Part 4 - Beliefs About Simple Approaches that are Mistakenly Believed to Hold Promise of a Quick Fix to the Population Problem

13. Myth: Reduce infant/child mortality rates and fertility rates are certain to follow.

The assumption behind this view is that people have large numbers of children out of fear that some of their children will die before reaching maturity. It is also assumed that, if infant and child mortality rates are reduced, people will quickly understand the reduced risk and adjust their fertility patterns accordingly.

The extent to which there may be a time lag between the actual reduction in mortality rates and popular understanding of the reduction of risk clearly is a function of both the mass media and the popular culture. Whether such understanding actually reduces family size preferences is not known.

As mentioned earlier, reduction in infant and child mortality rates since the early part of this century is a major cause of rapid population growth rates. While very significant progress in reducing infant and child mortality has occurred, it is clearly possible that further progress can be made in many countries. Whether the effect on attitudes regarding family size of such additional marginal reductions would be greater than that achieved already is questionable.

It is also possible to point to countries with high infant mortality rates (such as Sierra Leone, with infant mortality of 148 deaths per 1000 live births and fertility of 6.5 children per woman) where fertility rates are lower than in nearby countries with much lower infant mortality rates (such as Nigeria, with infant mortality of 84 per 1000 and fertility of 6.6 children per woman).

History shows that reductions in infant mortality have been only partially offset by reductions in births. Reducing infant mortality should be done for humanitarian reasons, but we should expect it to cause an increase in population growth, at least in the short term.

Michael Teitelbaum of the Alfred P. Sloan Foundation points out:

"In 1800, life expectancy at birth averaged less than 40 years for the world as a whole; by 1990 it had risen to 65 years globally (to 62 years in developing countries and 74 years in the industrialized nations). The key declines in mortality rates were among infants and children in the developing countries of Asia, Latin America and Africa, principally in the period since World War II. At the same time, however, there was no contemporaneous drop on the fertility side; for decades after mortality had declined greatly, many nations of Asia, Africa and Latin America continued to sustain very high fertility." (p. 64)

Abernethy (1993) cites a couple of examples that put in doubt any immediate causal link between reduced child mortality and fertility rates:

"In Haiti, Save the Children Fund set out to learn if women who had lost children compensated by increasing their total number of births. The exactly opposite effect was found: women who had never lost children had the most births; women who had an infant die were least likely to continue childbearing. Indeed, studies in several continents fail to find that high child mortality leads to more births. Comparison of Indian women who had lost young children with those whose family was intact showed no increased childbearing among the former. Research in Guatemala yielded similar results: women who had lost children did not desire additional births as replacements..."

"Still stronger evidence that declining mortality was not a cause of lower fertility comes from France, the country which led Europe into the fertility transition. Catherine Rollet-Echalier (1990) finds that small family size was established by 1850, but the decline in infant mortality was not recognizable until the 20th century."

While the above example indicates that fertility levels can be reduced in the absence of reduced infant and child mortality rates, more research is needed to determine whether reducing infant/child mortality alone can cause reduced fertility levels in the long term.

A cause and effect relationship between child mortality and fertility appears to run in the opposite direction. That is to say that one of the best ways to lower child mortality rates is child spacing and reduced family size. Modern medicine can only do so much in the face of people having more children than they can afford to feed or care for.

14. Myth: Economic development will lead automatically to a demographic transition.

At the 1974 World Population Conference, the phrase "Development is the best contraceptive" was on the lips of many delegates from developing countries. The example of the naturally-occurring reduction in fertility rates in Europe and North America over the last two centuries was proposed as evidence that improved economic welfare would lead automatically to such a demographic transition in the developing countries.

If one looks at the Demographic and Health Survey reports on 18 countries, it is clear that desired and actual levels of fertility are higher in countries with low levels of economic development and lower in countries with high levels of development. To what extent each is cause and effect, however, is open to question. As mentioned earlier in this paper, there is strong reason to believe that lower fertility rates lead to improved economic development.

