 1,138 0.60/0 113 24 ”/o 1.40/0 50
LDCs 3,357 2.1 34 39 4.0 17
Selactad countrios: Stratagic Importance
Bangladesh Collapse or political realignment
would have destabilizing effect
on Indian subcontinent . . . . . . . . . 91.4 2.60/. 27 440/0 6.70/, 10
Bolivia Source of tin, antimony, tungsten . . 5.7 2.5 28 42 4.3 16
Brazil Source of manganese ore,
columbium and iron ore; size;
leadership role in Latin
America . . . . . . . . . . . . . . . . . . . . . 130.0 2.4 29 41 4.0 17
Central America Panama Canal; excessive
emigration to U. S.; proximity . . . . 95.9 2.7 26 46 4.1 17
Egypt Key to U.S. strategies for peace
in Middle East . . . . . . . . . . . . . . . . 43.1 3.0 23 40 3.4 20
India World’s second largest country;
key to stability Indian Ocean
region and U.S.-Soviet balance . . 709.8 2.1 33 41 3.8 18
Indonesia Major source of U.S. oil imports;
fifth largest country in world;
strategic location as U.S. ally
in Southeast Asia . . . . . . . . . . . . . 155.4 2.0 35 42 4.2 17
Kenya Leader of pro-Western African
states; U.S. military access
agreement . . . . . . . . . . . . . . . . . . . 17.0 3.9 18 50 7.1 10
South Korea U.S. military ally; potential
staging area; possible North
Korean threat . . . . . . . . . . . . . . . . . 38.6 1.7 41 38 4.1 17
Mexico Size; proximity; major source of
strontium, cadmium, and major
potential source of oil and gas;
large labor migration to the-
U.S. . . . . . . . . . . . . . . . . . . . . . . ... 72.4 2.5 28 46 4.4 16
Morocco Major source of potassium; U.S.
friend in North African
conflicts . . . . . . . . . . . . . . . . . . ... 21.0 3.0 23 46 4.8 14
Nigeria Second largest source of U.S. oil
imports; one-fourth of total
African population. . . . . . . . . . ... 79.7 3.2 22 47 5.6 12
Pakistan Principal bulwark against
Russian move into Gulf of
Oman and Indian Ocean . . . . . ... 85.1 2.8 25 46 4.7 15
Philippines Source of chromite and copra;
military ally with key U.S.
bases; strategically important ... 52.5 2.4 29 43 4.1 17
Somalia Strategic location; U.S. friend in
conflicts over Horn of Africa . ... 3.8 2.8 25 44 5.4 13
Thailand Source of tin, tungsten and
tantalum; military ally; strate-
gic importance in Southeast
Asia. . . . . . . . . . . . . . . . . . . . . . ... 49.0 2.0 35 43 4.2 17
Turkey Eastern anchor of NATO; strate-
gic window on the U.S.S.R. , . . ... 46.5 2.2 32 40 4.3 16
Venezuela Source of oil and vanadium . . . . ... 15.4 3.0 23 43 3.9 18
Zimbabwe Major source of chrome; key to
political stability in Southern
Africa . . . . . . . . . . . . . . . . . . . . ... 7.7 3.4 21 47 6.3 11
aNatural increase, exclusive of emigration and immigration.

SOURCES: Draper Fund, 1981; U. N., 1979-World Population Trends and Prospects by Country, 1950-2000: Summary of the 1978 Assessment.
Ch. 3—ImpIications of World Population Growth . 53

Chapter 3 references
1. Brookha\’en National I,aboratory, “Energy Needs, 5. Draper Fund, “World Population Growth and U.S.
[Jses and Resources in Dmreloping Countries,” pre- Security Interests” (Washington, D. C.: Draper
pared for the (1.S. Agency for International De- Fund, 1981).
irelopment under PASA NO. F. RDA/TAB-995-18-76 6 Food and Agricultural Organization, Agriculture:
m’ith the LI. S. Department of Energy, Nlarch 1978. Toward 2000 (Rome: FAO, 1979).
2. Choucri, N,, Population D-vnamics and Inlerna?iona/ 7 National Academy of Sciences, Understandin g C/i-
i’iolence; Proposition, !nsights and Evidence (Lex- matic Change: A Program for Action, U.S. Commit-
ington Itlass.: Lexington Books, 1974). tee for the Global Atmospheric Research Program,
~. Council on Em’ironmental Quality and the Depart- National Research Council (M’ashington, D. C.:
ment of State, The (Johal 2000 Report to the Presi- NAS, 1975).
dent: Entering the ~vent}r-First Century, The Tech- 8 Sagan, C., Toon, O. B., and Pollack, J. B., “Anthro-
nical Report, \rol. 2 (i$’ashington, D. C.: U.S. Go\rern- pogenic Albedo Changes and the Earth’s Climate,”
ment Printing Office, 1980). Science 206(4425): 1363-1367, 1979.
4. Demeny, P., “The North-South Income Gap: A 9 The Futures Group, The Impacts qf Population
Demographic Perspecti\re, ” Population and Dew/- Growth on Less Developed Countries, report pre-
oprnent Revietfrl \rol. 7, No. 2, J u n e 1 9 8 1 , p p . pared for the Office of Technology Assessment,
297-310. Washington, D. C., 1980.
Chapter 4

The Direct Determinants of


Fertility Change
Contents

\ Page

. . . .— “ . . -. . .-

8.
9.

11,
12.

13,
14.
15.

16

17<
Chapter 4

The Direct Determinants of


Fertility Change

Abstract

Fertility, mortality, and migration determine population change: if births plus


net immigration exceed deaths, populations grow. Because no government advo-
cates raising mortality rates and few encourage emigration, fertility change is the
most viable option for countries that wish to lower population growth rates.
Among the many factors that influence fertility, such as education, desired fami-
ly size, and value and cost of children, eight directly influence the number of live
births that occur, and four of these—lactation, proportion married and age at
marriage, induced abortion, and contraceptive use-are most likely to contribute
to any significant reduction in birth rates in the next 20 years. The relative influ-
ences of the remaining direct factors—frequency of intercourse, natural sterility,
spontaneous abortion and fetal mortality, and duration of the fertile period dur-
ing a woman’s menstrual cycle—are likely to change only slightly. Because lacta-
tion temporarily suppresses ovulation, breastfeeding can lower fertility rates, but
is an unreliable contraceptive for individuals. Age at marriage and proportion
married influence fertility because most births take place in stable unions and
women who marry at later ages are exposed to the possibility of pregnancy for
fewer years. In some countries, both rising age at marriage and contraceptive use
have contributed to fertility declines. Age at marriage will continue to be an im-
portant factor in less developed countries (LDCs) for the next 20 years because
there will be more young adults in their peak reproductive years than ever
before in history. An estimated 55 million induced abortions are performed in
the world each year; more than half occur in LDCS . changes in abortion laws
have occurred in recent years for reasons of public health, social justice,
women’s rights, and government population policies. The incidence of induced
abortion and maternal mortality from improperly performed procedures can be
reduced by improving access to effective contraceptive services. Contraceptive
prevalence rates, which are reliable predictors of crude birth rates, vary widely
among countries, and more urban than rural women use contraception because
many family planning programs are not yet effectively reaching rural areas. Con=
traceptive use has been established as of central importance in achieving replace-
ment fertility.

Introduction

57
58 World Population and Fertility Planning Technologies: The Next 20 Years

Natural fertility
If ~$’onwn \$’erc to t)egin childbearing at the confirmed \tras for the North American rt?ligious
s t a r t of thei I’ reprodLlctive . vea I’s (menarc h e ) sect kno~t’n as the I+ Lltt(?I’i t(?s—ll(?ii I’l\’ 1:1 (tat)le
and to CO Iltill Lle \trithoLlt inter rLlpt ion until they l o ) . hlor(? I’WX?lltlJ’, ( ; Ll;ItCIll;lkI (lfl;()-~~) and
t$’(?l’[? no longer t’tK;LHId (IllwIop:ILN?), then, in S~I’ia ( 1 $)Y3) ha\’L? recorded marital fcrt ilit~ rates
the ahsence of limiting faders sLI(:h as iariat ions of nearly 10 (tat)lc 1 1).
in fI’c:(~LIt?IIC:\T ot intercx)LIIw?, nat LII’ttl s t e r i l i t y ’ ,
fetal 11101 ’td~tJ’, and k(:tation, they wLIl(i @[?ll- As ~1’OLl~S desiring hII’fje IILIIllt)[?I’S of offspring
tial]~ hak’e 3 0 t o 40 children Olrer their repro- ha\w Ix?(;I1 able to achimw f’w~rer than half of the
dLlcti\’t? li\’es. BLlt n o knoW’11 p(lpLll:l tioll—t?\’e Il possit)k? total p[?r ~tronmn, nat L]ral limiting i’a(;-
t h o s e t h a t ha\Te m a i n t a i n e d h i g h f’ertilit~f tors are clearl~T a t Jvork. FIqLlenql of inter-
~o~~ls-h~~s ~3\rf;I. I’f31Chd this ;i~wage. ‘rht; high- (: OLII”Se, IlatUI’1~1 StWi]itJ’, IMtLII’ti] f(?tii] INOI’tL~]it ~’,
est fertilitt’. rate (total marital f(?rtilitk’
. ratt?) el’(?r anci duration of the fertile period redLI(x; fertili -
Ch. 4—The Direct Determinants of Ferti/ity Change ● 59

ty from the potential level of 30 to about 15. To Table il.—Total Fertility Rate and Total Marital
reduce fertility rates further to those actually Fertility Rate for Selected Countries*
observed in most populations, the most impor-
Total
tant limiting direct factors are: 1) lactation, 2) Total marital
proportion married and age at marriage, 3) in- fertility fertility
duced abortion, and 4) contraception (3). Year rate rate
LDCs
Bangladesh . . . . . . . . . . . . 7.4
Colombia . . . . . . . . . . . . . . 7.5
Guatemala (rural) . . . . . . . 9.7
Indonesia . . . . . . . . . . . . . . 6.6
Table 10.–Total Fertility Rate and Total Marital Jordan . . . . . . . . . . . . . . . . 8.6
Fertility Rate for Selected Populations’ South Korea . . . . . . . . . . . 7.1
Panama . . . . . . . . . . . . . . . 6.8
Total Peru . . . . . . . . . . . . . . . . . . 8.9
Total marital South Lebanon . . . . . . . . . 8.9
fertility fertility Sri Lanka ., . . . . . . . . . . . . 6.9
Historical populations rate rate Syria . . . . . . . . . . . . . . . . . . 9.6
11.9
Turkey. . . . . . . . . . . . . . . . . 7.2
9.9 MDCs
10.7 Denmark . . . . . . . . . . . . . . . 1970 1.8 3.2
13.0 Finland, . . . . . . . . . . . . . . . 1971 1.6 3.1
12.1 France . . . . . . . . . . . . . . . . 1972 2.2 4.3
10.6 Hungary. . . . . . . . . . . . . . . 1966 1.8 2.9
12.7 Poland . . . . . . . . . . . . . . . . 1972 2.1 4.8
10.2 United Kingdom . . . . . . . . 1967 2.4 3.9
9.9 United States . . . . . . . . . . . 1967 2.3 3.7
9.4 Yugoslavia . . . . . . . . . . . . . 1970 2.1 3.7

Primary determinants of changes in fertility rates


added for 2 months of breastfeeding. Women
who breast-feed for 8 to 12 months canl b e g i n
menstruating again 4 to 7 months after child-
birth, and women who breast-feed for 2 years
can resume menstruation from 7 to 20 months
after the birth. Second, ovulation usually
precedes the first menses, so a woman may be-
come pregnant again before she realizes that
she is fecund (capable of becoming pregnant)
(18).

Most women in LDCs breastfeed their infants,


but both the prevalence and duration of breast-
feeding are declining. In Bangladesh, Nepal,
Pakistan, Indonesia, and Kenya, more than 95
percent of women breast-feed. In other coun-
tries, most mothers still breastfeed, but percent-
ages are low: 85 percent in the Philippines, 81
percent in Malaysia, and 79 percent in Panama.
60 • World Population and Fertility Planning Technologies: The Next 20 Years

women who are better educated and/or live in


urban environments are less likely to breast-
feed, and do so for shorter periods. In Malaysia,
for example, 85 percent of rural women breast-
-feed, but only 62 percent of urban women do,
and for half as long as their rural counterparts.
And there is usually an inverse relationship be-
tween the mother’s education and the length of
breastfeeding. In Thailand, women with no
education breastfeed for about 12,0 months on
average, those with a primary education for
10.7 months, and those with a secondary or
higher education for 7.8 months (9).
The practice of breastfeeding is accompanied Photo Credit: Agency for International Development

by lengthy periods of postpartum abstinence in Many women in LDCs become mothers while in their teens
some LDCs, especially in Africa. This norm was
virtually universal in sub-Saharan Africa during
creasing age at marriage shifts births from one
the 19th century, when in 55 percent of the 131
age group and time period to a later one, tempo-
societies for which records are available the
rarily lowering the birth rate. Although this in-
custom of abstinence was observed for longer
crease in age at marriage cannot be repeated
than 13 months (14). As traditional cultural sup-
once it has taken place, its effects continue. For
ports for these norms are breaking down, the
example, when other factors are equal, a family
overall contraceptive effect of breastfeeding
in which all women marry at age 15 and pro-
and breastfeeding accompanied by abstinence is
duce daughters every 5 years until age 40 will
decreasing.
have more than five times as many living mem-
Where fertility rates are high, breastfeeding bers after a period of 60 years than a family in
acts to prevent maximum fertility, For example, which all women marry at age 25 and also pro-
in the Philippines in 1973, it was estimated that duce daughters every 5 years until age 40 (see
the additional 5.5 months protection afforded to Technical Note C). This substantial difference
women who breastfed provided approximately occurs because women married at age 15 would
590,000 “couple years” of protection from average five children apiece in 60 years,
pregnancy, nearly equaling the 600,000 couple whereas women married at age 25 would aver-
years of protection provided to the then 2 mil- age only three children apiece in the same
lion participants in the family planning program period.
(4).
In many countries, both rising age at marriage
and contraceptive use have contributed to fertil-
Age at marriage and ity decline. Table 12 lists 26 of the 80 LDCs of
proportion married more than 1 million population where data are
available on fertility and marriage trends. Of
Because most births take place within some
the 80 countries, only these 26 have also experi-
form of relatively stable union in most LDC S )
enced appreciable fertility declines. The 13
age at marriage and proportion married have a
indicated by the letter “a” already record high
significant impact on fertility. In the absence of
ages at marriage (in Taiwan and Korea, fewer
premarital sexual activity, a woman who mar-
than 10 percent marry before age 20). In seven
ries at a later age is exposed to the possibility of
of these countries (marked a and b), fertility
pregnancy for fewer years.
among women 15 to 19 or 20 to 24 has dropped
Later age at marriage can also have an impact significantly, confirming the impact of higher
on population growth even when the number of age at marriage on fertility. In the other coun-
children is the same for later marrying women tries, substantial declines in fertility have oc-
as for those who marry at younger ages. In- curred even though age at marriage has not
Ch. 4—The Direct Determinants of fertility Change • 61

their rural counterparts may marry at the


slightly earlier ages of 23 and 25, respectively
(5).
The effectiveness of the Chinese emphasis on
delayed marriage and increased opportunities
for women is shown in data from Shanghai,
where there has been an increase in age at mar-
riage of 5 to 7 years since 1950 (table 13).
Later age at marriage is helping to reduce fer-
tility in the PRC, but age composition and pop-
ulation momentum play significant roles in the
country’s continuing population growth. De-
spite China’s lowered birth rate and a con-
traceptive prevalence rate as high as 84 percent
in some regions, the sharp rise in numbers of
women who will enter the marriageable ages in
the 1980’s—due to high levels of fertility during
the past 20 years— will make the country’s pop-
ulation goals difficult to achieve. As this strong
momentum for future growth is inherent in
China’s age composition, the government is tak-
ing steps to curb third (and higher) births by
1985 and is moving toward a one-child family
norm (table 14).

risen. Fertility in women 15 to 19 or 20 to 24 has SRI LANKA


fallen appreciably in Brazil, Dominican
the In Sri Lanka, 63 percent of the decline in birth
Republic, El Salvador, Panama, Peru, Trinidad rates between 1963 and 1971 is attributable to
and Tobago, and Venezuela (7). But as patterns changing patterns of marriage in the absence of
of marriage in these countries make age at first a government policy designed to encourage
marriage difficult to define, how much of the such change. Age at marriage has risen as a
decline in fertility is due to rising age at mar- result of:
riage and how much to increased contraceptive
use is unclear. ● Continuing adherence to cultural practices.
prospective mates are expected to be of the
Age at marriage is influenced by the sociocul- same caste and ethnic group; elaborate pro-
tural context in which marriage takes place. In cedures are undertaken to assure that the
China, Sri Lanka, and Tunisia, age at marriage
has risen and fertility has declined, but for very
different reasons. Table 13.—Mean Age at Marriage for Women in
Shanghai 1950 to 1979
CHINA
Period of City Suburban
In the People’s Republic of China (PRC), where marriage proper county
the government has embarked on a major cam- 1950 -54..... 19.9 19.8
paign to slow population growth, young people 1955-59 . . . . . 24.9 20.6
1960-64 . . . . . 26.3 23.9
are now expected to defer marriage well be- 1965-69 . . . . . 26.6 24.1
yond the minimum legal ages of 18 for women 1970-74 . . . . . 26.8 24.6
and 20 for men. In the cities, the norms for age 1975 -79..... 27.9 25.0

at marriage are 24 for women and 26 for men; SOURCE: Gu Xingyvan discussion at WFS Conference, London, July 1980.
62 ● World Population and Fertility Planning Technologies: The Next 20 Years

Table 14.–Women Expected to Reach Marriage Age, China, 1980=2000

As percent As percent
Year of 1980 Year of 1980

two horoscopes are compatible; the bride every 100 females ages 20 to 24. Tunisian
must be a virgin; the groom must be older, men are migrating to Europe and to other
and his potential job security and the dowry Arab countries to seek employment.
provided by the young woman and her ● A minimum age at marriage law passed in
family must be acceptable. 1964 set the minimum age at marriage at 17
● Increasing economic and job opportunities for women and 20 for men. An antipolyga-
for women. In 1971, 71 percent of Sri my law passed in 1956 also guaranteed a
Lankan women were literate, and 26 per- voice in marriage decisions and other legal
cent were in the labor force. rights to Tunisian women.

A stagnating economic climate. Employ- ● Committed leadership. President Bourguiba
ment is difficult to obtain, agricultural land has made a strong commitment to the
shortages have intensified, and males have emancipation of women.
migrated, leading to ● Increased educational and job opportunities
● “Marriage squeeze,” a sex ratio imbalance for women. By 1971, female literacy had
among those in traditional marriageable reached 40 percent, and 7 percent of Tuni-
ages. In 1974 there were 75 males aged 25 sian women had entered the labor force (l).
to 34 for every 100 females aged 20 to 30
When contraceptive use becomes extensive,
(l).
age at marriage will lose importance as a causal
TUNISIA mechanism in fertility change. Nevertheless, age
at marriage will continue to be an important
In Tunisia, both government intervention and factor for the next 20 years, because of the
unanticipated economic changes have contrib- number of people entering the marriageable
uted to rising age at marriage. Age at marriage ages in LDC populations:
has risen as a result of:
During the 1980’s and 1990’s, there will be
● Marriage squeeze. In 1975, there were 77 more young adults in their peak reproductive
males ages 20 to 24 for every 100 females and marriageable years (age 15 to 29) than ever
ages 15 to 19, and 58 males ages 25 to 29 for before in history. More than 40 percent of the
Ch. 4—The Direct Determinants of Fertility Change . 63

people in developing countries today are under morbidity associated with illegal abortion; 2)
15 years of age. By 1990, there will he 40 per- social justice, to give poor women the access to
cent more potential parents age 15 to 29 than induced abortion previously available only to
there were in 1975, and more than twice as wealthier women; 3) women’s rights, to provide
many as in 1960—in other words, a total of women greater control over their reproductive
more than 1 billion potential husbands and
lives; and 4) in a few countries (China, Singa-
wives, fathers and mothers. If this new genera-
pore) government population policies, to en-
tion marries young and then begins to repro-
duce at an earl.v age, it will he difficult for many courage women to utilize the procedure in the
countries to reduce population growth to de- event of contraceptive failure.
sired levels even if marital fertility is sharply re- In the United States, the 1978 abortion rate as
duced (7). reported by the Center for Disease Control was
23 per 1,000 women of reproductive age. New
Induced abortion estimates of induced abortion in China place
that country’s rate at 25 in 1978. Eastern bloc
Biological events such as life and death are
countries have very high rates. In the U. S. S. R.,
culturally defined. For example, in some cul-
there were 180 abortions per 1,000 women of
tures, a child is not considered “born” until its
reproductive age in 1970, the latest year for
naming ceremony, which can take place as long
which data are available, There were 88 abor-
as a month after the child’s birth. Where neo-
tions per 1,000 women of reproductive age in
natal mortality rates are high, various “neglect”
Romania and 68 per 1,000 for the same group in
behaviors are rationalized. In the view of those
Bulgaria (1979). The latest data from Japan
societies, if the child hasn’t been “born” yet,
then it didn’t ‘(die. ” Although cultural and ethi- (1975) show an equivalent rate of 84 per 1,000
cal issues are inexorably entwined in any discus- (16).
sion of induced abortion, it is a direct means of In countries where induced abortion is illegal,
fertility regulation, and certain facts pertaining maternal mortality from complications of im-
to abortion can be analyzed separately from properly performed procedures can be as high
ethical issues, as 1 in 100 procedures (16). When abortion is
performed during the first trimester under
An estimated 55 million abortions are per- medically supervised conditions, maternal mor-
formed throughout the world each year, or tality rates are very low. (In the United States in
about 70 abortion procedures for every 1,000 1978, 11 times more women died as a result of
women of reproductive age. More than half of pregnancy and childbirth than as a result of
these occur in LDCs (10,16). legal abortions). In the United States, where
In 1980, 9 percent of the world’s population changes in abortion laws to allow more legal
lived in countries where induced abortion was abortions began in 1967, maternal mortality
illegal. An additional 19 percent lived in coun- from abortion (spontaneous and induced) fell at
tries where the procedure was officially per- a rate of 18 percent per year from 1968 to 1978.
mitted only to save a woman’s life, Some 10 per- Maternal deaths attributed to illegal abortions
cent lived in countries authorizing abortion on declined 34 percent per year during the same
broader medical grounds, and an additional 24 period (16) (fig. 7).
percent lived where social factors were also Induced abortion occurs in all societies,
considered. The largest group—38 percent— whether legislation permits it or not. The fre-
lived in countries where induced abortion dur- quency of abortion procedures can often be re-
ing the first trimester of pregnancy was legal duced by making effective contraceptive meth-
and available at the request of the pregnant
ods readily available. The introduction of con-
woman (16).
traceptives can also reduce the maternal mor-
Changes in abortion laws over the past 15 tality that accompanies illegal abortions. This
years have taken place for four reasons: 1) pub- was the justification for establishing official
lic health, to combat the maternal mortality and family planning programs in Chile. A survey
64 world Population and Fertility planning Technologies: The Next 20 Years

Figure 7.– Number of Deaths Associated With Although induced abortion can be an effective
Abortion, by Type of Abortion: United States, 1958-78 method of fertility regulation for an individual
because it prevents a live birth, it is not an “effi-
cient” way for a society to reduce the total num-
ber of births. If an average couple in an MDC
were not practicing contraception and the
woman did not breastfeed the infant, the couple
could have a live birth about 17 months after
the previous birth (2 months of postpartum
infertility, plus 6 months—the average time to
become pregnant–plus 9 months of pregnancy)
(fig. 8). If the woman breastfeeds, the birth in-
terval could be 27 months on average because
lactation would increase the infertile period by
about 10 months. Using induced abortion (after
2 months of pregnancy) as a fertility planning
method shortens the pregnancy interval be-
cause 7 months of pregnancy and 1 to 11
months of postpartum infertility are inter-
rupted. The period between induced abortions
is about 9 months (1 month of postpartum infer-
tility, plus 6 months to become pregnant again,
plus 1 or 2 months of pregnancy before another
induced abortion interrupts the pregnancy).
on average, if a woman wished to have two
children (replacement fertility) rather than, say,
seven (the average number in some LDCs
today), and used abortion as her sole fertility
planning method, she could expect to have
about 9 to 10 induced abortions during her re-
productive years (i.e., two abortions for each
full-term birth averted). The number of induced
Illegal and Illegal Spontaneous Legal
abortions would be still higher were there no
spontaneous changes in natural sterility with age, divorce,
SOURCE: C. Tietze, Induced Abortion: A World Review, 1981, Population Coun- widowhood, coital frequency, etc. (12,13,16).
cil, 4th ed.

taken in the early 1960’s, when these efforts Contraception


began, found that at least 25 percent of women
Contraceptive prevalence rates are reliable
in Chile acknowledged having had an illegal
predictors of crude birth rates despite the ef-
abortion. Between 1964 and 1978, the number
fects of the other factors that directly affect fer-
of women of reproductive age using contracep-
tility” rates. In figure 9, the line relating the con-
tives increased from 3 to 23 percent. During the
traceptive prevalence rate and the crude birth
same period, the number of women admitted to
rate 1 year later indicates that every 2.4-per-
hospitals for complications from illegal abor-
centage-point increase in contraceptive preva-
tions declined from more than 56,000 to 37,900.
lence (X-axis) is associated with a l-point decline
Mortality among women undergoing illegal
in the birth rate (Y-axis) (11).
abortion also decreased markedly, from 11.8
per 10,000 live births to 4.2 per 10,000 live Knowledge of the relationship of various fac-
births (10). tors with the use of contraception is increasing

Ch. 4—The Direct Determinants of Fertility Change 65


Figure 8.— Birth Intervals and Induced Abortion lization. Oral contraceptive use is also high in
Malaysia (44 percent of contraceptive users),
Colombia (42 percent), and Mexico (31 percent).
IUDs are used by far fewer women in all coun-
tries except China; Colombia (16 percent) and
Korea (20 percent) have relatively high propor-
tions of IUD users, while IUD use is now esti-
mated by China’s State Council Birth Planning
Staff office to account for about 50 percent of
all contraceptive use in that country.
As a result of early marriage, in many LDCs
the majority of women have all the children
they want by age 25 yet face the possibility of
pregnancy for 20 more years. Thus demand for
sterilization is increasing in these countries, and
because simpler techniques that allow para-
medical personnel to perform the procedure
have been developed, many women and men
elect this as an efficient means to terminate
childbearing. About 87 percent of India’s con-
traceptive use rate in 1979 was attributable to
sterilization. In Thailand, a concentrated effort
to increase the availability of sterilization serv-
ices markedly changed the country’s contracep-
tive use rate in just 2 years. A significant portion
of the increase in overall contraceptive use in
SOURCE: Office of Technology Assessment.
Colombia is also attributable to an increase in
male and female sterilization; sterilization ac-
rapidly, as illustrated by the following examples counted for 9.4 percent of all contraceptive use
of the relationships between contraceptive use in 1976 and 17 percent of all use by 1978.
and place of residence, age, and education.
Contraceptive use varies with age and with
Contraceptive prevalence rates tend to have the number of children a woman has. Except
similar patterns in geographic regions. Contra- for Bangladesh, Pakistan, Kenya, and Nepal, of
ceptive practice is relatively high in Southeast the countries shown in table 15, 40 percent or
Asia and in Latin America, low in Middle South more of women with four children are using
Asia, and lowest in Africa. contraception. In many countries, contraceptive
use decreases when women have five or more
The proportion of couples using particular
children. This may be due to the fact that older
contraceptive methods differs widely among
women may resist the adoption of family plan-
countries (table 15 and figs. 10, 11, and 12), The
ning or may believe they are no longer capable
causes of these differences include cultural fac-
of bearing children. older women who do use
tors, the strength and historical antecedents of
contraception are more likely to use more effi-
the program effort, the methods available in the
cient methods, especially sterilization where it
country, and the socioeconomic setting. Fifty-
is available.
seven percent of women who use contracep-
tives in Indonesia (Java and Bali), a relatively Rural-urban differences in contraceptive use
poor country, use oral contraceptives. Orals re- follow the same pattern in all countries; a high-
quire fewer personnel with less medical sup- er percentage of urban women use contracep-
port than other methods such as IUDs and steri- tion. This difference is based on both personal
66 . Wor/d population and Ferti/ify Planning Technologies: The Next 20 Years

Figure 9.–Contraceptive Prevalence Rates Among Married Women of Reproductive Age and Crude
Birth Rates 1 Year Later

Rica ‘7$

N = 37

SOURCE: D. Nortman and E. Hofstatter, Population and Family Planning Programs: A Compendium of Oate Through 1978, Population Council, IOth edition.

Table 15.—Contraceptive Prevalence by Method In Selected Countries


Ch. 4—The Direct Determinants of Ferti/ity Change ● 67

Table 15.–Contraceptive Prevalence by Method in Selected Countries (Continued)

MWRA
total Orals/
Source Year Age prevalence Barrier Sterilization IUD injection Other

Pakistan . . . . . . . WFS 1975 15-49 — 1.0 2.5


Philippines . . . . . PC 1972 15-44 0 1.3
WFS 1977 15-44 3.5 5.4 20.2
Sri Lanka . . . . . . WFS 1975 15-49 10.2 15.8
Thailand . . . . . . . WFS 1975 15-49 7.9 3.6
CPS 1978 15-49 2.2 16.5 4.1
Latin America
Colombia . . . . . . WFS 1976 15-49 3.9 8.4 13.4 16.0
CPS 1978 15-44 7.8 7.4 17.0 13.8
Guatemala . . . . . CDC 1978 15-44 6.3 1.3 5.4 5.0
Mexico . . . . . . . . WFS 1976-77 15-49 2.9 5.7 12.5 8.2
CPS 1978 15-49 7.1 6.5 16.6 8.8
CPS 1979 15-49 9.1 6.1 15.0 7.0
Peru. . . . . . . . . . . WFS 1977-78 15-49 2.8 1.5 5.7 22.4
Brazil, . . . . . . . . . CDC
Sao Paulo , . . . 1978 15-44 64 16.1 27.8 13.4
Piaui . . . . . . . . 1979 15-44 31 15.4 10.0 5.4
Africa/Middle East
Egypt b . . . . . . . . . Government ? 20 0.3 o 1.7 16.5
Kenya . . . . . . . . . WFS 1977-78 15-49 9 — 1.3 0.9 3.4
MDCs
United Kingdom. WFS 1976 16-49 75 16.0 6.0 25.0 30.0
France. . . . . . . . . WFS 1978 20-44 79 4.7 9.5 30.8 34.0
United States . . . WFS 1976 15-44 68 19.0 6.1 22.4 20.4
CPS - Contraceptive Prevalence Survey of Westinghouse Health Systems.
Chen - From Office of Technology Assessment Contractor Report of Pi-Chao Chen.
PC - Population Council.
MWRA - Married women of reproductive age. CDC - Center for Disease Control Survey.
WFS - World Fertility Survey of international Statistical institute. FPS - Family Practice Survey of Korean institute for Family Planning.

SOURCE: Office of Technology Assessment.

factors and on the availability of contraceptive


methods. In many countries family planning
programs effectively reach only urban women.
I Latin America I
In Pakistan, for example, 15 percent of urban
women but only 3 percent of rural women are
currently using contraception. Yet the country’s
WFS population is predominantly rural–74 percent
1977-78
(15-44) of Pakistanis live in rural areas. In Bangladesh,
where the population is 91 percent rural, 23
percent of urban women use contraception but
only 9 percent of those in rural areas do so. In
Indonesia (Java and Bali), which is 82 percent
rural, a deliberate goal of the family planning
program has been to reach women in the coun-
tryside. Here the difference is less extreme; 40
percent of urban women are contraceptive
Colombia Guatemala Mexico Peru
users as compared with 36 percent of rural
Methods women. Where government programs make n o
special effort to reach rural couples, socioeco-
nomic factors such as educational level and in-
come substantialy influence contraceptive use,
but where governments provide services in
rural areas, the influence of these factors be-
SOURCE: Off Ice of Technology Assessment
comes less important.
68 ● world population and Fertility Planning Technologies: The Next 20 Years

Women who have more education are more


likely to use contraceptives. It should be noted,
however, that few women in these populations
achieve even a secondary education. Thus, the
high rates observed in the better educated
groups often represent only a small minority of
women in the country.

Figure il.—Contraceptive Prevalence in Selected


Countries Over Time Method Mix, Asia

I Asia
I

WFS
1977-78
WFS
1974 (15-49)
(15-49)

Philippines Kenya

Methods
Other Steroids IUDs

Barrier Sterilization (U) Unavailable

Methods Key
❑ Other ■ Sterolda ■ lUOa ■ Barrier ■ Sterlll.atlon (U) Unavailable W F S – World Fertility Survey (Int’1. Statistical Institute)
C P S – Contraceptive Prevalence Survey (Westinghouse
Key
WFS – World Fertility Survey (Int’1. Statistical Institute)
Health Systems)
CPS – Contraceptive Prevalence Survey (Westinghouse Health Systeme)
CDC — Center for Disease Control Survey C D C – Center for Disease Control Survey
Pc – population Council PC – Population Council
SOURCE: Office of Technology Assessment.
SOURCE: Office of Technology Assessment

Relative effects of the direct determinants


on fertility rates
What is the role of these direct factors in fer- A maximum fertility rate of almost 13 is the
tility change and why are some more important highest ever recorded in a human population.
than others? A useful way to evaluate these fac- High fertility rates prevail in populations where
tors is to examine their fertility-inhibiting im- there is little marital disruption due to divorce
pact in recent years in terms of the maximum or death, limited duration of breastfeeding, little
number of children women would have if these induced abortion, and no contraceptive use.
factors were not present. The total fertility rate, usually much lower than
Ch. 4—The Direct Determinants of Ferti/ity Change ● 69

the maximum of 13, is the rate actually meas- Figure 13.—Fertility4nhibiting Impact of
ured in populations and reflects the effects of Selected Factors
these fertility inhibiting factors. If only married Fertility Inhibiting
people are counted, the rate is higher than the impact of:

total fertility rate and is called the total marital Breastfeeding


fertility rate. If the inhibiting effects of con-
traception and induced abortion are removed,
fertility would rise to the total natural fertility
rate. And, finally, if the inhibiting effect of
breastfeeding is removed, fertility would rise to
ICOntraception
the maximum; about 15 births per woman on
average.
These relationships are summarized in figure
13. The vertical axis represents fertility rates,
and the partitions represent the contributions Induced abortion
of each of the four primary factors in lowering Nonmarriage
the potential rate. The horizontal axis repre-
sents successively smaller total fertility rates
(the white partition in each column) down to
below replacement levels. This figure illustrates
the relative importence of each fertility-inhibit- SOURCE: J. Bongaarts, “The Fertility Inhibiting Effects of the Intermediate
Fertility Variables,” paper prepared for the IUSSP and WFS Seminar
ing factor as replacement fertility levels are ap- on the Analysis of Maternity Histories, London, April 1980,

proached.
Figure 14 summarizes the historical contribu-
tries were included with LDCs and other MDCs
tion of each of the fertility inhibiting factors as
in this analysis, induced abortion was shown to
population fertility rates have changed. When
have a significant impact at replacement levels.
fertility rates are high, breastfeeding is found to
(Eastern European countries have total fertility
have a significant impact, reducing potential
rates at or below replacement levels and in-
fertility by 37 percent. At replacement levels of
duced abortion is used extensively.) In popula-
fertility, however, breastfeeding is not signifi-
tions with higher total fertility rates and similar
cant, contributing only 7 percent of the inhibit-
rates of induced abortion, the demographic ef-
ing effect on the total fertility rates (fig. 14).
fect of induced abortion may be more signifi-
By contrast, the fertility-inhibiting effect of cant than shown here.
the other factors has been found to increase as
The demographic transition in Europe was a
fertility approaches replacement levels. The ef-
relatively slow process by comparison with the
fect of proportions not married (later age at
current transition in LDCs, and the effects of
marriage) rises from 25 to 47 percent as total
these four direct factors—proportions married
fertility rates fall. Induced abortion is insignifi-
and age at marriage, contraceptive use, induced
cant when total fertility rates are above 3 but
abortion, and lactation—were different in the
has some impact when these rates are at re-
relative degree of their impact on declines in
placement levels. total fertility rates. Today, however, the find-
The pattern of the fertility-inhibiting effects ing that contraception has a markedly intensi-
of these variables changes slightly when differ- fied capability to reduce potential fertility as
ent countries are used in calculating the rates. total fertility rates approach replacement levels
For example, because Eastern European conf- is particularly important. Contraceptive use has

70 . World population and Fertility Planning Technologies: The Next 20 Years

Figure 14.—Fertility Inhibiting Effects of Marriage Patterns, Contraception, and Breastfeeding

60

40

7 6 5 4 3 2 1 7 6 5 4 3 2 1 7 6 5 4 3 2 1
Total fertility rate Total fertility rate Total fertility rate

NOTE: Percent reduction in fertility caused by late marriage, divorce, or death; contraception; and breastfeeding In groups of populations with declining total fertility
rates

SOURCE: J. Bongaarts, “The Fertility Inhibiting Effects of the Intermediate Fertility Variables,” Paper prepared for the IUSSP and WFS Seminar on the Analysis of
Maternity Histories, London, April 1980.

been found to contribute only 8 percent of the directly determine total fertility rates, con-
inhibiting effect at high total fertility levels but traceptive use has been established as of unique
73 percent when replacement rates are ap- importance in achieving replacement fertility.
preached (2). Thus, of all of the factors that

Technical Note A: The demographic transition


changes and has long intrigued social scientists.
Based on the apparent experience of Western Eu-
rope, a general “theory of the demographic transi-
tion” was developed, which held that fertility decline
follows only after, and as the result of, a decline in
mortality (particularly infant mortality) and improve-
ment in socioeconomic conditions, or “moderniza-
tion.” Because much of Europe’s fertility decline took
place before modern contraceptives or safe medical
Ch. 4—The Direct Determinants of Fertility Change ● 71

abortion were readily available, it is argued that around. The then-available fertility planning meth-
couples who limited their family size must have done ods—withdrawal, abstinence, and induced abor-
s. by practicing withdrawal or abstinence. Induced tion—may not have been used because they were un-
abortion was rarely resorted to because of the thinkable for married couples, ineffective, or simply
dangers associated with the procedures then in use. unknown.
The European demographic transition can be visu-
The demographic record has now been examined alized by contrasting the typical childbearing ex-
more closely. New information sources and analyti- periences of 100 women married in the middle of the
cal methods indicate that sustained fertility declines 19th century with those of a similar group at mid-
in Europe began under a much wider variety of so- 20th century (fig. 15). Much of 19th century Europe’s
cial, economic, and demographic conditions than had high fertility was neutralized by high mortality, pat-
been thought, appeared to follow cultural and lin- terns of delayed marriage, and lifetime celibacy.
guistic lines, were remarkably concentrated as to Because of late marriage and widowhood, mothers
onset—mostly between 1880 and 1910—and became averaged only five children apiece, a number well
irreversible processes once under way. Large fam- below their potential total. By the mid-20th century,
ilies were not necessarily desired in pretransition Eu- a substantial decline in fertility reduced the number
rope, according to these new findings, and high in- of children per family, but the likelihood that these
fant and child mortality may have been partly the re- offspring would survive to reach childbearing age
sult of high fertility rather than the other way had risen to almost 95 percent. Relatively more of

Figure 15.—Typical Demographic Patterns in Western Europe: Mid-19th and


Mid-20th Centuries

Fertility

SOURCE: E. van de Wane and J. Knodel, “Europe’s Fertility Transition: New Evidence and Lessons for Today’s Developing
-
World, ” Populafion Bulletin, vol. 34, No. 6, Population Reference Bureau, Inc. f Washington, D.C 1960. “
72 . World population and Fertility Planning Technologies: The Next 20 Years

these surviving daughters were likely to marry and persists in many regions. The techniques used to
fewer to emigrate. The net result was a 10-percent study historical data can detect stopping behavior
gain in population over a generation in contrast to a but cannot detect deliberate spacing behavior. This is
gain of 25 percent a century earlier. important because the introduction and spread of
Information on these occurrences has been drawn stopping behavior characterized the onset of the fer-
from three principal sources: censuses, parish regis- tility transition.
ters, and contemporary accounts. Family histories Because the decline in fertility in Europe resulted
are reconstructed from parish registers, compared from a shift from natural fertility to family limitation,
with censuses where available, and analyzed by new the age of women at last birth becomes an index for
techniques, Contemporary accounts of socioeconom- the degree of family limitation behavior being prac-
ic conditions are then used where possible to con- ticed. These trends are seen in two cultural groups in
firm the results. figure 16. The transition from natural fertility to
The concepts of natural fertility and family limita- family limitation began relatively early in the town of
tion are central to descriptions of the demographic Grafenhausen, Germany. The bourgeoisie of Geneva,
transition. “Natural” fertility occurs among couples Switzerland, were an elite group who began practic-
who make no attempt to limit or terminate childbear- ing family limitation early in the 17th century, long
ing during the biological reproductive lifespan. Fami- before most other European couples did so. In both
ly limitation describes couples who make a deliberate groups the shift is clearly evident: before the fertility
effort to terminate childbearing once a desired num- decline, women had their last birth at about 40 years
ber of offspring have been born. Such limitation is of age; toward the latter part of the decline they gave
not synonymous with “birth control” but refers in- birth for the last time nearer 30 years of age.
stead to behavior designed to halt childbearing alto- In general, although predecline levels of fertility re-
gether. Birth control, or family planning, refers to mained relatively constant within cultural or geo-
spacing and limiting the total number of births. Birth graphic areas, there was considerable variability in
spacing can occur under conditions of natural fertil- fertility levels among groups, due to a mix of physio-
ity, as when couples deliberately space births but are logical factors, social customs, health conditions, and
unconcerned with their total number. This practice differences in breastfeeding patterns. Evidence is
has been common in sub-Saharan Africa, where it strong that, despite regional differences in overall

Figure
— 16.—Trends in Average Age of Women at Last Birth: Grafenhausen and
Genevan Bourgeoisie, 17th-19th Centuries

Year of husband’s birth


Ch. 4—The Direct Determinants of Fertility Change ● 73

Table 16.—Child Abandonment: Tuscany, Italy,


18th Century
(Legitimate children abandoned at the Foundling Hospital
of Florence by number of children in the family: two near.
by villages, 1775-94)
Number of Percent
children of children
in family abandoned
1-3 . . . . . . . . . . . . . 24.8
4-5 . . . . . . . . . . . . . 37.1
50.6
NOTE: Refers to 170 children from 133 families who abandoned at least one
child and for whom there are complete records,
—.

