ISSUES IN BRIEF

A Response to Concerns about Population Assistance

The preference of couples for small families—well established in the United States, Japan and other industrialized countries—is now evident throughout the world. While average family size in the developing world is still very high by industrialized countries' standards, couples clearly want, and are having, fewer children. It is a trend that transcends culture, religion, ethnicity and national origin. The trend has been supported by the rapid dissemination of information and knowledge about contraception and by the increased availability of family planning services.

Since the 1960s, the United States has played a critical role in facilitating couples' desires for smaller families. Both the domestic family planning program, which provides subsidized services to the poor, and the international population assistance pr ogram were conceived about 30 years ago, at the urging of Presidents John F. Kennedy, Lyndon Johnson and Richard Nixon and with the bipartisan support of Congress.

Initially, some countries in the developing world rejected the view that there was reason for concern about the rate at which their population was growing. Many had regarded their own rapid population growth as a desirable or at least a neutral phenomenon. Over the years, however, governments from the developing and industrialized world alike have come to recognize the mutually reinforcing benefits of slowing population growth, supporting their peoples' desires for smaller families, improving the health o f women and children, and giving women and girls a chance to participate fully in the life of their communities and nations.

This extraordinary consensus was evident at the 1994 United Nations­sponsored International Conference on Population and Development (ICPD), held in Cairo. Some 200 governments from every region of the world affirmed the validity of demographic concerns, but stressed that all population policies and programs must be responsive, first, to meeting the needs and desires of individuals and families. They also emphasized that these policies must be considered and implemented in the context of overall deve lopment strategies and that, above all, they must take into account the centrality of women in the family and in society.

The United States played a major role in these deliberations and, even prior to the Cairo conference, had acted to broaden the scope of its own population program. The premise of that program, now reflected in the worldwide consensus, is that the most eff ective strategy to reduce unwanted childbearing and slow rapid population growth is one that relies on family planning at its core but is closely intertwined and integrated with other development strategies (see box).

However, just months after the ICPD officially embraced the importance of population and development as an issue and outlined key strategies to address it, Congress brought the U.S. program to a halt. After appropriating a record $547 million for population assistance in FY 1995, Congress slashed the program's funding by a third and imposed onerous limitations that greatly exacerbated the funding cut: None of the funds appropriated in FY 1996 were made available until July 1996, nine months into the fiscal year, and once available, the money could only be allocated at the rate of 7% a month for the next 15 months. Essentially the same formula has been continued into FY 1997.

The reasons for singling out this program for such harsh treatment stem from the politics of abortion and concerns raised by skeptics of population assistance in general and family planning in particular. This Issues in Brief identifies and attempts to respond to concerns that have been raised in the course of the ongoing debate.

What Population Problem?

The debate over whether there is such a condition as overpopulation and, if so, what it means and what to do about it may continue for decades to come. It is clear, however, that dilemmas involving population issues confront virtually all nations. Dependi ng on the country, these might include high rates of teenage and unintended pregnancy, migration across national borders, urbanization, an aging population (in industrialized countries) and the youth bulge (in the developing world). These, among other factors, affect a key determinant of the quality of life: the balance between population growth and economic development.

Indeed, it is just such a balance that countries are striving to achieve. The ICPD's Programme of Action summarizes the issue this way: "Efforts to slow down population growth, to reduce poverty, to achieve economic progress, to improve environment al protection, and to reduce unsustainable consumption and production patterns are mutually reinforcing. Slower population growth has in many countries bought more time to adjust to future population increases."

The disconcerting fact is that the world's current population of almost six billion is growing by 81 million people each year (equivalent to about one-third the population of the United States), but economic development and the availability of renewable n atural resources are not keeping pace with this growth. In addition, after years of rapid population growth, a record number of people are about to enter the childbearing years. Thirty-five percent of the population in the developing world is under the ag e of 15 (as opposed to 20% in the developed world); in Sub-Saharan Africa, about half of the population is younger than 15. This means that even if all couples were to have only two children (enough to replace themselves), the world's population would con tinue growing for many years to come because of the large absolute number of people having children. As Chart A indicates, the world's population is expected to increase by 319 million people by the turn of the century.

The "population problem" also can be defined in terms of women's self-described "unmet need" for high-quality family planning services. An estimated 230 million women worldwide do not have access to effective contraceptive methods and services, representing approximately one in six women throughout the developing world. The reasons for this unmet need include a lack of accurate information, poor-quality services and less than the full range of contraceptive choices, as well as legal, cultural and economic obstacles.

A compelling indicator of the failure to help women meet their childbearing goals is the 52 million abortions—half of them illegal—that occur worldwide each year, according to the World Health Organization. Another is the large number of pregnan cies that women report ending as unwanted or mistimed births: about 60% in Kenya; 50% in Japan, Mexico and the Philippines; and 40% in Egypt, Jordan and the United States.

These indicators of a population problem do have solutions. Making abortion less necessary can be achieved in large part through greater access to preventive family planning services. And that, in turn, could be expected to significantly lower the staggering number of maternal deaths that occur each year in connection with pregnancy and childbirth.

In addition, reducing the rate of unintended pregnancy, and therefore improving women's ability to achieve their own childbearing goals, would not only benefit the lives of individuals, but also have a significant impact globally. If all unwanted births w ere prevented, the annual number of births worldwide would drop from 130 million to 122 million—a decline of almost 19% in the global rate of population growth.

Is Progress Possible?

In light of the seemingly overwhelming size and scope of the population problem, ameliorating the situation may appear impossible. There are encouraging signs, however. The United Nations' recent announcement that the planet is growing by 81 million peopl e annually may sound daunting, but the fact that it is only 81 million more people each year means that global population growth already is slowing down.