Abernethy (1993 correspondence) points out a number of cases that cast doubt on the theory of an orderly demographic transition:

"Land redistribution in Turkey promoted a doubling in family size (to six children) among formerly landless peasants. In the United States and much of Western Europe, a baby boom coincided with the broad-based prosperity of the 1950s. More water wells for the pastoralists of the African Sahel promoted larger herd size, earlier marriage and much higher fertility. The introduction of the potato into Ireland in about 1745 increased agricultural productivity and caused a baby boom."

Some further examples from Abernethy include the 17 percent drop in Sudan's fertility rate during the late 1980s at a time of extreme deterioration of the economy and a similar correlation of falling fertility rates and declining economic conditions in Brazil in the 1980s.

It is also true that the United States had its lowest fertility rate in history prior to 1970 during the Great Depression.

Robley, Rutstein, and Morris (1993) cite Bangladesh as a perfect example of how the theory that economic development must precede fertility declines has been disproved:

"It is one of the world's poorest and most traditional agrarian countries. Infant mortality is high, women have low social status and most families depend on children for economic security. Nevertheless, fertility rates there declined 21 percent between 1970 and 1991...During this period, the use of contraception among married women of reproductive age rose from 3 to 40 percent."

The above indicate that economic prosperity may lead to higher fertility levels and that economically depressed conditions may motivate people to limit family size. The theory that prosperity causes fertility declines cannot explain many situations in both developed and developing countries.

Despite the above examples, improved economic conditions in many societies may actually lead to reductions in fertility levels. As mentioned above, there is a strong inverse correlation between levels of economic development and levels of fertility in many countries of the world. While there is a link between industrialization and lower fertility levels, the nature of the relationship is not well understood. But few would take the position that poverty is a solution to high rates of population growth.

In general, the evidence would lead us to conclude that not only will people's lives be improved through economic development, but that, in most cases, such development is likely to be associated with smaller family size.

The point of this section is that economic development by itself, without other measures that affect family size desires or the ability to achieve those desires, is not necessarily a cure-all for the population problem. Nor is there any clear understanding of the length of time that may elapse in various societies between achieving higher standards of living and reduction in fertility levels.

Countries with similar levels of economic development may have markedly different fertility levels, indicating that factors other than economic welfare, such as access to family planning services and cultural norms regarding childbearing, may be far more important in determining completed family size.

Delaying the establishment of family planning programs until economic development occurs may well have the effect of ensuring that economic development will never occur.

If development does work as a contraceptive, it appears to have a high failure rate. Where it does work to lower fertility, the effect may be indirect: the growing economy may include opportunities for women's employment outside the home, thus giving childbearing a greater opportunity cost. On the other hand, while improvement in the standard of living in developing countries is desirable, economic development does not appear to be a necessary

15. Myth: Educate women, and fertility rates will automatically drop.

I use the word "myth" cautiously here, for I happen to believe that much of what is behind this statement is true. In fact, in many countries there is a strong inverse correlation between the level of education of women and their fertility level. In addition, as Kenya has experienced, keeping girls in school longer can have a demographic impact in countries with high teenage pregnancy rates.

On the other hand, achieving high rates of female literacy, without any other interventions, may not lead to fertility decline. Tanzania is an example of a country with high rates of female literacy (88 percent, according to the government) where the fertility rate has not declined markedly (as of 1993, at 6.4 children per woman). As with the issue of economic development, other factors, such as access to family planning services and cultural norms regarding childbearing, cannot be ignored by those concerned with population growth.

There is a need for more research on the relationship between various aspects of women's status and fertility rates. In his 1991 study of comparative reproductive preferences, Charles Westoff of Princeton University's Office of Population Research found,

"The relationship between education and the percentage of women who want no more children is positive in several of the countries, but weak or non-existent in many others. In fact, [the data] give the general impression that the intention to terminate childbearing is similar across educational levels...There is little evidence to support any strong pattern of diffusion or differential penetration of norms of family limitation across educational levels or from urban to rural areas. (pp. 5-6)

Abernethy (1993 correspondence) raises some interesting issues:

"Raising women's legal, health, and social status, and providing women with educational opportunity are very worthwhile objectives in themselves. Nevertheless, only correlational data link these factors to fertility decline. On the contrary, participation in the labor market, particularly if a woman's earnings make a significant contribution to family income, appears to significantly affect family size targets: Penn Handwerker and Diane Macunovich have found in Third World countries and the United States, respectively, that women prefer and have fewer children when child rearing carries an opportunity cost.