74 . world population and Fertility Planning Technologies: The Next 20 Years

European countries
France. . . . . . . . . . . . . . . ca. 1800 185C 70 81 7 High
Belgium. . . . . . . . . . . . . . 1882 161 30 56 22 30
Switzerland . . . . . . . . . . . 1885 165 33 78 9 Low
Germany . . . . . . . . . . . . . 1890 221 38 68 21 Low
Hungary . . . . . . . . . . . . . ca. 1890 250 73 84 11 49’
England and Wales . . . . 1892 149 15 28 57 Low
Sweden . . . . . . . . . . . . . . 1892 102 49 81 11 Low
Scotland . . . . . . . . . . . . . 1894 124 13 27 49 Low
Netherlands . . . . . . . . . . 1897 153C 29 26 42 Low
Denmark . . . . . . . . . . . . . 1900 131 42 61 23 Low
Norway . . . . . . . . . . . . . . 1904 76 37 72 18 Low
Austria. . . . . . . . . . . . . . . 1908 205 40 19 21
Finland . . . . . . . . . . . . . . 1910 114 66 9 44
Italy . . . . . . . . . . . . . . . . . 1911 146 46 28 39
Bulgaria. . . . . . . . . . . . . . 1912 159 70 7 60
Spain . . . . . . . . . . . . . . . . 1918 158 66 26 46
Ireland . . . . . . . . . . . . . . . 1929 69 48 20 Low
Developing countries
Costa Rica . . . . . . . . . . . 1962 0.89b 0.50 b 74 58 66 20 14
Taiwan. , . . . . . . . . . . . . . 1963 0.70 0.70 49 47 42 31 30
Chile . . . . . . . . . . . . . . . . 1964 0.65 b 0.50 b 103 37 29 53 15
Thailand . . . . . . . . . . . . . ca. 1970 ca. 0.75 0.75 77 75 85 12 18
Ch. 4—The Direct Determinants of Fertility Change ● 75
76 Wor/d Population and Fertility Planning Technologies: The Next 20 Years

Technical Note B: The measurement of


contraceptive prevalence
Estimating the prevalence of contraceptive use in a resent a significant proportion of the effective con-
population, which is a measure of the proportion of a traceptive protection in a population. Thus, the prev-
population practicing contraception at a particular alence rate may be lower than expected when com-
point in time, is analogous to taking a snapshot of the pared with the birth rate because women are relying
reproductive behavior of that population. The preva- on postcoital methods in cases of contraceptive
lence rate is the percentage of all women of repro- failure. For example, because pills or IUDs may not
ductive age (15 or 20 to 44 or 49) currently living in be as available as spermicides or condoms in some
some type of stable union (“married”) who are cur- countries, menstrual regulation and/or induced abor-
rently using contraception. For example, 23 percent tion are used in the event of method failure.
of such women in India are currently using some It is necessary to distinguish between sterilization
form of contraception while only 5 percent of their for contraceptive purposes and sterilization for
counterparts in Pakistan are doing so. These figures health reasons. The basis for the sterilization pro-
are snapshot views for 1979 and 1975, respectively cedure is ascertained from women survey respond-
(table 15). ents. It is often difficult for a woman to distinguish
Although prevalence rates appear straightforward, the primary cause for sterilization when she has as
reliable prevalence rates are difficult to obtain for many children as she wants, her doctor has advised
several reasons. If there is extensive use of con- her that having more would probably threaten her
traception outside of marriage, this use will not be health and well-being, and when the couple’s income
measured since rates are calculated on the basis of is inadequate for the support of another child.
women currently in some type of stable union. Un- Thus, there is always a margin for error in the
less the survey is truly representative of the popula- determination of contraceptive prevalence rates. In
tion and the quality of research, questionnaire de- surveys such as the World Fertility Survey and the
sign, and fieldwork are adequately controlled, the contraceptive prevalence surveys currently being
data will be questionable. Even with good quality undertaken by Westinghouse and the Center for Dis-
control, contraceptive use can be underreported ease Control, z this “sampling” error is being calcu-
because respondents may be shy, may wish to hide lated and prevalence rates are shown with calcula-
the truth, or may misunderstand the questions. tions of probable ranges of error (e.g., a rate of 50
Prevalence rates can vary depending on the con- percent plus or minus several percentage points).
traceptive methods included in the index of current These sampling ranges have not been included in this
contraceptive use. Traditional methods such as document, but may be obtained from the sources
herbs, withdrawal, or abstinence can augment the cited in the text tables of contraceptive prevalence.
percent of women who report using contraception.
Traditional methods, however, are not usually reli-
‘F”or drtaiis on (wllrwf,pt itf, prtII alwlw suI.I (,}s w{, Sir klauricr Kendall,
able and such women are in effect at risk of un- “’1’tl(’ L\’()[’lfi E’ertililj, Sur\q\ (;llrrw}t S l a t LIs and h’indings, ” PqJ[//atj{Jn Rf..
wanted pregnancy. Menstrual regulation and in- porfs, Series 11, No 3, Populiilk]n
Information Program, The Johns Hopkins
duced abortion as post coital methods are usually ex- ( l[~i, {.r~i[} , Jtl]jr 1 :)~:); ;i[l(l 1, ~lo[li~, ~,1 ~il,, “(’() [11[’il(x’pt ii(l P1’t>\ill(>ll(Y>
N(It\, %)lll.(i(~ (It p’illl)llj, l)!iillllillg [>illii, ” /’(J/llJ/;lfi(Jfl Hfporl,s, Srrim
S i l l ’ \ (>~s’ /\
cluded from calculations of the percentages of hl, NO . 5 , Nlii}-Jtill[, 1 9 8 1 , Popuklkm Ir]lo[m)iition” P r o g r a m , [h, J[)llns
women using contraception, but their use may rep- tlophins [ 11111 (>l’s[l}, Billlilllo[,(,, kid.

3
Technical Note C: Age at marriage
Women who marry early tend to have more chil- ● they begin childbearing at an early age, live
dren than those who marry later for three demo- througha longer period of exposure to the possi-
graphic reasons: bility of pregnancy, and thus, in the absence of
● they are likely to have sexual intercourse fre-
quently throughout their most fecund years
!t’’ol ” f’lil’th(, r (I(,tilils \lW> ,\ ~{ fIlll-\I :Illd ]) ]]i[)tlX)\! , “ A#’ ii[ Alill’l’iiig[} .111(1
(later-marrying women will have sexual inter- Fwlililj ,“ Pf)pu/;tlhn Hf,f)orts, Swim hl, No 4, NOI vmbw 1979 P(pIht I(In In.
course during fewer of their fecund years); loI’l)liltloIl” 1)l’()~l’illll, ‘ 1 ho Jotllls llo~)hllls L llll\ [wil} I\illllllloI’l>, 31[1
Ch. 4—The Direct Determinants of Fertility Change ● 77

contraception, are apt to have more children 40, she has had 5 daughters and the eldest has given
than women who marry later; and birth to her first daughter. After a period of 60 years,
● by their early childbearing, they shorten the in- if age at marriage is 15, the resulting female popula-
terval before the next generation is born. tion would total 22. Using the same assumptions, but
Figure 17, which illustrates the effect of age at changing age at marriage to 20 (as shown in the cen-
marriage (in the absence of contraceptive use), as- tral portion of the figure), the total female population
sumes that a woman gives birth to a daughter every would rise to only 11 after 60 years. If age at mar-
5 years until she reaches age 40. If her age at mar- riage is raised to age 25 (as shown at the right of the
riage is 15, she gives birth to a daugher at age 20 (at figure), the female population would consist of only 5
left of figure). By the time this woman reaches age members after the same time period.

Figure 17.—Effect of Age at Marriage

Chapter 4 references
1. Bald\vin, C. S., “Policies and Realities of Delayed Population Information Program, The Johns
Nlarriage: The Cases of Tunisia, Sri Lanka, Malay- Hopkins University, Series J, No. 4, July 1975.
sia, and Bangladesh, ” PRB Report, vol. 13, No. 4 5. Chen, P., OTA working paper, 1980.
(Washington, D. C.: Population Reference Bureau, 6. Davis, K., and Blake, J., “Social Structure and Fer-
1977). tility: An Analytic Framework,” Economic Dc\’el-
2. Bongaarts, J., “The Fertility Inhibiting Effects of opment and Cuhural Change, vol. 4, No. 4, 1956, p.
the Intermediate Fertility Variables, ” paper pre- 211.
pared for the IUSSP and WFS Seminar on the 7. Henry, A., and Piotrow, P. T., “Age at ~larriti~e
Analysis of klaternity Histories, London, April and Fertility, ” Population Reports, Population In-
1980. formation Program, The Johns Hopkins [Jni\ersi-
3. ‘(A Framework for Analyzing the Prox- ty, Series M, No. 4, November 1979.
imate Determinants of Fertility, ” Population and 8. Jain, A. K., and Bongaarts, J., “Socio-Biological
D e v e l o p m e n t Review 4(l), M a r c h 1 9 7 8 , p p . Factors in Exposure to Child-Bearing: Breastfeed-
105-132. ing and Its Fertility Effects, ” paper presented at
4. Buchanan, R., “ Breast feeding, Aid to Infant the k$rorld Fertility Sur\ey Conference, London,
Health and Fertility Control, ” Population Reports, July 1980.
78 . World Population and Fertility Planning Technologies: The Next 20 years

9. Kent, M. M., “Breastfeeding in the Developing Africa: Anthropological Evidence,” paper pre-
World: Current Patterns and Implications for Fu- pared for the IUSSP Workshop on Child Spacing
ture Trends,” Reports on the World Ferti/ittiv in Tropical Africa: Tradition and Change, Brus-
Surve-v, No. 2 (Washington, D. C.: Population Ref- sels, Apr. 17-19, 1979.
erence Bureau, June 1981). 15. Scrimshaw, S. C. M., “Infant Mortality and Be-
10. Liskin, L. S., “Complications of Abortion in Devel- havior in the Regulation of Family Size,” Popula-
oping Countries, ” Population Reports, Population tion and Development Review 4(3), S e p t e m b e r
Information Program, The Johns Hopkins Uni- 1978, pp. 383-403.
k~ersity, Series F, No. 7, July 1980. 16. Tietze, C., Induced Abortion: A World Review,
11. Nortman, D. L., and Hofstatter, E., Population and 1981, Population Council Fact Book, 4th cd., New
Fami/y P/arming Programs, A Population Council York, 1981.
Fact Book, New York, IOth edition, 1980. 17. \’an Ginneken, J. K., “The Impact of Prolonged
12. Potter, R. G., “Additional Births Averted When Breastfeeding on Birth Intervals and on Postpar-
Abortion is Added to Contraception, ” Studies in tum Amenorrhea,” Nutrition and Human Repro-
Fami/eY Planning, vol. 3, No. 4 (New York: The Pop- duction, W. Henry Mosley (cd.) (New York:
ulation Council, April 1972). Plenum Press, 1978), pp. 179-196.
13. Potts, M., Diggory, P., Peel, J., Abortion (New 18. Wray, J. D., “Maternal Nutrition, Breastfeeding,
York: Cambridge University Press, 1977). and Infant Survival)” IVufrition and Human Repro-
14. Schoenmaeckers, R., et al., “The Child-Spacing duction, W. H. Mosley (cd.) (New York: Plenum
Tradition and the Postpartum Taboo in Tropical Press, 1978), pp. 197-230.
Chapter 5
The Technology of Fertility
Change: Present Methods and
Future Prospects
Contents

81
82
82
84
84
85
85
86
89
98
98
99
The Need for Better Fertility Planning Technologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..100
Chapter 5 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............101

LIST OF TABLES
Table No. Page
18. Theoretical and Use Effectiveness of Various Means of Contraception. . . . . . . . . . . . . . . 85
19. U.S. Birth-Related, Method-Related, and Total Deaths per 100,000 Women per Year,
by Contraceptive Method and Age of Woman, 1972-78. . . . . . . . . . . . . . . . . . . . . . . . . . . 89
20. Annual Number of Birth-Related and Method-Related Deaths per 100,000
Nonsterile Women, by Fertility Planning Method, Age,
and Development of Country. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
21. Future Fertility Planning Technologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

LIST OF FIGURES
Figure No. Page
18. Human Reproductive Cycle. .,....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
19. Mortality From All Circulatory System Diseases, Females, Aged 10-84, by 5-Year
Age Groups, United States, 1951-75.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Chapter 5

The Technology of Fertility Change:


Present Methods and Future Prospects

Abstract —
Of the technologies that change birth rates, contraceptive technologies are the most important.
Current contraceptive methods, in the order of their use effectiveness, are sterilization, the various
forms of steroid hormones, IUDs, barrier devices, vaginal spermicides, coitus interruptus, periodic
abstinence (rhythm, natural family planning), and postcoital douches. Contraceptives are judged by
the degree to which they are effective; safe; reversible; easy to produce, provide, and use; inexpen-
sive; and acceptable to governments, cultures, religions, and individuals. The “ideal” contraceptive
neither exists nor is expected to be developed. A realistic goal is for each country to have enough
technologies that are appropriate for local conditions and standards so that each individual has ac-
cess to at least one that meets current needs. Method risks of contraceptive use are largely confined
to oral contraceptives and IUDs. Circulatory system diseases associated with oral contraceptives
have caused the most concern and could theoretically cause a fivefold increase in deaths. But nearly
three-quarters of the cardiovascular disease deaths occurring annually in the United States to
women of reproductive age would be attributable to oral contraceptive use if the increased risk
were indeed fivefold. This has not been reflected in vital statistics trends. In extending comparisons
of relative risks to women in less developed countries (LDCs), all methods are found safer than no
method at all because of high maternal mortality rates in these countries.

81
82 World Population and Fertility Planning Technologies: The Next 20 Years

Introduction
Technologies modify each of the three com- wanted pregnancy: contraceptive technologies.
ponents–birth, death, and migration-of popu- Less common but important at present are
lation growth. medical, agricultural, and sanita- those used for early termination of unwantecl
tion technologies are essential to the reduction pregnancy. Still less common but very impor-
of death rates. Communication and transporta- tant in some societies are technologies used to
tion technologies play key roles in all aspects of prevent or correct unwanted infertility, uncom-
population change. This report, as stated mon and little developed are the sex selection
earlier, focuses on the technologies that help to technologies used to determine an infant’s sex at
change birth rates, and this chapter deals with conception. Techniques to detect pregnancy or
the specific fertility planning technologies that important abnormalities of pregnancy or to pre-
human beings use to affect the numbers and select genetic characteristics are not included in
characteristics of births. this study.

The most common and most important of


these technologies are those used to prevent un-

The human reproductive process


Sperm are produced continuously in the tes-
tes from puberty throughout most of the male’s
life. The process begins with division of germ
cells (spermatogonia) which, in combination
with supporting (Sertoli) ceils, make up the long
seminiferous tubules that take up most of the
testes. Interspersed Leydig cells produce male
hormones (androgens), notataly testosterone,
which affect both sperm production and male
sex characteristics. S p e r m p r o d u c t i o n t a k e s
about 72 days. The fina1 stages of sperm matura-
tion take place in the small ducts and long
epididymis at the back of the testes. The sperm
a r e e j a c u l a t e d b .y a muscular tube, the vas
deferens, which enters the urethra as it
traverses the prostate gland.
Ch. 5—The Technology of Fertility Change: Present Methods and Future Prospects ● 83

Sertoli cells and is necessary for the initiation of and other male hormones act as the feedback
spermatogenesis. LH regulates the secretion of mechanisms. Figure 18 summarizes the human
testosterone by the Leydig cells. Testosterone reproductive cycle.

Figure 18.—Human Reproductive Cycle

Male Reproductive Organs


Bladder

Penis
84 ● World Population and Fertility Planning Technologies: The Next 20 Years

Human reproduction, as for other mammals, human chorionic gonadotropin (HCG), secreted
is characterized by relatively long intervals of by the implanted embryo, and estrogen and pro-
natural infertility in the female. Fertilization can gesterone continue to be produced. Once
only take place within a few days after ovula- delivery has taken place, further ovulation is
tion. Pregnancy occurs following fertilization of temporarily blocked by the hormonal changes
the ovum by the sperm, usually in the fallopian induced by the infant’s suckling, including a rise
tube, and implantation of the embryo in the in the level of another pituitary hormone, pro-
uterus. When pregnancy occurs, the corpus lu- lactin.
teum is maintained by another hormone,

Contraception
Methods to interference with implantation in the
uterus. There is also some evidence that
The major methods of contraception current- IUDs lead to increased sperm damage and
ly in use, listed in order of their use effec- affect the motility of the ovum in the fal-
tiveness in preventing pregnancy, are: lopian tube.
● Sterilization—vasectomy in the male, and ● Barrier devices—the condom for the male
tubal ligation/occlusion in the female. and the diaphragm and cervical cap for the
● Steroid hormones–combined (estrogen and female.
progestin) or low dose progestin oral pills, ● Vaginal spermicides—high viscosity fluids
or intramuscular, long-acting progestin in- that both kill sperm and block them from
jections. These synthetic steroids are given entering the cervical canal.
in different combinations and different ● Coitus interruptus—male withdrawal prior
doses, depending on the commercial prod- to ejaculation.
uct, but they act primarily by inhibiting ● Periodic abstinence (rhythm, natural family
ovulation through suppression of the hypo- planning) –timed to avoid coitus near the
thalamic hormones that stimulate the re- day of ovulation. *
lease of FSH and LH from the anterior pitui- ● Postcoital douches—water or spermicidal
tary. The synthetic steroids also cause en- solutions that flush out and kill sperm in the
dometrial changes that make the uterus in- vagina.
appropriate for implantation should break-
through ovulation and fertilization occur.
Other changes that contribute to the con-
traceptive effect include scant and thick
cervical mucus, reduced sperm transport *The tJasal bod~’ temperature (BBT) method of periodic coital ab-
and penetration into the uterus, and altered stinence uses daily temperature-taking to identifj’ the tempera-
ture shift that occurs at or shortly after mwlation to determine the
sperm and ovum transport capabilities ‘(safe” days of the menstrual c~’cle. B~~ the evening of the third da~
within the fallopian tubes. of sustained high temperature readings fo]louring the shift, which
● Intrauterine devices (IUDs)—the insertion may be abrupt or gradual, the posto~wlatory infertile phase is
assumed to be under w’a~l. [ntermurse must be limited to this
of a foreign body, made either of an inert phase for highest effectiveness. Ctl~][~s during which ovulation
substance or impregnated with other mate- does not occur and there is no tem~erature shift can be a problem
rials (copper, progesterone). Although the during postpartum and premenopaosal periods, [n the (]\wla-
tion-or Billings—method, a woman is taught to identifJ/ the
IUD prevents implantation in mammals, its precise characteristics of the cer~’ical mucus produced at ~arious
mode of action is unknown in the human stages of her menstrual cycle and their relationship to her fertile
being. There are several possible modes of and infertile da~ls. In the S~wlpto-Thernlal method, which charts
both temperature changes and changes in \Iolunw and viscosity of
action, from interference with sperm trans- cerlica] mucus, women are also taught to recognize such subjec-
port, to interference with ovum transport, tive symptoms of ovulation as intermenstrual pain.
Ch. 5—The Technology of Fertility Change: Present Methods and Future Prospects . 85

Characteristics lives. No such method exists or is expected to be


developed. A realistic goal is for each country to
The potentials of present contraceptive tech- have enough technologies that are appropriate for
nologies and the limitations that future technol- local conditions and standards so that each indivi-
ogies will need to overcome depend upon how dual has access to at least one that meets current
well their characteristics meet the requirements needs.
of such diverse groups as users, providers, pro-
gram administrators, physicians, scientists, the-
Effectiveness
ologians, and politicians in various countries
and cultures. Contraceptive failure rates are usually quanti-
fied according to theoretical v. use effective-
Contraceptive technologies are judged by the
ness, because contraceptive failure under aver-
degree to which they are:
age conditions of use can be significantly higher
● effective—prevent pregnancy; than when methods are used correctly and con-
● safe—are free of deleterious side effects; sistently. The effectiveness of the contraceptive
● reversible—permit subsequent pregnancies methods listed above is summarized in table 18,
upon discontinuation of use; where they are listed in descending order of ef-
● easy to produce —do not require complex fectiveness under ideal and actual conditions of
industrial processes; use, The failure rates represent the number of
● easy to provide —do not require frequent pregnancies among 100 nonsterile women using
resupply or specialized personnel; the method for 1 year in the United States. If
● easy to use—do not require periodic appli- they were to use no contraceptive method,
cation or interfere with coitus; about 90 percent of these women would be-
● inexpensive—have low economic costs to come pregnant within a year.
user or society;
Sterilization is the most effective contracep-
● acceptable to governments—are permitted
tive method. Use effectiveness equals theoret-
or encouraged by laws and regulations;
● acceptable to cultures—are consonant with
local beliefs and customs; Table 18.—Theoreticai and Use Effectiveness of
● acceptable to religions—are consonant with Various Means of Contraception
religious beliefs; and (by pregnancies per 100 woman-years in MDCs)
● acceptable to individuals—promote general Theoretical Use effectiveness
well-being, enhance sexual enjoyment, fit Method effectiveness Range Average
lifecycle, and protect privacy.
0.06
How well any characteristic of a contraceptive 0.15

technology meets individual and societal re-


quirements depends not only on the technology,
but on the views and actions of the society in 0.24
which it is used and of the individuals who use 0.7

it.
The myth of the ultimate, “ideal” contracep-
tive is precisely that. The perfect contraceptive
would be completely effective in preventing
pregnancy, have no harmful effects, be fully re-
versible, simple and inexpensive to produce and
use, need no supplies, specialized personnel, or
repetitive use, be acceptable to all governments,
cultures, and religions, and fit the needs of all
potential users at all stages of their reproductive
86 . World Population and Fertility Planning Technologies: The Next 20 Years

ical effectiveness because the procedure is usu- their use of barrier methods or periodic absti-
ally performed adequately in the United States nence. Couples who are using contraception to
and there is no need for additional contracep- prevent any future births achieve much higher
tive practice once the surgical procedure is per- effectiveness than couples merely spacing the
formed. The obvious drawback of sterilization next birth. Highly motivated and experienced
is its permanence. For female sterilization, al- couples can prevent pregnancy much more ef-
though individual surgeons have reported re- fectively than less motivated couples.
versal rates as high as 60 percent, it is estimated
that only about one-fifth of all women sterilized Risks
by current techniques could have their steriliza-
tions reversed (8). For reversal of male steriliza- Risk estimates attempt to compare the relative
tion, the rate of anatomical success as deter- risks of each contraceptive method not only
mined by the reappearance of sperm is in the against other methods but also against the risk
range of 40 to 90 percent, but functional success of using no contraceptive method. The latter
as determined by the pregnancy rate is much risk is in becoming pregnant and the morbidity
lower, on the order of 18 to 60 percent (3); new and mortality associated with pregnancy and
microsurgery techniques are reported to have childbirth. The risks of each contraceptive
increased the upper range to 70 percent (21). method are the morbidity and mortality associ-
ated with use of the method and with those
The steroid hormones and IUDs are very ef- pregnancies that the particular method does not
fective in preventing pregnancy, but the degree prevent. For these comparative estimates, the
of prevention depends on how correctly and measure of risk used is the death rate, com-
consistently they are used. Barrier devices (con- prised of method-associated (use of a particular
doms, diaphragms) approach the IUD in theoret- contraceptive method or failure of a contracep-
ical effectiveness but have three to four times tive method) and birth-associated (use of no con-
the failure rate of the IUD in use effectiveness. traceptive method) deaths.
The use of vaginal spermicides, coitus interrup-
A further distinction must be made between
ts) and periodic abstinence also significantly
lower pregnancy rates, but about 20 percent of
absolute and relative risks. For example, relative
incidence in the population is important.
users will still become pregnant within a year.
Postcoital douching also has a preventive effect If the incidence of a disease is 1 per million
but will protect only about 35 percent of users. among non-exposed persons, and the use of a
particular drug increases the relative risk of
New techniques are now being employed to disease tenfold, then one would anticipate 10
evaluate pregnancies that occur during use of cases per million users of the drug. On the other
periodic abstinence methods. Unintended preg- hand, if the incidence of another disease is 100
nancies are analyzed in terms of when in the per million, and drug exposure increases the risk
only twofold, then one would anticipate 200
woman’s cycle they occurred and whether the
cases per million among users of the drug. The
couple proceeded with a particular act of inter-
latter situation would clearly entail a much
course despite advance knowledge of the rea- greater public health problem, even though the
sonable likelihood of conception; which of these relative risk is much smaller (24).
pregnancies can be attributed to the methods
themselves; and which pregnancies are likely to Language is also important when studies of
have resulted from difficulties in teaching or risk are discussed. For example, the conclusion
learning the various methods (10). that oral contraceptive users have a five times
greater risk of dying from circulatory disease
Most determinants of effectiveness are in- than nonusers can be rephrased to point out
herent in the technology, but variations occur that pill users decrease their chances of survival
depending on the conditions and behavior of during a year from 99)995 per 100,000 to 99,974
the user. The closer a couple are to the number per 100,000-a reduction of only two-hun-
of children they want, the more effective is dredths of a percent (0.02 percent) (12).
Ch. 5—The Technology of Fertility Change: Present Methods and Future Prospects ● 87

The method-related risks of contraceptive use topic pregnancies—a life-threatening emer-


are largely confined to oral contraceptives and gency–and septic abortions.
IUDs. Some morbidity and mortality are also as-
Circulatory system diseases associated with
sociated with sterilization procedures, but these
oral contraceptives have caused the most con-
are limited to the time at which the procedure is
cern. Venous thromboembolic disease—
performed. Barrier devices and spermicides are
principally of the legs—was the first recognized
relatively risk-free except for the risks asso-
circulatory system risk associated with oral con-
ciated with pregnancy from the higher degree
traceptive use. Excess mortality has been
of contraceptive failure with these methods.
estimated at 2 to 3 per 100)000 women annually,
Barrier devices, principally those used by the with no increase of risk associated with dura-
woman, have been associated only with minor tion of use. Heart attacks and subarachnoid
side effects—allergic reactions, vaginal irrita- hemorrhage–a type of stroke probably from
tion, and infections (26). rupture of congenitally weak cerebral blood
vessels—are the other circulatory system risks.
Spermicides, apart from local reactions such
The risk of heart attack depends on other pre-
as tissue irritation to either partner, have been
disposing factors, e.g., cigarette smoking, hyper-
considered very safe insofar as method-related
tension, diabetes. The chances of heart attack
risks are concerned. Such risks might be in-
thus increase with age, smoking, and other pre-
curred from: 1) systemic effects on the woman
disposing factors, The risk of subarachnoid
resulting from absorption of the spermicide
hemorrhage increases with smoking and dura-
through the vagina; 2) damage to a developing tion of use (17).
fetus from spermicide components or metabo-
lites in the woman’s circulation; and 3) genetic Together, these circulatory system diseases
damage to conceptions involving sperm dam- would theoretically account for a fivefold in-
aged by spermicides (5). A recent study has crease in deaths, but questions have arisen as to
shown a positive correlation between spermi- why such an increase has not been reflected in
cide use in the 10 months prior to conception vital statistics trends. A researcher at the U.S.
and the prevalence of certain major congenital Center for Disease Control estimates that nearly
anomalies (9). The prevalence of such abnormal- three-quarters of the cardiovascular disease
ities as limb-reduction deformities, neoplasms, deaths occurring annually in the United States
and syndromes associated with chromosomal to women of reproductive age would be attrib-
abnormalities was 2.2 percent, compared to an utable to oral contraceptive use if the increased
incidence of 1 percent in infants born to moth- risk was indeed fivefold. Such a high propulation
ers who had not used spermicides in the 10 of cardiovascular deaths attributable in oral
months prior to conception. The rate of sponta- contraceptive use should have been reflected in
neous abortion requiring hospitalization was dramatically increased rates of cardiovascular
also 1.8 times more common. The investigators deaths in women of reproductive age since the
considered these findings tentative, as these ab- onset of oral contraceptive use, but such in-
normalities were diverse and did not appear as creased rates have not appeared. In addition, in-
a well-defined syndrome. This area clearly war- stead of the death rate from these diseases
rants further investigation. diverging for men and women as would be ex-
pected, U.S. cardiovascular disease death rates
The basic risks of IUDs are: 1) increased have been falling nearly equally and steadily for
menstrual bleeding or spotting; 2) perforation of men and women of reproductive ages since
the uterus; 3) increased frequency of pelvic in- 1950 (13). (See fig. 19 for circulatory system
fection; and 4) unwanted pregnancies that are death rates for U.S. women.)
more likely to be ectopic (implanted outside the
uterus in the fallopian tube or abdominal cavity) Research on long-term risks of oral contracep-
or to result in septic midtrimester abortion than tives has found no statistically significant in.
pregnancies in nonusers (17). Method-related crease in the cancer rate. A rare type of benign
mortality from IUDs stems principally from ec- liver tumor does occur, especially with the older
88 ● World population and Fertility Planning Technologies: The Next 20 Years

Figure 19.—Mortality From All Circulatory System formed in medically approved Settings)) either
Diseases, a Females, Aged 10-84, by 5-Year Age alone or in conjunction with barrier methods, is
Groups, United States, 1951-75
included.
Age
group
In MDCs, between ages 25 to 35, the risk for
80-84 oral contraceptive users who smoke is about the
same as for those using no method, but is 50
75-79
percent higher between ages 35 to 39 and about
70-74 three times higher after age 40. For nonsmoking
oral contraceptive users, the risk is much less
65-69
under age 40. Barrier methods in combination
W-64 with access to legal abortion in the event of con-
A11 ages
55-59 traceptive failure are the safest, but induced
abortion is a controversial method which is
50-54
morally unacceptable to many, or, if acceptable,
45-49 may not be readily available. IUDs have low risk
40-44 rates throughout the reproductive years.
35-39 This model has been extended to the LDCs
and is summarized in table 20. The principal
30-34 assumptions are: 1 the ability to become preg-
25-29 nant is the same in more developed countries
20-24 (MDCs) and LDCs but lactational amenorrhea
following childbirth is 8 months longer in LDCs
15- 19
because of the higher prevalence of breastfeed-
lo- 14 ing; 2) maternal mortality in Korea and Taiwan
is representative of rates for middle-income
LDCs and maternal mortality in Bangladesh is
representative of rates in poorer LDCs; 3) ma-
ternal mortality due to induced abortion is
twice as high in middle-income LDCs and five
times as high in low-income LDCs as in the
United States; 4) use-effectiveness of all methods
except IUDs is slightly lower in LDCs; 5) meth-
od-related risks from IUDs and sterilization are
two to five times higher in LDCs; and 6) risks of
circulatory disease are lower in all LDCa. Oral
contraceptive users are separated into those
with and without predisposing conditions, and
sterilization in women—tubectomy—is also in-
cluded.
Because of the higher maternal mortality
rates in LDCs, all methods are safer than no
method at all except for some methods for older
women. In middle-income LDCs, oral contracep-
tive users with predisposing conditions and over
age 40 have a higher risk of death than those
who use no method, but in poorer countries,
oral contraceptive use is safer. As in the MDCs,
barrier methods in combination with access to
Ch. 5—The Technology of Fertility Change: Present Methods and Future Prospects ● 89

legal abortion provided under adequate medical contraceptive injections, drug-releasing IUDs,
supervision in the event of contraceptive failure outpatient sterilization methods, and low-dose
are the safest, but the higher maternal mortality oral contraceptives.
rates make all methods—with the exceptions
noted above—safer than no method at all. Thus, A second element is the present base of
in LDCs, the risks of the different methods are knowledge available to researchers. As early as
relatively less significant than in MDCs because 1974, it was evident that the field of reproduc-
of much higher maternal mortality rates, and tive biology was benefiting from the explosion
the choice of methods depends more on dif- of basic research in biology and especially from
ferent legal and medical circumstances, kinds of fundamental new discoveries in biochemistry
methods available, and the convenience and ac- and genetics made during the 1960’s (2). The
ceptability of particular methods. consolidation of knowledge about these new dis-
coveries that took place during the 1970’s has
been extensively applied in the areas of scien-
Future technologies
tific methodology, medicine, and fertility.
The following forecasts are based on four A third element is the magnitude of current
major elements. The first is the past rate of applied research and development efforts. A
innovation in reproductive and contraceptive worldwide network of facilities is engaged in
research. Between 1960 and 1970 a revolution the development of fertility planning agents
in contraceptive technology occurred, and more with government and private foundation sup-
than a dozen new technologies—oral contracep- port. Private companies are also working to
tives, IUDs, and new sterilization and abortion develop new methods.
techniques— reached the public. This rapid pace
of innovation continued through the 197 0 ’s) The fourth basis for these forecasts is expert
which saw the widespread introduction and opinion on both the overall likelihood of innova-
adoption of new types of vaginal spermicides, tion in this field, and on the likelihood of devel-
90 ● world population and Fertility planning Technologies: The Next 20 Years

Table 20.—Annual Number of Birth-Related and Method=Related Deaths per 100,000 Nonsterile Women, by
Fertility Planning Method, Age, and Development of Country

Age group/country type


15-19 20-24 25-29
Regimen MDC LDC-1 LDC-11 MDC LDC-I LDC-II MDC LDC-I LDC-II
No method:
Birth-related . . . . . . . . . . . . . . . . . . . . 5.6 8.3 290.0 6.1 9.2 183.8 7.4 10.8 215.9
Oral contraceptives (no pre-
disposing conditions):
Birth-related . . . . . . . . . . . . . . . . . . . . 0.1 0.3 11.1 0.2 0.5 10.6 0.2 0.7 13.0
Method-related . . . . . . . . . . . . . . . . . . 1.2 0.8 0.8 1.2 0.8 0.8 1.2 0.8 0.8
Total deaths . . . . . . . . . . . . . . . . . . 1.3 1.1 11.9 1.4 1.3 11.4 1.4 1.5 13.8
Oral contraceptives (with pre-
disposing conditions):
Birth-related . . . . . . . . . . . . . . . . . . . . 0.1 0.3 11.1 0.2 0.5 10.6 0.2 0.7 13.0
Method-related . . . . . . . . . . . . . . . . . . 1.4 1.0 1.0 1.4 1.0 1.0 1.4 1.0 1.0
Total deaths . . . . . . . . . . . . . . . . . . 1.5 1.3 12.1 1.6 1.5 11.6 1.6 1.7 14.0
IUDs:
Birth-related . . . . . . . . . . . . . . . . . . . . 0.1 0.2 8.0 0.2 0.4 7.7 0.2 0.5 9.5
Method-related . . . . . . . . . . . . . . . . . . 0.5 1.0 1.5 0.5 1.0 1.5 0.5 1.0 1.5
Total deaths . . . . . . . . . . . . . . . . . . 0.6 1.2 9.5 0.7 1.4 9.2 0.7 1.5 11.0
Tubectomy:
Birth-associated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 0 0.4 0 0 0.5
a
Method-associated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.5 0.9 2.3 0.6 1.2 3.0
Total deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.5 0.9 2.7 0.6 1.2 3.5

Age group/country type


30-34 35-39 40-44
Regimen MDC LDC-I LDG-II MDC LDC-I LDC-II MDC LDC-I LDC-II
No method:
Birth-related . . . . . . . . . . . . . . . . . . . . 13,8 20.0 199.7 21.0 34.2 171.0 22.6 35.9 191.5
Oral contraceptives (no pre-
disposing conditions)
Birth-related . . . . . . . . . . . . . . . . . . . . 0.4 1.2 12.0 0.6 1.8 9.2 0.5 1.3 7.1
Method-related . . . . . . . . . . . . . . . . . . 1.9 1.3 1.3 4.0 3.0 3.0 7.3 5.5 5.5
Total deaths . . . . . . . . . . . . . . . . . . 2.3 2.5 13.3 4.6 4.8 12.2 7.8 6.8 12.6
Oral contraceptives (with pre-
disposing conditions)
Birth-related . . . . . . . . . . . . . . . . . . . . 0.4 1.2 12.0 0.6 1.8 9.2 0.5 1.3
Method-related . . . . . . . . . . . . . . . . . . 11.4 6.0 6.0 28.8 13.0 13.0 103.8 63.0 63.0
Total deaths . . . . . . . . . . . . . . . . . . 11.8 7.2 18.0 29.4 14.8 22.2 104.3 64.3 70.1
IUDs:
Birth-related . . . . . . . . . . . . . . . . . . . . 0.4 0.9 8.7 0.6 1.3 6.6 0.5 1.0 5.1
Method-related . . . . . . . . . . . . . . . . . . 0.8 1.5 2.3 1.0 2.0 2.0 1.0 2.0 3.0
Total deaths . . . . . . . . . . . . . . . . . . 1.2 2.4 11.0 1.6 3.3 8.6 1.5 3.0 8.1
Tubectomy:
Birth-associated . . . . . . . . . . . . . . . . . 0 0 0.4 0 0 0.4 0 0 0.2
a
Method-associated . . . . . . . . . . . . . . 0.9 1.7 4.4 2.3 4.6 11.5 13.3 26.7 66.7
Totaldeaths . . . . . . . . . . . . . . . . . . 0.9 1.7 4.8 2.3 4.6 11.9 13.3 26.7 66.9

Age group/country type


15-19 20-24 25-29
Regimen MDC LDC-I LDC-lI MDC LDC-I LDC-II MDC LDC-I LDC-II
Traditional contraceptionb:
Birth-related . . . . . . . . . . . . . . . . . . . . 0.6 1.5 53.0 0.9 2.3 46.6 1.2 2.8 56.5
Abortion:
Method-reiated . . . . . . . . . . . . . . . . . . 1.2 2.4 6.0 1.6 3.2 8.0 1.6 3.2 7.9
Ch. 5—The Technology of Fertility Change: Present Methods and Future Prospects ● 91

Table 20.—Annual Number of Birth”Related and Method-Related Deaths per 100,000 Nonsterile Women, by
Fertility Planning Method, Age, and Development of Country-Continued
Age group/country type
15-19 20-24 25-29
Regimen MDC LDC-I LDC-II MDC LDC-I LDC-II MDC LDC-I LDC-II

Traditional contraception and


abortion:
Method-related . . . . . . . . . . . . . . . . . . 0.1 0.2 0.6 0.1 0.4 0.9 0.1 0.4 0.9

Age group/country type


30-34 35-39 40-44
Regimen MDC LDC-I LDC-II MDC LDC-I LDC-II MDC LDC-I LDC-II
Traditional contraception?
Birth-related . . . . . . . . . . . . . . . . . . . . 2.2 5.2 52.3 2.9 8.1 40.8 2.4 6.3 33.7
Abortion:
Method-related . . . . . . . . . . . . . . . . . . 2.0 4.0 10.1 1.7 3.4 8.5 1.5 3.0 7.4
Traditional contraception and
abortion:
Method-related . . . . . . . . . . . . . . . . . . 0.2 0.5 1.2 0.1 0.4 0.9 0.1 0.3 0.7

opment of specific versions of new technology velopment or to greatly accelerated develop-


(4,7). These views, from personal consultations, ment of methods now under study.
mail surveys, and reviews of literature, were Developments arising from one category of
brought together in a comprehensive assess- methods—folk methods—deserve special men-
ment of prospective technologies by a senior
tion. They are not treated further in the discus-
scientist as a working paper for this study,
sion to follow because the methods are diverse,
which was in turn submitted for critique by ex- and their bases poorly understood. The World
ternal reviewers. The paper reviews each major Health Organization (WHO) is conducting a col-
category of fertility planning technology and ex-
laborative global effort to identify and develop
amines its current level of development, nature
the potential antifertility agents present in
of action, mode of administration, probable ef-
plants believed (and used) in numerous LDCs to
fectiveness, probable side effects and safety,
prevent pregnancy. Among the compounds thus
delivery requirements, probable cost, probable
far isolated are extracts from the plant Mon-
extent of use, likely time frame for develop-
tanoa tomentosa, which has been used as an ear-
ment, and obstacles to development (7).
ly abortifacient in Mexican folk medicine for
The predictive power of these forecasts de- centuries, and from the roots of Trichosanthis
pends on the assumption that current trends kirilowii maxim, which has long been used in
continue. Such unforeseen developments as Chinese medicine to induce menstruation. The
funding changes, toxicity findings, or alterations likelihood of developing new fertility planning
in cost factors could intervene to retard or even techniques from these sources is unknown, but
curtail the development of particular technol- the potential is unquestionably present. Gossy-
ogies. It is also impossible to foresee the sci- pol, a derivative of the cottonseed plant, induces
entific discoveries that almost certainly will male infertility and is currently under clinical
emerge during the next two decades, giving rise investigation in China as a male contraceptive,
to entirely new opportunities for technology de- but significant side effects, including potassium
92 ● World population and Fertility Planning Technologies: The Next 20 Years

depletion and delayed return to fertility, have METHODS HIGHLY LIKELY TO BE


been encountered in studies of the extract. AVAILABLE BY 1990
Between now and the end of the century, All of the technologies listed below meet two
more than 20 new or significantly improved conditions. They are already in advanced stages
technologies for contraception could become of research and development, and the scientific
available. They have been classified in table 21 and technical knowledge required to complete
in three categories: 1) technologies highly likely their development and to permit their manufac-
to become available by 1990; 2) technologies ture and distribution appears either to be in
that could become available by 199 0 ) but for hand or easily attainable.
which prospects are in doubt; and 3) technol-
ogies that are unlikely to become available by Safer Oral Contraceptives.—New versions of
1990, but which could emerge by 2000 (19,7). the contraceptive pill are being tested that will
cause fewer changes in the body metabolism,
Table 21 .—Future Fertility Planning Technologies either because they utilize a smaller amount of
contraceptive drug (e.g., the triphasic pill), be-
Highly Iikely before 1890 cause they avoid the peak blood levels of drug
Safer oral contraceptives that occur following ingestion of current pills,
Improved IUDs or because the effect of the drug is more fo-
improved barrier contraceptives for women
improved long-acting steroid injections
cused on a specific target or end point. It is as-
Improved ovulation-detection methods for use with sumed that this will reduce the incidence of cir-
periodic abstinence culatory system disease, liver hepatomas, and
Steroid implants
Steroid vaginal rings other rare long-term side effects shown to be as-
LRF-analog contraceptives for women sociated with current formulations of oral con-
Prostaglandin analogs for self-administered induction traceptives.
of menses
Possible by 1990 but prospects doubtful Improved IUDs. —Three improved types of
1. Monthly steroid-based contraceptive pill IUDs are anticipated before 1990. The first are
2. Improved monthly steroid injection
3. New types of drug releasing IUDs advanced versions of the copper-releasing IUDs
4. Minidose vaginal rings introduced in the mid-1970’s. The improved ver-
5. Antipregnancy vaccine for women sions will be effective longer than current IUDs
6. improved barrier contraceptives for men
7. Sperm suppression contraceptives for men and will not require replacement during the
8. Reversible female sterilization lifetime of the user. The second are advanced
9. Simplified female sterilization techniques versions of the progestin-releasing IUD in-
10. Simplified male sterilization techniques
11. LRF analogs for self-administered induction of troduced in the late 1970’s. By employing dif-
menses ferent, more potent contraceptive steroids, the
Unlikeiy by 1990 but possible by 2000 new versions will be much more effective—pos-
Antifertility vaccine for men sibly equaling the pill—and will not require
Antisperm drugs for men replacement more often than every 5 to 10
Antisperm maturation drugs for men
Lactation-linked oral contraceptives for women
years. These new IUDs may cause much less
Ovulation prediction methods for use with periodic bleeding than existing models, but questions of
abstinence long-term safety will be present because they
New types of antiovuiation contraceptive drugs for
women
release drugs. The third new types are postpar-
Contraceptive drugs for women that disrupt ovum tum IUDs—devices that can be safely inserted
transport immediately following delivery without exces-
Reversible male sterilization
Pharmacologic or immunologic sterilization for
sively high expulsion and pregnancy rates. They
women would enable intrauterine contraception to be
Pharmacologic or immunologic sterilization for men made available to large numbers of women in
Agents other than LRF analogs for self-administered
induction of menses LDCs who otherwise might not have access to
SOURCE: Office of Technology Assessment survey; S. B. Schearer and M. K.
the medical personnel needed for insertion of
Harper, 1980. other types of IUDs.
Ch. 5—The Technology of Fertility Change: Present Methods and Future Prospects ● 93

Improved Barrier Contraceptives for ovulates. Improved methods that provide clear-
women.-Improvements center on two areas: cut evaluation of, for example, changes in cer-
increases in convenience of use and increases in vical mucus, hormones in urine and saliva, and
contraceptive efficacy. Among the former are basal body temperature would enable larger
one-size-fits-all diaphragms, disposable dia- numbers of users of periodic abstinence to
phragms, spermicide-impregnated diaphragms, know with certainty when they could safely en-
vaginal films, vaginal sponges, vaginal rings that gage in sexual intercourse during the second
release spermicides, and cervical caps that can half of the menstrual cycle without risk of preg-
be left in place for weeks or months. Increases nancy, although the prediction of ovulation is
in contraceptive efficacy include new formula- likely to remain problematic. Such techniques
tions of existing spermicides and new types of would also free users of barrier contraceptives,
spermicides. Which of these are likely to survive withdrawal, or coitus reservatus from the need
the R&D process and become new products is to employ these methods during the second half
uncertain. Because the level of resources being of the cycle. The excretion pattern of urinary
devoted to this work is very low, progress is metabolizes of estrogen and progestogen has
likely to be slow, and major improvements are been identified and has been successfully used
unlikely. A substantially increased level of effort to determine when ovulation has occurred, ac-
would be required to develop highly effective cording to studies conducted by the WHO Spe-
new spermicides or radically improved barrier cial Programme of Research, Development and
devices by 1390. Research Training in Human Reproduction,
which reports that the measurement of these
Improved Long-Acting Steroid Injections.—A substances in early morning urine was indica-
wide variety of improved injections under de- tive of ovulation in 90 percent of women tested.
velopment make use of controlled release of A number of firms are working to develop a kit
contraceptive steroids from biodegradable pol- for women to use at home, and at least one of
ymers. Which polymer systems will prove most the methods is expected to be ready for testing
useful is not certain, but prospects are excellent when final analysis of the studies is completed
that one or more will provide the basis for a later this year (10).
new form of contraceptive injection. Effective-
ness should be extremely high, and duration of
Steroid Implants. —This new, reversible con-
action is likely to be between 1 and 6 months, traceptive method is likely to undergo several
depending on the properties of the polymer sys- rounds of technological innovation between
tem eventually selected. Side effects are ex- now and 1990. The first generation prod-
pected to be moderately reduced over existing uct—six steroid-releasing capsules implanted in
long-acting injections because of a more stable, the forearm providing extremely effective con-
controlled release of contraceptive steroid. traception over 5 years—is likely to be either
However, the nature of side effects, including
supplemented or supplanted by second genera-
alterations in menstrual bleeding patterns in tion products employing fewer and smaller cap-
many users, is expected to be similar to those of sules that are biodegradable. The first genera-
existing products. tion product is now being introduced in LDCs
improved Ovulation-Detection Procedures for and will offer an alternative to sterilization for
Use With Periodic Abstinence Methods.–Al- women who wish to terminate births, as well as
though R&D investments continue to be small, a new contraceptive option for long-term spac-
technological prospects for development of a ing between births. While the second genera-
routinized, simple test for ovulation appear tion implants will not require removal, thus
good. A wide variety of biological and biochem- eliminating a major drawback of the silicone
ical parameters are altered when a woman rubber implants, they will probably need to be
ovulates, and researchers are endeavoring to replaced at much more frequent intervals than
improve or simplify the physical tests that a the six-capsule silicone-rubber method. It is like-
woman can use herself to determine when she ly that a variety of products lasting from 6
——

94 ● World Population and Fertility Planning Technologies: The Next 20 Years

months to 2 years will be available. All of these will offer a major new alternative to the pill,
methods are expected to be at least as effective with the advantages of many fewer short-term
as oral contraceptives and to have a similar in- side effects and, at least potentially, many fewer
cidence and range of side effects. They are ex- long-term health hazards. Depending on which
pected to have the disadvantage of causing ir- chemical analogs are employed and their pre-
regular patterns of menstrual bleeding in most cise mode of action, the new contraceptives
users, much the same as do the injectable. could also offer the advantage of monthly in
place of daily administration.
Steroid Vaginal Rings. —As for the implants,
prostaglandin Analogs for Induction o f
this new reversible contraceptive method
Menses.–After more than a decade of R&D, the
employs a previously unused system to admin-
first prostaglandin analogs for inducing men-
ister steroid hormones. A one-size-fits-all sili-
struation are now being introduced in clinical
cone rubber ring that releases an ovulation-sup-
trials. These drugs, which are administered as
pressing dose of contraceptive steroids is left in-
vaginal suppositories, successfully induce abor-
side the vagina for 3 weeks, then removed for 1
tion during the first 8 weeks of pregnancy in
week, during which time menstruation occurs. about 90 percent of cases. Side effects—tran-
Because this is a monthly schedule and sient fever, nausea, vomiting, and cramp-
estrogens as well as progestins are used, men-
ing—are generally manageable, although dis-
strual bleeding patterns are not greatly altered.
agreeable. Second and third generation prod-
This new method offers an alternative to the
ucts are likely to emerge over the course of the
pill: it is self-administered, highly effective,
next decade: new uterotonic prostaglandin ana-
potentially available over-the-counter, and has
logs and formulations that are effective in bring-
the advantage of simplified administration in
ing about a complete abortion in over 95 per-
comparison with daily pill-taking. The method is
cent of cases and that cause fewer side effects,
likely to have at least some of the rare long-term
However, it is doubtful that these agents, which
side effects of pills, As with implants, this
depend on uterine muscle contraction for their
method is in advanced development, and second
action, will ever be 100 percent effective or
generation products are therefore also likely to
completely free of gastrointestinal side effects.
emerge before 1990. Second generation vaginal
These drugs can be used in place of surgical
rings are likely to have improved administration
abortion during early pregnancy if surgical fa-
schedules, such as continuous wearing of the
cilities are available to treat severe complica-
ring for long periods, and new ring designs that
tions and to surgically complete the abortion
offer advantages in price and convenience,
procedure in cases where the medication fails to
do SO.
LRF-Analog Contraceptives for Women.
—Although this prospective new contraceptive METHODS THAT COULD EMERGE BY 1990, BUT
method has only recently entered clinical test- FOR WHICH PROSPECTS APPEAR DOUBTFUL
ing, relatively extensive R&D investments and a
The following technologies are possibilities
high level of technological promise may make it
currently being investigated or seriously consid-
available during the next 10 years. Many modes
ered by R&D groups. Some of them are in ad-
of antifertility action for new chemical analogs
vanced stages of development.
of LRF are being investigated. The one that
stands out as most clearly feasible is reversible It is likely that the majority will be eliminated
inhibition of ovulation using chemically synthe- as realistic prospects during the next 10 years as
sized agonists or antagonists of the naturally oc- new information and R&D findings become
curring LRF. It is not yet clear whether these available, A number will survive as continuing
drugs will be given by injection, nasal spray, prospects and be carried forward into the fol-
suppository, buccal insert, or oral capsule, nor lowing decade for additional R&D to complete
is the duration or frequency of administration their development. A few might meet with
that will be required yet known. It is antici- greater success and emerge as new technologies
pated, however, that these new contraceptives during the course of the next decade.
Ch. 5—The Technology of Ferti/ity Change: Present Methods and Future Prospects • 95

Monthly Steroid-Based Contraceptive Pi[[.—New Minidose Vaginal Rings. —Minidose rings, while
developments in technology for formulating similar to the steroid-releasing vaginal rings that
sustained-release preparations of contraceptive inhibit ovulation described earlier, would em-
steroids may be put to use to develop a pill that ploy much lower doses of progestational steroid
need only be taken monthly. Effectiveness and no estrogen. Like the minipill, they would
would be expected to be about equivalent to dai- exert their contraceptive action primarily
ly oral contraceptives. Short-term side effects through effects on cervical mucus instead of on
would be similar, although a somewhat greater ovulation. Minidose vaginal rings would offer
incidence of altered menstrual patterns might the advantage of reduced short- and long-term
occur. Long-term effects would also be similar. side effects except with respect to menstrual
The primary advantage of this new pill would bleeding patterns, which would probably be sig-
be the added convenience offered by monthly nificantly changed in most users. Another major
use. advantage of this method over the ovulation-
suppressing rings would be its continuous use
Improved Monthly Steroid Injection.—As for by a woman, avoiding the complexities of a
the pill, a monthly injection would use new sus- 3-week in, l-week out schedule. A major draw-
tained-release formulation techniques to deliver back would be lower effectiveness, probably in
a monthly dose of estrogen and progestin suffi- the range of the present-day minipill or inert-
cient to block ovulation and produce a hormo- IUD contraceptives.
nally induced menstrual bleeding at the end of
the month. Such new monthly injections might Antipregnancy Vaccine for Women. —
be superior to existing ones in their much lower This prospective, reversible contraceptive
incidence of menstrual bleeding alterations, in method uses a vaccine to immunize women
their use of steroids compatible with U.S. Food against the hormone in a specific component of
and Drug Administration toxicity standards, the fertilized egg, such as the zona pellucida.
and perhaps in a slightly reduced incidence of Initially, a series of injections would probably be
such short-term side effects as headaches and needed over a period of several weeks or
weight gain. Effectiveness and the general spec- months to establish immunity. Immunity might
trum of short- and long-term side effects would last from 1 to several years and then disappear
be similar to those associated with daily oral unless a booster injection were given. Effective-
contraceptives. Costs would likely be somewhat ness of a vaccine contraceptive is theoreticall y
higher. very high. A number of different antigens are
being investigated for use in developing such a
New Types of Drug-Releasing IUDs.—Several vaccine, and tests in monkeys and women have
current R&D projects are testing drugs that shown the feasibility of several of these. This is
reduce menstrual bleeding and uterine cramp- one of the prospective future methods that
ing associated with the IUD. It is likely that one could benefit from greatly expanded R&D ef-
or several of these drugs will eventually be in- forts, since feasibility appears good, but a wide
corporated into a drug-releasing IUD that will range of technical problems needs to be over-
cause significantly less bleeding and discomfort come to realize this potential.
than existing IUDs. Another type of drug that
may be incorporated into IUDs is antibiotics. Improved Barrier Contraceptives for
Low doses of such agents released locally into Men.—Although very little R&D is currently
the uterus would reduce the incidence of pelvic under way in this area, a growing market for
infection associated with IUDs, thus overcoming barrier contraceptives could stimulate signifi-
one of the major drawbacks of this contracep- cant innovation over the course of the next dec-
tive method, especially for young women. None ade. Present R&D centers on biodegradable
of the new varieties of drug-releasing IUDs is condoms, spermicide-impregnated condoms (al-
likely to incorporate the improvements in effec- ready marketed in Great Britain), and penile
tiveness anticipated for the new copper- films. The goal is to overcome the drawbacks of
releasing and steroid-releasing IUDs. decreased sensation, problems of disposal, and
96 • World Population and Fertility Planning Technologies: The Next 20 Years

variable effectiveness associated with existing quent ectopic pregnancies stand in the way of
condoms. The scale of this effort is very small, successful development of these methods.
however, as condoms are already an acceptable These methods could make sterilization much
and effective method. But it is possible for radi- more widely available to women in LDCs at
cally improved condoms to be available by 1990 lower cost and in a manner not requiring
if private sector companies respond to the new hospital stays or surgery.
market demand by investing in R&D using new Simplified Male Sterilization Techniques.—
synthetic materials. Vasectomy is already performed as a simple out-
Sperm Suppression Contraceptives for patient technique with very low rates of mor-
Men.—For almost a decade, different drugs have bidity or medical complications. One modest im-
been tested for their capacity to suppress sperm provement being studied entails the injection of
production in men. At least two types of a sclerosing chemical into the vas deferens, thus
drugs-steroids and LRF analogs–are currently eliminating the need for opening the scrotum
under clinical study, and other agents are being and cutting and tying off the vas.
investigated in the laboratory. A future sperm- LRF Analogs for Self-Administered Induction of
suppressing contraceptive based on one of these Menses.—A pill that can be taken each month at
agents would for the first time offer men a the expected time of menstruation to ensure
means of contraception similar to the pill for that bleeding will occur whether or not a preg-
women. Depending on the type of drug used, it nancy has been established is under study. Such
could take the form of a daily, weekly, or a self-administered, menses-inducing agent
monthly pill or, possibly, a long-acting injection might also be effective as an abortifacient if
or implant. Concerns about possible rare or taken up to a week or two after a missed period.
long-term safety hazards (e.g., teratological ef- New uterotonic prostaglandin analogs are likely
fects in any offspring) associated with such a to offer some but not all of these features. For
new form of treatment will be important and complete effectiveness, a luteolytic agent (one
difficult to overcome. that destroys the corpus luteum) will probably
Reversible Female Sterilization. -Short of ex- be needed, and current research findings point
tremely expensive and highly uncertain tubal to LRF analogs as the most likely future can-
reconstruction surgery, female sterilization is didates.
rarely reversible. This major limitation could be
overcome if current R&D efforts using fimbrial METHODS UNLIKELY TO EMERGE BY 1990,
hoods, tubal plugs, or other methods that per- BUT WHICH COULD BE AVAILABLE BY 2000
mit easy reversal of sterilization are successful. The following methods are either in the early
Numerous technical problems remain to be stages of development or still the subject of mis-
solved, however, before a highly effective, safe, sion-oriented research. All appear unlikely to
and reversible means of female sterilization is emerge as new fertility planning methods ear-
developed. lier than 1990, but could become available over
the course of the following decade. For several,
Sirnplfied Female Sterilization Techniques.—At
greatly expanded R&D programs could acceler-
least three major lines of R&D work are being
ate their development. For several others, it is
undertaken in hopes of developing an outpa- likely that substantial additions of knowl-
tient method for female sterilization that could edge from basic research will be needed as a
be performed by ancillary medical personnel. precondition for successful R&D efforts.
All of the methods require entry into the uterus
via the vagina and cervix in order to apply scle- Antifertility Vaccine for Men.—Although little
rosing (scarring) chemicals or to use freezing R&D has yet been conducted on a male contra-
temperatures to destroy a portion of the fallo- ceptive vaccine, this area could benefit very
pian tubes. Technical problems in assuring high substantially from work on a vaccine for
effectiveness, safety, and freedom from subse- women. In men, immunity would be established
Ch. 5—The Technology of Ferti/ity Change: Present Methods and Future Prospects ● 97

against sperm or sperm production in a manner New Types of Antiovu/ation Contraceptive


that would render the man infertile. Suitable Drugs for Women.— Intensive basic and goal-
antigens for such a vaccine have not yet been oriented research is under way on factors re-
identified. Whether such a vaccine would be a quired for maturation of the ovum in the ovary.
reversible contraceptive or a permanent sterili- If maturation could be prevented, either
zation technique is not known. through direct action or via inhibition of FSH re-
lease by the pituitary gland, ovulation would not
Antitisperm Drugs for Men.—A moderate
amount of goal-oriented research has been con- occur. Prospects that future contraceptives
ducted to identify enzymes essential to the employing a synthetic “inhibin” or chemical ana-
metabolism of sperm, and research for inhib- log of an ovum maturation factor will eventually
itors of these enzymes has been undertaken. It emerge from this research appear good. If such
is possible that specific metabolic processes in efforts are successful, a new type of nonste-
roidal monthly pill or injection for women could
sperm could be halted by certain drugs that
result.
men could take on a regular basis. A reversible
male contraceptive agent in the form of a daily
or weekly pill might be developed using this Contraceptive Drugs for Women That Disrupt
principle. Ovum Transport. —It is known that the transport
of the newly fertilized egg and its implantation
Antisperm Maturation Contraceptive Drugs for in the uterus can be disrupted by high doses of
Men.—Such drugs would act on maturing sperm estrogens, and this is believed to be the mode of
rather than on fully active sperm. If specific action of the current postcoital pill. A radically
steps in the maturation process can be identi- improved postcoital pill that could be taken af-
fied that could be blocked by specific drugs, a ter every coitus without unpleasant side effects
reversible contraceptive could be developed. or disruption of the menstrual cycle might be
Administration would need to be on a daily or developed in the future, using new drugs that
weekly basis or by means of a sustained-release interfere with fertilization, ovum transport, or
formulation such as an implant or injection. implantation. Despite considerable research,
Lactation-Linked Oral Contraceptives for however, no promising agents have yet been
Women.—Efforts to develop a drug regimen that identified, and extensive basic and goal-oriented
could be administered to breastfeeding women research will be required to achieve this goal.
to extend both the duration and ovulation-sup-
Reversible Male Sterilization. —Vasectomy is
pressing intensity of their lactation after child-
safe, easy to perform, and highly effective. Easy
birth have been unsuccessful. In view of the
reversal of this procedure to restore fertility
great health benefits of breastfeeding and the
would probably have great impact in making
very widespread reliance on this as a means of
the method more widely used. Unfortunately,
birth spacing by women in LDCs, this remains a
numerous R&D projects to develop tubes,
high priority technological goal. Recent findings
valves, plugs, and other devices that could be
about LRF and other gonadotropin-releasing
implanted in the vas deferens and reversibly
factors may make it feasible.
block sperm from passing have ended in failure,
Ovulation Prediction Methods for Use With so the biological feasibility of a reversible tech-
Periodic Abstinence. —The development of sim- nique is uncertain. New surgical techniques
ple techniques for predicting when ovulation coupled with new biocompatible synthetic
will occur would permit the rhythm or natural materials are likely to be required for develop-
family planning methods to be practiced with ment of such a method.
full effectiveness. The development of such
techniques is beyond the capacities of current Pharmacologic or Immunologic Sterilization for
scientific knowledge, but prospects a decade Women.—A pill or injection that confers per-
from now should be much better. manent infertility has been part of the folklore
98 Ž World Population and Fertility Planning Technologies: The Next 20 Years

of many cultures. While toxicity concerns production or a vaccine that permanently


would have to be resolved, if sufficient R&D blocks male fertility. Both types of agents are
were devoted to a careful selection of proper already known, but no significant R&D pro-
pharmacologic or immunologic agents, high gram has been established to develop them into
safety and effectiveness should be attainable. a male sterilization technique. As for the female
The method could be based on drugs that de- method, considerable research would be
stroy the capacity of the ovaries to produce needed to assure both safety and effectiveness.
viable ova or on an immunization against a body Since vasectomy is already a simple technique,
protein that is essential for reproduction. Al- the advantages of a pharmacologic or immuno-
though the method could be effective following logic male sterilization method are less dramatic
a single administration, it is more likely that a than those associated with a similar method for
series of administrations of the drug or vaccine women.
would be needed. Such a method would offer a
Agents Other Than LRF Analogs for Self-
low-cost, noninvasive alternative to surgical
Administered Induction of Menses.—A variety of
sterilization.
agents are being investigated for this purpose:
pharmacologic or Immunologic Sterilization for luteolytic prostaglandin analogs, plant extracts,
Men.—Analogous to the method for women chemicals that bind to different types of hor-
summarized above, this prospective future tech- mone receptors, and antibodies that could be
nology would produce sterility in the male by administered by injection as a one-time, passive
using drugs that permanently eliminate sperm immunization.

Induced abortion
Natural or spontaneous abortion occurs in performed later in pregnancy, and also when
about one in five known pregnancies. However, the quality of personnel and facilities is low-
the loss of fertilized ova prior to or immediately ered.
following implantation is much higher. The
Although induced abortion is ubiquitous, its
combined total may be as high as 70 percent of
legal use is constrained in some countries by
all fertilized ova (20). Many of these spon-
religious beliefs. The limitations of current con-
taneous abortions are due to defective fetuses,
traceptive technologies, particularly lack of
such as those with chromosomal abnormalities.
access to their use, cause many women in all
Induced abortion is a medically safe pro- parts of the world to seek induced abortions to
cedure when performed early in pregnancy terminate unwanted pregnancies. Abortion is
(first trimester) by skilled personnel. Simple suc- not a preferred method of birth control but at
tion equipment, such as that developed in rural times is the only means of preventing an unde-
China, and manual syringe equipment for office sired birth. The large numbers of women who
use, such as that developed in the United States, seek abortions are more an index of how strong-
have begun to replace the primitive methods ly births are not wanted and contraception is
traditionally used in less developed regions. But needed than an indication of the preference for
the risks of maternal death or serious complica- abortion.
tions increase greatly when induced abortion is

Sterility prevention or reversal


Unwanted sterility is due to a wide range of tubes with venereal disease; lack of ovulation;
etiological factors; e.g., infection of the fallopian defective sperm production; developmental ab-
Ch. 5—The Technology of Fertility Change: Present Methods and Future Prospects ● 99

normalities of the uterus; the effects of repeated drugs to verify the woman’s capacity for
or improperly conducted abortions, such as in- ovulating.
jury to the cervix; etc.
In women, the major preventable cause of in-
Except for a few congenital defects, the prin-
fertility is infection leading to damage of the
cipal criterion for the diagnosis of sterility is
fallopian tubes. A variety of public health
failure of a couple to achieve pregnancy after a
measures can reduce the incidence of such in-
significant period (e.g., 2 years) of cohabitation
fections, including control over the transmis-
without practicing contraception. Worldwide
sion of venereal disease and, in some countries,
infertility has been estimated as involving 5 to
prevention of tuberculosis. Two technological
10 percent of couples (25). The prevalence of
developments could be significant: the develop-
sterility rises from a low of 3 to 4 percent among
ment of IUDs associated with a lower risk of
young couples, to 20 percent among couples in
pelvic inflammatory disease, and the develop-
their early 30’s, and rapidly to 100 percent
ment of vaccines against venereal diseases.
(menopause) during the woman’s 40’s. In some
areas, as in parts of sub-Saharan Africa, sterility
New technologies likely to be extremely useful
from infectious diseases is common enough to
for inducing fertility in couples are LRF agonists
lower birth rates and to be a major reason for
for inducing ovulation and LRF agonists and
seeking medical care. In Zaire, for example, the
other possible releasing-factor analogs for in-
high prevalence of sterility caused by venereal
creasing sperm production. For some couples,
infections was documented in the 1950’s in asso-
infertility in one partner cannot be treated, and
ciation with lower than expected birth rates.
assistance will only be possible in the form of
Following effective efforts to reduce venereal
adoption, use of another person’s sperm via ar-
diseases, the occurrence of sterility was
tificial insemination, or use of in vitro fertiliza-
markedly reduced and birth rates rose (18).
tion followed by embryo transfer to the uterus.
Several technological innovations could have a These technologies now exist but are expected
major impact on the capacity to diagnose the to benefit from improvements in sperm banking
causes of infertility. These include development and techniques for artificial insemination, and
of reliable, simple techniques for predicting as from new developments in ovum extraction, in
well as for confirming ovulation; development vitro fertilization, and embryo implantation.
of similar tests for determining the level of func- These techniques, however, are expected to
tioning of the male seminiferous tubules; and have little global impact on the treatment of in-
further development of ovulation-inducing fertility.

Sex selection -— —
Sex selection is included as a fertility planning as female infanticide (see ch. 7). Despite political
technology in this study because a strong pref- actions of a few countries like China to elim-
erence for sons persists in many LDCs, scientists inate preference for males by raising the status
are working on new technologies, and the prob- of women, it seems likely that a simple, effective
able impacts of effective technologies could be technology for sex selection would be widely
highly disruptive and contrary to rising expecta- used.
tions of sexual equality. Current technologies are highly ineffective
The evidence for sex preferences in different for sex selection short of performing amniocen-
parts of the world is well documented in de- tesis to ascertain the sex of the developing em-
scriptions of the divisions of power and labor bryo and then carrying out a second trimester
between men and women and in such practices abortion if the embryo is of the unwanted sex.

84-587 0 - 82 - 8
100 . World Population and Fertility Planning Technologies: The Next 20 Years

Noninvasive techniques for sampling cells of almost certainly prevent this from becoming a
early embryos might emerge in the next 20 generally used procedure.
years, enabling much earlier determination of
Claims that certain chemicals present in the
sex. This would make possible the choice of first vagina at the time of ejaculation or that the tim-
trimester abortion if the sex were unwanted,
ing of intercourse during the menstrual cycle
but any such technological advances would face
could affect the sex of the offspring have proved
strong social, political, and ethical pressures
largely unfounded. Nonetheless, there exists a
against the use of induced abortion for what
remote possibility that a chemical or im-
most perceive to be a trivial purpose. munological agent might be discovered that
A second approach to sex selection that has would differentially destroy male- or female-
been the subject of limited research entails determining sperm. If such a substance were to
separation of sperm into male-determining be developed, a male pill or injection or a
sperm (those bearing Y chromosomes), and vaginal preparation for selecting the sex of the
female-determining sperm (those bearing X offspring could become a practicable reality. In
chromosomes), followed by artificial insemina- view of the lack of research aimed at this objec-
tion with the desired sperm. While this ap- tive, the serious social questions about the value
proach might be more acceptable, prospects for of sex selection, and uncertainty of an MDC
developing highly effective sperm separation market for sex selection products, it is highly
techniques are limited and even if these existed, unlikely that a product for general use will
the need to employ artificial insemination would become available by 2000 A.D.

The need for better fertility planning technologies


Each existing fertility planning method has methods for clean water and a degree of
one or more serious limitations, such as mode of privacy can deter their use in LDCs.
administration, interference with coitus, need
for frequency of use, cost (a significant factor in Many methods require medical personnel for
LDCs), requirements for special personnel and delivery and follow-up care, and because their
facilities, and conflicts with cultural, religious, use is not well-researched for LDC groups, rela-
and medical norms. Side effects of IUDs and tive risks are unknown. A number of methods
steroids are sufficient to discourage adoption by require logistical support systems that are
some women and discontinuation of use by beyond the capacities of many LDC S) where
many, refrigeration, transport, and storage facilities
may be inadequate. The complexities of many
One-year discontinuation rates in LDCs are methods require high levels of scientific and
high for both the pill (60 percent) and the IUD technical sophistication for their selection, pro-
(40 percent) (11). These and other methods can curement, and delivery. The difficulty of ster-
be inappropriate for use in many settings. Pills ilization reversal remains a principal drawback
can be misused by being taken irregularly or in despite improvements in surgical techniques,
the wrong sequence, resulting in low effec- and no method other than periodic abstinence is
tiveness, and because the mode of action of acceptable to the Roman Catholic Church.
IUDs is not well understood, the devices are
sometimes suspected of “migrating” to other The failure rate, or inability of the method to
parts of the body by women in LDCs. Changes accomplish its primary purpose of preventing
in menstrual duration and flow sometimes unwanted pregnancy, is a critical shortcoming.
cause fears, as do reports of death and injury Even in MDCs, where levels of use of the most
from various methods. Requirements of vaginal effective methods are high, contraceptive
Ch. 5—The Technology of Fertility Change: Present Methods and Future Prospects Ž 101

failure continues to result in large numbers of needs of both MDC and LDC couples—who will
unwanted births and large numbers of induced require an effective, safe, reversible, easy-to-use
abortions, Some 500,000 babies are born in the contraceptive method for 20 to 25 years of their
United States each year to parents who did not lives–are taken into account, the disparity be-
want them, and an approximately equal number tween technology and need is greater still. Cur-
of induced abortions are reported for married rent methods have considerable unused poten-
women (6). tial for lowering LDC birth rates in the next 20
years, but cannot yet adequately meet the needs
It is clear that although current fertility plan- and desires of people either in MDCs or LDCs.
ning methods are far superior to those of just 20 When the urgent desire to reduce the incidence
years ago, they remain inadequate to the needs of induced abortion is also taken into account,
of MDC users and fall critically short of the the magnitude of need for better contraceptive
needs of couples in LDCs. When the lifetime technologies cannot be underestimated.

Chapter 5 references
1. Armed Forces Institute of Pathology, Hepatic Series C, No. 8, September 1980, Population In-
Branch, and Center for Disease Control, Bureau formation Program, The Johns Hopkins Univer-
of Epidemiology, Family Planning Evaluation Divi- sity, Baltimore.
sion, “Increased Risk of Hepatocelhdar Adenoma 9. Jick, H., et al., “Vaginal Spermicides and Con-
in Women with Long-Term Use of Oral Contra- genital Disorders,” Journal of the American
ceptives)” Morbidity and Mortality Weekly Report, Medical Association, 245(13): 1329-1332, 1981.
26(36): 293-294, 1977. 10, Kane, L. J., Executi\re Director, Human Life and
2. Barnes, A. C., Schearer, S. B., and Segal, S. J., Natural Family Planning Foundation, Alexandria,
“Contraceptive Development,” in Working Papers: Va., personal communication, 1981.
The Be/lagio Conference on Population (New York: 114 Mauldin, W. P., “Experience With Contraceptive
The Rockefeller Foundation, 1974). Methods in Developing Countries,” in Contracep-
3. Bradshaw, L. E., “Vasectomy Reversibility–A tion: Science, Technology, and Application, Pro-
Status Report, ’’Population Reports, Series D, No. 3, ceedings of a Symposium, National Academy of
May 1976. Population Information Program, The Sciences, Washington, D. C., 1979.
Johns Hopkins University, Baltimore. 12. May, D., “Mortality Associated With the Pill” (let-
4. Cain, P., “Future Prospects for the Development ter to the editor), Lancet, 2(8044): 921, 1977.
of Birth Planning Technology: What the Experts 13, Ory, H, W., “The Health Effects of Fertility Con-
Think,” report prepared for OTA, Washington, trol,” presented at the Symposium on Contracep-
D. C., 1980. tive Technology, National Academy of Sciences,
5. Coleman, S., and Piotrow, P. T., “Spermicides Washington, D. C., May 19, 1978.
—Simplicity and Safety are Major Assets,” Pop- 14, Piotrow, P. T., Rinehart, W., and Schmidt, J. C.,
ulation Reports, Series H, No. 5, September 1979, “IUDs-Update on Safety, Effectiveness, and Re-
Population Information Program, The Johns search,” Population Reports, Series B, No. 3, May
Hopkins University, Baltimore. 1979, Population Information Program, The
6. Forrest, J. D., Sullivan, E., and Tietze, C., “Abor- Johns Hopkins University, Baltimore.
tion in the United States, 1977 -1978,” Family P[an- 15. Potts, M., Speidel, J. J., and Kessel, E., “Relative
ning Perspectives, vol. II, No. 6, November-Decem- Risks of Various Means of Fertility Control When
ber 1979, Alan Guttmacher Institute, New York, Used in Less Developed Countries, ” in Sciarra, J.,
pp. 329-341. Zatuchni, G., and Speidel, J. J. (eds.), Risks, Ben-
7. Harper, M. J. K., “Prospects for New or Improved efits, and Controversies in Fertility Control (Hag-
Birth Control Technologies by the Year 2000 erstown, Md.: Harper & Row, 197’6).
A. D., “ report prepared for OTA, Washington, 16. Ravenholt, R, T., and Rinehart, W., “Mortality
D. C., 1980. From Circulatory System Disease in Four Coun-
8. Henry, A., Rinehart, W., and Piotrow, P. T., “Re- tries,” January 1978 (unpublished). Reproduced
versing Female Sterilization, ” Population Reports, in: Population Reports, “Oral Contraceptives: OCs-
102 ● Wor/d Population and Fertility Planning Technologies: The Next 20 Years

Update on Usage, Safety, and Side Effects.” Series ber (cd.), Microsurgery (Baltimore: Williams &
A, No. 5, January 1979 (reprinted May 1980). Wilkins, 1979), p. 185-242.
17. Rinehart, W., and Piotrow, P. T., “Oral Contra- 22. Tietze, C., Induced Abortion: A World Review,
ceptives–Update on Usage, Safety, and Side Ef- 1981 (4th cd.) (New York: The Population Coun-
fects,” Population Reports, Series A, No. 5, May cil, 1981).
1980, Population Information Program, The 23, Wheeler, R. G., Duncan, G. W., and Speidel, J. J.
Johns Hopkins University, Baltimore. (eds.), Intrauterine Devices: Development, Evalua-
18. Romaniuk, A., “Increases in Natural Fertility Dur- tion, and Program Implementation (New York:
ing the Early Stages of Modernization: Evidence Academic Press, 1974).
From an African Case Study, Zaire)” Population 24. World Health Organization, Special Programme
Studies, 34:293-310, 1980. of Research, Development and Research Training
19. Schearer, S. B., “Future Birth Planning Technol- in Human Reproduction, Seventh Annual Report,
ogies)” report prepared for OTA, Washington, 1978.
D.C. 1980. 25, World Health Organization, Special Programme
20. Schlesselman, J. J., “How Does One Assess the of Research Training in Human Reproduction,
Risk of Abnormalities From Human In Vitro Fer- Eighth Annual Report, 1979.
tilization?” American Journal of Obstetrics and 26, Wortman, J., “The Diaphragm and Other Intra-
Gynecology, 135:135-148, 1979. vaginal Barriers—A Review,” Population Reports,
21 Silbur, S. J., and Cohen, R. S., “Microsurgical Re- Series H, No. 4, January 1976, Population Infor-
versal of Female Sterilization: Techniques and mation Program, The Johns Hopkins University,
Comparison to Vasectomy Reversal)” in S. J. Sil- Baltimore.
Chapter 6

Reproductive Research and


Contraceptive Development
.