If overpopulation is a threat to women's well-being (as Abernethy points out), jobs for women deserve high priority. Particularly effective in reducing fertility rates may be income-producing jobs outside of the home, which create a situation where children carry a higher opportunity cost. It is reasonable to believe that education and training programs that prepare women for such jobs are an important element of a women's employment strategy. This implies providing far more than literacy training, as important as that may be.

For obvious humanitarian reasons, job creation for women should be combined with broad-scale programs to elevate the status of women--both in law and in practice. The evidence to date suggests all such efforts will be useful.

Clearly more research is needed. But in general, it is safe to conclude that if women lack the right or practical ability to make decisions about family planning and family size, reducing fertility rates will be much more difficult.

16. Myth: Meeting all "unmet need" for contraceptive services will essentially solve the population problem.

This is an extreme statement of the view that "the top priority in the population field should be focused on providing family planning medical services because lack of access to these services still is the major barrier to fertility reduction." It is true that over the last 30 years increasing access to contraceptive services has helped reduce fertility rates to the current levels. The view of those who subscribe to the "medical model" of solving the population problem is that additional family planning services will complete the job.

This is perhaps the most important issue within the population field. Of the $4.5 billion spent by developing and developed countries for population-related work in the developing world, the largest share has gone to providing family planning medical services to individuals and couples. Inherent in this approach is the belief that a large portion of births are unwanted and that contraceptive availability will solve this problem.

In Kenya, which until recently was the fastest growing country in the world, contraceptives were within reach of nearly 90 percent of the population by the late 1980s (Hammerslough, 1991). Yet currently only about a third of the women use them (Kenya Demographic and Health Survey, 1993).

Where did the idea come from that merely making contraceptives available would solve the population problem? Since the late 1960's and throughout the 1970's, studies were conducted in numerous countries measuring women's knowledge of, attitudes toward, and practice of birth control as well as their family size desires. These knowledge, attitude and practice (or KAP) studies resulted in a term "KAP-gap"--or "unmet need"--to describe those women who wanted to delay their next pregnancy by at least two years but were not using a modern method of contraception. In the minds of many policy makers and funders, "unmet need" became confused with "lack of access" to contraceptive services. However, Charles Westoff and Luis Hernando Ochoa of the Demographic and Health Surveys determined in 1991 that about half the women categorized as having an "unmet need" have no intention of using contraceptives even if they are made freely available. In other words, it is probably not theoretically possible to "meet" more than half of the remaining "unmet need" in the developing world.

The World Health Organization (WHO) in 1986 estimated that "300 million couples are not practicing contraception despite a stated desire to stop childbearing." In a recent (1991) analysis of unmet need, demographer John Bongaarts of the Population Council stated that WHO did not describe the methodology used to arrive at its estimate. Earlier estimates from the 1970's indicated that there might be 500 million women whose actions differed from their stated desires to delay or stop childbearing.

The term "unmet need" is really a misnomer that has misled many people in leadership positions. Many world figures assume that "unmet need" means "unmet demand" and that such demand can be overcome by improving family planning services and contraceptive distribution.

The reasoning of these policy makers has been that, if there was a gap between what people wanted and what they were doing, improving access to contraceptives would close that gap. The problem is that the discrepancy between attitudes and behavior has had less and less to do with availability in recent years.

Interestingly, in his 1991 analysis, John Bongaarts concluded that total "unmet need" was between 87 and 100 million women in the developing world outside of China. He also concluded that many factors account for the gap, of which lack of access is only one.