Contents

LIST OF TABLES

LIST OF FIGURES
Figure No. Page
20. Worldwide Expenditures for Reproductive Research, 1965-79. ....................107
21. Worldwide Expenditures for Fundamental Reproductive Studies and Training of
Scientists, Contraceptive Development and Evaluation of Contraceptive Safety,
1965-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .........109
chapter 6

Reproductive Research and


Contraceptive Development

Abstract —– ——
Reproductive research and contraceptive development are carried out by academic in-
stitutions, the pharmaceutical industry, private foundations, U.S. and foreign governments,
and international agencies. U.S. Government support for contraceptive development began
in the late 1960’s when the National Institutes of Health’s (NIH) Center for Population Re-
search and the Agency for International Development’s (AID) Office of Population were cre-
ated. Although worldwide expenditures for reproductive research and contraceptive devel-
opment rose from $31 million to $155 million between 1966 and 1979, when adjusted for in-
flation there has been a decline of 20 percent since 1973. Public sector expenditures (by
governments and philanthropic and nonprofit organizations) constitute about 85 to 90 per-
cent of these worldwide expenditures. In 1979, the U.S. Government’s share of this total
was 72 percent or $111.6 million. Government research agencies stimulate private sector
initiatives in contraceptive development in two ways. First, they support basic research
projects in academic and other nonprofit research institutions. Private firms can then build
on these findings to develop new products. Second, Federal agencies can directly finance
projects (e.g., clinical trials) that might otherwise require industry financing in order to
stimulate industry to develop and market new products.
Before U.S. manufactured drugs and medical devices can be marketed, they must meet
the safety and efficacy standards of the laws passed by Congress and administered by the
U.S. Food and Drug Administration (FDA). Testing requirements for contraceptives are
more stringent than for other drugs because they are used for long periods by healthy indi-
viduals rather than by individuals with disease. Drugs not approved for marketing in the
United States cannot be exported for use abroad. Medical devices not approved for market-
ing in the United States can be exported under limited conditions. These export provisions
will become more important as pharmaceutical manufacturers shift their marketing efforts
from the United States, where population growth is close to replacement level, to the less
developed countries (LDCs), where the number of people entering the reproductive ages is
increasing. FDA’s market approval process has been criticized as shortening effective pat-
ent life, leaving manufacturers too little time to recoup their investments. Drug patents run
for 17 years, and the market approval process averages 7½ years-8½ years for hormonal
contraceptives. However, for the oral contraceptives, patent holders have been able to in-
crease prices and retain a dominant share of the market even after their patents have ex-
pired. Liability insurance costs have risen, and, in some cases, pharmaceutical manufac-
turers have had difficulty in obtaining satisfactory insurance coverage. These product lia-
bility problems may be deterring some pharmaceutical manufacturers from the contracep-
tive products line as well as affecting the kinds of future contraceptives to be developed.
Liability problems have also affected the clinical testing that new contraceptives must
undergo, as insurance is more difficult to obtain and its cost is substantially higher.

105
106 . World Population and Fertility Planning Technologies: The Next 20 Years

Introduction
As in other areas of pharmaceutical investiga- carried out in varying degrees by the following
tion, reproductive research and contraceptive entities:
development are comprised of the following ac- . academic institutions;
tivities: ● the pharmaceutical industry;

● basic research (in both the reproductive ● private foundations;

process and in related fields; e.g., immunol- ● the U.S. Government;

● foreign governments; and


ogy);
● training of scientists; • international agencies.
● applied research (i.e., goal-oriented R&D); In the following analysis, recent trends in the
and financing of reproductive research and contra-
● evaluation of the safety and effectiveness of ceptive development are discussed. The major
methods already in use. public sector organizations involved are de-
scribed, and selected factors that affect repro-
These activities and, in some cases, the in- ductive research and contraceptive develop-
troduction and marketing of contraceptives, are ment are examined.

Support of reproductive research and


contraceptive development
Trends in financial support In 1979, worldwide funding for reproductive
research and contraceptive development to-
Throughout the 1940’s and 1950’s, contracep- taled approximately $155 million, an increase
tive development was not directly supported by from $31 million in 1965. However, expressed in
the U.S. Government. Oral contraceptives, for constant (1970) dollars, this $155 million was
example, were developed with the support of equal to $82.6 million, and the high point in
private philanthropy (particularly the Rocke- funding was 1972-73 (fig. 20). There has thus
feller Foundation) and the pharmaceutical in- been a decline in these funds of about 20 per-
dustry, cent since 1973 (table 22).
In the late 1960’s, the U.S. Government cre- During the 1970’s, the U.S. contribution re-
ated agencies that eventually began allocating mained at approximately 70 percent of the
relatively small amounts of research funds to worldwide total; the remaining 30 percent was
contraceptive development. In 1967 the Office provided largely by other industrialized nations
of Population was created within AID, and in and by the LDCs (table 22). The U.S. contribu-
1968 the Center for Population Research was es- tion in 1979 was $111.6 million (actual dollars),
tablished in the National Institute of Child or 72 percent of worldwide expenditures.
Health and Human Development within NIH. On
the international level, the United Nations Fund U.S. contributions consist of funds from the
for Population Activities (UNFPA) was created in U.S. Government, philanthropic and nonprofit
1969, and in 1972 the Special Programme for organizations, and industry, and there has been
Research, Development and Research Training a shift in relative contributions among these
in Human Reproduction was established within sources. In the 1960’s, these three sources pro-
the World Health Organization (WHO). vided roughly . equal percentages of the total
Ch. 6—Reproductive Research and Contraceptive Development ● 107

Figure 20.—Worldwide Expenditures for percent of total funds go to basic research and
Reproductive Research, 1965-79 training, 20 to 25 percent to contraceptive de-
velopment, and less than 10 percent to safety
assessments. In contrast, about 80 percent of
150 public sector funds are spent on basic research
and training, 10 to 15 percent on contraceptive
140
development, and 10 percent on evaluation of
130 current methods (compare tables 24 and 25).
120 The public sector thus allocates proportionately
110 more funding to basic research and less to con-
traceptive development than does the private
100
sector.
90
The proportionate distribution of public sec-
80
tor expenditures in 1978 for contraceptive de-
70 velopment (approximately 15 percent of total
public sector expenditures) is summarized in
table 26. Approximately 71 percent was spent
on contraceptive methods for women, 6 percent
on methods for men, and 23 percent on meth-
ods (such as sterilization) for female or male
20 use. Of the 71 percent of expenditures on meth-
10 ods for women, 37 percent was spent on new
approaches to use of steroids, including subder-
0 mal implants, improved oral products, inject-
able, and vaginal rings. Another 10 percent
was spent on vaccines against pregnancy. The
remaining 24 percent was spent on sterilization
methods, antifertility and anti-implantation
agents, intracervical and intrauterine devices,
SOURCE: L. Atkinson, et. al., “Prospects for Improved Contraception,” family
P/arming Perspectives, 12(4), pp 173-192, 1900.
menses-inducing and abortifacient drugs, and
barrier methods.
U.S. contribution, but by the late 1970’s, the U.S.
Government was by far the major contributor, Major agencies involved in
providing 70 to 80 percent of the total U.S. con- reproductive research and
tribution (table 23). The U.S. Government is contraceptive development
thus the major current contributor to reproduc-
tive research and contraceptive development, The following organizations or scientific in-
providing more than 50 percent of total world- stitutions currently either finance or conduct
wide expenditures. reproductive research and contraceptive devel-
opment, largely for LDCs:
The components of worldwide total expendi-
tures for reproductive research and contracep- The Center for Population Research (CPR)
tive development are summarized in table 24 was established in 1968 within the National
and figure 21. Worldwide public sector expend- Institute of Child Health and Human Devel-
itures, by governments and philanthropic and opment at NIH. In turn, CPR established its
nonprofit organizations, constitute about 85 to Contraceptive Development Branch, which
90 percent of total expenditures (table 23). The in 1979 spent about $7 million.
components of these public sector expenditures The International Fertility Research Pro-
are summarized in table 25. Approximately 70 gram (IFRP) was founded in 1971. It con-
108 ● World Population and Fertility Planning Technologies: The Next 20 Years

Table 22.—Total Expenditures for Research in the Reproductive Sciences and Contraceptive Development,
by Country of Origin, 1965 and 1969-79 (In thousands of current and constant [1970] U.S. dollars)

NOTE: Totals may not add because of rounding.

SOURCE: L. Atkinson, et al., “Prospects for Improved Contraception,” Family Planning Perspectives, 12(4), pp. 173-192, 1980.

Table 23.—Estimated Worldwide Funding for Reproductive Biology and Contraceptive Development,
1965 and 1969-79, by Sector (in millions of constant 1970 dollars and by percent distribution)

Sector 1965 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979

International
Constant dollars:
Governments. . . . . . $ 6 . 2 $ 1 3 . 7 $ 1 6 . 3 $ 2 1 . 2 $ 2 4 . 7 $ 2 4 . 4 $ 2 3 . 3 $ 2 4 . 8 $ 2 5 . 8 $ 2 4 . 3a $ 2 2 . 6a $20.3a

SOURCE: L. Atkinson, et al., “Prospects for Improved Contraception,” Family Planning perspectives 12(4), pp. 173-192, 1960.
Ch. 6—Reproductive Research and Contraceptive Development ● 109

Table 24.—Percentage Distribution of Expenditures in the Reproductive Sciences


and Contraceptive Development, by Purpose, 1965 and 1979-78

Purpose 1965 1989 1970 1971 1972 1973 1974 1975 1976 1977 1978
Fundamental
studie/training . . . . 62.0 65.0 68.0 65.4 62.6 66.6 61.8 7 1 . 8a 7 3 . 8a 6 8 . 0 70.1
Contraceptive
development. . . . . . . 35.3 30.0 24.7 27.1 28.3 26.2 29.5 20.5 19.4 22.0 22.8
Safety . . . . . . . . . . . . . . 2.7 5.0 7.3 7.5 9.1 7.2 8.7 7.7 6.8 10.0 7.1
Total . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
a
lncludes unclassified expenditures.

SOURCE: L. Atkinson, et al., “Prospects for Improved Contraception,” Family Planrrhrg Perspectives, 12(4), pp. 173-192,1980
110 • World Population and Fertility Planning Technologies: The Next 20 Years

Table 25.—Public-Sector Funding for Research in


Reproduction and Contraception,” 1969.79

Research to
evaluate
current
Year Total methods
1969 . . . . . .
1970 . . . . . .
1971 . . . . . .
1972 . . . . . .
1973 . . . . . .
1974 . . . . . .
1975 . . . . . .
1976 . . . . . .
1977 . . . . . .
1978 . . . . . .
1979 . . . . . .

ducts clinical trials, mainly in LDCs, to de- also promotes the building of local research
velop and adapt new and existing methods skills and the introduction and use of con-
of contraception and to evaluate long and traceptive methods. About $3.7 million of
short-term risks and benefits of use, IFRP IFRP’s $5.8 million annual budget is devoted
Ch. 6—Reprocfuctive Research and Contraceptive Development • 111

to contraceptive development. IFRP is sup- setting scientific and technical standards,


ported by AID, NIH, and private donors (pri- providing supplies and equipment for re-
marily the Hewlett Foundation). search, and providing information about
● The Program for Applied Research on Fer- the performance of existing family planning
tility Regulation was established in 1972 programs.
and, through subcontracts, has established ● The Program for the Introduction and

its own clinical testing network for new Adaptation of Contraceptive Technology
contraceptives. Its annual budget is about (PIACT) was founded in 1976 to serve as a
$1.9 million, approximately 90 percent of bridge between the clinical researcher and
which is provided by AID. the family planning program manager, and
● The International Committee for Contra- a significant part of its program effort is
ception Research was founded in 1971 by directed toward introducing new and im-
the Population Council for contraceptive proved contraceptive technologies into pub-
product development. Its $2.7 million an- lic sector family planning programs. It is
nual budget is funded in roughly equal por- currently helping several countries, includ-
tions by the Rockefeller Foundation, the ing the People’s Republic of China, establish
Ford Foundation, the International Devel- the local capability to produce the contra-
opment Research Centre (IDRC) (a Canadian ceptives they require. PIACT was initially
Government agency), and AID. financed largely by the Ford Foundation.
● The Special Programme of Research, Devel- About 50 percent of its 1981 budget of over
opment, and Research Training in Human $4 million is provided by UNFPA, approxi-
Reproduction was established by WHO, a mately 15 percent by IDRC, approximately
U.N. agency, in 1972. A little over $4 million 30 percent by American private founda-
of its 1979 budget of $16.9 million was tions (primarily the Ford Foundation, the
allocated to applied contraceptive R&D. Andrew W. Mellon Foundation, and the
Other activities include developing scien- Hewlett Foundation), and the remainder
tific institutions and manpower in LDCs, from other sources.

Factors affecting reproductive research and


contraceptive development
Availability of R&D funds from mained fairly stable, but its share of total fund-
public sector sources ing has decreased from about 20 to 10 percent
(table 27) while government contributions have
Government agencies now provide most of increased.
the funds for reproductive research and con-
traceptive development. The U.S. Government Public sector funding has historically been
provides over 50 percent of worldwide funds; largely devoted to basic research and training.
other nations contribute about 25 percent (table Because funds from these sources increased
27). Philanthropic institutions, nonprofit orga- from about two-thirds of the worldwide total in
nizations, and industry provide the remaining 1965 to about 90 percent in the late 1970’s,
25 percent in roughly equal proportions. Sup- funds for this purpose were adequate to keep
port from U.S.-based philanthropic and non- pace with inflation. However, funds for contra-
profit organizations peaked in 1971-72, while ceptive development did not increase enough to
nonprofit organizations in other countries have offset inflation. Funds for research on safety
increased their contributions since that time and other evaluations of current methods rose
(table 23). Industry’s contributions have re- to about 10 percent of expenditures by 1972
112 • World Population and Fertility Planning Technologies: The Next 20 Years

Table 27.—Estimated Worldwide Funding for Reproductive Biology and Contraceptive Development,
1965 and 1969=79, by Sector (in millions of constant dollars and by percent distribution)
Sector 1965 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979

and have remained at approximately that level ventions to which the Government retains title
(see fig. 21). but that were previously left undeveloped. The
new law seeks to: 1) use the patent system to
Basic research is primarily investigator-initi-
promote the utilization of inventions arising
ated and administered through grants. The re-
from federally sponsored research; 2) encour-
search enterprise has historically emphasized
age maximum participation of small business
investigator-initiated research, and this empha-
firms; 3) promote collaboration between com-
sis is likely to continue. Contraceptive devel-
mercial concerns and nonprofit organizations
opment and safety and other evaluations of cur-
(including universities); 4) ensure that inven-
rent methods are goal-oriented and usually ad-
tions made by nonprofit organizations are used
ministered through contracts. In addition, con- to promote competition and free enterprise; (5)
cerns over the safety of drugs and medical de- promote the commercialization and public avail-
vices—concerns that are especially acute in the
ability of inventions made in the United States
contraceptive field—translate to pressures to in-
by U.S. industries and labor; 6) retain by the
crease safety testing. Contraceptive develop-
Government sufficient rights to protect the pub-
ment thus faces competition for funds not only
lic against nonuse or nonreasonable use of in-
from basic research activities but also from the
ventions; and 7) minimize the cost of administer-
burgeoning field of safety assessment.
ing policies in this area.
Government research agencies stimulate pri-
Second, Federal agencies can directly finance
vate sector initiatives in contraceptive devel-
selected research projects that normally would
opment in two ways. First, they support basic
be financed by the industry itself. For example,
research projects in academic and other non-
the National Cancer Institute will conduct ani-
profit research institutions. Private firms can
mal toxicity tests and clinical trials of anticancer
then incorporate these research findings into
drugs developed by the industry. This is also
their product development activities. This ave-
true for vaccines. The National Institute of
nue has recently been enhanced by a new pat-
Allergy and Infectious Diseases will finance
ent law (Public Law 96-517), which contains
basic and epidemiologic research, as well as
more liberal provisions for the transfer of pat-
clinical trials, to stimulate vaccine manufac-
ent rights arising from inventions sponsored by
turers to develop and market new vaccines (10).
the Government. This law creates a uniform set
of procedures by which small businesses can The agency within NIH that finances con-
gain licenses to develop federally sponsored in- traceptive development is CPR in the National
Ch. 6—Reproductive Research and Contraceptive Development ● 113

Institute of Child Health and Human Develop- these issues are especially sensitive in the con-
ment. In 1979, CPR's Contraceptive Develop- traceptive area.
ment Branch (CDB) spent about $7 million,
about 14 percent of CPR’s research budget. Cur- TESTING METHODS
rently, CDB is helping the industry develop FDA regulations specify the kind and length of
three contraceptives (3). For the past 6 years, tests that must be completed for market ap-
CDB has jointly financed long-term animal tox- proval. Testing requirements for oral contra-
icity tests and clinical trials of norethindrone ceptives are more stringent than for other types
enanthate with Schering A. G., a German phar- of drugs because they are used for long periods
maceutical company. CDB will probably con- by healthy individuals rather than by individ-
tinue to help finance clinical testing of this drug uals with disease. Table 28 summarizes the ani-
through completion of the new drug application mal tests that must be completed before testing
(NDA) process. For 3 years, CDB, Alza Phar- in humans can take place and an NDA is sub-
maceutical, and WHO have jointly financed the mitted. In each phase of testing, the regulations
development of a biodegradable implant of a require longer testing periods and more animal
progestin-type contraceptive. CDB began financ- species for oral contraceptives than for other
ing a joint effort with Syntex pharmaceutical drugs: 90-day studies in rats, dogs, and mon-
company in June 1980 to conduct early animal keys, v. 2- to 4-week studies in two animal
toxicity tests and clinical trials with a lutein- species prior to Phase I; l-year studies in rats,
izing-releasing factor agonist. dogs, and monkeys v. 90-day studies in two ani-
mal species prior to Phase II; 2-year studies in
The market approval process rats, dogs, and monkeys, and initiating 7-year
Before U.S.-manufactured drugs and medical
devices can be marketed, they must meet the
minimum standards of safety and effectiveness Table 28.—Preclinical and Clinical Requirements
for Oral Contraceptives in the United States
established by Congress through a series of leg-
islative actions. The principal laws are: Phase 1: Ninety-day studies in rats, dogs, and monkeys
must be completed prior to Phase I studies,
● The 1906 Food and Drug Act; which involve 10-20 individuals for up to 10
● The 1938 Food, Drug, and Cosmetic Act; days. (For other drugs, Phase I studies can be
● The 1962 Drug Amendments; and
initiated after 2-4 week studies in two animal
species.)
● The 1976 Medical Devices Amendment. Phase 11: One-year studies in rats, dogs, and monkeys
must be completed prior to Phase II studies,
The interpretation of these laws and the en- which involve approximately 50 women for
forcement of the standards set are the respon- three menstrual cycles. (For other drugs,
Phase II studies can be initiated after W-day
sibility of the FDA. studies in two animal species.)
Although postmarketing surveillance is also Phase Ill: Two-year studies in rats, dogs, and monkeys
must be completed and 7-year dog and
conducted, U.S. laws are designed to screen 10-year monkey studies must be initiated
drugs and medical devices before they are used before Phase Ill testing may begin.
by the public, so premarket testing is used to Market ing Progress reports on long-term studies in dogs
predict whether or not significant harm could approval: and monkeys are required at the time of new
occur with human use. FDA regulations thus drug application (NDA) submission. (For other
drugs, chronic toxicity studies—including
emphasize the use of predictive methods which, l-year dog, 18-month mouse, and 2-year rat
given the state of current scientific knowledge, studies—must be completed by the time of
depend heavily on tests in laboratory animals. NDA submission.)
SOURCES: M. Finkel: “Contraceptive Regulation in the U.S.,” paper presented
The issues concerning the market approval at the PIACT Workshop on Developing Countries and the Regula-
tion of Contraceptive Drugs and Devices, Seattle, Wash., July 24,
process and its effect on contraceptive develop- 1978; E. 1. Goldenthal, “Current Views on Safety Evaluation of
ment are generic to FDA’s role in the regulation Drugs,” FDA Papers, May 1988, pp. 13-18; E. 1. Goldenthal, “Contra-
ceptives, Estrogens, and Progestogens: A New FDA Policy on Ani-
of drugs and medical devices in general, but mal Studies,” FDA Papers, November 1969, p. 15.
114 ● World Population and Fertility Planning Technologies: The Next 20 Years

dog and 10-year monkey studies v. l-year dog, ministered over a period of 30 years. FDA re-
18-month mouse, and 2-year rat studies before quires testing in both the beagle and the mon-
an NDA can be submitted. key because the beagle is highly susceptible to
spontaneous breast tumors, the monkey is rela-
FDA regulations also require that the beagle
tively resistant, and the human female falls be-
be the breed of dog used to test oral contracep-
tween the beagle and the monkey in the in-
tives for safety. This requirement has raised the
cidence of spontaneous breast tumors. FDA also
most controversy, because the appearance of
points out that no contraceptive currently ap-
breast tumors in beagles when given depot med-
proved for marketing has shown a carcinogenic
roxyprogesterone acetate (Depo-Provera) was
potential in the beagle dog assay similar to
one of the reasons why the FDA denied Upjohn Depo-Provera (14).
Co.’s supplemental NDA in 1978.
In contrast, other internationally recognized
The reasons given for FDA’s nonapproval
agencies have taken the position that the beagle
included more than the appearance of breast
dog is not predictive of any risk of breast cancer
tumors in beagle dogs. The complete list of
in women using steroid hormones. These agen-
reasons was:
cies include the Special Programme of Research,
● malignant breast tumors in beagle dogs; Development, and Research Training in Human
● estrogen may be administered to women re- Reproduction of WHO (october 1978); the Com-
ceiving Depo-Provera in order to control mittee on the Safety of Medicines in the United
the irregular bleeding disturbances often Kingdom (February 1979); and the International
caused by this drug. In FDA’s opinion, the Planned Parenthood Federation (IPPF) (Novem-
added risk of cancer from the simultaneous ber 1980). In addition, a recent review of Depo-
use limited the benefits that might be asso- Provera concluded that “a great deal of human
ciated with a progestin-only contraceptive; data have been collected and these show no
● the patient population originally targeted evidence of human risk at present” (7).
for Depo-Provera had diminished substan-
The Depo-Provera issue has focused much at-
tially as other methods of contraception
tention on the beagle dog, but this specific con-
and sterilization became increasingly avail-
troversy should be viewed in its broader con-
able and accepted;
text. Safety testing for contraceptives is under-
● doubts that the proposed postmarketing
standably more stringent than for other drugs
studies on breast and cervical carcinomas
in both the length of testing required and in the
would yield meaningful data; and
kinds of laboratory animals subjected to testing.
● progestin and estrogen-progestin drugs in-
Both requirements increase the time and ex-
crease the risk of congenital abnormalities
pense incurred in contraceptive product devel-
in the fetus. Depo-Provera is a progestin,
opment compared with product development
and a failure of contraception or an error
for drugs in general.
made by injecting a woman already preg-
nant would result in exposure of the fetus
to this hormone (9). EXPORT OF DRUGS AND MEDICAL DEVICES
Depo-Provera is currently approved for use in A large, expanding market for contraceptives
the United States only for inoperable cancer of no longer exists in the United States but does in
the uterus and renal cancer, a use approved the LDCs, where large percentages of people
since 1972. It is manufactured and used as an in- are either in their reproductive years or about
jectable contraceptive in other countries. Drugs to enter them.
produced abroad for use abroad are beyond
In general, the U.S. Food, Drug, and Cosmetic
FDA’s regulatory reach.
Act prohibits U.S. pharmaceutical manufac-
Contraceptive drugs are given to young, turers from exporting drugs not approved for
healthy individuals and can potentially be ad- marketing in the United States. Two categories
Ch. 6—Reproductive Research and Contraceptive Development ● 115

of drugs are at issue: 1) drugs unevaluated for risk/benefit analyses, differing risk/benefit ra-
use; and 2) drugs evaluated but found unaccept- tios in other countries, and economic concerns.
able for use. A few exceptions to this provision
The belief that an importing country has a
exist; e.g., investigational drugs can be exported
right to assess the risk/benefit ratio for a drug’s
for investigational purposes, provided that an
use among its people is consistent with the in-
importing country’s government has approved
ternational legal principle of comity, which
such imports.
states that countries have a duty to respect the
Medical devices that are not approved for sovereign rights of other nations. Further, be-
marketing in the United States can be exported, cause of international variatio~s in life expect-
provided: 1) they conform to the laws and speci- ancy, standards of living, prevalence of diseases,
fications of the importing country; and 2) their and availability of health care, the relative risks
export is not considered by the Secretary of and benefits of a given drug are different
Health and Human Services to be contrary to among different populations.
the public health and safety of the importing
In order to market products unapproved in
country.
the United States, several American pharma-
Changes in the export provision of non-FDA ceutical companies have either established, pur-
approved drugs have been considered by Con- chased, or used manufacturing facilities in
gress. In the 96th Congress, a bill adopting the foreign countries, where their products are
medical devices export law for drugs passed the either approved for use or where laws permit
Senate but died in the House of Representatives. the export of unapproved products. Some U.S.
manufacturers argue that if they were able to
The U.S. Government’s policy of prohibiting
export their nonapproved products from the
the export of non-FDA approved drugs is based
United States, they would manufacture such
on safety and efficacy concerns. FDA recognizes
products in this country rather than abroad.
that different standards may exist elsewhere
They further argue that such manufacturing
but does not know which ones to apply when
would contribute to the U.S. economy (in terms
U.S. standards are not met, Some importing
of capital formation and employment) and thus
countries also do not have mechanisms to either
help improve the United States’ international
evaluate or regulate the quality of drugs they
balance of payments.
import (18), so the United States is unable to
defer to or apply these standards. There are The Depo-Provera controversy has also con-
also documented episodes of “drug dumping;” tributed to this debate over current law on the
i.e., situations in which drug companies pro- exportation of drugs not approved for use in the
mote products in LDCs deemed unsafe or inef- United States. Because it is approved for U.S.
fective in more developed countries (MDCs), use for the treatment of endometrial and renal
The analgesic drug Dipyrone, for example, was cancer but not for use as a contraceptive, Depo-
removed from the U.S. market because of its Provera manufactured in the United States can-
documented toxicity, yet it is marketed over- not be exported as a contraceptive. But it is
the-counter in several Central and South manufactured abroad, and in 1977 was in use in
American countries (4). In addition, substantial 42 countries (13).
differences in product labeling—e,g., indications
AID has received requests from LDCs for
for use and precautions—have been noted for
financial assistance to purchase Depo-Provera
selected products marketed in different coun-
for contraceptive purposes. But AID’s usual
tries (15), but attempts to develop international
position has been to refrain from providing
uniform labeling standards have been only par-
other countries with drugs not approved by the
tially successful.
FDA for use in the United States. A panel of ex-
Those who advocate exportation of drugs un- ternal advisors to AID recommended in 1980
approved in the United States base their argu- that the agency make Depo-Provera available to
ments on the right of a country to make its own those nations that request it for contraceptive
——

116 • World Population and Fertility Planning Technologies: The Next 20 Years

use, despite FDA’s nonapproval (17). In October is still in effect, but the patent on norethindrone
1981, FDA had chosen the members of a Public (the progestin in the products marketed by Or-
Board of Inquiry to evaluate the findings on tho, Syntex, Parke-Davis, and Mead-Johnson) ex-
Depo-Provera; AID is awaiting the Board’s rec- pired in 1973. After the expiration of the patent
ommendations. However, AID does help finance on norethindrone, only Mead-Johnson and Le-
UNFPA and IPPF, both of which purchase Depo- derle entered the market with oral contracep-
Provera. Because UNFPA commingles its funds, tives. Even though competitive pricing was uti-
money from a particular donor cannot be ear- lized by these companies, they did not capture a
marked for specific uses. IPPF, however, item- substantial share of the market, and Lederle
izes its expenditures by donor so that AID is subsequently withdrew. No generic pharmaceu-
assured that its funds are not used for purchas- tical house has entered the market.
ing Depo-Provera.
The Pharmaceutical Manufacturers Associa-
Here again, as with the case of the beagle dog tion (PMA) reported in August 1980 that of all
findings for Depo-Provera’s carcinogenic poten- classes of pharmaceuticals, oral contraceptives
tial, the specific controversy surrounding the experienced the greatest increases in price for
ban on export of U.S.-manufactured Depo-Pro- the reporting periods 1969-79 (187 percent) and
vera for contraceptive use should be viewed in 1978-79 (23.7 percent). In contrast, for over
its broader context. That is, it should be taken as 1,000 ethical drugs, PMA reports only a 37.4-
illustrating, and not controlling, the difficult percent average increase in price for the period
issues surrounding current U.S. policy on the 1969-79 and a 6.5-percent increase for 1978-79.
exportation of U.S.-manufactured drugs. Attractive profits would be expected from such
price increases and would be expected to lead to
Patent life price competition or the entry of new competi-
tors. But these price increases occurred primar-
Drug patents run for 17 years, but the in-
ily after the patents on norethindrone and nor-
dustry has expressed concern that the FDA mar-
ethynodrel (Searle’s progestin) had expired and
ket approval process takes so long–an aver-
during Mead-Johnson’s and Lederle’s entries
age of 71/2 years— that effective patent life is into the oral contraceptive market.
shortened and too little time is left for them to
recoup their investments (6). Patent life could be PMA estimates that between 8 and 9 million
legislatively extended beyond the current 17- women in the United States now use oral con-
year limit, or effective patent life could be traceptives, and a substantial number of women
lengthened if the FDA approval process were (between 500,000 and 1 million) currently initi-
shortened. How significantly does the short- ate use of oral contraceptives each year. But be-
ening of effective patent life diminish incentives cause the U.S. birth rate is close to replacement
to research and develop new contraceptives? level, the U.S. market is relatively static as new
The first company that puts a product on the users of oral contraceptives replace those aging
market has the advantage of capturing a larger beyond the reproductive years and those who
proportion of potential users than a company discontinue use for other reasons. Thus, phar-
entering the market later. Its initial investment maceutical companies that seek to market ge-
is also greater, since it must underwrite the re- neric versions of brand name contraceptives
search costs. Once its patent runs out, if other after patents expire must compete in a limited
companies then enter the market and manage market, with high advertising costs the prob-
to cut into its sales, its return on investment is able entry price.
diminished.
Oral contraceptives have also had difficult
In the field of oral contraceptives, Wyeth Lab- product liability problems. These contribute to
oratories and Ortho Pharmaceutical share ap- uncertainties in business profit/loss projections
proximately 70 to 80 percent of the market in and project a negative image that may affect the
the United States. Wyeth’s patent on norgestrel public’s confidence in a pharmaceutical com-
Ch. 6—Reproductive Research and Contraceptive Development “ 117

pany’s other products as well as in its contracep- Although oral contraceptives represent only
tive products. The ability of the original oral about 4 percent of the total ethical pharma-
contraceptive manufacturers to retain their ceutical market, more suits are filed on oral con-
market share and raise prices significantly traceptives per year than on any other class of
despite expired patents may not be completely ethical pharmaceutical products. Several man-
explained by a limited U.S. market and the ufacturers of oral contraceptives reported to
negative image that may be keeping other phar- OTA that they have more product liability
maceutical companies out of the field. However, claims for contraceptives than for all of their
this ability to keep the market captive in the other pharmaceutical products combined.
face of patent expiration and rising prices does
lead to the conclusion that, at least for the oral Injuries from these causes do not usually
contraceptive market, initial entry into the result from negligence in their manufacture,
market seems to be the determining factor, not distribution, or administration, but rather are
the length of patent life as affected by the FDA statistically rare injuries that will inevitably oc-
market approval process. cur in a few people. In legal parlance, these are
“unavoidably dangerous” though socially useful
products, and the U.S. courts have developed
Product liability
many legal doctrines as possible avenues
Product liability, its costs to business, and through which the injured person might obtain
possible inhibition of new product development compensation for the injuries suffered. That is,
have been prominent issues in recent years. rather than leaving the economic burden of the
While not limited to the pharmaceutical and injury on the injured persons, courts have tried
medical devices industries, its most visible im- to shift the economic loss to the “deep pockets”
pacts have been through the national swine flu of the product manufacturers; for example, by
immunization program of 1976 and in lawsuits imposing a “duty to warn” of serious side effects
involving the hormone diethylstilbestrol (DES), on the manufacturer and developing a test of
oral contraceptives, and intrauterine devices whether the product user had given his/her “in-
(IUDs). formed consent” to use the product after being
warned of the possible side effects that could
Product liability problems, and the ability of occur with use. But legally adequate “duty to
manufacturers to pass on their insurance and warn” and “informed consent” do not avoid in-
litigation costs to purchasers, may affect the jury. Successfully meeting both tests simply
kinds of future contraceptives developed. Prod- means that the already injured plaintiff will fail
ucts that involve a single sale or limited repur- in the lawsuit.
chase, such as IUDs, provide little means to ad-
just for increasing liability exposure once the Product liability is part of business costs for
device is sold. Oral contraceptives, on the other manufacturers and has traditionally been cov-
hand, require periodic purchases. A. H. Robins ered by insurance. Expansion of product liabil-
ceased selling its Dalkon Shield IUD in 1974, and ity has led to uncertainties in pricing such in-
in 1980 some of the devices were still in place, surance, which in turn has led insurance com-
so some users maintained the device in place for panies to treat such products as special risks or
at least 6 years. An oral contraceptive would to move out of the market, leaving manufac-
have required repeated purchases during that turers to self-insure such losses by pooling
period of time, and the price of the monthly funds among several manufacturers or by es-
dose package could have been adjusted to re- tablishing “captive” insurance companies. These
flect changing product liability risks. Or if the product liability and insurance problems have
sale of the contraceptive had been terminated, been examined in a previous OTA report, “A
existing supplies of the contraceptive would Review of Selected Federal Vaccine and Immu-
have been disposed of or consumed. nization Policies” (11). One result of that report
118 ● World Population and Fertility Planning Technologies: The Next 20 Years

was a request by Congress to enumerate the ele- and follow their own legal doctrines. However,
ments that would constitute a Federal compen- a State’s supreme court may adopt the doctrine
sation program for injuries caused by vaccines. of another State, and it is difficult to predict
That report, “Compensation for Vaccine-Related when and if this will happen.
Injuries, ” was released in November 1980.
Recently, the California Supreme Court (16)
Does product liability have an inhibitory ef- decided that an injured party who does not
fect on the propensity of the pharmaceutical in- know which manufacturer made the product
dustry to research and develop new contracep- that led to the injury can sue any of those who
tives, to continue to produce proven contracep- act in ‘(conscious parallelism” and who may have
tives, and to enter established markets after the produced the drug used by the patient. The
developer’s patent has expired? These are dif- plaintiff had developed cancer alleged to be
ficult questions to answer for the contraceptive caused by the hormone DES, taken by her
products field in isolation from what is happen- mother 26 years earlier to prevent a miscar-
ing in product liability in general (e.g., football riage. No evidence existed as to which of the
helmet manufacturers) and in liability per se defendant companies manufactured the DES
(e.g., professional malpractice, whether in med- used by the mother. More than 200 companies
icine, law, engineering, the clergy, etc.), but the manufactured DES at that time. Michigan has
evidence does point to an inhibitory effect. reached a similar result but on different legal
Whether product liability does or will funda- reasons (l).
mentally affect the contraceptive field is specu-
The variance in damages for a successful law-
lative, but the following findings indicate that it
suit may literally be millions of dollars. Spokes-
is a significant problem.
persons for manufacturers of oral contracep-
product liability and the adverse publicity that tives estimate that most jury verdicts for death
attaches to a specific product can affect con- or severe injury range from $100,000 to $4 mil-
traceptive development and use in two ways. lion, and a suit involving its Dalkon Shield IUD
First, product liability affects the predictability resulted in a $6.2 million verdict against A. H.
of business expenses and what profit margins Robins.
can be expected. If these costs are predictable,
In addition to judgment costs, there are ad-
the product’s price can be adjusted. If not, the
ministrative costs of handling claims, the great
manufacturer cannot limit its exposure except
majority of which never reach the courtroom
by taking the product off the market. In addi-
stage. For instance, A. H. Robins marketed its
tion, however, such costs may become so large
Dalkon Shield IUD from 1970 to 1974 and sold
that they affect the price to the extent that de-
approximately 2 million. According to Robins,
mand may be depressed. And adverse publicity
the first reports of problems (septic abortions)
about a specific contraceptive may: 1) turn con-
occurred in late 1973. As of September 30, 1980,
sumers to other contraceptives (which would be
there had been 4,660 claims filed against
justified if the information is correct; i.e.,
Robins, with 1,482 pending and 3,178 closed.
market forces and “informed consent” would be
Total settlements and judgments paid were $69
working appropriately); and 2) affect the man-
million, and Robins estimates its legal fees and
ufacturer’s decision on what kinds of contracep-
expenses to be about $20 million, or a total of
tives to develop and continue to sell (e.g., oral v.
about $45 (and still growing) for each IUD sold.
injectable contraceptives, IUDs v. oral contra-
Robins was receiving 100 claims per month at
ceptives).
the end of 1980, Robins’ insurer increased pre-
Predictability and the spreading of costs are miums and deductibles for IUD coverage to the
fundamental insurance tenets. But two develop- extent that Robins rejected the policy in 1978.
ments have affected their stability in recent Robins found that its loss record on the Dalkon
years. Lawsuits are usually filed and contested Shield prejudiced its ability to obtain coverage
in State courts, whose supreme courts develop on other pharmaceutical products. In order to
Ch. 6—Reproductive Research and Contraceptive Development • 119

obtain product liability insurance on other harm was developed under their support could
pharmaceutical products, Robins had to pay a subject them to liability.
$1.4 million surcharge (8). The developer of a new contraceptive product
These escalations in the scope of liability costs also bears the risk of liability during clinical
have had two effects: raising the price of con- trials. The standards for liability are in general
traceptives that have remained on the market, more varied with respect to clinical trials and
and leading insurers to treat contraceptives as often the doctrine of product liability does not
special risks. For example, one oral contracep- apply. Uncertainties nevertheless exist. While
tive manufacturer estimated that product liabil- many developers of pharmaceuticals and med-
ity expenses for a 20- to 30-percent share of the ical devices have asserted in an OTA telephone
market have totaled about $15 million for the survey that they have had no liability problems
past 10 years and have been escalating at about in clinical trials, there have been reports of dif-
$3 million to $4 million per year. Another oral ficulties for contractors and developers in ob-
contraceptive manufacturer estimates that 10 taining affordable and meaningful insurance.
percent of its sale price is earmarked for prod- Liability problems arise when the research is
uct liability claims (10). sponsored at institutions that do not belong to
the pharmaceutical industry (3). The cost of
As for contraceptives as special risks, stand- liability insurance is included in contracts when
ard product liability policies for pharmaceuti- necessary, but it is expensive and difficult to ob-
cals now specifically exclude only four types of tain. WHO has reported difficulty in securing
products— swine flu vaccines, DES, oral contra- contractors for clinical trials because insurance
ceptives, and IUDs. Also, insurance usually was not available to the contractor. In at least
comes in a trifurcated form—a deductible, the one instance, a potential NIH contractor could
standard policy, and excess insurance—and not procure adequate liability insurance for a
these components have changed. For example, phase I clinical trial. In another NIH-funded
the deductible may have been several hundred phase I clinical trial, the insurance for a 1-
thousand dollars, the basic policy for the next month, 12-woman study was in the neighbor-
$5 million to $15 million, and the excess in- hood of $30,000, and the policy required consid-
surance up to a specific limit; e.g., $25 million to erable amounts of time and effort to procure.
$30 million. This excess insurance would be
provided at a separate premium, either through There are clear indications that current prod-
a pool of several insurance companies to spread uct liability in the contraceptive field is more
the risk, or through a high-risk insurer such as severe than for other classes of products, has
Lloyd’s of London. Today, the self-insurance re- raised costs, and is severe enough in cost escala-
quirement may be up to $5 million, the premi- tion and unpredictability to have affected the in-
um itself for the standard policy in the millions, surance companies’ way of doing business with
and the excess insurance either not available or pharmaceutical manufacturers. This situation is
with a premium in the million-dollar range. conducive to diminished interest in future con-
traceptive research by profitmaking companies.
Organizations supporting R&D of contracep- In addition, liability insurance in the clinical
tive products are not immune to liability. For in- trial phase of development has become expen-
stance, the Ford Foundation and the Population sive and sometimes hard to obtain, thereby add-
Council both carry liability insurance. Even ing to developmental costs and, because of dif-
though such organizations may not manufac- ficulty in purchasing such insurance, imposing
ture or sell contraceptives in the United States, another impediment to the developmental
the fact that a contraceptive product that causes process.
120 ● Wor/d Population and Fertility Planning Technologies: The Next 20 Years

Chapter 6 references
1. Abel v. Eli Lilly & Co., 94 Mich. App 59, 289 N.W. munication with the Office of Technology Assess-
2d 20 (1980) (Michigan Court of Appeals). ment, 1980.
2. Atkinson, L., et al., “Prospects for Improved Con- 11. Office of Technology Assessment, U.S. Congress,
traception,” Familwv P/anrzing Perspectives, 12(4): A Review of Selected Federal Vaccine and immuni-
173-192, 1980. zation Policies (Washington, D. C.: U.S. Govern-
3. Bialy, G., Chief, Contraceptive Development ment Printing Office, 1979).
Branch, Center for Population Research, National 12. Office of Technology Assessment, U.S. Congress,
Institute of Child Health and Human Develop- Compensation for Vaccine-Related Injuries: A Tech-
ment, National Institutes of Health, U.S. Depart- nical Memorandum (Washington, D. C.: LJ. S. Print-
ment of Health and Human Services, personal ing Office, 1980.)
communication to the Office of Technology As- 13. Sai, F. T., former Assistant Secretary General of
sessment, 1981. the International Planneci Parenthood Federation
4. Bueding, E., Professor of Pharmacology and of before the [J.S. House of Representatives, Select
Pathohiology, School of Hygiene and Public Committee on Population, in Select Committee on
Health, The Johns Hopkins [University, letter to Population, [J.S. House of Representatives, hear-
Dr. Donald Kennedy, Commissioner, Food and ings on 7’he Depo-Provera Debare, 95th Cong., 2d
Drug Administration, dated Feb. 5, 1979. sess. (Washington, D. C.: U.S. Go\~ernment Print-
5. Cook, R., “U.S. Drug and Devices Regulation and ing Office, 1978).
Contraceptive Innovation, ” and “Laws Regulating 14. Select Committee on Population, U.S. House of
the LJ.S. Export of Drugs and Devices: Options for Representatives, hearings on The Depo-Provera
the Future, ” OTA working papers, 1981. Debate, 95th Cong., 2d sess. (Washington, D. C.:
6. Demkovich, L. E., “Drug Companies Plead With U.S. Government Printing Office, 1978).
Congress: Don’t Shortchange LJs on Patents, ” Na- 15. Silverman, M., The Drugging of the Americas (Ber-
tional Journal, 12(47): 1980-83, 1980. keley and Los Angeles, Calif.: University of Cali-
7. Fraser, I. S., and Weisberg, E., “A Comprehensive fornia Press, 1976).
Review of Injectable Contraception with Special 16. Sinde// v. Abbott Laboratories, 26 Cal. 3d 588, 607
Emphasis on Depot Medroxyprogesterone Ace- P. 2d 924 (1980) cert. denied, 49 USLW 3270
tate, ” “l%e A4edica/ Journal of Ausfraiia, 1(1) (spe- (198,0).
cial supplement): 3-19, 1981. 17. U.S. Agency for International Development, f?e-
8. Grayson, G. S., A. H. Robins Co., personal com- port to USAID of the Ad Hoc Consultative Panel on
munication with the Office of Technology Assess- Depot Medro~+vprogesterone Acetate, 1980.
ment, 1980. 18. Wegman, M. E,, Professor of Public Health, Uni-
9. Hubbard, W. N., Jr., President of the Upjohn Co., versity of Michigan, testimony before the U.S.
testimony before the U.S. House of Representa- Senate, Select Committee on Small Business, Sub-
tives, Select Committee on Population, in Select committee on Monopoly, hearings on the Present
Committee on Population, U.S. House of Repre- Status of Competition in the Pharmaceutical Indus-
sentatives, hearings on The Depo-Provera Debate, try; Pharmaceutical Company Practices in Labeling
95th Cong., 2d sess. (Washington, D. C.: U.S. and Promoting Prescription Drugs Sold in Latin
Government Printing Office, 1978). America, 94th Cong., 2d sess. (Washington, D. C.:
10. Huff, S., G. D. Searle and Co., personal com- U.S. Government Printing Office, 1976).

chapter 7
Factors That Affect the
Distribution, Acceptance, and
Use of Family Planning in LDCs

Contents

Page

nBbktNo.

#
chapter 7

Factors That Affect the


Distribution, Acceptance, and
Use of Family Planning in LDCs

123
124 ● World Population and Fertility Planning Technologies: The Next 20 Years

,
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 125

Points of intervention and choice


The adoption of family planning can have a di- Most women are fecund (capable of bearing
rect and important impact on the reduction of children) from age IS to about age 45 and most
population growth. LDC government leaders, men are able to sire children throughout adult
aware of the potential benefits of family plan- life. The decision to have a child, or to use a con-
ning programs and faced with the prospect of traceptive, is influenced by both past and pres-
the doubling of many of their populations over ent conditions. Recent research centers on the
the next 25 years, are giving greater attention to four factors that have the greatest direct impact
the status of family planning in their countries. on fertility (see ch. 4):
The findings are often contradictory:
● age at marriage and proportion married;
● An average of 50 percent of married . lactation (breastfeeding);
women in LDCs report that they want no . induced abortion; and
more children, yet from 25 to 90 percent of ● contraceptive use.
these women do not now practice contra-
ception. (Asian and Latin American esti- Efforts to change fertility rates by changing the
mates; data from Africa are not yet avail- relative influence of these factors, which are in
able.) turn influenced by such indirect determinants
● Variations in contraceptive use are enor- as community attitudes about contraception,
mous. Contraceptive prevalence rates levels of education, income, and family relation-
range as high as 70 percent and as low as 2 ships (fig. 22) can have unanticipated results.
percent of currently married women in The socioeconomic determinants affect fertility
LDCs. in ways that are only partially understood. Nev-
● Many women in LDCs report having from ertheless, their influence is extremely impor-
one to as many as three more children than tant. For example, fertility has declined at a
they wanted. The policy implications of this more rapid rate in Colombia, Thailand, and
acknowledged unwanted fertility—of chil- South Korea, which have relatively high socio-
dren already born–are important in that economic settings, than it has in the lower in-
resulting fertility rates are one-third to one- come countries of Bangladesh, Pakistan, and
fourth higher than these women desire. Kenya, but the relatively low-income country of

Figure 22.— The Pattern of Influence of Direct and Indirect


Factors on Fertility
126 ● World Population and Fertility Planning Technologies: The Next 20 Years

Indonesia (Java and Bali) has also experienced icy. The type of policy and the rationale and
rapid fertility decline. support for that policy influence the country’s
population growth rate. A second crucial point
Because contraceptive use has become in-
of intervention/choice is the determination of
creasingly important in reducing fertility, fam-
the structure, form, and function of a family
ily planning programs focus on this interven-
planning program. Some governments choose to
tion. Yet policies and programs that are multi-
keep programs and their implementation entire-
faceted–that simultaneously take account of
ly under official control; others choose to keep
both the other primary factors and the indirect
programs exclusively in the private sector; still
influences listed in figure 22—are the most like-
others choose a combined approach. A third
ly to be successful. This chapter examines the
point of intervention/choice is the selection of
results of directed or undirected changes in the
delivery system or systems used to implement
four direct factors listed above.
the program. These systems include IEC efforts.
At least five separate levels of interaction can Intervention and choice also operate at the com-
be distinguished. Each is a point of both in- munity level. Social structure, culture, personal
tervention and choice. At each point choices are networks, and voluntary groups all come into
available and decisions must be made (fig. 23). play, but the most important decision is that of
At the government level, a point of interven- the individual, who chooses whether to adopt
tion/choice is the formation of population pol- family planning. All governmental or orga-

Figure 23.—Selected Points of Intervention and Choice

Program Implementation
Contraceptive methods available
IEC activities
Logistical support
Training and infrastructure capability
Demographic data and program evacuation support
Delivery system
User access to delivery points
Data collection/evaluation
Community perspective
1. indigenous social, economic, and political organizations
2. Midwife and auxiliary health personnel

SOURCE: Office of Technology Assessment


Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 127

nizational interventions can be effective only to intimate part of human life. Awareness of the
the degree that they affect individual behavior. individual and social factors impinging on this
process can help to avoid the mistaken view of
modern contraceptive methods as “technolog-
ical fixes” that can, by themselves, lower fertil-
ity rates. one of the most important and encour-
aging findings of recent years is that family
planning attitudes and behavior can change
rapidly. Population programs thus need to be
Fertility change is an interactive, dynamic designed to take account of individual rights
process in which individuals, groups, and gov- and cultural values while educating individuals
ernments seek to modify the attitudes, customs, and helping them to change. This chapter high-
and behavior that surround the most personal, lights the complexity of this process.

Individual concerns: the user perspective


When I think of all the things I ate or swal- tions and attitudes influence her choice. (See
lowed, hoping that they would prevent me from table 29 for categories of influences.) For exam-
having another child! But they didn’t work. Now ple, a woman might perceive the side effects (ir-
it is better because I have an IUD. (A village regular menstrual patterns) of a contraceptive
woman, Mexico) (10) injection as intolerable over a long period. Yet
The perceptions of the individual—based on she might find them tolerable when she and her
the degree of benefit expected from contracep- husband have agreed that she will be sterilized
tive use, and the expected duration of that ben- but she must wait 6 months until a sterilization
efit—determine whether he or she will use a team visits the village.
fertility planning method. Because individual
fertility behavior is both the impetus for and the Table 29.-Types of Influences That Pertain to
target of family planning systems, individual the Acceptance and Continued Use of
Contraceptive Methods
needs must be respected and incorporated into
these systems.
Although a significant proportion of males use
condoms and some elect to be sterilized, most
contraceptives are used by women and this sit-
uation is unlikely to change greatly in the near
future. This section is thus devoted to the in-
dividual woman’s perspective. (See Community
Concerns for a discussion of what is known
about male attitudes toward family planning
and use of contraception.)
The myriad influences on a woman’s decision
to adopt family planning include not only the at-
titudes of her husband, family, and social net-
works but also the availability and cost of
methods. Moreover, the impact of various fac-
tors is different depending on her status, age,
and the number of children she already has.
Once she decides to use a method, her percep-
128 . Wor/d Population and fertility Planning Technologies: The Next 20 Years

Latent demand for family planning a high of 47 percent in Bangladesh and more
than 30 percent in Korea, Sri Lanka, and Peru to
WFS data provide good evidence of the latent a low of 12 percent in Costa Rica.
demand for contraception in their measure-
ment of the percentage of women who want no Rates of contraceptive knowledge–knowl-
more children yet use no contraception. Al- edge of at least one modern family planning
though this measure may be inflated because method—are high in these countries, with the
some women who want no more children exception of Nepal, where only 21 percent of
would not use contraception even if readily women know of a modern method. Rates in
available because of pressures from peer group, Bangladesh and Indonesia (81 percent), Kenya
family, or spouse, it does provide a useful (88 percent), and Pakistan (71 percent) fall into
estimate of unmet demand for family planning the middle range, but in all other countries for
services. which data are available, 90 to 100 percent of
women know of modern contraceptive methods
The proportion of “exposed” women (those (15).
currently married, nonpregnant, and fecund—
capable of childbearing) who want no more Women in countries where WFS surveys
children varies from a low of 17 percent in were conducted were also asked if their most
Kenya to a high of 74 percent in Korea (table recent pregnancy was desired. Although their
30). The estimates of unmet demand are con- answers provide a conservative estimate of un-
tained in column 2 in table 30; they range from wanted fertility because many women are likely
to rationalize a child as wanted after it is born,
the levels of admitted unwanted fertility are
Table 30.—Percentage of Exposed” Women Who striking (fig. 24). For example, when women in
Want No More Children, Percentage Not Currently Peru and Colombia complete their childbearing,
Using Contraception, and Estimates of Unmet Need they have an average of 2.75 and 2.19, respec-
for Effective Contraceptive in 15 LDCs
tively, more children than they wished to have
Of all currently (table 31). In national terms, the percentage of
married women,
percent who are unwanted births constitutes about a third of all
exposed and want births in Peru and Colombia and a quarter of
no more and are
not using those in Panama and Sri Lanka. The lowest rates
Of exposed women,
percent who want Any Modern of unwanted fertility are observed in Indonesia
no more children method method and Korea. In Korea, high rates of induced abor-
Asia ● nd Pacific tion make unwanted fertility rates correspond-
Bangladeshb . . . . . . . . 64 47
Indonesia . . . . . . . . . . . 40 ingly low (50)0
South Korea . . . . . . . . . 74 ::
Malaysia . . . . . . . . . . . . 46 22
Nepal. . . . . . . . . . . . . . . 30 21 Cultural values and the adoption of
Pakistan . . . . . . . . . . . . 42 27
Sri Lanka. . . . . . . . . . . . 62 31 family planning
Thailand . . . . . . . . . . . . 61 22
Latin America Why do large numbers of women admit to
Colombia . . . . . . . . . . . 22 wanting no more children or to having more
Costa Rica . . . . . . . . . . 7
Dominican Republic . . 17 children than they wanted, yet use no con-
Mexico . . . . . . . . . . . . . 21 traception despite high levels of knowledge of
Panama. . . . . . . . . . . . . 14
Peru. . . . . . . . . . . . . . . . 25 contraception? Among the many possible con-
straints to contraceptive use—lack of supplies,
Africa
Kenya . . . . . . . . . . . . . . 17 NA NA fear of side effects, antipathy of the hus-
band—personal attitudes and customs appear to
play a major role. Individual cultural traditions,
sexual taboos, and attitudes toward menstrua-
tion, sexuality, childbearing, and “proper” sex
role behavior can strongly influence the ac-
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 129

Figure 24.—Levels of Unwanted Fertility in Selected LDCs

I RC
7.47

6;.16

Sc SC RC
5.40 RC
5.34 SC c

Colombia Panama Peru Indonesia Korea Sri Lanka

ference, London, 1980.

Table 31.— Probability of Ever Having an Unwanted


Birth and the Cumulative Unwanted Fertility Rate per
Woman by Interval (Years) Since the Last
Wanted Birth

Years since
last wanted South Sri
birth Colombia Panama Peru Indonesia Korea Lanka
Cumulative unwanted fertility rate
1. . . . . . . . 0.03 0.04 0.05 0.01 0.01 0.02
2 ........ 0.31 0.20 0.30 0.07 0.09 0.17
3 ........ 0.55 0.39 0.80 0.21 0.31 0.37
4 ........ 0.73 0.52 0.82 0.32 0.43 0.52
5 ........ 0.89 0.64 1.04 0.39 0.53 0.62
10 . . . . . . . . 1.48 1.06 1.82 0.59 0.91 0.98
15 . . . . . . . . 1.93 1.33 2.41 0.72 1.06 1.16
20 . . . . . . . . 2.19 1.55 2.75 0.76 1.12 1.26

SOURCE: C, W. Westoff, “Unwanted Fertility in Six Developing Countries,”


paper presented at World Fertility Conference, London, 1980.
Photo credit: Agency for International Development

Village family in a remote sector of Madhya Pradesh, India


130 • World Population and Fertility Planning Technologies: The Next 20 Years

ceptance and continued use of contraceptive to bereassured that the flow will not necessar-
methods. ily be less, or that the shorter duration is not
harmful.
Women in the Philippines, Korea, Indonesia,
and Mexico rated the four most important at- Although some women in this 10-country
tributes of a contraceptive as: 1) effectiveness; study believe that menstruation is like an illness,
2) absence of side effects and convenience; they do not necessarily behave as though
3) route of administration (oral, injectable, or unwell. Conversely, those not holding this belief
vaginal); and 4) frequency of use. There were were found to exhibit the greatest behavioral
cultural differences in preference for route of changes during menstruation. Even though the
administration, with the vaginal route generally women studied said they wanted no changes in
least preferred (11). As the most frequent rea- their bleeding patterns, many of them—and
son cited for discontinuing use of a method is many women in other countries—are currently
the presence of side effects (20), priorities may using injections and orals that do in fact change
depend on whether women are simply rating the volume and duration of blood loss and do
their preferences for attributes of contracep- sometimes cause amenorrhea. Among the trade-
tives in the course of a survey or actually using offs in the process of deciding whether to use an
a method. injection method, efficacy and ease of ad-
ministration may be more important than
Women’s perceptions of menstruation vary
changes in menstrual cycle. Such considerations
widely. Because many contraceptives change
as need for surreptitious use of a method or un-
menstrual patterns, these perceptions can hin-
availability of other contraceptive methods may
der—or sometimes enhance—acceptance of par-
also come into play.
ticular methods. Rural and urban women from
14 cultural groups in 10 countries—Egypt, India The knowledge that beliefs are often incon-
(Hindu High and LOW Caste), Indonesia (Java- sistent with behavior can be put to creative use
nese, Sudanese), Jamaica, Korea, Mexico, in the delivery of services. The IUD was unac-
Pakistan (Punjab, Sind), Philippines, United ceptable in the Indian village of Bunkipur
Kingdom, and Yugoslavia (Moslem, non- because the indigenous interpretation of its
Moslem)–expressed reluctance to use a method mechanism of action conflicted with cultural
that produces amenorrhea. They feel that definitions of health. The people of Bunkipur
menstrual bleeding offers regular reassurance divide their world (food, religion, medical
that they are able to bear children and denotes system, etc.) into “cold” and “hot” attributes,
youth and femininity, provides evidence that which must be properly balanced in order to
they are not pregnant, and indicates that the maintain equilibrium. Villagers believe that the
body is eliminating impure blood. Many women IUD functions by “increasing the heat in a
feel that if “bad blood” is not removed, disease, woman’s genital region above the threshold at
failing eyesight, and mental illness are likely to which conception can occur.” Under normal cir-
ensue. Women tend to confuse the duration of cumstances this heat production is perceived as
their menstrual periods with the amount of acceptable, but should the individual contract a
flow. Light bleeding was equated with 1 to 3 disease perceived as hot—such as smallpox,
days duration and heavy bleeding with 6 or diarrhea, or venereal disease—the combination
more days duration (52). If family planning pro- would induce too much body heat and the in-
viders are to be sensitive to individual concerns, dividual would die (38). By contrast, perceptions
they must be certain that side effects that pro- of hot and cold can evoke a positive reaction to a
duce amenorrhea are fully understood by the device such as the IUD. In one Mexican village,
user and that she is aware that she will not suf- where the IUD is interpreted as cold and the
fer disease or hold ‘(impure” blood in her body if uterus as hot, villagers believe that after about 3
she adopts a particular method. If a method months the IUD takes on heat and becomes
decreases the duration of flow, the user needs compatible with its uterine environment (39).
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 131

An intriguing example of integrating a con- fears: they believe that conception occurs
traceptive into local cultural religious practices through the union of male and female blood or
and beliefs comes from the Indonesia family liquid. As oral contraceptives are thought to
planning program. A family planning official of prevent conception either by weakening the
West Sumatra, a physician, became interested blood of one of the partners, which causes “ill
in giving birth control pills to women in such a health,” or by destroying the joined male and
way as to prevent menstruation during the female blood in the uterus, many women hesi-
sacred observance of Ramadan, when Muslims tate to use them. And since the pill must be
fast from sunrise to sunset. A menstruating taken daily, it is believed that its constant action
woman is regarded as ritually unclean and thus allows no time for recuperation. The injectable,
may neither participate in the fast nor pray in however, is administered every 3 months, and is
the mosque. He reasoned that many women thought to give sufficient time for the blood to
would wish to inhibit menstruation during regain its strength. These beliefs, which rein-
Ramadan, and having overcome their initial re- force a desire to curb family size, and effective
luctance to use the pill would be motivated to instruction regarding the harmless effects of
continue its use. According to custom, women possible amenorrhea, account for much of the
may “pay back” missed days after Ramadan is success of the injectable in this setting (37).
over but receive less pahala (grace from God)
for these days. A three-cycle pill had been used Misinformation about reproductive anatomy
elsewhere; this pill was approved for use and as and function can also cause resistance to the use
the “Ramadan pill” has become a part of the pro- of fertility planning methods. Some women in
gram (9). Mexico and the Dominican Republic voiced
fears that an IUD would either be lost, appear in
Decreased sexual desire, especially among various openings in their bodies, or cause them
males, is perceived as one of the most salient to interlock with their mates during intercourse
disadvantages of any method, yet a method that (38).
increases sexual desire is not necessarily more
acceptable. Some Indian males, for example, be- Clinic locations and hours of operation are im-
lieve that vasectomy increases sexual desire, but portant, though sometimes in unexpected ways.
this factor is unacceptable because Hindus be- Women in a Barbados village, ignoring the clinic
lieve that semen is an important source of specifically set up for them, journeyed instead
strength that should not be depleted by high to a clinic an hour’s bus ride away in order to
frequency of sexual intercourse (38). Never- keep their attendance a secret. Clinics should
theless, vasectomy becomes acceptable when also be open at hours other than those during
Indian men are informed that vasectomy allows which women must do their chores.
the semen to remain in the body, thereby pre-
Lack of privacy is a major problem in family
serving virility, youth, etc. (23).
planning clinics in many countries. A study in
In some instances, attitudes.likely to prejudice Equador found that clinic personnel failed to
people against a method can be mitigated by take account of their women patients’ sense of
more pervasive beliefs. In one Mexican village modesty. Women in Guayaquil are shy about
where, except for postpartum amenorrhea, their sexuality. They are expected to be chaste
amenorrhea is greatly feared and is widely be- at marriage, and to display no enjoyment of sex-
lieved to cause ill health, hemorrhage, and ual activity. Menstruation is not discussed, and
tumors, women often resort to herbal teas and undressing in front of their husbands causes
injectable medications to induce menstruation. embarrassment. A clinic visit is at best a difficult
Contraceptive agents that induce amenorrhea undertaking for these women, but the clinics in
would thus be expected to be totally unaccept- question made it virtually impossible by inter-
able in this setting. Yet the villagers there accept viewing them within hearing distance of other
a 3-month injectable that causes amenorrhea patients, by requiring them to undress in front
because other beliefs supersede these basic of male physicians (and remain nude, without

84-587 0 - 82 - 10
132 ● World Population and Fertility Planning Technologies: The Next 20 Years

gowns or drapes, while being examined, and by functions and local attitudes toward sexuality
asking irrelevant personal questions. Pref- cannot be overstated. Program planners must
erence for female physicians is documented in also be aware of the importance of waiting time
India, Puerto Rico, Honduras, Brazil, and for clinic patients. In many LDCs lengthy
Muslim countries (37, 38). waiting times are apt to lead to client dissatisfac-
tion, but in some cases this interval may provide
The kind of information clients are pleasurable social contact for village women, be-
given–how much or how little they are told, coming an inducement to visit the clinic and to
and the attitudes of those giving the informa- accept and continue to use family planning.
tion—can also hinder adoption of contraceptive
methods. Women seated in a room where clinic As providers of family planning services often
staff members lecture to them, who are given favor different methods than do their clients,
no chance to ask questions, may feel too uncom- the distribution of types of methods used in
fortable about the subject matter to acquire the particular countries may be less a function of
motivation needed to successfully use a method. what is preferred than of what is available. In a
In one clinic in the Dominican Republic, pro- recent study of user preferences in India,
spective pill users were told: Korea, the Philippines, and Turkey, the pattern
You cannot take them in a disorganized man- of contraceptive selection differed from the
ner, or ever stop taking them, or lend them, or previous pattern in each clinic after providers
borrow them because these pills are hormones were trained to give balanced presentations of
and every one has a distinct function in the body the three methods available—pills, IUDs, or in-
and if you take them incorrectly, a tremendous jectable. For example, in Korea for a year prior
lack of control will occur and it will be a long to the study, 36 percent of the patients had used
time before it is corrected. Ladies, do not stop IUDs and 64 percent pills. When freedom of
taking the pills at any time. If you do stop, it will choice was encouraged, 50 percent chose the
cause hemorrhaging. (37). IUD. There were also rural-urban differences;
The necessity for clinic administrators and rural women in India and Turkey preferred in-
staff members to fully understand both the level jectable, while these differences were not
of their patients’ knowledge of reproductive significant in Korea.

Community concerns: The sociocultural perspective


I am tired. Look at me. I am nothing but a beast ban migration accelerates, governments are in-
working in the fields and bearing all these creasingly attempting to provide people with al-
children. I don’t want any more children, but my ternatives that will allow them to remain in
husband says I must have as many as come (A rural areas. Because the community is usually
village woman, Kenya). the local economic, political, cultural, and social
As for religion, its importance in this connec- base, existing organizations and structures can
tion varies. Just 1 week ago, a woman came and be utilized to promote family planning accept-
said that she wanted to have her IUD removed ance, and community level interactions will con-
because she wanted to take communion in tinue to have a significant impact on the adop-
church. The priest had told her that if she had tion of small family norms and the utilization of
an IUD he would not give her the sacrament (A
Mexican doctor) (10). fertility planning methods.

Most people in LDCs live in rural commu- It is extremely difficult to predict the most im-
nities, which provide excellent settings for portant factors in people’s decisions to use con-
many development efforts, including family traception. In comparing Venezuelan and Ken-
planning programs. As the pace of rural to ur- yan women’s motivations to adopt family plan-
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 133

each other, their friends, family, and their


children. In most countries men play a domi-
nant role in the major decisions of everyday life.
This decisionmaking power—and the extent to
which women share in it—has a significant im-
pact on whether a couple will choose to limit the
size of their family and adopt family planning.
Family planning programs have historically
regarded women as the focus of their efforts.
Until recently little attention was paid to the in-
fluences of male dominance, male decisionmak-
ing, and spousal communication in the motiva-
tion to adopt and use family planning methods.
In surveys on the value of children undertaken
in seven Asian countries, wives mentioned
much more frequently than husbands that chil-
dren restricted their activities. In questions on
attitudes toward children, women more fre-
quently responded that “children tie me down”
or “prevent me from doing things” (table 32).
In most LDCs, wives bear most of the burdens
and receive few of the benefits of raising large
families. A cogent example of these differences
is given in the summary of a recently completed
survey on male and female attitudes toward
family planning in Mexico:
There exists ‘(widespread” conflict between
men and women. The majority of men reject the
idea that women should be permitted to work
outside the home, while the majority of women
endorse this proposition. The majority of men
think women are better wives when they have
many children, while the majority of women
disagree and view women with few children as
intelligent, fortunate, concerned about their
children, and blessed with considerate,
understanding husbands. Many men express
fears that their wives will become adulterous if
they use contraceptives, and many women
believe their husbands wish to keep them tied
down with pregnancies so that their power and
control over the wife will remain unthreatened
(33).
Because of traditional male attitudes, where
husbands dominate fertility decisions, perceive
the costs of childrearing differently than wives,
and believe that women are better off and more
trustworthy if they are not using contracep-
134 ● World Population and Fertility Planning Technologies: The Next 20 Years

Table 32.—Frequency of Responses to Attitudes Toward Chiidren


(respondents could give multiple answers)

Children tie Prevent me from


me down doing things Fulfillment
Country Females Males Females Males Females Males

SOURCE: R. A. Bulatao, “On the Nature of the Transition In the Value of Children,” papers of the East-Weet Population ln-
stitute, No. 60A, Current Studies on the Value of Children, March 1979, Honolulu, Hawaii.

tives, there will be substantial pressures for likely to state that the men make the final deci-
high fertility. sion. This same pattern prevails in Mexico,
where more women felt that men had the ulti-
In a comparison of attitudes toward family
mate say (20 percent) than did men (12 percent).
size in Malaysia and Thailand, Malaysian hus- Although there is disagreement as to who in-
bands and wives were found to differ frequent- itiates the discussion of whether to use con-
ly about ideal family size and especially about
traceptives and who makes the final decision,
the desired sex distribution of children. In
there is ample and consistent evidence that the
Thailand, interestingly, spousal attitudes tended role of the husband is extremely important in
to be very close. When asked whether they the adoption and continuing use of a method.
wanted additional children, 71 percent of the
couples agreed (in 51 percent of the couples nei- In the WHO study of user preferences (53),
ther wanted more and in 20 percent both when women were asked why they were using
wanted more) (43). In Thailand, men and women or would use particular methods, one of the
have relatively equal status, especially in most frequently cited reasons was that the hus-
comparison with other LDCs. band liked or would like the method. More than
During a 1977 conference in West Africa, the half of the women in India and Turkey reported
participants, predominantly African women, that the choice of method was made with or by
emphatically stated that ‘(African women did the husband. In the Philippines and Korea,
not need to be reminded of the benefits of small- fewer than half of the women reported a joint
er families; African husbands did.” At another decision. Joint decisions were more often asso-
meeting a West African man stated, “Men here ciated with IUD use, which may be because the
are never sterile, only women are.” That is, a husband can sometimes feel the IUD string dur-
woman who is barren for a certain amount of ing intercourse.
time will take a clandestine lover to assure her
In Iran, where women at selected clinics who
husband of offspring, Both will derive status
were given oral contraceptives showed very low
from offspring but the responsibility is hers. If
continuation rates (only 12 percent after 6
she fails to produce she will be divorced or her
months), husbands were asked to participate in
husband will take an additional wife.
family planning and encouraged to supervise
Husbands and wives sometimes disagree as to pill use; during the next 6 months the continua-
whose decision is final. Results from surveys in tion rate rose to 93 percent (35). In Jamaica, the
Santiago and São Paulo note that although the primary reason given by women for discontinu-
men feel that husbands and wives are about ing contraceptive use was the objection of their
equally concerned with the number of children male partner. In Santiago, Chile, among couples
and most men report sharing in decisions on in which the husband was in agreement with
family size with their wives, women are more contraceptive use, nearly 75 percent had used
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 135

contraception, but among couples in which the are using a contraceptive method. If not, when a
husband was opposed to the use of contracep- worker comes to give the woman supplies, or
tion the figure was only 40 percent. In Kenya, during the course of an acceptor survey, the in-
Venezuela, and the Philippines, spousal com- terviewer can use a pretense for her visit if the
munication was critically important in decisions husband is at home. Although the use of subter-
to use contraceptive methods. The frequency of fuge between spouses raises difficult questions,
discussions on such topics as household budget, some women in LDCs are willing to take ex-
education of children, and contraceptive use is treme measures to avoid or delay pregnancy,
less important than the wife’s role in the deci- and welcome innovative means of introducing
sionmaking process and her degree of family planning into their lives. Women who are
autonomy in various family decisions. Women innovators in the use of contraception often
with more independence are more likely to use become enthusiastic supporters of family plan-
contraception (12,13,14). ning in their communities.
Women can manage to “beat the system”: When men agree that their wives should use
Juana was in her late thirties or early forties. family planning they often have reservations
Of her 15 pregnancies 8 children were currently because of misinformation about the safety, ef-
living. Although all her children had been de- fectiveness, and potential side effects of par-
livered by a midwife, discomfort after her fif- ticular methods. In one village in Mexico, 46 per-
teenth delivery sent her to a regional health cent of the women thought that their husbands
clinic, where she was told that another pregnan- would approve of their using contraception,
cy would endanger her life. She had an IUD in- usually for economic or health reasons. But
serted and then proceeded to figure out how to some were concerned that their husbands
involve her husband. She felt both guilt at having
taken such a step without consulting him and might change their minds while intoxicated, as
fear that he would find out and be angry. She ap- there had been episodes in the village when
proached an American woman, who was a clinic drunken husbands had attempted to remove
outreach worker, and asked her to help. She had their wives’ IUDs. Twenty-one percent of the
her “drop by” on a specific day, just when women had never discussed the issue with their
Juana’s husband would get home. She coached husbands and did not know what their reac-
her in great detail on bringing the subject up, tions might be. One-third of the women
beginning with a discussion of the new baby, the reported such negative attitudes as the desire to
doctor’s health warning, and then working have many children to gain prestige and to en-
around to family planning. She warned her sure the couple’s future economic security, fear
friend that she would not speak up in support of
the idea; all the approval had to come from her that if the wife used contraceptives it would
husband. The actual conversation took place just undermine the husband’s authority and en-
as Juana had predicted. When the discussion on courage her sexual autonomy, and fear that ill-
contraceptive methods began, Juana’s husband ness and even death might result from using
listed many concerns, not the least of which was contraception. Men’s fears, based on rumor and
that Juana’s personality would change. Juana did misinformation, are also recorded in a study in
not speak except to say, “whatever he wants” Guayaquil, Equador, where some men felt that
and to bring up potential problems the health the pill would “eat the red blood cells” or change
worker had not covered. The conclusion was a woman’s temperament, or that withdrawal
that Juana should have an IUD inserted, but only would make a man’s head swell up (36).
if the health worker accompanied her. The
woman had to fake a trip to the doctor for the in- Studies of male contraceptive use indicate that
sertion (36).
use of current methods (condoms and vasec-
Women who appear to play a secondary role tomy) can be expanded and new methods would
may actually be very good at manipulating their find considerable acceptance. In Ghana’s Danfa
husbands. In one African clinic, women are project, men’s continuation rates were higher
asked whether their husbands know that they than women’s, although this was attributed to
136 ● World Population and Fertility Planning Technologies: The Next 20 Years

their extramarital or premarital affairs, during able to stop having children when their ideal
which there is strong motivation to prevent family size/sex ratio composition is attained (51).
pregnancy. There is some reserve among men
In Japan, Singapore, and Hong Kong fertility is
in many groups toward the use of condoms be-
low and son preference has diminished, largely
cause of their association with prostitutes.
as a result of social and economic development,
Groups of 150 rural and 200 urban men in Fiji,
urbanization, and increased opportunities for
India, Iran, Korea, and Mexico were asked to
women. The birth rate has fallen sharply in
evaluate the attributes of existing male methods
China, where, in a radical reversal of traditional
(condoms and vasectomy) and potential male attitudes, campaigns are now under way to en-
methods (a daily pill and a monthly injectable).
courage the one-child family. In these cam-
Willingness to use a daily male pill if available
paigns, a major emphasis is on reducing the
ranged from 48 percent in Fiji to 77 percent in
preference for sons by raising the status of
India. Somewhat lower proportions of men
women.
stated that they would use an injectable. Ap-
proximately one-third of the men reported that The implications of son preference are direct
they were currently using no method (11). and powerful. In societies where son pref-
erence is strong, women are directly affected
As better methods are made available to men,
from birth to death. For example, in India in
their responsibility for and involvement in fami-
1972, mortality among girls from birth through
ly planning is likely to increase. For the short
9 years of age was 8 to 23 percent higher than
term, it is important that family planning ad-
among boys, depending on the region of the
ministrators be aware of the influence men
country and the 5-year age group (7). Although
have on their wives’ fertility decisions and of the
girls die from the same causes as boys, boys
need to include men in family planning educa-
tend to be given better quality medical care and
tional efforts.
probably more food. As boys are also pref-
erentially educated, they have a better chance
Son preference to become economically self-sufficient. Women
“A daughter lets you down twice, once when often suffer from anemia and poor health
she is born and again when she marries. ” Korean because they must undergo many pregnancies
proverb (26) in rapid succession in order to assure sons for
their husbands. This cycle of female deprivation
The evidence that couples prefer sons is con-
is unlikely to be broken until women are given
sistent across all countries, including the United
opportunities to increase their self-sufficiency.
States. In many countries this preference is
This can be accomplished when governments
even more marked in women than in men.
undertake active campaigns to educate women
The importance of son preference to fertility (and men concerning new roles for women),
rates changes as fertility begins to decline. assure them equal economic opportunities and
Several factors are involved. Unless preferences legal protection, and convince society that
are strong there will be no fertility effect. The daughters can be as reliable as sons in assuring
amount by which the desired ratio within the the old age security of their parents.
family diverges from the natural ratio is impor-
tant; if the ratio is three or more boys to each Social networks and organizations
girl the effect will be greater than if it is just two
boys to one girl. Preferences for family size are Many existing networks and organizations
related; if family size is large—four or more can have marked impact on adoption and use of
children—son preference will not have an ap- contraceptives when they incorporate family
preciable effect on fertility because most planning efforts into their activities, especially
families will have at least one son, And if con- women’s organizations and traditional mid-
traceptives are unavailable, families will not be wives who can be trained to deliver family plan-
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 137

ning information and supplies. In Indonesia, and use and in improving the status of women
where the local infrastructure is well in the community. The clubs have branched out
developed, the family planning program has and now encompass cooperative agricultural ef-
specifically targeted community leaders and forts, community construction projects, and
local women’s groups as elements of the family income-producing activities (28).
planning effort.
Similar women’s organizations are becoming a
Mothers’ clubs in Korea are an outstanding ex- part of family planning program efforts in
ample of the role of voluntary organiza- Nepal, Thailand, and Egypt. Their leadership in-
tions-and of women—in family planning adop- cludes women professionals who join together
tion and rural development. Groups called Kae to help poorer women, and community political
had traditionally been formed by Korean activists who are selected and trained to help
women as revolving credit associations and lot- deliver family planning information and con-
teries to provide opportunities for women to ac- traceptives, usually pills (3). Women’s credit
cumulate funds for special purposes. The organizations in Nigeria and other African coun-
Korean National Family Planning Program tries are expanding their functions to include
decided to distribute contraceptive information family planning. These grassroots women’s
and supplies through these mothers’ clubs. groups can be encouraged to aid both family
Their goals were to encourage family planning planning efforts and rural development pro-
practice and continuation by example and grams (27).
through social and emotional support to users,
Sixty to 80 percent of births in LDCs occur at
to aid overburdened fieldworkers in recruiting
home. Hospitals are likely to be too far away or
new users and supplying contraceptives (pills
too expensive, and many women prefer to have
and condoms), to aid in the introduction of a
their babies delivered by local women whom
new method (the pill), and to encourage par-
they know. Midwives thus already play a vital
ticipation of women in community development
role in the community, and with training can
activities. These efforts were highly successful
improve and expand their services to include
both in increasing family planning acceptance
prenatal and postnatal care and family plann-
ing. In Thailand, 2-week training courses for
midwives on aseptic delivery, care of newborns
and mothers, nutrition, and family planning
have been held since the 1950’s. By 1968, some
16,000 women had been trained and provided
with UNICEF midwifery kits. In 1965, midwives
who used a coupon system to refer women to
clinics for IUD insertion were responsible for 5
percent of acceptors in the program’s first year.
A national program has been under way since
1978 to train all active and interested traditional
midwives under age 60; or about 80 percent of
the country’s total. Although the family plan-
ning aspects of this effort may have limited
results, improvements in overall maternal and
Photo credit: Agency for International Development
child health care are expected to be significant
Family planning worker explains IUD-use (8).
to Korean mothers
138 . World Population and Fertility Planning Technologies: The Next 20 Years

National concerns: The role of governments


Significant fertility declines are usually traception as a health measure, and as a human
associated with some or all of the following con- right, but as some actively encourage family
ditions that involve government policy and ac- planning while others take no direct role, the
tion with regard to population programs (order- actual availability of family planning informa-
ing does not imply relative importance): 1) tion and supplies varies widely. Most of the
governmental policies that encourage and pro- world’s 50 most populous countries are in
mote equal status and opportunities for women, Africa and Asia. But only 35 percent of African
higher age at marriage, and more equitable countries with high growth rates consider their
distribution of wealth and educational oppor- rates too high, while 75 percent of their Asian
tunities, all of which lead to a higher standard of counterparts hold this view. By contrast, 13 of
living; 2) programs designed to bring about a the 15 most populous countries consider their
decline in infant mortality; 3) a government fertility rates too high (table 33).
policy with explicit goals for reduction of birth
The process of policy formulation varies
or population growth rates; 4) a strong commit-
among countries because of differing political
ment to population planning by the country’s
and historical factors. In many countries, both
leaders; 5) a family planning organizational
the private sector and the demographic com-
structure with executive power to mobilize
munity have been instrumental in influencing
more than one government sector and to coor-
governments to formulate population policies
dinate with the private sector; 6) population
and implement family planning programs.
program funding (usually both external and in-
ternal sources); 7) provision of a broad range of Even when rapid population growth is seen
contraceptive methods; 8) sufficient numbers of by government leaders as a problem, cultural
well-trained and motivated family planning pro- and/or historical constraints may mitigate
gram personnel; 9) population and family plan- against the adoption of a specific policy of fertili-
ning information and communication efforts ty reduction and the implementation of a gov-
that effectively reach all sectors of the populace; ernment-sanctioned family planning program,
and 10) direct or indirect incentives that en- The contrast between Latin America and Asia
courage couples to limit the size of their fam-
ilies. The relative importance of these com-
ponents is not known because country settings
differ, and the nature of the country’s
developmental process and the level of certain
key indicators (life expectancy, Gross National
Product, nonagricultural labor force participa-
tion, literacy rates, etc.) affect the extent to
which program implementation efforts can suc-
ceed in lowering fertility. But the degree of
political will and commitment and the extent
of administrative capacity play major roles in
determining the magnitude of fertility decline.