The report of the 1989 Kenya Demographic and Health Survey is illustrative of findings in numerous countries recently. Ninety percent of currently married women and 91 percent of the husbands know where they can obtain a modern contraceptive. Among the reasons given for not using contraception by women who are not pregnant and do not want to become pregnant, only one percent cited lack of availability of contraceptives. The top four reasons? 1) Lack of knowledge (23%); 2) infrequent sex (12%); 3) concern with the medical side effects of contraceptives (11%); and 4) opposition from the husbands (10%). These are all issues that are best responded to by information and motivational communications.

Country by country, the Demographic and Health Surveys show a similar pattern. Lack of access is cited infrequently by those who are categorized as having an unmet need for family planning. The following chart illustrates that reasons having to do with information and cultural attitudes are predominant.

Reasons Cited For Non-Use of Contraception By Non-Pregnant Women Who Are Sexually Active, Not Using Any Contraceptive Method and Who Would Be Unhappy If They Became Pregnant

Country	Percent Citing Lack of Access As a Reason	Most Common Reason (Percent)
Botswana	0.1	Don't know (18.7)
Egypt	0.2	Post partum/breast-feeding (27)
Thailand	0.7	Menopausal/sub-fecund (34.4)
Dominican Republic	1.0	Fear of side effects (20.8)
Kenya	1.0	Lack of knowledge (22.5)
Ghana	1.9	Lack of knowledge (23.7)
Indonesia	1.9	Health concerns (26.3)
Sri Lanka	2.6	Health concerns (18.4)
Peru	5.2	Don't know (17.8)
Uganda	8.8	Lack of knowledge (33.4)
Liberia	10.5	Fear of side effects (17.4)

A 1992 paper by Etienne van de Walle showed that another factor is at play for many women and men--fatalism. Many people have simply not reached the realization that reproductive decisions are a matter of conscious choice. Many who did not particularly want another pregnancy in the near future still reasoned that God had determined since the beginning of the universe how many children they would have and that it did not matter what they thought or whether they might use a contraceptive, because they could not overcome God's will. The 1990 Demographic and Health Survey found that in Nigeria, Africa's largest country, over half the women questioned about their ideal family size responded by saying, "It is up to God." Overcoming this situation takes more than access to contraceptive services. It requires helping people understand that they are responsible for their own life experiences and that they have the power to effect changes in their life situation.

A 1992 publication of UNICEF carried the following statement: "If all women were able to decide how many children to have and when to have them, the rate of population growth would fall about 30%."

If this statement is true, the stunning significance of it is that--if all women everywhere had full access to contraceptives and used them to have only the children they want--the rate of world population growth would drop only 30 percent. A large share of the money and effort worldwide is going into solving 30 percent of the problem.

The above statement should not be interpreted as suggesting that the level of effort in providing contraceptive services be reduced. High quality, low cost reproductive health care services are an essential element of fertility planning. I happen to believe that both quality and quantity of contraceptive choices and services are in dire need of improvement throughout much of the developing world. But access to family planning methods is not sufficient if men prevent their partners from using them, if women don't understand the relative safety of contraception compared with early and repeated childbearing throughout the reproductive years, or if women feel they cannot take control of their own lives.

Many population planners measure progress on the basis of contraceptive prevalence rates. Use of effective family planning methods is critical, but will not result in population stabilization if desired family size is five, six or seven children. The contraceptive prevalence rate in Brazil is higher than it is in Spain (66 percent vs. 59 percent), but the total fertility rate in Brazil is twice that of Spain.

Delaying the first pregnancy and spacing children is important to the health of women and children--and to slowing population growth rates. But spacing seven children will still lead to a high growth rate.

Having talked about myths through most of this paper, I do not want to leave the reader depressed with the thought that the population problem will be difficult or impossible to solve. There are some steps that can be taken now to bring about accelerated progress in reducing population growth. Many of these steps have to do with addressing personal beliefs and cultural norms with regard to the status of women, ideal family size and age of initiating childbearing. Many of these issues revolve around the concept of personal motivation.

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