Policy development and formulation


Although most LDC governments have some
policy with respect to population, their percep-
Photo credit: Agency for International Development
tions of whether population growth rates are
satisfactory differ greatly. Nearly all govern- Family planning slogan that has become famous
ments allow access to modern methods of con- throughout India reminds cyclists that “two are enough”
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 139

Table 33.—National Population Policies


Government policy
Policy and
interventions / Access
population growth to family
a
Perception of or birth planning
Country birth rate rate goals services %
1 China . . . . . . . . . . . . . . . . . . . . . . H – (BR) 4
2 India . . . . . . . . . . . . . . . . . . . . . . . H – (BR) 4
3 Indonesia. . . . . . . . . . . . . . . . . . . H – (PG) 4
4 Brazil . . . . . . . . . . . . . . . . . . . . . . s o 4
5 Bangladesh . . . . . . . . . . . . . . . . . H – (BR) 4
6 Pakistan. . . . . . . . . . . . . . . . . . . . H – (BR) 4
7 Nigeria . . . . . . . . . . . . . . . . . . . . . s o 3
8 Mexico . . . . . . . . . . . . . . . . . . . . . H – (PG) 4
9 Vietnam . . . . . . . . . . . . . . . . . . . . H – (PG) 4
10 Philippines . . . . . . . . . . . . . . . . . . H – (PG) 4
11 Thailand . . . . . . . . . . . . . . . . . . . . H – (PG) 4
12 Turkey . . . . . . . . . . . . . . . . . . . . . H – (BR) 4
13 Egypt . . . . . . . . . . . . . . . . . . . . . . H – (BR) 4
14 Iran . . . . . . . . . . . . . . . . . . . . . . . . H –(PG) 4
15 South Korea . . . . . . . . . . . . . . . . . H –(PG) 4
16 Burma . . . . . . . . . . . . . . . . . . . . . s o 2
17 Ethiopia . . . . . . . . . . . . . . . . . . . . s o 3
18 South Africa . . . . . . . . . . . . . . . . H — 4
19 Zaire . . . . . . . . . . . . . . . . . . . . . . . s o 3
20 Argentina . . . . . . . . . . . . . . . . . . . L + 1
21 Colombia . . . . . . . . . . . . . . . . . . . s o 4
22 Afghanistan . . . . . . . . . . . . . . . . . H o 4
23 Morocco . . . . . . . . . . . . . . . . . . . . H –(BR) 4
24 Algeria . . . . . . . . . . . . . . . . . . . . . s o 4
25 Sudan . . . . . . . . . . . . . . . . . . . . . . s o 4
26 Tanzania . . . . . . . . . . . . . . . . . . . s o 4
27 North Korea . . . . . . . . . . . . . . . . s = 4
28 Peru . . . . . . . . . . . . . . . . . . . . . . . s o 4
29 Kenya . . . . . . . . . . . . . . . . . . . . . . H –(PG) 4
30 Venezuela . . . . . . . . . . . . . . . . . . s o 4
31 Sri Lanka . . . . . . . . . . . . . . . . . . . H –(BR) 4
32 Nepal . . . . . . . . . . . . . . . . . . . . . . H –(BR) 4
33 Malaysia . . . . . . . . . . . . . . . . . . . s o 4
34 Uganda . . . . . . . . . . . . . . . . . . . . H — 4
35 Iraq . . . . . . . . . . . . . . . . . . . . . . . . L + 2
36 Ghana . . . . . . . . . . . . . . . . . . . . . H –(PG) 4
37 Chile . . . . . . . . . . . . . . . . . . . . . . . H o 4
38 Mozambique . . . . . . . . . . . . . . . . s = 4
39 Cuba . . . . . . . . . . . . . . . . . . . . . . . s o 4
40 Kampuchea . . . . . . . . . . . . . . . . . L + 1
41 Madagascar . . . . . . . . . . . . . . . . H o 3
42 Syria . . . . . . . . . . . . . . . . . . . . . . . s o 4
43 Cameroon . . . . . . . . . . . . . . . . . . L o 3
44 Saudi Arabia . . . . . . . . . . . . . . . . s = 1
45 Ecuador . . . . . . . . . . . . . . . . . . . . s o 4
46 IvoryCoast . . . . . . . . . . . . . . . . . s = 2
140 • World Population and Fertility Planning Technologies: The Next 20 Years

demonstrates the importance of historical, There are clear differences in outcome be-
political, and cultural traditions. In general, Asia tween policies with demographic objectives and
has had a relatively long tradition of govern- those aimed primarily at improving general
ment family planning programs while Latin health care. About two-thirds of the countries
America has traditionally relied on the private with policies to reduce population growth have
sector. Government policies have not always either strong or moderate programs. when the
been explicit in Latin America but government effects of social setting and population program
support has been unobtrusively provided to are compared, more specific policies are shown
private family planning efforts. Ness and Ando to be associated with greater declines in the
(22) argue that Latin America has implemented crude birth rate after controlling for social set-
few government programs because there must ting (table 34); only a high social setting can
be a perceived “legitimacy” for the government overcome a weak policy position. (Social setting
to implement such efforts. This legitimacy stems is an index of socioeconomic development level
from underlying value sets of the nation’s used by Mauldin and Berelson,)
cultural groups. In Latin America there is deep-
Three very important considerations lie
seated antipathy toward government-
behind policy as a level of intervention–the
implemented family planning among diverse
country’s degree of political commitment, its ad-
groups: conservatives oppose contraceptive use
ministrative capability, and the ability of
because of commitment to Roman Catholic
government planning and statistical agencies to
values; social reformers have supported limiting
analyze projects and programs with respect to
population growth but have been suspicious of
their population dynamics. Experience to date
the U.S. emphasis on family planning; and
indicates that a nation’s political elite must be
revolutionaries oppose population growth
committed to population planning efforts to the
limitation either from strict Marxist opposition
extent that it supplies the program—whether
to Malthusian theory or from objection to any
public, private sector, or both—with ample
social reform that reduces pressures for radical
resources, Highly qualified personnel must be
change. Because Latin America has a high pro-
chosen to administer the programs, bureaucrat-
portion of countries that support fertility reduc-
ic impediments to program effectiveness must
tion without specific public policies for fertility
be removed, and program goals given high
planning, successful family planning programs visibility in the government’s development plan.
require a substantial degree of commitment on Administrative capability is generally correlated
the part of strategic groups of leaders. Latin
with the country’s level of development; if levels
America’s general public appears to be in a
of skills are low and basic infrastructure is
greater state of readiness for serious collective
weak, institution-building must be a part of the
population growth limitation than do some of its
program. This is a slow, expensive undertaking.
leaders (22).
If infrastructure and skills are in place and only
By contrast, Asia has taken the lead in
government-sponsored fertility reduction pro- Table 34.–Decline in Crude Birth Rate (percent) by
grams. The greater penetration of modern colo- Social Setting and Nature of Family Planning Policy
nialism in Asia produced strong nationalist 1965=75
movements which led to strong political and
To reduce For other than
organizational commitment to economic devel- population demographic No program
opment and centralized economic development Social setting growth rate reasons and unknown
planning. These antecedents led, finally, to High . . . . . . . . . . . . 28(1 1) 21(7) 3(6)
Upper middle. . . . . 15(14) 4(6) 2(4)
political decisions for population growth limita- Lower middle. . . . . 7(4) 4(8) 2(1 1)
tion by planning authorities, justified largely on Low . . . . . . . . . . . . . 1(2) 1(4) 2(17)
economic arguments. These decisions led in Number of countries In parentheses.

turn to government organizations to promote SOURCE: P. W. Mauldln, B. Berelson, Z. Sykes, “Conditions of Fertility Decline
in Developing Countries, 1905-75,” Studies in Fare//y Planning 6(5):
fertility planning (22). 89-147, The Population Council, New York.
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 141

specific training programs are required, such goals, and to explain what family planning is
training programs can be very cost effective. and where services are available. IEC efforts
When the social setting is less than congenial to range from mass media campaigns to the infor-
the idea of family planning, political commit- mation that individual family planning workers
ment and administrative capability are crucial give personally to their clients. Knowledge of
(40). the ability to control one’s fertility favorably in-
fluences use of fertility planning methods; this
Decline in infant mortality use, in turn, increases knowledge and receptivi-
ty to education efforts which, in turn, increase
In the ongoing debate over the relationship use of family planning methods (49). This con-
between infant mortality and fertility, it has stant feedback process can occur quickly—as
generally been believed that infant mortality evidenced by the rapid spread of family plan-
rates must begin to decline before fertility rates ning in Mexico, Indonesia, Colombia, Brazil, and
will do so. The underlying assumption is that Thailand-and can establish family planning as
couples will continue to try to replace children a subject of open and free discussion.
who die in infancy until they have a sufficient
number to insure the survival of at least several.
Now, however, new evidence from the Euro- Strategies for the structure and func-
pean demographic transition and from many tioning of family planning programs
LDCs shows that fertility can begin to decline in Contraceptives have usually been available on
countries with high rates of infant mortality. a limited basis prior to the establishment of
When various neglect behaviors are im- government programs. Often the private sector,
plemented toward unwanted children, their including the medical profession and social
risks of dying rise, and high infant mortality scientists, has been active in alerting govern-
may be associated with high fertility (see also ment officials and the population’ in general to
Tech. Note A, ch. 4). Although the relationship is
the need for family planning services, These
complex, both MCH and family planning pro-
services have in may cases been provided by
grams respond to an important humanitarian local affiliates of IPPF.
need to reduce death rates among infants, their
siblings, and their mothers. In Colombia, the medical community and
voluntary organizations played a major role in
Demographic information, education, encouraging the government to adopt a popula-
and communication efforts tion policy and to sponsor and implement a
family planning program. The Colombian
Up-to-date demographic information and Association of Medical Schools (ASCOFAME)
statistics for program evaluation are crucial to through its division of Population Studies (DEP)
policy development, and to the implementation demonstrated the existence of the country’s
and functioning of family planning programs. population problems by gathering data on fer-
Reliable demographic information from cen- tility and rates of illegal abortion and by
suses and surveys must be available to inform generating awareness of Colombia’s demo-
government leaders of the dimensions of graphic situation among both medical and aca-
population growth in their countries. Data col- demic professionals and the Colombian people.
lection to document the initiation, growth, and Through the combined efforts of ASCOFAME,
change of programs is essential, as is the capaci- Profamilia (IPPF’s Colombian affiliate), other
ty to analyze demographic data and recognize government and private organizations, and ex-
the consequences of population growth in terms ternal support, public health personnel were
of a country’s economic and social goals. trained in the delivery of family planning ser-
Parallel to this demographic support are IEC vices, these services were made available, and
efforts to increase awareness of the effects of the government was encouraged to undertake a
rapid population growth on socioeconomic national program. Much of the institu-
142 ● World Population and Fertility Planning Technologies: The Next 20 Years

tionalization of family planning was thus taking Locating a program in the health ministry can
place while the government was formulating its cause problems if there is no vehicle (an ex-
policy. ecutive governing board or some form of coor-
dinating and executive power) to expand the
Governments must consider not only the program beyond the ministry. For example,
structure of their official programs but the health ministries are not usually equipped to
relative contributions and continuing roles of launch major education and information cam-
those organizations whose family planning ef- paigns, nor do they have the marketing skills to
forts precede the implementation of a national launch projects to distribute contraceptives
program. ASCOFAME, Profamilia, and the through commercial channels. In addition, the
health ministry continue to deliver services in health ministry usually focuses on maternal and
Colombia; each organization fulfills varying child health, which is important but often limits
roles according to its individual strengths. A male access to and involvement in family plan-
parallel experience is seen in Malaysia, where ning.
the private family planning organization and
government-run program work hand-in-hand. One strategy used by several countries is to
establish a coordinating board that has execu-
Most government family planning programs tive power to coordinate the various activities of
are located in health ministries or in the mater- a family planning program. Thus, as in the case
nal and child health sections of health minis- of Mexico, such a board can coordinate the ac-
tries. This is more likely to be the case when tivities of various ministries and the private sec-
policies are primarily aimed at health care, tor in order to reach populations with different
although many policies with specific characteristics. Mexico’s coordinating board
demographic objectives are implemented consists of the directors of the major sources for
through programs in the health ministry. Coun- health care and family planning in the country.
tries also have the option to rely heavily on the The board, called Coordination General del Pro-
private sector. In these cases the private sector grama Nacional de Planificacion Familiar, is
can include the medical community as well as under the direction of an executive coordinator
affiliates of such nongovernmental organiza- within the Ministry of Health, and is composed
tions as IPPF. Brazil is a country where cultural of all cabinet members and heads of institutions
and religious factors mitigate against a strong in the health sector, the Directors-General of
population policy at the national level while the Mexican Social Security Institute and In-
family planning activities proceed in various stitute of Social Security for Government
sectors through state governments and through Workers, the Undersecretaries of Planning and
extensive use of the medical community and of Health and Welfare, and the Director-General
nongovernmental organizations. The national of the National System for the Integral Develop-
government simply does not bar these activities. ment of the Family. The board coordinates and
streamlines the family planning effort of the ex-
Family planning programs located in health
isting public health infrastructure in order to
ministries can encounter problems when family expand services, especially to rural and margin-
planning priorities are submerged by the de- al zones, and is responsible for setting stand-
mand for basic health services. In Kenya, where ards, creating new programs, and monitoring
there are fewer than 15 doctors for each the activities of all family planning service
100,000 people and it is impossible for doctors organizations, public and private, in Mexico. It
to reach all patients even for the most basic of is a semiautonomous state agency with close ac-
health services, family planning becomes a low cess to the President through the Executive
priority health measure. In Korea, by contrast,
Coordinator and the Secretary of Health and
there are enough doctors to provide basic Welfare.
health care and they have been trained in family
planning, incorporated into the system, and Indonesia also has an autonomous coor-
paid for delivery of family planning services. dinating board. Indonesia’s first 5-year develop-
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 143

ment plan, introduced in 1969, set a target of 3 Ministries of health are typically weak in LDCs
million family planning users by 1973-74. The because of the severity of health problems and
National Family Planning Coordinating Board the lack of trained personnel. In the MCH ap-
(BKKBN) was set up as a separate board with proach, sick women and children are given pri-
direct responsibility for reporting to the presi- ority. If special hours and specific personnel are
dent on family planning activities. This board not delegated for family planning, services will
does not directly provide contraceptive services not be delivered. If the family planning budget
to the public; instead, it coordinates the work of is integrated into that of the health ministry,
the various ministries and private institutions funds earmarked for family planning may be
that provide contraceptives and conduct infor- diverted to more acute health needs. As MCH
mational and motivational campaigns. BKKBN clinics primarily serve women, there is little
employs fieldworkers who complement staff motivation or opportunity to incorporate men
from other ministries. into family planning activities. Services tend to
remain clinic based as health ministries rarely
Unfortunately, few data are available on how command the educational or marketing exper-
the structure of family planning organizations tise necessary to launch non-clinic-based pro-
relates to the effective functioning of the family grams, The rationale for integration into other
planning system. Some data are available from sectors—that a plateau is reached in a clinic
structure charts of organizations, but how com- based approach—may be valid but it may also be
munication channels work or don’t work and true that a weak administrative infrastructure
the implications of structure for the functioning causes a leveling off of new users of contracep-
of the system remain to be investigated (24). tion.
Integration of family planning with Even when there is a definite goal the process
other development programs of integration crosscuts several organizational
concerns. Are the linkages to be temporary or
The belief that integrating family planning long term? Which development sectors are to be
into other development and welfare efforts is linked? Is the linkage to be along administrative
essential to the success of family planning pro- or service lines, or both? Does the target
grams is being given wide currency at a time group-rural or urban, male or female, married
when the success of nonintegrated family plan- or single—warrant an integrated approach?
ning programs is being well-documented UNFPA has made a number of recommenda-
around the world. Questions thus arise about tions based on their examination of the ex-
the evidence supporting the efficacy of in- perience of several types of integration in
tegrating family planning with other programs. several countries.
The rationale for integration and the criteria
Integration of family planning with rural
used as evidence for its need must be carefully
development activities can help to improve the
examined. A government considering an inte-
program in specific circumstances:
grated program must first consider its goals, its
target population, the existing infrastructure, ● Because many rural people are extremely
and how the integration is to be carried out. poor and isolated, current clinic-based pro-
The process must be carefully planned because grams are unlikely to reach them, and link-
different procedural actions are required when ing family planning with other development
integration occurs at the service delivery level activities—especially with existing struc-
than when one ministry is to become a part of tures and with the rural community it-
another. self—can increase the availability of all ser-
“Integration” usually means integrating family vices.
planning with health or MCH. An inherent prob- ● Where there are politically influential
lem is that the addition of a new program to an groups who are averse to family planning,
already fragile program is apt to weaken both. programs can be linked to more popular
144 ● World Population and Fertility Planning Technologies: The Next 20 Years

Photo credit: Agency tor International Development

Mobile family planning unit visits a remote village in the Turkish countryside

services in order to make family planning effective when existing personnel are given
more acceptable. heavier workloads without being given the nec-
● It is preferable to focus on integration that essary additional resources (23)41,47). In gener-
links specialized services at the point of ser- al, integrating family planning with other devel-
vice delivery, and to approach with caution opment interventions works best at the service
integration that creates large umbrella ac- delivery level, when the needs of the target
tivities. Experience has shown that the group are carefully considered, and when in-
delivery of other services can be added terventions are simple and straightforward.
after the delivery of family planning ser- when a family planning service delivery system
vices is established, e.g., addition of oral is strong, other interventions can strengthen
dehydration kits to family planning out- the total program. In Thailand, for example, the
reach workers. Care must be taken not to local production of methane gas is among a
overburden workers with too many in- number of program interventions incorporated
terventions in settings where unmet health into the family planning commodities delivery
needs are acute. system. In Mexico, the distribution system set
up for the government’s PROFAM brand of con-
Although integrated programs may achieve traceptives-was so successful that a major pen
some long-run efficiencies and cost reductions, manufacturer asked to include the PROFAM
they require large investments in resources, es- network of pharmacies in its distribution
pecially in the beginning. Integration cannot be system,
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs • 145

Considerations governing the contra- tional and international levels among donors
ceptive methods provided who purchase commodities for LDC programs.

Among the most crucial choices a government For example, since costs are high, program
must make is that of the methods to be provided managers must have sophisticated knowledge of
in the country, both within and outside the pro- the exact contraceptive, packaging, labeling,
gram. Legal considerations and cultural and in- and quality control specifications they want if
dividual preferences must be carefully assessed. contraceptives are purchased from private-
Each method has its logistical requirements: sector companies. Costs can often be reduced if
supply considerations, warehousing support, bulk purchases are made. Purchasing from the
transport, need for specially trained personnel, private sector offers the advantage of a wide
specific types of information and education choice of products and, usually, high quality,
campaigns, knowledge of brands available, shelf prompt delivery, and good service. In contrast,
life, and cost. Import regulations apply or are purchase of contraceptives from manufacturers
determined by a government’s decision regard- that sell to donors such as AID, UNFPA, IPPF,
ing manufacture of contraceptives within the FPIA, etc., reduces cost and offers high quality
country, which must take into account the num- products and arrangement of procurement,
ber and kinds of methods to be distributed. Pro- shipment, and customs clearances. However,
duct safety and reliability considerations are im- only a limited choice of products may be avail-
portant, as is cultural acceptability, and who able. Given current high costs and the expected
will prescribe and who will use the methods. increases in use of contraceptives, many LDCs
will still prefer this route. It is also likely to be
Six major factors—in addition to cultural con- the best option for procurement of new contra-
siderations—generally determine the adoption ceptive methods because of the high costs
and use of fertility planning technologies by associated with other options.
governments and national family planning pro- Another option for an LDC government is to
grams and will continue to do so in the future. manufacture the commodities locally. (see app.
They are: 1) cost of the technologies, 2) ade- D for a detailed description of the logistic re-
quacy of information about the technologies, 3) quirements and processes involved in establish-
adequacy of sources of supply of technologies, ing local manufacture of contraceptives in
4) nature of government policies with respect to LDCs.) The major advantages of local manufac-
importing goods, 5) nature of laws, policies, and ture include the benefits of increased local em-
commodity financing arrangements pertaining ployment, technical skills, and output, and,
to the technologies themselves, and 6) capacity sometimes, reduced expenditures of foreign ex-
of program administrators to arrive at and change currency. packaging and labeling can be
implement technical decisions about these designed to meet local specifications and needs.
technologies. The interval between manufacture and use of
The fundamental problem that governs tech- product is reduced, which is especially impor-
nology transfer in the fertility planning field is tant for products with limited shelf life. Major
the still unresolved question of who will bear disadvantages include the difficulty of retooling
the very substantial costs associated with the for new technologies, the narrower range of
development, distribution, and use of both pres- choices available, and potentially higher costs.
ent and future technologies. Many future tech- Most importantly, unless a country is able to
nologies that could be of use in LDCs will be commit the technical and managerial resources
much more costly than existing technologies ei- necessary for the highly sophisticated produc-
ther because they will be sold at higher prices tion of contraceptives, problems with reliability
than current methods or because it will cost of manufacture and product quality can occur.
more to acquire the rights and technical capaci- If a government decides to build up local pro-
ties to manufacture them locally. These prob- duction capacity through strict foreign ex-
lems of cost will have to be resolved at both na- change controls and import substitution poli-
.

146 ● World Population and Fertility Planning Technologies: The Next 20 Years

cies, planning and finance ministries will find it ministrator must not only be aware of user
difficult to approve the purchase of new tech- preferences and logistical requirements, but
nologies manufactured abroad. And, as was dis- have up-to-date information and be able to
cussed in chapter 6, because new methods are assess medical properties of the methods. These
most likely to be developed in MDCs in the next considerations are likely to become more com-
20 years, governments will need to import plex as overall prevalence rates increase and as
them, at least until they can establish local new methods are introduced.
manufacturing capabilities. Because govern-
ments are likely to favor local production in the Commercial retail sales and
future, there could be severe delays in local community-based distribution systems
availability of many new technologies and
blocked access to others. When a country has determined the structure
of its program, the development of service-
In addition to these economic considerations, oriented operational strategies is needed.
technical and programmatic factors determine
Governments can choose clinic-based systems
the method mix in LDCs now and will continue for government-provided services, heavy re-
to do so in the future. The importance of the ef-
liance on existing health facilities and utilization
fective dissemination of information about the
of private physicians, distribution through
technologies, on which the transfer of technol-
nongovernmental private voluntary organiza-
ogy depends, cannot be exaggerated. For exam-
tions, retail sales distribution systems, or
ple, there are three major variants among IUDs,
community-based distribution systems, or they
and these are further subdivided into almost
can mobilize all of these sources. Among the in-
100 specific products or techniques, Oral con-
novative approaches in current use are com-
traceptives are available in more than 40 dif-
munity-based distribution (CBD) programs, and
ferent formulations. Brands with different for-
commercial retail sales (CRS). These systems in-
mulations and dosages often differ in packaging,
corporate subsidized government sales through
cost, shelf life, and side effects. Efforts are now
pharmacies, local boutiques, village centers, and
under way to provide program administrators
distribution through institutions and in-
with up-to-date information on different meth-
dividuals, and involve people who are closely
ods; PIACT, the Program for Introduction and
linked to the community and well-known to the
Adaptation of Contraceptive Technology, is dis-
clientele they serve. These workers may be
seminating comprehensive information on con-
village elders, midwives, merchants, or volun-
traceptives to LDCs. Once an administrator de-
teers who assume responsibility for any num-
cides which contraceptives to purchase, the
ber of tasks, including contraceptive storage,
sources of supply must be chosen. Contracep-
program administration, and transmittal of
tives can be purchased from private manufac-
family planning education and information. Ap-
turers or from special manufacturers that sell to
proaches differ from country to country, but
the public sector, obtained as gifts from interna-
several characteristics are common to success-
tional donors, or manufactured locally. Each
ful programs. These include prices that are af-
source has attendant advantages and disadvan-
fordable to the target community, culturally ap-
tages.
propriate methods, convenient dissemination
Levels of expertise and infrastructure are im- techniques, integration of family planning with
portant in contraceptive choice decisions. Even other health, nutrition, and socioeconomic
if all the information could be listed in a com- development delivery systems, providing IEC
pendium and constantly updated, people would materials (including population education) along
need special training in order to adequately with methods, efficient and regular systems for
evaluate the properties of various methods (36). resupply of contraceptives, and adequate
methods of program evaluation.
Each decision about the method mix in a par-
ticular country is extremely important and has Innovative advertising has helped make
its ramifications and repercussions. The ad- discussion of contraception and individual pur-
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use ot Family Planning in LDCs ● 147

chase of contraceptives open and acceptable. Table 35.—Prices to Consumer of Contraceptives


Buyers would rather ask for a “panther” in Available Through Commercial Retail Market and
Jamaica, a “Preethi” (“joy”) in Sri Lanka, or a Through Social Marketing Programs in Selected
Countries
“Raja” in Bangladesh than a condom. (in U.S. dollars)
Raja (the Bengali word for “king”) is the name Price through
of the condom which is characterized by a pic- social marketing
ture of a playing card king, symbolizing strength Country Contraceptive programa
and power. The pill is called Maya (affection) and 0.01
is associated with a picture of an attractive 0.05
woman. The familiar Raja picture adorns the 25-45
sails of sea vessels delivering contraceptives to 0.35
0.04
outlying areas. The picture has become a part of 0.40
the country’s successful mass media campaign, 0.016
which has included newspaper, cinema, and TV 0.03
advertising. This has resulted in Raja and Maya 0.17
0.05
being the most heavily promoted consumer 0.30
items in Bangladesh, next to cigarettes. The 0.11
Maya radio jingle is the most recognizable song 0.39
on the radio in Dacca (l). 1.91
0.013
By April 1981, Raja and Maya were available 0.13
0.013
in some 69,000 outlets in Bangladesh and 0.15
monthly sales averaged 4 million Rajas and
44,000 cycles of Maya.
Because CRS projects offer commodities for a
price, there is ongoing disagreement over
whether the contraceptives should be free (as is
often the case in clinic or community-based pro-
grams), or whether a small charge will make the LDCs, of traditional clinic-based family planning
commodities seem more valuable. Both ap- services, Distribution points include family plan-
proaches have been successful, and social ning outreach workers, mobile delivery units,
marketing efforts have substantially reduced and contraceptive resupply depots. CBD pro-
consumer costs in’ many countries (table 35). grams evolved from demand for better access to
services and a lack of trained health personnel
Social marketing/CRS programs have had a and facilities in remote rural areas, and operate
number of political and administrative pro- in a variety of ways. Some provide services at a
blems. The need for mass media advertising
central point in a village, as in Indonesia, while
campaigns in support of CRS programs can
others feature door-to-door service by way of
create political difficulties in securing govern-
household canvassers, as in Egypt and Bang-
ment approval of these efforts, and traditional ladesh.
attitudes toward and laws governing the use
and sale of contraceptives make program im- Although some of the CBD projects now active
plementation difficult. These projects have, in 38 countries are relatively small, there are
however, expanded existing family planning large-scale operations in Bangladesh, Egypt, In-
programs, have been highly cost effective, and donesia, India, Mexico, Nicaragua, Thailand,
have spurred increases in contraceptive sales. Colombia, Jamaica, Philippines, Korea, and Sri
Countries with CRS programs are listed in table Lanka (table 37).
36.
Current evidence shows that many kinds of
while CRS programs are built into existing household and village distributions can be more
commercial marketing networks, CBD pro- effective than clinic programs. Rates of accept-
grams utilize existing social structures and in- ance, continuation, and prevalence consistently
stitutions and were the first extensions, in fall within–rather than below–the “ac-

84-587 0 - 82 - 11
148 ● World Population and Fertility Planning Technologies: The Next 20 Years

Table 37.—Countries Having Community-Based


Distribution Programs, 1980

Asia Middle East/North Africa


Bangladesh Egypt
China Lebanon
Hong Kong Morocco
India Sudan
Indonesia Tunisia
South Korea
Malaysia
Nepal Sub-Saharan Africa
Papua New Guinea Ghana
Pakistan Liberia
Philippines Nigeria
Sri Lanka
Taiwan
Thailand
Latin America and the Caribbean
Brazil
Colombia
Dominican Republic
Ecuador
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
St. Lucia
St. Vincent
Trinidad and Tobago
SOURCE: Family Planning in the 1980’s: Review of the Current Status of Family
Planning (Annex to the Background Document), International Con-
ceptable” range of clinical programs (5). Con- ference on Family Planning in the 1980’s, April 1981, Jakarta, ln-
tinuation rates among oral contraceptive users donesia. Cosponsored by the UNFPA, IPPF, and the Population
Council.
in Indonesian CBD programs are higher than
those among clinic-based users (table 38). Table 38.-Continuation Rates for OCs in Clinic-
Although provision must be made for clinical Based and Community. Based Programs: Village
support for management of side effects of meth- Family Planning Program, Indonesia
ods, costs of operating CBD programs are com-
OC users
petitive with clinical approaches. Because volun- resupply depot
Time
teer personnel are extensively used, these costs period Clinic Village
are expected to decline. 12 months. . . . . . . . . . . . . . . . . . . . 65.9 76.3
24 months. . . . . . . . . . . . . . . . . . . . 47.7 61.5
The availability of family planning 36 months. . . . . . . . . . . . . . . . . . . . 33.1 47.9
SOURCE: J. R. Foreit, M. E. Gorosh, D. G. Gililespie, C. G. Merritt, “Community-
services Based and Commercial Contraceptive Distribution: An Inventory and
Appraisal,” Population Reports, series J, No. 19, March 1978, Popula-
Few assessments of the conditions of fertility tion Information Program, Johns Hopkins University, Baltimore
Md.
decline in LDCs take account of differences in
the availability of contraception among coun- ignore a causal link in the factors influencing
tries because of the paucity of reliable data, Yet the use of family planning. In order for con-
these differences are at least as great as the traception to be used, information, services, and
socioeconomic differences among LDCs. There- supplies must be available (2). Services and sup-
fore, to examine rural-urban and education dif- plies are unavailable if the financial cost is too
ferentials in contraceptive use without first high, if clinics are open at hours convenient on-
ascertaining whether distribution of services to ly to clinic staff, if supplies are insufficient or
urban, and better educated, women varies is to privacy is lacking in clinics, etc.
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCS • 149

Availability research carried out in the course forts to provide more accessible services could
of recent national fertility surveys has focused result in higher levels of use.
on a single index of availability, the perceived
availability of family planning services and their Incentives
relationship to contraceptive use. Rodriguez
(34) analyzed the perceived accessibility (ac- Because incentive schemes to increase family
cessibility and availability are used inter- planning vary considerably, their impact on fer-
changeably) of services in terms of women’s tility cannot be adequately assessed. Never-
perceptions of travel distance to the nearest theless, they have engendered considerable con-
outlet and the relationship of this distance to troversy—less because the incentives them-
use of family planning methods in Nepal, Colom- selves are inherently discriminatory or coercive
bia, Costa Rica, Korea, and Malaysia. In Nepal, than because of the ways in which they have
only 6 percent of currently married women been implemented. India’s widely publicized
know where contraceptives are available, and sterilization campaigns are a prime example.
only 2 percent know of a place less than 2 hours
An incentive is here defined as something of
away from their homes. In Nepal, 27 percent of
value (usually, though not always, financial)
those who live within 2 hours of an outlet use a
given by a government or an organization to an
method in contrast to 14 percent of those who
individual, couple, or group to encourage cer-
live within a day or more of a source. In every
tain fertility planning behaviors. Both the
country except Costa Rica (where virtually
‘(value” and the ‘(behavior” must be specified for
everyone knows of an outlet nearby), the closer
each type of incentive scheme.
the source the more likely women are to be us-
ing it (table 39). Traditional associations with Value is usually specified in terms of
education and rural-urban residence are not as payments in cash or commodities (government
strongly tied to use of contraceptives when the provision of family planning services and/or
nearness of an outlet is controlled. The reduc- commodities is excluded because many govern-
tion in association is most marked in Nepal, ments already provide these services free or at
where sources are rarely available in rural minimal cost), but can be in the form of indirect
areas. benefits. In Singapore, for example, access to
better education is offered as an incentive to en-
The relationship between current use of con-
courage couples to have small families. Educa-
traceptives and knowledge of the distance to an
tion is free for their first two children, but costs
outlet is shown for 10 countries in table 40. The
rise for third and higher order births.
level of motivation is obvious when even 30 or
40 percent of women who live 30 minutes or The desired fertility planning behavior is
more from an outlet are using contraception. Ef- specified by the government or organization

Table 39.—Percentage of Currently Married Women Using an Efficient


Contraceptive by Perceived Availability of Services

South
Colombia Costa Rica Korea Malaysia Nepai
150 ● World Population and Fertility Planning Technologies: The Next 20 Years

Table 40.-Contraceptive Use Among Currently Married Women Who Knew a Family
Planning Source, and Travel Time to Outlet
Percent currently married
women using contraception
Know outlet
Travel time Do not
Country date Less than 30 minutes know
and survey Total 30 minutes or more outlet
Costa Rica, CPS, 1978 . . . . . . . . . . . . . . . . . . 67.5 88.8 63.0
Panama, WFS, 1976 . . . . . . . . . . . . . . . . . . . . 59.9 NA NA
Colombia, WFS, 1976 . . . . . . . . . . . . . . . . . . . 55.2 57.2 51.4
Thailand, CPS, 1978 . . . . . . . . . . . . . . . . . . . . 52.9 56.6 44.8
South Korea, CPS, 1978 . . . . . . . . . . . . . . . . . 50.7 52.0 46.9
Mexico, WFS, 1976 . . . . . . . . . . . . . . . . . . . . . 50.3 52.4 48.6
indonesia, WFS, 1976 . . . . . . . . . . . . . . . . . . . 47.6 NA NA
Mexico, CPS, 1978 . . . . . . . . . . . . . . . . . . . . . . 47.4 51.4 32.2
Philippines, WFS, 1978 . . . . . . . . . . . . . . . . . . 43.9 47.2 38.0
Malaysia, WFS, 1974 . . . . . . . . . . . . . . . . . . . . 39,3 42.3 34.7
South Korea, WFS, 1974 . . . . . . . . . . . . . . . . . 39.0 41.2 38.9
Kenya,WFS,1978 . . . . . . . . . . . . . . . . . . . . . . 13.0 15.5 12.3
Pakistan,WFS, 1975a.... . . . . . . . . . . . . . . . 7.7 NA NA

providing the incentive, and in most cases is the tives are paid to the diffusers. In most Asian
adoption of a particular method—the IUD, for countries the medical practitioner who inserts
example—or consent to a sterilization. In IUDs is reimbursed on a fee-for-service basis.
Singapore, limiting family size to two children is
the desired birth platining behavior. Voluntary sterilization has been a traditional
In some incentive schemes payment is made focus of incentive schemes. Many payment
to a “diffuser,” who motivates individuals to use schemes have been tried; clothing was given to
specific methods, to a ‘(provider,” such as the in- those undergoing sterilization in India and food
dividual who inserts an IUD, or to a community rations were offered in India and the Republic
when its percentage of couples practicing con- of Korea. In 1974, Singapore relaxed certain of
traception reaches a target level. its disincentives for families who chose steriliza-
tion. If one parent is sterilized, the fourth child,
Most current schemes usually include the who would otherwise be given lower priority in
following elements: the government is the gran- primary school admission, is given the same
tor of incentives; payment is made to individuals priority as the first three, and women with two
rather than groups; funds come from the pro- or more living children, who are not otherwise
gram budget; cash rather than in-kind incen- entitled to paid maternity leave, receive this
tives are used; immediate and single, rather benefit if they choose postpartum sterilization
than installment and deferred, payments are (table 43).
made; payments are of a fixed amount and are
made at the time of adoption of a family plan- Governments that elect to implement incen-
ning method; and incentives are positive rather tive schemes must plan carefully to avoid com-
than negative. promising individual choice. Incentives cannot
Table 41 contains a listing by country of in- substitute for full availability of services, and
centives paid for IUD insertion and contracep- although culturally defined, questions of coer-
tive sterilization (no countries are paying incen- cion must be carefully considered. The often
tives to pill or condom users). In Bangladesh, In- overlooked aspect of coercion is the social coer-
dia, Pakistan, and the Republic of Korea, incen- cion to have more children than are wanted.
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 151

Table 41.—lncentives Provided for IUD Insertion, by Legal considerations apply to four major areas
Country (1975-77) in the implementation of family planning pro-
Incentives grams:
provided to Fees charged to
Region and diffused user in U.S. 1. dissemination of fertility planning informa-
country provider dollars tion and provision of methods;
Africaf 2. distribution of fertility planning meth-
Botswana . . . . . . . . . . . . . — ods—whether a prescription is required,
Egypt . . . . . . . . . . . . . . . . . 0.58-1.15
Gambia a . . . . . . . . . . . . . .
which methods can be sold and where, and
Ghana . . . . . . . . . . . . . . . . — who can provide the services (included
Kenya 2 . . . . . . . . . . . . . . . . — here are laws governing voluntary steriliza-
Mauritius . . . . . . . . . . . . . . 3.00-4.00
Morocco . . . . . . . . . . . . . . — tion and induced abortion);
Zimbabwe . . . . . . . . . . . . . — 3. training requirements for personnel who
Tunisia . . . . . . . . . . . . . . . . 0.50-2.00 will distribute contraceptives; and
Uganda . . . . . . . . . . . . . . .
Asia and Pacific 4. who shall be eligible to obtain family plan-
Bangladesh. . . . . . . . . . . . 0.40-0.80 ning advice and contraceptives. - -
China 3b . . . . . . . . . . . . . . . —
Fiji . . . . . . . . . . . . . . . . . . . Eligibility is especially relevant where both
Hong Kong . . . . . . . . . . . . premarital and extramarital sexual activity con-
India C . . . . . . . . . . . . . . . . . 0.14-0.27
Indonesia . . . . . . . . . . . . . tribute significantly to fertility rates (30).
Malaysia . . . . . . . . . . . . . .
Nepal . . . . . . . . . . . . . . . . . 0.24-0.47 Legislation that specifically affects women
Pakistan d . . . . . . . . . . . . . . 0.25-0.60 and their positions in the family is important
Philippines . . . . . . . . . . . . —
South Korea . . . . . . . . . . . 0.42-1.05
because it affects the options available to them
Singapore . . . . . . . . . . . . . beyond their traditional roles as wives and
Sri Lanka . . . . . . . . . . . . . . mothers, In some countries, under Moslem law,
Thailand . . . . . . . . . . . . . . —
Turkey . . . . . . . . . . . . . . . . — a husband can terminate a marriage by simply
Americas declaring his intention to do so to his wife. In
Chile . . . . . . . . . . . . . . . . . . — others, married women must be represented in
Colombia . . . . . . . . . . . . . . —
Costa Rica. . . . . . . . . . . . . — judicial proceedings by their husbands, cannot
Dominican Republic. . . . . work without their husband’s permission, and
El Salvador . . . . . . . . . . . .
— often need the approval of their husbands be-
Guatemala . . . . . . . . . . . .
Honduras . . . . . . . . . . . . .
fore they can avail themselves of family plan-
Jamaica . . . . . . . . . . . . . . . — ning services (30).
Mexico . . . . . . . . . . . . . . . . —
Nicaragua . . . . . . . . . . . . . — As pointed out in chapter 4, minimum age at
Puerto Rico . . . . . . . . . . . . —
marriage is a direct determinant of fertility
change. Directly related to changes in age at
marriage is the legal right of women to consent
to a marriage, a right still not available in many
SOURCES: countries. Child betrothal and subsequent early
marriage also aggravate the low position of
women, both because they lack free choice and
must marry while young, and because husbands
are traditionally 2 to 5 years older than their
wives. Although many countries have set mini-
Legal considerations mum ages for marriage, these laws are not al-
ways strictly enforced, and may not be suffi-
cient to raise the status of women unless
women are given opportunities beyond
childbearing, such as education and paid em-
ployment.
152 . World Population and Fertility Planning Technologies: The Next 20 Years

Table 42.–incentives Provided for Sterilization, by Country, 1975-77

Cash payments to:


Region and Fees charged to
country User (U.S. dollars) Provider (dollars) user (dollars)
Africa
Botswanaa No cash payment 0.57
Tunisia (female) 11.65 2.35 Free
(male) 4.89 Free

Asia and Pacific


Bangladesh (male) 2.10 2.10’ Free b
Hong Kong No cash payment 2o.ood
India 2.00-3.00 1.37
0.69’ Free
Indonesia No cash payment — Free
Iran No cash payment Free
Malaysia No cash payment — Free
Nepal No cash payment 1.98 Freec
Pakistan (male) 1.50 1.50 0.50’ Free
(female) 2.00 2.00 0.50’ Free
Singapore No cash payment 1.68
Sri Lanka No cash payment — Free
South Korea No cash payment 10.50
(for male)
31.50
(for female) Free
0.74’
Thailand No cash payment 2.50 (male)e
7.50 (female)

When family planning information is mester abortions in countries where the num-
restricted, couples can remain unaware that ber of physicians is limited, illegal abortions
they can limit their fertility. In Chad and several continue to be performed by untrained person-
other countries, an old French law makes it a nel.
criminal offense to disseminate “contraceptive
or antinationalist propaganda” through In many LDCs, where marriage is nearly
speeches in public or by placing in “public chan- universal and takes place at a very young age,
nels” books, written material, drawings, pic- premarital sexual activity is negligible and laws
tures, or posters. A major restriction on con- that restrict access of supplies and/or informa-
traceptive distribution in LDCs is the require- tion to married adults are not a problem. In
ment for a prescription. In Nigeria, where a pre- countries where there is increasing demand
scription is required for oral contraceptives, from adolescents and single adults for con-
there is one physician for each 40,000 people. traceptive information and supplies, laws that
(In some countries where prescriptions are re- restrict dissemination of family planning educa-
quired for the pill, the legal requirement is ig- tion in schools and other settings can interfere
nored and they are available on a nonprescrip- with the ability of these individuals to plan their
tion basis in the private sector (48).) fertility (30).
The status of induced abortion is always legis-
lated. Even where induced abortion is legal, ac- Do family planning programs make a
cess to properly performed procedures can be difference?
impeded because restrictive legal provisions
limit induced abortion to hospital settings or Although there are exceptions, and the
determine who may perform the procedure. If reasons for these exceptions are fairly well
only physicians may legally perform first tri- known, family planning programs do make a
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 153

difference in reducing fertility. In 1978, quired to implement a strong program ef-


Mauldin, Berelson, and Sykes undertook a ma- fort (19).
jor analysis to determine the relative contribu-
The contributions of various factors to ob-
tions of program effort and social setting (level
served fertility declines can be separated. These
of socioeconomic development) to fertility
contributions vary among countries, but on av-
declines in LDCs. Countries classified by both
erage, about 60 to 65 percent of the decline in
strength of family planning effort and level of
fertility is attributable to social setting, 15 to 20
socioeconomic development produced the
percent to the family planning effort of the pop-
groupings in table 43. The authors found that:
ulation program, about 5 to 10 percent each to
●In 94 LDCs during 1965-75 there were the age structure of the population and to pro-
significant—some quite spectacular—fertili- gram efforts to raise age at marriage, and about
ty declines. 15 to 25 percent to various unknown or un-
● The large countries—those with popula- measured factors (table 44). Program effort thus
tions of 35 million or more—showed greater accounts for 20 to 25 percent of the observed
declines than did the smaller countries declines in fertility between 1965 and 1975.
(although Bangladesh, Pakistan, and Nigeria McGreevey (18) added national income
are exceptions to this).
distribution to the index that Mauldin and
● The better-off countries, particularly those
Berelson used (the original index used GNP and
near the top in table 43, do better than the GNP per capita), in an attempt to relate distribu-
less well-off. But, on balance, family plan- tion of income to changes in fertility. He found
ning programs have a significant, indepen- that fertility is higher when poor people are
dent effect over and above the effect of so- much poorer relative to the rich. If the poor
cioeconomic factors. Weak programs might stay poor relative to the rich, fertility will
as well not exist, so far as fertility reduction decline more slowly than if the poor raise their
is concerned. relative income levels. He also added a govern-
● The longer a family planning program has ment index which was associated with fertility
been in operation, the greater its effect decline, further confirming the Mauldin and
(although several weak programs have ex- Berelson finding that program effort may be an
isted for many years). index for effective government in general.
● Countries that have adopted population

policies with demographic goals to reduce Tsui and Bogue (42) extended the analysis by
their rates of population growth have ex- adding the total fertility rate at the time the
perienced much greater fertility declines family planning program was initiated. This ad-
than countries without family planning pro- ditional variable serves as an index for a fertility
grams or countries whose programs were decline which may or may not already be in pro-
adopted for health reasons only. cess when the program begins. They found the
greatest effect on the total fertility rate of 1975
● There is synergism between social setting
to be associated first with this rate for 1968 (the
and program effort. Countries that rank
index of whether a fertility decline may be in
well on levels of socioeconomic variables
process); second, with family planning program
and also make substantial program effort
effort; and third, with socioeconomic variables.
average much greater declines than do
countries that have one or the other, and Another approach to assessing the impact of
far greater declines than those with nei- family planning programs is to first estimate the
ther. A country that wants to reduce its fer- fertility change resulting from a particular
tility should seek a high degree of moderni- change in contraceptive use and then use these
zation (which of course all do, and find cost- estimates to determine the effect on fertility
ly and difficult) and should adopt a substan- rates of a family planning program. Two coun-
tial family planning program; for countries tries for which these analyses have been carried
at or near the bottom of the socioeconomic out are Thailand and Colombia. Khoo and Park
scale, a special kind of determination—as (16) estimated that some 200,000 births were
found in India, Indonesia, and China—is re- probably averted by the Thailand program in
154 . World Population and Fertility Planning Technologies: The Next 20 Years

Table 43.-Crude Birth Rate Declines (in percents), by Social Setting and Program Effort: 94 LDCs, 1965-75

Program effort
Strong Moderate Weak
(20 +) (10-19) (o-9) None
Social setting Country Decline Country Decline Country Decline Country Decline Total
Singapore . . . . . . . . .40% Cuba . . . . . . . . . . .40°/0 Venezuela .. ......1 10/0 Korea, North . . . . . . . .5%
Hong Kong . .......36 Chile . . . . . . . . .. .29 Brazil . . . . . .......10 Kuwait . . . . . ........5
Korea, South .. .....32 Tdnldad and Mexico . . . . ........9 Peru . . . . . . . ........2
Barbados. . . .......31 Tobago .. .....29 Paraguay . . ........6 Lebanon. . . . ........2
Taiwan. . . . . .......30 Colombia .. .....25 Jordan . . . . . ........1
High Mauritius. . . .......29 Panama. . . . . . .. .22 Libya . . . . . . . . . . . . – 1
Costa Rica . .......29
Fiji . . . . . . . . .......22
Jamaica . . . .......21
Mean . . . . .......30 Mean . . .......29 Mean. . . . . . . . . . . .9 Mean . . . . ........3 19%
Median . . .......30 Median .. .....29 Median . .........9.5 Median. . . ........2 22
China. . . . . . .......24 Malaysia . .......26 Egypt . . . . . .......17 Mongolia . . . ........9
Tunisia . . .......24 Turkey. ... , .. .....16 Syria. . . . . . . ........4
Thailand . .......23 Honduras .,.... ..,.7 Zambia . . . . . . . . ...-2
Dominican Nicaragua , ........7 Congo . . . . .......-2
Republic ... ...2l Zaire . . . . . . . . . . ....6
Philippines . . . . . .19 Algeria . . . . ........4
Upper middle Sri Lanka . . . . . . . .18 Guatemala . . . . . . ...4
El Salvador . . . . . .13 Morocco . . . . . . . ....2
Iran . . . . . ........2 Ghana . . . . . . . . . . ...2
Ecuador . . . ........0
Iraq . . . . . . . ........0
Mean . . . . .......24 Mean . . .......18 Mean. . . . . . . . . . ..6 Mean . . . . ........2 10
Median . . .......24 Median .. .....20 Median . . ........4 Median ... ... .....l 7
Vietnam, North. ....23 India . . . . .......16 Papua Angola . . . . . . . . . ....4
Indonesia .. .....13 New Guinea . . . ...5 Cameroon . . ........3
Pakistan . . . . . . . . . . .1 Burma . . . . . ........3
Bolivia . . . . ........1 Yemen,
Nigeria . . . . . . . . ....1 P.D.R.of . . . . . . . . ..3
Kenya . . . . . . . . . ....0 Mozambique ,. ......2
Liberia . . . . ........0 Khmer/
Lower middle Haiti . . . . . . ........0 Kampuchea. . . . ...2
Uganda . . . . . . . . . .-4 Ivory Coast . ........1
Senegal . . . . ........0
Saudi Arabia... .....0
Vietnam,South ......0
Madagascar .. ......0
Lesotho ... ... ....–4
Mean . . . . .......23 Mean . . .......14 Mean. ... ... .....l Mean . . . . ........1 3
Median . . .......23 Median . ......14.5 Median . . . . . . . . ..0.5 Median . . . . . . . ....1.5 1
Tanzania . . . . . . . ....5 Laos . . . . . . . . . . .....5
Dahomey . . ........3 Central African
Bangladesh .. ......2 Republic . ........5
Sudan . . . . . . . . . . ...0 Malawi ..,...... ....5
Nepal . . . . .......-1 Bhutan . . . . . . . . .....3
Mali . . . . . . . . . . . ..-1 Ethiopia . . . . . . . . . ...2
Afghanistan . . . . ..-2 Guinea . . . . . . . . .....2
Chad . . . . . . ........2
Low Togo . . . . . . . . . . . ....2
Upper Volta . . . . .....1
Yemen . . . . . ........1
Niger . . . . . . ........1
Burundi . . . . ........1
Sierra Leone .. ......0
Mauritania . . . . . .....0
Rwanda . .........0
Somalia ......, .....0
Mean. . . . . . . . . . ..1 Mean . . . . ........2 2
Median . . . . . . . . . .0 Median . . . . . . . . ...1.5 1
Mean 29 21 4 2 9
Median 29 22 2 2 3
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 155

Table 44.–Sources of Fertility Decline in 94 LDCs During 1965.75

Age Marital Marital


Factor structure patterns fertility Total

1975, and that 47 percent of the decline in fer- In both of these cases the presence of family
tility between 1968-69 and 1975 could be at- planning programs has clearly made a dis-
tributed to contraceptive protection provided ference. The declines in birth rates would not
by the program. Londño and Bogue (17) found have been as great if the programs had not
that about 56 percent of the fertility decline made fertility planning services widely
observed in Colombia from 1964-75 is attrib- available.
utable to organized family planning programs.

Meeting future needs


At least 495 million couples (excluding China) have formal policies in support of family plan-
will need contraception in 2000 (See table 51, ning, the financial commitment of their govern-
ch. 9). If fertility were to fall to replacement ments to family planning remains a small frac-
levels over the short term, there would have to tion of current health expenditures. In many
be a fourfold increase in contraceptive use at a countries, half or more of total government
minimum cost of $4.5 billion in 1980 dollars. health budgets are devoted to a few urban hos-
Although there are regional differences, and pitals and clinic based medical systems that do
countries within regions vary widely, several not reach the vast majority of the country’s ru-
policy and program issues will be of concern for ral poor. Developing administrative systems to
both the short and long term: 1) allocating re- effectively provide fertility planning services to
sources; 2) establishing cost effective, self- rural areas is one of the most important tasks
supporting programs; 3) expanding availability for the next 10 to 20 years.
of services to reach rural populations; 4) in-
tegrating family planning with other compo-
nents of development; 5) strengthening pro- Establishing cost effective,
gram management; 6) increasing opportunities self-supporting programs
for women and raising their status; and 7) effec-
tively using present and new technologies (45, Development of the private sector through
46). social marketing techniques is crucial to the
gradual self-financing of family planning pro-
Allocating resources grams in LDCs. These systems not only effec-
tively reach rural areas where clinic coverage is
Although over 90 percent of the population of weak and expensive to maintain, they also allow
the developing world lives in countries that governments to put resources into medical sup-
156 ● World Population and Fertility Planning Technologies: The Next 20 Years

port for MCH and for complications due to con- cies in allocation and control of resources,
traceptive use. determination of priorities, and development of
personnel policies, integration attempts often
Countries that use multiple delivery
encounter administrative problems. Their ex-
systems—government health services, private
perimental nature can also make them expen-
physicians, private family planning clinics, com-
sive to establish, particularly where few devel-
mercial retail sales networks, and community-
opment services are in place. A decentralized
based distribution systems—can give couples
approach that identifies and meets community
the advantages of a comprehensive range of
level needs, focuses on primary health care, and
methods. Moreover, because many of the meth-
capitalizes on local institutions appears to hold
ods most easily distributed in community-based
the most promise.
systems (condoms, pills, spermicides, etc.) need
only backup medical sew-ices, a multiplicity of
systems is also cost effective. Strengthening program management

As the demand for services grows and pro-


Expanding the availability of services grams expand in coming years, a crucial need
to reach rural populations will be for well-trained, highly skilled managers
for family planning programs; experience has
Countries with strong programs where fertili- shown that expert managers can have tremen-
ty is beginning to fall have been, for the most dous impact on program performance. Senior
part, “easy,” that is, these countries have management skills, which tend to be in short
relatively high levels of socioeconomic develop- supply in LDCs, will be a major need, but
ment, a fair degree of infrastructure, and substantial numbers of middle-level managers
trained personnel. The countries that will need and supervisory personnel and a wide range of
support for the next 20 years are “difficult.” family planning workers will also be required.
These are countries that will require innovative Governments will have to give high priority to
approaches to reach rural populations and ma- management recruitment and training and to
jor efforts to train personnel and develop infra- devising the new directions and flexible, innova-
structure capabilities and support for basic tive approaches that will be necessary to
health services. In most, only small sectors of broaden services provision. Decentralized
urban populations presently have real access to organizational structures designed to foster
family planning services. local decisionmaking and community participa-
Rural couples who have sufficient resources tion will be needed to supplement today’s large-
and time can usually obtain some type of con- ly centralized organizational patterns.
traceptive method, but full access to family
planning services— nearby presence of an outlet Increasing opportunities for women
that offers services, information, and supplies, and raising their status
without major cost or inconvenience—remains
out of reach of all but a few rural populations in Women in many LDCs are restricted in their
LDCs. ownership of property, their ability to marry
and divorce, their freedom of movement and
Integrating family planning with other employment, and their access to education and
components of development other resources. These social and economic con-
straints adversely affect their status and
Although family planning programs have strengthen existing cultural pressures for
traditionally been linked in varying degrees women to define their lives solely in terms of
with other health services, recent efforts have their maternal roles. Improving the status of
combined family planning with other communi- women through legal change, greater access to
ty services (e.g., nutrition, nonformal education) education and income-generating opportunities,
and existing organizations (e.g., cooperatives, and fuller participation in community life are
women’s clubs). Because most of these projects key factors in redressing this imbalance. Great-
require significant collaboration between agen- er ability to control decisions about their fertili-
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 157

ty will benefit women as spouses, mothers, Effectively using present and


and/or active members of the community, and new technologies
enable them to make important contributions to
the development process. Because all of today’s available fertility plan-
ning technologies have significant deficiencies
The needs of adolescent women in LDCs to- and drawbacks, it will be a continuing challenge
day are particularly acute. There are far more for family planning programs to use these tech-
adolescents in the world at present than ever nologies in ways that minimize their shortcom-
before in history because of high fertility in the ings. Ideally, programs offer a wide range of
recent past, and their potential fertility is far m e t h o d s ,
greater than that of their counterparts of pre- s have difficulty providing even four or
vious centuries because better nutrition has five. The logistics of distribution, storage, and
lowered the age of menarche, making these backup medical services can intervene to pre-
adolescents capable of childbearing at much vent the provision of some methods, as can CUL
younger ages. tural, religious, and legal restraints. With costs
Their access to contraceptive services is fre- of supplies expected to increase at the same
quently limited, especially in LDCs, and those time that numbers of prospective users multiply
who do use contraception tend to use ineffec- rapidly, countries will have to carefully con-
tive methods. In Latin America, for example, sider the costs and benefits of establishing their
most married teenagers have never used a con- own production facilities. Couples will need reli-
traceptive method even though they want to able counseling to enable them to choose fertili-
limit their fertiliy. Many use ineffective meth- ty planning technologies that are appropriate to
ods—some by choice—but often because of in- their needs. Governments should thus give high
sufficient supplies or difficult access. Special ap- priority to efforts to communicate accurate in-
proaches responsive to the needs of this vast formation on current methods and on new
group of young people will require major family methods as they become available.
planning program efforts in coming decades.

Chapter 7 references
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17. Londono, J., and Bogue, D. J., “An Estimate of the 1980.
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Family Study Center Monographs, The Univer- Acceptable Fertility Regulating Methods,” in Mar-
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1979, in AID Program Evaluation Report No. 1, Planning in Mexico: A Comprehensive Marketing
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Workshop, Agency for International Develop- Among Consumers and Retailers” (New York:
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Sykes 1978 “Conditions of Fertility Decline in De- 34. Rodriguez, G., “Family Planning Availability and
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of a Symposium, National Academy of Sciences, tive Technology,” paper prepared for the PARFR
Washington, D.C. 50-104, 1979. International Workshop on Research Frontiers in
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22. Ness, G. D., and Ando, H., Population Planning in ruary 1980.
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37. ‘(Women’s Modesty: One barrier to the ties, Background Document, International Con-
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(Hagerstown: Harper and Row 1980, pp. York, 1981b.
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39. Shedlin, M. G,, Hollerbach, P., “Modern and Tra- On Integration of Family Planning with Rural Devel-
ditional Fertility Regulation in a Mexican Commu- opment, a Report on the UNFPA/EWPI Technical
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Working Papers 27, Center for Policy Studies, Planning with Rural Development, UNFPA, New
Population Council, New York, 1978. York, 1979.
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grammed)” A report of UNFPA/EWPI Technical 53. “A Study of User Preferences for Fertility
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45. UNFPA, IPPF, and the Population Council, Family 11(9-10):267-273, September-October 1980.
Planning in the 1980b: Challenges and Opportuni-
chapter 8
Research Needs
Chapter 8

Research Needs

Abstract

Meeting the needs of couples to freely choose the number and spacing of
their children and of nations to develop beneficial population policies will require
extensive research. Areas of need range from fundamental knowledge of
reproductive processes to development of service delivery systems to better un-
derstanding of the processes that give rise to population policies. Accurate,
descriptive data are needed for current and continuing evaluation of population
growth and change. Present information gaps include the causes of today’s wide
differences in mortality, the dimensions and consequences of international
migration, and the specific impacts of rapid population growth. Despite the con-
sensus that current fertility planning technologies fall short of ideals of safety, ef-
fectiveness, acceptability, and ease of use, there is little support for basic
research to develop new or improved methods for planning fertility or to correct
and prevent infertility. Specific R&D efforts are needed on male contraceptive
methods and new approaches to female contraception; improved barrier and
periodic abstinence methods, and better methods of nonsurgical sterilization.
Evaluation research on the safety and side effects of various methods is a further
need, as is research aimed at improving the contraceptive R&D process itself.
Factors that influence acceptance of fertility planning technologies and the
relationships between culture- and age-specific factors and these technologies re-
quire investigation, and one of the greatest needs is for a sound theoretical
framework on the factors that determine fertility. Such factors include men’s and
women's differing roles, beliefs, and attitudes, and the influence of political and
administrative systems. How various institutional arrangements influence family
planning programs and how different political processes lead to population
policies require clarification. Improved formulation of population policy requires
the results of broad-based research on the effects of population growth, which in
turn requires intensified coordination and’ improvement of data collection ef-
forts. Systematic analysis of family planning “success stories” could be productive
in developing predictive capability and designing better programs. Evaluation of
the impact of past and present policies and programs (both those with specific
family planning objectives and those with indirect impact on population growth
such as education and nutrition programs) has been identified as a critical need.
Finally, there is a need to better understand what research is most needed by pol-
icymakers and how it can most effectively be brought to bear on policy. Because
of the inadequacies of current technologies and the acknowledged increase in
need for them in the years ahead basic and developmental research is clearly
needed. But because of the long lead times in the development of new contracep-
tive methods, more effective use of current technologies is central to meeting less
developed countries (LDCs) population goals. Research that will lead to better
utilization of these technologies is thus of key importance in the immediate
future.

163
164 • World Population and Fertility Planning Technologies: The Next 20 Years

Introduction
A “research need” is an area of basic or ap- edge of reproductive processes to characteriza-
plied research where additional effort would be tion and development of effective service deliv-
likely to result in information or products of ery systems to better understanding of the polit-
value to polivymakers, providers, or consumers. ical processes that give rise to population poli-
The focus of this chapter is on research that will cies. The breadth and number of research
improve the ability of couples to choose the needs in this field arise from the complexity and
number and spacing of their children and na- number of factors influencing population
tions to develop beneficial population policies. growth and the fact that current understanding
Research needs in the population field are of them is limited.
many. They range from fundamental knowl-

Basic data and theory


Verifiable reporting of the levels, trends, and
differentials of the three components of popula-
tion growth-fertility, mortality, and migra-
tion—requires careful collection of data. Ac-
curate, descriptive data are needed for coun-
tries, regions, and various socioeconomic
groups so that the magnitude of population
growth and the factors influencing it can be
assessed.
Existing studies, for example, show wide dif-
ferences in mortality among different social
classes in LDCs. The causes and magnitude of
these differences need clarification so that
health services can be designed for maximum
effect.
Both the amount and impacts of internal
migration require study, as does the relation-
ship between internal migration and the larger
development contexts of particular countries.
Each country’s overall development goals lead
to an associated political structure and basic
political philosophy. These determine both the
country’s desire to control internal migration
and the means it is prepared to use. While this
general statement can be made, quantitative
characterization of the forces that determine
internal migration cannot presently be accom-
plished,
Better information is needed about the dimen-
sions and consequences of international migra-
tion and the roles played by migrant workers in
various countries. Because international migra-
Ch. 8—Research Needs ● 165

traditional explanations cannot fully account for that have proved increasingly important in the
the major declines in fertility that have recently past 25 years. Such variables include political
occurred in some countries, better explanatory systems, public policies, and methods of pro-
variables and theories are needed. Most existing gram implementation.
explanatory models fail to consider the variables

Fertility planning technologies


Basic biomedical research is fundamental to half of those using IUDs have stopped using
the development of new or improved methods these methods. Sociocultural influences and dis-
for regulating fertility and correcting or pre- tribution problems contribute to these high
venting infertility. Better understanding of re- discontinuation rates, but drawbacks associated
productive biology will permit identification of with the methods themselves are unquestion-
new points of intervention that may lead to ably significant. Although the likelihood of an
safer, more effective and/or easier-to-use meth- ideal contraceptive is remote because the char-
ods than those now available. However, as a acteristics of that ideal differ among cultures
National Science Foundation (NSF) report (10) and during different stages in the reproductive
points out, “mixed feelings about the value of lifespan, new or improved methods can certain-
pure science have recurred as a theme through- ly be produced by undertaking the appropriate
out U.S. history. ” A major reason is that the rela- research. A variety of improved technologies,
tionship between basic research and useful including those for treatment of infertility,
technology is often unclear. The report pro- would provide couples with more varied, effec-
vides 26 examples of NSF-funded research over tive, and safer choices to meet their changing
a 30-year period in which the applications were needs for contraception.
not anticipated when the research began.
While development of new technology in this
Another factor in the lack of support for basic field is often time-consuming and expensive,
research is the long time lag between funda- this is not always true. Some highly effective in-
mental work and its application. This is es- struments and procedures have been developed
pecially true in pharmacologic technologies for relatively low expenditures of time and
where the need to meet Food and Drug Admin- dollars. Examples include minilap sterilization,
istration requirements adds to the time between syringe equipment for menstrual regulation and
research and application. As in the case of the induced abortion, and cautery equipment for
contraceptive pill, 20 years may pass before the vasectomy. Such new developments generally
fruits of research are realized. Additional deter- depend less on new knowledge than on im-
rents are the high costs of field trials and prod- provements in technology, which may arise
uct liability suits (see ch. 5). These factors make from other fields (e.g., the fiber optics used in
basic research in reproductive processes aimed minilap sterilization). An opportunity for similar
at developing a new method of contraception in- rapid, relatively low-cost development in the
creasingly unattractive. near term may lie in contraceptive delivery sys-
tems such as implants, injections, and drug-re-
Yet there is general agreement that current
leasing IUDs and vaginal rings, and in foolproof
fertility planning technology falls short of meet-
methods for detecting the time of ovulation.
ing ideals of safety, effectiveness, acceptability,
and ease of use, In LDCs, family planning is The opportunities for basic research are
practiced by fewer than one-fifth of couples broad. They range from characterization of the
of reproductive age (excluding China). Dis- structure of molecules fundamental to the re-
continuation rates are high; after 2 years, near- productive process (such as gonadotropin) to
ly two-thirds of oral contraceptive users and the physiological level (such as the relationship
-— —.

166 Ž World Population and Fertility Planning Technologies: The Next 20 Years

between sperm development and testicular sup- Many causes of unwanted infertility could be
port cells). The 1976 “Greep Report” (3) lists eliminated by improved understanding of
more than 230 gaps in knowledge of reproduc- reproductive processes.
tive processes; most of these still exist. Evaluation research, as opposed to research
on new contraceptive methods, is also needed.
R&D needs in specific areas of family plan-
ning technology include: Of primary concern are the safety and side ef-
fects of current contraceptive technologies. Spe-
● Development of better male contraceptives. cific interest lies in:
Prospective methods include those to sup- ● risks for cardiovascular diseases and other

press sperm production and to intercept diseases associated with use of oral contra-
sperm maturation, and simplified steriliza- ceptives in different populations and under
tion procedures. different dosages of different hormones;
● Further development of barrier methods. ● the effect of disease states such as anemia,

Highly effective methods that would elim- malaria, and schistosomiasis on absorption,
inate the need for coitus-related application effectiveness, and safety of different fertil-
or for privacy during application would be ity planning methods;
welcomed not only in LDCs but by the ● the hypothesized carcinogenic effects of

growing number of MDC women con- spermicides and therefore the need for
cerned about the side effects of most non- safer spermicides to be used with various
barrier methods. Better materials, product methods;
designs, and modes of administration could ● better understanding of how genetic differ-

result from further research in this area. ences, nutrition, and body characteristics
● Improved methods of periodic coital absti- alter method safety, effectiveness, and side
nence. The development of means to reli- effects;
ably identify the fertile and infertile phases ● the safety of contraceptive implants and in-

of the menstrual cycle could, by sharply in- jections;


creasing use-effectiveness, both increase ● whether induced abortion under medically

the use of such methods and improve their supervised conditions is associated with ad-
low continuation rates. verse outcomes in subsequent pregnancies;
● New approaches to female contraception. ● methods to counteract the blood loss associ-

Areas of promise include LRF analogs, im- ated with nonprogesterone-releasing IUDs
munizing antigens, vaginal steroid rings, which can result in iron deficiency;
and post-coital methods such as menses in- ● the long-term effects of contraceptive meth-

ducers. ods, such as the risk of cancer; and


● Better methods of nonsurgical sterilization. ● medical bases for high discontinuation

The World Health Organization (WHO) (13) rates.


has noted that the demand for sterilization Finally, there is a need for research aimed at
by surgery cannot be met in some LDCs be- improving the R&D process itself. Better under-
cause of lack of trained personnel, oper- standing of species differences between animals
ating rooms, and anesthetics. and humans, for example, would improve test-
● Better methods of preventing and correcting ing for side effects, safety, and effectiveness of
infertility. new methods of fertility planning.

Factors influencing acceptance of fertility


planning technologies
LDCs are homogeneous only in their designa- and intracountry differences in economic and
tion as “less developed countries.” Intercountry social structure, religious beliefs, public pol-
.

Ch. 8—Research Needs . 167

icies, and personal values and attitudes range cycles continue to use contraceptive methods
through a broad spectrum and affect the rel- that cause such changes. Much remains to be
ative acceptability of different fertility planning learned about what menstruation means to
technologies. Appropriate technologies also women of different cultures, whether and how
vary with age, reproductive status, and fre- their beliefs can be modified, and how decisions
quency of sexual activity. The consequences of are made in selecting among contraceptive
an unplanned birth are very different for a methods.
woman with no children than they are for a
On the psychosocial level, the relationships
mother of five, and for single and married
between contraceptive practice and the follow-
women. Thus, the relative weight placed on the
ing areas need investigation:
criterion of effectiveness, for instance, in select-
ing among various methods will vary for women ● the role of women in a given class and/or
in these different circumstances. Other criteria culture;
vary in relative weight in similar fashion. ● women’s autonomy for decisionmaking;
and
Therefore, a fundamental research need is ● women’s perception of themselves, their
the relationship between culture-specific (11) bodies, and childbearing.
and age-specific factors and various fertility
planning technologies. Theoretically, it should Male beliefs about different fertility planning
be possible to develop physiological and psycho- methods and about the responsibility of men for
logical self-tests for use by an individual—or as their use also require clarification. WHO studies
guides for family planning workers–to help a suggest that there is demand for male contra-
man or woman select the contraceptive method ceptives in different cultures, but the very low
most appropriate to his or her needs and values usage rates and the difficulty encountered by
at a given point in time. Information on age- investigators in recruiting male volunteers for
specific factors as they affect acceptability clinical studies raise questions about male ac-
would also be of great value to policymakers in ceptance of both existing and new contraceptive
deciding which drugs or devices to include in technologies.
family planning programs.
Decisionmaking with regard to the adoption
One of the greatest needs is for development of family planning is influenced not only by the
of a sound theoretical framework describing feelings and beliefs of the individual man and
the factors that determine fertility. Information woman in a couple but by considerations of that
to develop such a framework requires research couple as a family. Achieved family size and de-
on patterns of social organization and their in- sired family size, the role and status of children
fluence on the reproductive and economic deci- within a culture, male-female communication,
sions of individuals. The economic value of chil- and participation of various family members in
dren and institutional factors governing fertility decisions on the number and spacing of births
incentives need elucidation. are all little-understood factors which influence
acceptance and use of family planning and the
Among cultural factors, a very important area
methods specific to achieving desired family
of investigation is women’s beliefs and attitudes
size. The same can be said of the relationships
and how these influence their practice of family
between individual men and women or between
planning. These relationships require investiga-
couples and their peers.
tion on both physiological and psychosocial
levels. At the physiological level, understanding To make choices among various fertility plan-
attitudes toward changes in menstrual patterns ning technologies, individuals must be aware of
is particularly important because these changes the methods that exist and the benefits and con-
are most frequently cited as reasons for discon- sequences of each. How best to communicate
tinuance of such contraceptives as orals and such information both within a given mode (e.g.,
IUDs. At the same time, women who state that different forms of package inserts) and across
they will not tolerate changes in their menstrual modes (e.g., the media v. physicians v. family
168 ● World Population and Fertility Planning Technologies: The Next 20 Years

planning workers) requires further research. research. This type of program research is a
The role of pharmacists, physicians, and others major gap on both theoretical and empirical
who provide information on family planning grounds and may pay high dividends in the
methods also needs attention. short run.
Many of the conditions that determine accept- Finally, some research on the determinants of
ance of contraceptive technologies do not lie in fertility has been aimed at increasing the use of
the users themselves but in the political and ad- family planning services, thus enabling parents
ministrative systems that distribute the technol- to have the family size they want. But this is
ogies. Elites make decisions on what methods to only one of two fundamental social objectives in
use, how the distribution shall be organized, fertility policy. The other is to balance the
who shall be the distributors and educators, numbers of children individual couples want
what price to charge, what the message will be, for themselves with the number the whole soci-
and how the methods will be packaged. Yet, the ety thinks best. Research on how this second ob-
managing elite and the delivery systems them- jective is accomplished and how it influences
selves have rarely been the subject of systematic fertility is needed.

Population policy
The relative contributions of availability of A systematic analysis of “success stories”
fertility planning methods and of general socio- —areas where dramatic reductions in popula-
economic development to reducing population tion growth have been achieved—could be pro-
growth have been a subject of considerable ductive. Through careful analysis, factors that
controversy, with strong advocates on both have led to success might be identified and
sides. Each undoubtedly contributes and the ranked in probable importance for further eval-
relative contribution in a particular case will uation. The objective of such work would be to
vary with culture-specific factors. Further re- improve predictive capability with regard to the
search to bolster either position might better be factors likely to lead to effective programs in
directed toward broader based research on the different contexts.
complex interaction of the many factors that in-
fluence population growth, Methodologies are The need for viewing family planning activ-
ities in a broader context was recognized by
available for study of these interactions, and
Congress in 1978 in passage of an amendment
data collection efforts need to be designed so
that these can be used. Data on social, eco- (sec. 104d) to the Foreign Assistance Act of 1961.
Section l04d requires that all assistance pro-
nomic, and political variables are often collected
grams, not just those specifically directed at
in different ways at different times by different
population, be evaluated for their impact on
groups, Coordination of data collection efforts
would also facilitate disaggregated analysis at population growth.
the subnational level, which is necessary to Policymakers attending the workshops held
better design family planning programs. The by the International Review Group to identify
comparative research within and across coun- social science research needs for the 1980’s also
tries that is needed to improve predictive abil- identified evaluation of past and present policies
ity—which approach to family planning is likely and programs for their impact on population as
to work best under what conditions—would be one of their most critical needs (8). Evaluation of
facilitated as well. Critical analysis of individual both those policies and programs with specific
variables is also needed. Assistance to LDCs in family planning objectives and those expected to
experimental design and use of the new meth- have indirect impact, such as in the areas of
odologies would be beneficial. education and nutrition, was called for. The
Ch. 8—Research Needs ● 169

lack of existing knowledge, however, about how ● service delivery—research has supported
specific factors interact to influence population the use of paramedical or nonmedical per-
growth makes this an as yet impossible task and sonnel to provide fertility planning services
points up the need for research to make such ef- and information traditionally supplied by
forts achievable. physicians. Research findings have also had
a major influence on the implementation of
Research is needed both on the effect of gen- hospital postpartum programs and on selec-
eral policies and programs and on specific inter- tion of particular contraceptive methods
ventions. For example, how effective is a pro- such as the pill and the IUD;
gram which promotes breastfeeding as a meth- ● development of population growth tar-
od of limiting fertility likely to be? What is its gets–research findings have been used to
cost? What are its nutritional and other effects? formulate programs and estimate budgets
How does such a program compare to one pro- necessary to meet specific population
moting later ages at marriage? growth goals; and
● migration and redistribution of population—a
The situational aspect of specific interventions
good example of the influence of research
should not be neglected. A finding of WHO ac-
on policy in these areas comes from Colom-
ceptability research is that not enough is known
about the application of various fertility plan- bia (5).
ning methods in specific situations. Though In a fifth area, that of population education, it
some might not consider how IUDs are inserted is too early to evaluate the many recently imple-
in women of an Indian village as a subject for re- mented specific programs providing education
search, information on similar situation-specific on population-related topics in LDC schools, but
applications is considered a significant need in a number of these programs include compar-
many LDCs. isons of the effectiveness of various teaching
methods and the relationship between educa-
How various institutional arrangements influ- tional level and material presented. This infor-
ence family planning programs in particular mation is of obvious value to policy makers.
countries should be further studied. Whether,
how, and under what conditions family plan- Research, by showing the high mortality rates
ning should be combined with health care or associated with abortions performed under in-
other socioeconomic programs are the kinds of adequate medical conditions in Chile and other
questions on which further information is Latin American countries, was of considerable
needed. Such information would permit devel- significance in the establishment of family plan-
opment of guidelines that administrators could ning programs in these countries; “programs
use in designing family planning programs. were often justified, and sometimes evaluated,
in terms of their effectiveness in preventing in-
Finally, there is a need to better understand duced abortion” (5). Such research has also in-
the political processes that lead to population fluenced policy on the legal status of induced
policies and the relationship of research to pol- abortion.
icy formation. Although it is often difficult to
show that a specific piece of research has had Much remains to be learned, however, about
an influence on policy, a number of cases where the research most needed by policy makers, how
the relationship is clear have been documented. such research should be done, and especially
In a review of such work (5), evidence is sum- how it can be brought to bear on policy. As Miro
marized that clearly shows that research find- and Potter (7) point out, it is widely assumed
ings have influenced policy in four areas: that “if research succeeds in identifying the
relationship between demographic variables
● development of antinatalist population poli- and social, economic, and cultural indicators,
cies—definitive evidence comes from Co- then a tool will have been obtained for use in
lombia, Thailand, and Taiwan; policy decisions. But that is as far as it goes.
——

170 ● World Population and Fertility Planning Technologies: The Next 20 Years

Policy relevance is not attached to a thorough ing how different research results might be
analysis of how, in fact, government policies used and which individuals and government
eventuate and the decisionmaking processes agencies should be kept aware of new develop-
that are involved.” They argue that such infor- mants in the field of population.
mation would provide a firmer basis for predict-

The relative importance of different


kinds of research
The preceding sections cover three kinds of given society. Despite its importance, utilization
research that might be described as basic, devel- research is often inadequately err hasized in
opmental, and utilization research. Basic re- the process of developing and distributing fer-
search includes studies of reproductive proc- tility planning technologies.
esses and fundamental studies in apparently un-
Research on delivery systems, institutional ar-
related areas (such as in materials science which
rangements, and evaluation of program effec-
may eventually lead to improved contraceptive
tiveness is included in utilization research. Also
devices). Also included are development of basic
included is development of techniques that can
demographic data and theory, and development
be used to increase use of family planning meth-
of explanatory models and new measurement
ods, usually termed operations or management
techniques.
research. Although utilization research could be
Developmental research links knowledge and considered market research, it is broader than
practice and is particularly applicable to such what usually falls under that rubric; hence the
important aspects of new or improved contra- term “utilization research.”
ceptive technologies as dosage levels, mode and
Each of these three categories of research
frequency of administration, and safety. Reg-
serves different purposes. Because of the inade-
ulatory requirements that must be met add to
quacies of current fertility planning technol-
the expense and risks involved in developmental
ogies and the acknowledged increase in need
research.
for them in the years ahead, basic and develop-
Utilization research, as applied to fertility mental research to develop improved methods
planning technologies, is the study of cultural, is clearly needed. But because of the long lead
economic, and political factors that impede or times in development of new methods, current
promote use of technically safe, effective tech- technologies will have to be used more effec-
nologies. The objective of utilization research is tively if population goals are to be met in the
to ensure that the technology is distributed and next 20 years. Utilization research will thus be
administered in ways that are consistent with of key importance in the immediate future.
the cultural, economic, and political values of a

Chapter s references
1. Committee on Human Resources, U.S. Senate, ington, D, C.: U.S. Government Printing Office,
Voluntary Family Planning Services, Population 1978).
Research, and Sudden Infant Death Syndrome
Amendments of 1978, report of the Committee on 2. Djerassi, C., The Politics of Contraception, vols. I
Human Resources to accompany S. 2522 (Wash- and 11 (New York: W. W. Norton, 1979).
Ch. 8—Research Needs • 171

3. Greep, R. O., Koblinsky, M. A., and Jaffe, F. S. Re- 8. Mire, C. A. and Potter, J. E., “Social Science and
productive and Human Welfare: A Challenge to Re- Development Policy: The Potential Impact of Pop-
search (Cambridge, Mass.: MIT Press, 1976). ulation Research, ” Population and Development
4. Harper, M. J. K., “Prospects for New or Improved Review 6(3), 1980, pp. 421-430.
Birth Control Technologies by the Year 2000 9. National Research Council, Contraception: Sci-
A.D.,” report prepared for OTA, Washington, ence, Technology, and Application, proceedings of
D. C., 1980. a symposium (Washington, D. C.: National Acad-
5. Mauldin, W. P., “The Role of Population Research emy of Sciences, 1979).
in Policy Formation and Implementation (A Pre- 10. National Science Foundation, How Basic Research
liminary Note),” working paper prepared for the Reaps unexpected Rewards (Washington, D. C.:
International Review Group of Social Science Re- NSF, 1980).
search on Population and Development, Septem- 11. Salyer, S. L., and Bausche, J. J., Toward Safe, Con-
ber 1977. venient, and Effective Contraceptives: A Policy Per-
6 Mertens, W., Research Priorities for Population spective (New York: The Population Council,
and Socioeconomic Development: Recommenda- 1978).
tions for UNFPA inter-Countr tiy Programmed, 12. Schearer, S. B., “Future Birth Planning Technol-
United Nations Fund for Population Activities, ogies, ” report prepared for OTA, Washington,
1978. D.C. 1980.
7. Mire, C. A., and Potter, J. E., Social Science Re- 13. World Health Organization, Annual Report 1979,
search for Population Policy: Directions for the World Health Program, Geneva, Switzerland,
1980’s, IRG, El Colegio de Mexico, 1979. 1980.
chapter 9
Financial Support for
LDC Population Programs
Chapter 9

Financial Support for


LDC Population Programs
Abstract
In 1980, total resources committed to population and family planning programs in less
developed countries (LDCs) amounted to about $1 billion; $450 million came from more de-
veloped countries (MDCS) governments and international agencies, $100 million from pri-
vate organizations, and $450 million from LDCS themselves (excluding China). The largest
providers of intermtional population assistance today are the U.S. Government through the
Agency for International Development (AID), the United Nations Fund for Population Ac-
tivities (UNFPA), the International Planned Parenthood Federation (IPPF), and the World
Bank. The United States provided over 50 percent of all population assistance prior to 1973,
but this share has since leveled off to about 40 percent, where it has remained for the last 4
years. Several of the Scandinavian countries, Japan, and West Germany have increased
their population assistance donations by 30 to 60 percent over the past few years; as of the
end of fiscal year 1981 the U.S. contribution had risen only 6½ percent since 1978. Inflation
has also cut the purchasing power of AID’s population assistance efforts to below that of
the peak year of 1972 ($121 million). AID obligates international population assistance to
LDCS through four major charnels: 1) bilaterally to LDC governments; 2) multilaterally to
UNFPA; 3) indirectly through private U.S.-based intermediary organizations; and 4) through
contributions to the private multilateral IPPF. The U.S. contribution to the World Bank is
authorized separately by Congress; the Bank then administers population projects as com-
ponents of its total development program.
About 75 percent of international population assistance from all sources is provided for
family planning services, including contraceptive supplies. The remaining 25 percent sup-
ports information and education activities, policy development, data collection, institutions
and training, and research efforts. 1979, Asia received the largest share of population
assistance (60 percent); followed by La tin America (20 percent), Africa (12 percent) and the
Middle East (8 percent). International’’population assistance has had diverse impacts over
the last two decades. More people are aware of the problems associated with rapid popula-
tion growth; data of better quality are available to enable governments to formulate policy;
countries are becomiing increasingly self sufficient and taking greater financial and admin-
istrative responsibility for their family planning programs as they mature. The strongest
impact has been on fertility rates, which have begun to decline and are declining more
rapidly in countries with strong family planning programs. Despite this recent decline in
fertility rates, high fertility persists in many LDCs. Their populations also have enormous
momentum for growth because of their youthful age structures. In the next 20 years there
will be a 65-percent increase in the need for contraception as increasing numbers of cou-
ples enter their childbearing years. Excluding China, in the year 2000 some 495 million cou-
ples of reproductive age (compared, with 300 million in 1980) will need contraceptive pro-
tection if population growth is to stabilize. Using conservative present-day family planning
cost estimates as a base ($15 per couple) the cost of achieving replacement fertility today
would be $4.5 billion annually. The cost of this achievement in 2000, in 1980 constant
dollars, would rise to $7.4 billion. Under this formula, the amount rises to $10.7 billion
when China’s childbearing-age population is added.

175
176 ● World Population and Fertility Planning Technologies: The Next 20 Years

Introduction
International assistance for population and plex and expanding field of population assist-
family planning programs in LDCs today comes ance. They operate in different ways both
from three major sources: private organiza- because the LDCs and regions are at varying
tions, national governments, and intergovern- stages of their demographic transition to lower
mental agencies. Most of these agencies took on birth and death rates, and because the complex-
this role during the 1960’s, when the implica- ity and sensitivity of population issues require a
tions of rapid population growth emerged as a mix of programs and agencies to enable each
worldwide concern. During the 1970’s, these country to have access to one or more sources
agencies, working in a generally cooperative that meet their needs.
way, assumed different functions in the com-

Origins of population assistance from the


United States
Awareness of the magnitude of population heightened public recognition of the hazards of
growth in LDCs grew gradually during the late rapid population growth.
1950’s and early 1960’s. Statements from the
countries themselves heightened this aware- Until the mid-1960’s, private agencies played
ness, as did the activities of such organizations the major role in international population assist-
as the Population Council and the United Na- ance. These agencies were of two types: activist
tions (U. N.). The U.N. published its first Demog- citizen organizations like the International
raphic Yearbook in 1949 and its first series of planned Parenthood Federation (IPPF), estab-
population projections in 1952, which forecast a lished in 1952, and the Pathfinder Fund, estab-
1980 world population of 3.6 billion. This total
lished in the 1930’s, in which business leaders
was revised upward in 1957 to 4.2 billion. and community workers merged to promote
public recognition of population problems and
India adopted a national family planning pol- provide family planning services directly to
icy in 1951 and Pakistan included demographic those who wanted them; and professional scien-
policy and family planning activities in its na- tific organizations like the Population Council,
tional development plan in 1955. Demographer also established in 1952, which focused on spe-
Ansley Coale and economist Edgar Hoover built cialized demographic and biomedical research
a population growth model in 1958 which dem- and then on technical assistance as requested.
onstrated that family planning expenditures Private donors—individual philanthropists and
would, over various intervals, increase per such major foundations as Ford and Rockefel-
capita income to a greater degree than any ler—provided financial support for these scien-
other type of goverernment investment. Although tifically oriented programs. Princeton, North
this model was developed for India, its message Carolina, Michigan, and Johns Hopkins Univer-
to other LDCs was clear: a reduced rate of pop- sities, with this help, were able to develop train-
ulation growth would always mean additional ing programs for population/family planning
funds for capital investment because there specialists.
would be fewer dependents and smaller ex-
penditures for consumption and social needs. Although private agencies had been seeking
The actions taken by India and Pakistan, and the Government support for more than a decade,
activities of private organizations and the U. N., several factors combined in the 1960’s to stim-
Ch. 9—Financial Support for LDC Population Program ● 177

ulate official concern and to prompt the first velopments closely. The news that food produc-
U.S. public support for population assistance. tion in many LDCs was failing to keep pace with
The 1960 round of censuses showed high rates population growth was highlighted in House
of population growth in LDCs, especially in Asia. and Senate hearings. As a result, the Congress
The governments of Pakistan and India had by took the initiative in 1963 and again in 1966 and
the 1960’s begun to ask the United States and 1967 to provide specific legislative authority for
other MDCs for help, The U.N. Population Com- the United States to assist LDCs with their pop-
mission and the U.N. Economic Commission for ulation growth problems.
Asia and the Far East brought population issues
The AID population assistance program, first
to international attention.
created by Congress as a part of a concerted
Within the U.S. Government, such expert ad- War on Hunger, and then as an important ele-
visory groups as the Draper Committee (in 1959) ment of humanitarian and social development,
recommended that the U.S. provide assistance grew from a $5 million effort in 1965 to one of
for population planning at the request of LDCs. $190 million in 1981. From the beginning, the
The election of John F. Kennedy in 1960 as the U.S. program has made extensive use of private
first Catholic President of the United States organizations. Influenced by both the important
helped defuse religious issues and brought to role of private voluntary agencies in other
power an administration that viewed popula- assistance efforts and by the fact that until the
tion growth as a national policy matter. mid-1970’s many LDC governments were not
yet ready to adopt bilateral assistance for offi-
The food crisis that developed in South Asia in cial population programs, AID and other donors
the mid-1960’s also spurred U.S. Government support a network of private agencies that pro-
concern. Members of Congress had initiated the vide family planning services, training, informa-
Food for Peace Program (Public Law 480) in tion, and education; demographic and policy
1954 and were following international food de- data; and public health research.

Origins of population assistance from the U.N. and


from MDCs other than the United States
The government of Sweden, the first to give ance. Although the impetus for response to in-
assistance to an LDC for family planning, sup- ternational population problems came from a
ported pilot projects in Sri Lanka in 1958 and number of U.N. agencies, a viable U.N. unit with
Pakistan in 1961. The United Kingdom followed a specific mandate in the field of population did
with small-scale assistance programs in India not exist until 1969 when the U.N. Fund for Pop-
and Pakistan in 1964. Denmark made its first of- ulation Activities (UNFPA) became a separate
ficial grant in 1966 in support of a pilot study to unit within the U.N. Development Programme
test the suitability of a Danish IUD for India’s na- (UNDP). Following the unanimous General As-
tional family planning program. The Nether- sembly Resolution in 1966, a trust fund was es-
lands offered bilateral support to a family plan- tablished to become UNFPA, and operational ac-
ning project in Kenya in 1968. The Federal Re- tivities began 3 years later.
public of Germany and Finland followed in 1969
Within the U.N. system different offices and
with support to multilateral programs and Can-
agencies have different responsibilities for the
ada, Japan, and Norway joined in the effort in
execution of population programs: the Statis-
the early 1970’s.
tical Office gathers statistics and the Population
International agencies had meanwhile begun Division conducts research on population issues
o respond to LDC needs for population assist- and makes demographic projections; the World
178 ● World Population and Fertility Planning Technologies: The Next 20 Years

Health Organization provides technical exper- mortality reduction, and maternal and child
tise for assistance to maternal and child health health (MCH) activities in addition to fertility
and family planning services; UNESCO deals planning, while the AID Office of Population, as
with population education and communications; legislated by Congress, is primarily concerned
UNDP provides general development assistance with family planning activities. Separate ac-
on request but relies on UNFPA for population counts within AID handle health activities.
expertise.
The World Bank initiated a population pro-
Most U.N. agencies depend on contributions gram in 1969, The Bank, which has more devel-
assessed from member nations on a population/ opment resources than any other international
income formula and are reluctant to start new agency, deals with high level finance and plan-
programs without additional funds. Their gov- ning officials in LDCs. Population planners
erning bodies and staff were at first apprehen- hoped this influence would be used within LDC
sive about the political implications of a pro- governments to provide more support for pop-
gram that might be controversial. Established ulation programs, but banking officials have re-
first as a trust fund of the Secretary-General mained skeptical of such programs; less than 1
and entirely dependent on voluntary contribu- percent of Bank resources have been directed
tions from interested governments and on the toward population projects in recent years.
technical expertise of other agencies, UNFPA About 20 population projects totaling $400 mil-
came into being with a minimal mandate in a lion have been initiated since 1969 through the
field where responsibilities were fragmented Bank’s International Development Association
and bureaucratic rivalries strong.
(IDA) and International Bank for Reconstruction
UNFPA uses a broader definition of popula- and Development (IBRD), and the Bank is now
tion planning than does AID’s Office of Popula- working to integrate population, health, and
tion. UNFPA programs, often in conjunction nutrition projects to provide a broader operat-
with LDC health ministries, focus on migration, ing base.

Support for population activities


Channels of assistance Pathfinder Fund, and Family P1anning Interna-
tional Assistance (FPIA). These in turn provide
Donor governments are the principal sources both funds and advisory personnel to local orga-
of population assistance. Most smaller donors nizations within LDCS. Some international pri-
contribute only to UNFPA or to other U.N. pro- vate agencies, like IPPF and the Population
grams, but larger donors such as the United Council, also make expert advisory personnel
States, the Scandinavian countries, Germany, available to assist LDC governments or to orga-
Japan, Britain, and Canada have contributed in nize U.N. or global programs such as the 1974
three ways: I) to private intermediaries or non- World Population Conference in Bucharest and
governmental organizations (NGOs), i.e., IPPF the 1981 conference in Jakarta on Family Plan-
and the Population Council; 2) directly to LDC ning in the 1980’s.
governments through bilateral loans and grants;
and 3) to UNFPA. UNFPA contributes in turn to
LDC governments and also provides a small Kinds of assistance
amount of support for private intermediaries
Kinds of population assistance, although not
and for global activities, such as conferences
strictly comparable, can be grouped under six
(see fig. 25).
functional headings (see table 45): I) family plan.
Private sector donors contribute primarily to ning services—purchasing and distributing con.
NGOs such as IPPF, the Population Council, the traceptive commodities, and providing support
Ch. 9—Financial Support for LDC Population Program ● 179

Figure 25.—Channels and Directions of International population Funding and Technical Assistance

Primary sources Secondary sources Final recipient

— Dollar flows
--- Technical assistance flows

SOURCE: Office of Technology Assessment.

Table 45.—Composite of Kinds of Assistance Provided by Major


Assistance Agencies

Office of Technology
Assessment composite AID UNFPA IPPF World Bank
Family planning services Family planning Family planning Medical, health Delivery of
services, com- programs, services services, com- services,
modities and training modities management,
construction
Information, education, Information, Communication Information, corn- Information,
and communication (l EC) education, coe- education munication education,
munication communication,
motivation
Institutions and training Institution Population Training Training
building, training dynamics,

Research and evaluation Biomedical and Population Evaluation Research and


operations determinants evaluation
research Multi sectoral
activities
Policy development Policy develop- Formulation and Special projects —
ment, social impiementation
science research
Data collection Demography Basic population — —
data collection

SOURCES: Annual reports of each agency, AID Congressional Presentation, 1980.


180 ● World Population and Ferti/ity Planning Technologies: The Next 20 Years

for family planning program management and vate family planning associations have provided
operations, personnel, and equipment (AID, a measure of continuity.
UNFPA, IPPF, and World Bank all expend close
to half or more of their population funds for The role of international agencies is necessar-
family planning services, and the Bank includes ily different, and less experimental. UNFPA, for
clinic construction in this category); 2) informa- example, works with other U.N. agencies and
tion, education, and communication (lEC)—in- national governments to fund efforts to build
forming or educating the public about family national capacity to formulate and implement
planning, contraceptive mehtods, and the im- population policies and programs. UNFPA has
plications of rapid population growth; 3) institu- served three main population assistance func-
tions and training—teaching and training of tions that supplement and complement U.S.
clinic personnel, midwives, and family planning Government efforts:
practitioners; 4) research and evaluation—spon- 1. As a multilateral agency, UNFPA has been
soring biomedical and social science research able to stimulate substantial additional
activities, family planning program evaluation, funding for population assistance. Of the
and operations research; 5) policy deve[op- more than 85 governments that have con-
ment—conducting leadership awareness activi- tributed to UNFPA, fewer than 10 have
ties in the government and private sector in separately staffed bilateral population
LDCS (AID also includes research on fertility de- assistance programs. Most would probably
terminants and women’s roles); and 6) data co/- have made little contribution to population
Iection–gathering, analyzing, and disseminating programs had they not had the opportunity
relevant population information through cen- either to contribute directly to UNFPA or to
suses and surveys. support multilateral-bilateral projects com-
bining national funds and UNFPA-U.N. spe-
Roles of assistance agencies cialized agency monitoring and expertise.
The private agencies (Population Council, 2. The various international agencies, in-
IPPF, FPIA, AVS, etc.) are major innovators in cluding UNFPA and the World Bank, have
service delivery, training, and research. For ex- helped to define rapid population growth as
ample, IPPF, FPIA, and others initiated commu- a global concern, an obstacle to economic
nity-based distribution (CBD) of contracep- development, and a problem in need of high
tives—usually cond’oms and pills—by networks level national attention. Their efforts un-
of local community leaders. The Ford Founda- derscore the fact that population assistance
tion initiated contraceptive sales activities in is a cooperative response to an interna-
LDCS through retail storekeepers. Private agen- tional need. Whether the immediate issue is
cies and universities have trained and equipped rapid urbanization or high levels of unem-
physicians in newly simplified techniques of ployment, UNFPA has called government at-
female sterilization, and were the first to tention to the underlying demographic
establish collaborative international research causes and made assistance available to ad-
networks to pool data and evaluate new con- dress the problem at hand, World Bank offi-
traceptive technologies in a pattern now being cials can articulate the adverse economic
expanded by WHO. They have tested new com- impacts of rapid population growth while
puter techniques for storing and retrieving working with the planning and finance min-
population data and presenting these data visu- istries that set government budgets.
ally to government leaders, and have experi- 3. International agencies can mobilize techni-
mented with women’s programs to develop cal assistance to help LDCs help each other.
women’s management skills and spread aware- Even though national programs may suffer
ness and knowledge of family planning. In coun- temporarily if skilled people leave to join
tries where population policies are in flux, pri- these agencies, these experts can bring
Ch. 9—Financial Support for LDC Population Program ● 181

their specialized experience to bear on simi- velopment assistance for population activities.
lar problems in other LDCs, where it is like- In 1980, total resources committed to popula-
ly to carry more weight than advice from tion and family planning programs in LDCS
MDC governments that have not faced com- amounted to about $1 billion. LDC contribu-
parable population problems. Through this tions accounted for about $450 million in 1980,
process of mutual support, LDCs can move excluding China; roughly $55o million origin-
toward greater self-sufficiency. ated externally as international population
assistance. (See app. A for China expenditures. )
Among these channels of population assist-
ance, AID has played a multiple role. As one of MDC governments over the last decade have
the first and still the largest of government consistently generated more than 80 percent of
assistance programs, AID has provided part of all international population assistance; the re-
the basic strategy for population programs. mainder has originated with the World Bank
AID’s strategy is based on the established public and private sources. Among MDC donor coun-
health principle of availability-making infor- tries, the United States, through AID, continues
mation, supplies, and services readily available to be the largest contributor of population
so that individuals who choose to plan their fer- assistance. The United States provided 50 per-
tility can do so conveniently. As a result, AID cent or more of all primary source assistance
has been the principal supplier of contracep- until 1973, when the U.S. share of this funding
tives, purchasing in bulk from U.S. firms at low decreased and the portion provided by other
competitive prices. (For example, AID now pays sources increased (see fig. 26). By the mid-
$0.15 for a cycle of oral contraceptives that 1970’s, the U.S. share leveled off to about 40
would otherwise wholesale in an LDC for about percent, and has remained at this level for the
$3.50.) Through the use of intermediary agen- last 4 years. This decrease is largely due to in-
cies, AID has encouraged CBD of contraceptives creased contributions from other MDCs. Several
and other cost effective approaches for the of the Scandinavian countries, Japan, and West
delivery of family planning information and Germany have increased their funding over the
supplies to rural populations that lack access to past few years by 30 to 60 percent. United
clinic-based services. In addition, AID has been States funding for population assistance has in-
responsible for many major improvements and creased only 61/2 percent since 1978 after having
innovations in the field of fertility planning increased by 40 percent between 1975 and 1978
technology. (see table 46). The impact of inflation has cut to-
day’s funding level–in constant dollars–to be-
The AID program has been both a catalyst and
low that of the peak year of 1972. In that year
a stimulus to other agencies in developing such
Congress provided AID with a budget of $121
projects as the World Fertility Survey, which is
million. Inflation has cut the value of AID’s 1981
also supported by UNFPA and other govern-
ments, AID’s efforts have encouraged other gov- appropriation of $190 million to about $100 mil-
ernments and agencies to improve their pro- lion, and the 1982 appropriation of $211 million
is $28 million below the amount required to
grams, and universities, private agencies, LDC
maintain the 1972 level (see fig. 27).
governments, and the World Bank to undertake
more intensive efforts in program implementa-
tion. Components of U.S. population
assistance
U.S. share in international assistance
AID obligates its population assistance
Less than 2 percent of official development as- through four channels: 1) direct bilateral from
sistance from all MDC donors is currently allo- AID to LDC governments; 2) indirect bilateral
cated to population activities, which represents through U.S.-based private organizations to
a small decline since 1970. The United States NGOS in LDCS; 3) intergovernmental muhilater-
provides just under 4 percent of its global de- al (e.g., UNFPA), in which MDC donations are
182 ● World Population and Fertility Planning Technologies: The Next 20 Years

Figure 26.—Primary Sources of International Population Assistance


1971-74 1975-78 1979

ank

‘odd
4Y / 0

Table 46.—AID Annual Budgets for Population ents of U.S. bilateral aid for population activities
Assistance, 1975-81 (in millions) were:
Percent increase Millions of dollars
Year Budget over previous year Indonesia . . . . . . . . . . . . . . . . . . . . . . . . . $11.4
Bangladesh. . . . . . . . . . . . . . . . . . . . . . . . 4.0
Philippines . . . . . . . . . . . . . . . . . . . . . . . . 2.4
Tunisia . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8
Thailand. . . . . . . . . . . . . . . . . . . . . . . . . . 1.7
Nepal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7

INDIRECT BILATERAL
NOTE: Figures and percentages reflect actual dollar figures, not allowing for
inflation.
In 1979, some $90 million (52 percent of the
AID population budget) went to private inter-
mediary organizations. Eighty-five percent of
this assistance was channeled through 14 agen-
pooled and redistributed to LDC governments cies (see table 47), which provide substantial
and NGOs; and 4) private multilateral (IPPF), in amounts of technical assistance to countries
which donor funds are pooled and redistributed where bilateral assistance is not always appro-
to IPPF affiliates in LDCs (see fig. 28). The priate. U.S.-based NGOs provided technical
United States also contributes to the World assistance to 64 LDCs in 1979: 22 in Africa, 19 in
Bank, but this separate authorization from Con- Latin America, 14 in Asia, and 9 in the Middle
gress is not channeled through AID. East.

DIRECT BILATERAL INTERGOVERNMENTAL MULTILATERAL


In calendar year 1979, the latest year for In 1979, the United States contributed about
which complete data are available, about $48 $30 million (16 percent of the AID population
million (26 percent of the AID population budg- budget) to UNFPA. This constituted 27 percent
et) went directly to 33 LDC governments: 11 of UNFPA’S budget. UNFPA grants went to 116
each in Africa and Latin America, 8 in Asia, and LDCS in 1979: 37 in Africa, 31 in Latin America,
3 in the Middle East. In 1979, the largest recipi- 28 in Asia, and 20 in the Middle East/Mediterra-
Ch. 9—Financial Support for LDC Population Proaram ● 183

1972 1973 1974 1975 1976 1977 1978 1979 1960 1981
Fiscal year

NOTE: Actual dollar levels exclude operating expenses except when these were combined with program funds.

SOURCE: Agency for International Development.

Figure 28.—Distribution of AID Population Funds: 1965-79, 1980, 1981, 1982 (proposed)

Actual FY 1965-1979 Actual FY 1980 Estimated FY 1981 Proposed FY 1982


184 ● World Population and Fertility Planning Technologies: The Next 20 Years

Table 47.–Principal Organizations Administering of UNFPA, is a proportional decline of U.S. input


AID Population Funds, 1979 since 1970 (see fig. 30). IPPF provided grants to
Estimated 88 private family planning affiliates in LDCS in
expenditures from 1979: 21 in Africa, 32 in Latin America, 20 in
AID for fiscal Asia, and 15 in the Middle East.
year 1979
Intermediary organization (in millions) The countries receiving the largest grants
Family Planning International from IPPF during calendar year 1979 were:
Assistance (FPIA). . . . . . . . . . . . . . . $14.0 a
Association for Voluntary Millions of dollars
Sterilization (AVS) . . . . . . . . . . . . . . 7.7 a Brazil . . . . . . . . . . . . . . . . . . . . . . . . . . . . $3.4
Johns Hopkins Program for Colombia . . . . . . . . . . . . . . . . . . . . . . . . . 2.9
International Education in India. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.0
Gynecology and Obstetrics
(J HPIEGO) . . . . . . . . . . . . . . . . . . . . .
Mexico . . . . . . . . . . . . . . . . . . . . , . . . . . . 1.4
7.2
Pathfinder Fundb . . . . . . . . . . . . . . . . . 6.7 a
Republic of Korea. . . . . . . . . . . . . . . . . . 1.2
International Statistical Institute
(World Fertility Survey) . . . . . . . . . . 5.0
International Fertility Research
International assistance to LDCs
Program (IFRP) . . . . . . . . . . . . . . . . . 4.2
Development Associates . . . . . . . . . . 3.0 The quantification of dollar flows from MDC
Westinghouse Health Systems . . . . . 2.9 governments and international agencies to spe-
University of North Carolina . . . . . . . . 2.2 cific LDCs cannot be precise because:
Johns Hopkins University . . . . . . . . . . 1.6
Population Council . . . . . . . . . . . . . . . 1.6 funds that pass through a variety of agen-
Battelle Memorial Institute. . . . . . . . . 1.5
Program for Applied Research on cies are often commingled, making identifi-
Fertility Regulation (PARFR). . . . . . 1.1 cation of initial donors difficult;
East-West Center. . . . . . . . . . . . . . . . . 1.0 interpretations vary as to what interna-
tional population assistance is, as opposed
to, for example, MCH assistance;
different accounting methods, fiscal years,
and exchange rates are used; and
nean. Those countries receiving the largest commitments span several years and are
grants from UNFPA in 1979 were: often reprogrammed through continuing
evaluation and review processes, making
Millions of dollars identification of given-year expenditures
India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $17.0 exact.
Vietnam . . . . . . . ... , . . . . . . . . . . . . . . 4.9
Bangladesh. . . . . . . . . . . . . . . . . . . . . . . . 4.5 The relative proportions of all external pop-
Thailand, . . . . . . . . . . . . . . . . . . . . . . . . . 3.0
Egypt . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4
ulation assistance to each region were fairly
constant from 1977 through 1979, with Asia re-
In 1980, the U.S. share of contributions to ceiving the greatest share (see fig. 31), Excluding
UNFPA fell to 26 percent of its budget where it funds for regional, interregional, and global
remained during 1981. This marks the lowest purposes, country-specific dollar expenditures
point of declining U.S. input to this agency (see increased from $208 million in 1977, to $232
fig. 29). million in 1978, to $280 million in 1979 (see table
A-3, app. A) for total amount of external assist-
PRIVATE MULTILATERAL (lPPF) ance to each LDC).
The remaining $22 million (12 percent of the AFRICA
1979 AID population budget) was channeled Total average international assistance to
through IPPF. * This represents 28 percent of Africa during 1977-79 for all population activ-
IPPF’s total operating budget and, as in the case ities remained at about $0.09 per capita per
year. Almost half of this aid came from UNFPA.
● Note: This was not a representative year for the IPPF appro-
priation from AID. The figures for 1978 and 1980 were about $10 Among African countries, Kenya and Tanzania
million less. received the larges population assistance grants,
Ch. 9—Financial Support for LDC Population Program Ž 185

Figure 29.—Contributions to UNFPA by the United States and All Donors

I 4U

120

100

80

60

40 ‘/0

20
5

Figure 30.–Contributions to IPPF by the United averaging $0.59 and $0.22 per capita per year,
States and All Donors respectively, over the 3-year period. West
International Planned Parenthood Federation income and African countries received less: Nigeria, $0,03
expenditures 1970-79
per capita; Niger, $0.04; Upper Volta, $0.01; and
Cameroon, $0.04.

African countries either do not generally rec-


ognize rapid population growth as a problem or
are at early stages of program development.
Population assistance to Africa, relative to other
regions, places greater emphasis on demograph-
ic data collection, IEC, and family planning in
the context of maternal and child health. Never-
theless, family planning services and commod-
ities accounted for 58 percent of all assistance to
Africa in 1979 (see fig. 32).

ASIA
Per capita population assistance (excluding
China) rose from $0.09 in 1977 and 1978 to
$0.12 in 1979. Because Asia contains 8 of the 13
most populous countries in the world, and be-
cause Asian countries have the longest history
186 ● World Population and Fertility Planning Technologies: The Next 20 Years

Figure 31.— Regional Distribution of All External Population Assistance, 1977=79


1977 1978 1979

Figure 32.—Kinds of Population Assistance Thailand $0.38, and the Philippines $0,28. A
Provided to Africa, 1979 large portion of assistance to Asia has been ear-
marked for expansion of services and purchase
of commodities (see fig. 33).

Figure 33.—Kinds of Population Assistance


Provided to Asia, 1979

Institutions and training/


research and evaluation
13%
SOURCE: Percentages derived from: UNFPA Report on Population Assistance,
1979-Table 3—Assistance to Population Programs by Country and
Region and Major Population Sector.
Data
of government-sponsored programs, more collection Policy Institutions and training/
20%
funds flow into this region. In 1979, 90 percent development research and evaluation
of all international population assistance to Asia 30/0 7%
came from U.N. agencies and direct bilateral SOURCE: Percentages derived from: UNFPA Report on Population Assistance,
1979-Table 3—Assistance to Population Programs by Country and
donors. Bangladesh received $0,49 per capita, Region and Major Population Sector.
Ch. 9—Financial Support for LDC Population Program • 187

LATIN AMERICA $23.3 million, the relative share of total world


Latin American countries rely extensively on population assistance remained at only 8 per-
intermediaries for population assistance. In cent. Total per capita population assistance in
1979, IPPF and the Ford and Rockefeller Foun- 1979 amounted to about $0.12. UNFPA contrib-
dations provided 36 percent of population as- uted more than half of this assistance through
sistance to Latin America. NGOS provided 53 large grants to Egypt, Jordan, and Tunisia.
percent of the $9.7 million contribution to Egypt also obtained substantial World Bank sup-
Brazil, 44 percent of the $11.2 million contribu- port during the late 1970’s and 1980-81. Tunisia
tion to Colombia, and 65 percent of the $8.3 mil- received one of the largest per capita population
lion contribution to Mexico. Although Latin assistance donations in 1979 ($0.78), principally
American countries received less total popula- from AID and UNFPA. Like Africa, the Middle
tion assistance than Asia in 1979, per capita Eastern/Mediterranean region is at a compara-
averages were higher (about $0.19); relative tively young stage of policy and program devel-
proportions of assistance were similar, with opment, and data collection for increased demo-
most funds spent on family planning services graphic awareness is a major focus of popula-
(see fig. 34). tion activities (see fig. 35).

MIDDLE EAST/MEDITERRANEAN THE 13 MOST POPULOUS LDCS


Middle Eastern and Mediterranean LDCS re- External population assistance trend data and
ceived the smallest share of international pop- per capita estimates for 1977-79 to the 13 most
ulation assistance of all major regions over the populous LDCS are shown in table 48 (for com-
last few years. Although total country-specific plete list of countries see table A-3, app. A, ch.
assistance in this region grew 62 percent be- 9). Thirty-nine percent of all external population
tween 1977 and 1979, from $14.4 million to assistance in 1979 went to these countries,

Figure 34.—Kinds of Population Assistance Figure 35.—Kinds of Population Assistance


Provided to Latin America, 1979 Provided to Middle Eastern/Mediterranean
Regions, 1979

r evaluation

Policy development 1‘/0


188 “ World Population and Fertility Planning Technologies: The Next 20 Years

Table 48.—Total Intemationai Population LDC support for population activities


Assistance Fiows to 13 Most Popuious LDCS,
1977=79, (in millions of dollars) Of the $1.0 billion spent for population ac-
Cents received tivities in 1979, LDCS contributed $450 million.
per capita The LDC commitment is thus a crucial compo-
Countw 1977 1978 1979 1979 nent of support for population programs.
China . . . . . . . . . $0 $ o+ $0.4 o+ Although data are not available for all coun-
India . . . . . . . . . . 19.5 35.6 36.5 5
Indonesia . . . . . . 42.4 23.8 24.2 16 tries, there is evidence that some LDCS assume
Brazil. . . . . . . . . . 5.0 9.0 9.7 8 funding and operational responsibilities in pro-
Bangladesh . . . . 18.0 20.7 43.8 49
Pakistan . . . . . . . 4.2 2.3 3.1 4 portion to the length of time the program has
Nigeria . . . . . . . . 1.4 1.9 2 been in operation. In Indonesia, trend data illus-
Mexico . . . . . . . . i:; 7.6 8.3 12 trate this growing government commitment as
Vietnam . . . . . . . 1.2 0.7 5.4 10
Philippines. . . . . 4.3 19.0 14.5 28 the family planning program has matured (see
Thailand . . . . . . . 7.3 11.7 18.2 38 fig. 36). In 1968, 96 percent of Indonesia’s total
Turkey. . . . . . . . . 1.5 2.1 5
Egypt . . . . . . . . . ;:: 7.3 6.6 16
budget came from external assistance; by 1980,
this share had fallen to 35 percent. Some of this
current assistance is for raw materials for local
production of contraceptives, as the govern-
ment’s goal is self-reliance in the production of
orals by 1985-90.
which comprise 75 percent of the world’s popu- Many populous LDCS are contributing more
lation. If China’s population is excluded from the than 50 percent of the funds needed for their
total count, the proportion becomes more equal: population programs. Table 49 shows 16 such
39 percent of population assistance goes to 46 countries for which data are available. Of the 13
percent of the LDC population. most populous countries, China, Bangladesh, In-

Figure 36.—Trends in Monetary Population Support in indonesia

SOURCE: AID’s Role In Indonesian Family Planning; Program Evaluation Report No. 2, app. table 3. Compiled from AID
estimates from various sources.
Ch. 9—Financial Support for LDC Population Program ● 189

Table 49.—Degree of Support Provided by Seiected LDCS for Population


Activities/Number of Years Government and Private Agency Sponsored
Services Avaiiabie

Local dollars
for population As a percent of Years family planning
activities services available
all population
Country (thousands) funding Government Private
Category 1: Countries providing more than 50 percent of all resources (1980)
Bangladesh . . . . . . . . . . . . . $22,000 54 21 28
India . . . . . . . . . . . . . . . . . . . 175,000 79 29 32
Indonesia. . . . . . . . . . . . . . . 49,700 65 13 24
Malaysia . . . . . . . . . . . . . . . 8,000 78 14 23
Nepal . . . . . . . . . . . . . . . . . . 4,145 54 15 23
Philippines . . . . . . . . . . . . . 23,500 69 16
South Korea . . . . . . . . . . . . 16,186 84 ; : 20
Thailand. . . . . . . . . . . . . . . . 10,914 60 14 26
Costa Rica. . . . . . . . . . . . . . 2,496 58 13 15
El Salvador . . . . . . . . . . . . . 4,030 62 13 18
Jamaica . . . . . . . . . . . . . . . . 1,366 56 14 24
Mexico . . . . . . . . . . . . . . . . . 48,207 81 8 16
Panama . . . . . . . . . . . . . . . . 2,562 66 12 15
Mauritius . . . . . . . . . . . . . . . 800 69 9 24
Senegal . . . . . . . . . . . . . . . . 2,428 77 — —
Morocco. . . . . . . . . . . . . . . . 8,000 73 15 11
Category 11: Countries providing less than 50 percent of all resources (1980)
Colombia . . . . . . . . . . . . . . . 2,100 33 14 16
Dominican Republic. . . . . .