Between 1985 and 1990, which was the peak period of population growth in human history, the world's population grew by 87 million people annually. The decline in the growth rate that has been observed more recently has been attributed to the introduction of programs in the 1960s and 1970s that enabled people to begin to have the smaller families they wanted by increasing access to family planning services. More recent efforts to enhance women's economic power and social status have also played a key role.

The drop in the population growth rate to about 1.5% per year (from 2.5% in the 1960s) largely reflects a decrease in the average number of children each woman is having. Over the last 30 years, average family size in developing countries has dropped from 6.0 children to 3.3. This phenomenon also corresponds to improvements in related health and social indicators, such as lower infant mortality rates and improved female literacy. Together, these results suggest that at both the global and the individual levels, there has been enormous progress.

Over the same period, developing countries gradually have begun to adopt formal policies addressing the issue of population growth. Of the 125 developing countries that participated in the ICPD, more than half reported that they already have policies in place. Further, virtually all developing countries subsidize family planning programs, even if they have not yet adopted a formal policy. The combination of financial and technical resources, political commitment, and laws and policies that protect and respect the rights and conscience of the individual and promote personal health and well-being are equally key to the success that worldwide efforts have seen so far.

U.S. Interests and Funds

In 1969, President Nixon told Congress that investing in international population assistance is important to the United States "whether it is moved by the narrowest perception of national self-interest or the widest vision of a common humanity." Even then, it was becoming clear that stabilization of the global population growth rate would be critical to creating a climate of economic and political stability. It was also apparent from the experience of American women that access to family planning would co ntribute significantly to the health of women and their children in developing countries, and that giving these women more control over their childbearing decisions would afford them greater educational and economic opportunities.

The population assistance program has shown itself to be in the economic interest of the United States by laying the groundwork for export markets. Indeed, half of the top 35 consumer countries of American agricultural products are former or current recip ients of U.S. population aid. More prosperous economies create the possibility of more consumers: U.S. exports to the developing world increased more than 14% in 1993 alone, dwarfing exports to industrialized countries.

Population growth also affects the U.S. interest in encouraging political stability and building strategic alliances. Most analysts have concluded that rapid population growth, in conjunction with poverty and scarcities of natural resources, has been link ed to instances of political upheaval all over the world, particularly in Haiti, Mexico, Pakistan and, most recently, Rwanda.

The international population aid program is also consistent with the fundamental American value of helping the most vulnerable members of society and providing the tools for them to help themselves in the future. Experience has shown that increased use of family planning is associated with higher levels of education among women and girls. Further, according to the U.S. Census Bureau, the eight million infant deaths that occur annually worldwide are likely to be cut in half by 2020 if current programs continue, because of improvements in child survival and reductions in high-risk births.

The United States initiated its population assistance program with all of these considerations in mind. Today, the developing countries themselves account for three-quarters of the $4 billion spent worldwide each year on family planning services; it is impossible, however, for them to absorb the full cost of this critical endeavor. Often, they must rely on outside donors for technical assistance, supplies, training and even direct services.

Historically, the United States has been the largest donor country; in 1994, it contributed almost 40% of the approximately $1.2 billion in population aid given collectively to developing countries. But the total U.S. per capita contribution, even at its peak, amounted to only $1.78—placing the United States fifth behind Norway ($9.47), Denmark ($6.27), Sweden ($5.08) and the Netherlands ($2.85), and on a level with Finland, Germany, Australia and the United Kingdom.

Put another way, the federal government spent $554 million in FY 1994 in response to the needs of some 15 million American women for subsidized family planning services. That same year, the United States allocated only $463 million toward family planning programs overseas in an effort to respond to the 230 million women in the developing world who need services.

For this small price, the U.S. population aid program over three decades has acquired a unique role and vast capacity that cannot be easily transferred or replicated by any of the existing donors without losing valuable time and expertise. The United Stat es has established an extensive field presence, and it is the only donor that works widely both with the public and private sectors and with nonprofit as well as for-profit entities—all of which are integral to the success and ultimate self-sustainability of local programs. The U.S. Agency for International Development (USAID), which administers the population program, is widely recognized for its high level of technical expertise upon which other countries rely.

Similarly, the United States is the only donor country that conducts research on new contraceptives and program operations, which not only are essential in guiding an effective family planning services program but also sometimes directly benefit American women. It was USAID-funded research, for example, that led to the two most recently approved major methods of birth control in the United States: Norplant and Depo-Provera.

Finally, to the extent that U.S. policymakers wish to have any real policy influence on the worldwide effort to stabilize population growth rates, the United States must remain a major financial player. Issues of special concern to the United States inclu de the quality of family planning services, the availability of a wide range of method choices (including natural family planning) accompanied by full and accurate information, an emphasis on preventing unintended pregnancy and an insistence that programs are truly voluntary and free of coercion.

Concerns About Coercion

Coercion and cultural imperialism are real and serious concerns that arise in connection with family planning programs; to protect against them requires ongoing vigilance. Not only are both anathema from an individual rights perspective, but experience has demonstrated that the most successful programs are purely voluntary, promote maximum choice of family planning methods and are provided in a culturally sensitive manner in response to what women say they want.

Coercive family planning practices are expressly prohibited by U.S. law under both the domestic and the international programs. This is not to say that coercion has not occurred or will not occur in the future, either here or elsewhere, but it is condemne d as a matter of policy. As with any law, constant attention is required to assure compliance. This is especially true since coercion can manifest itself directly as well as indirectly.

China's one-child-per-family policy, for example, has been associated with instances of forced sterilization and abortion that have warranted worldwide opprobrium. Limiting the range of available contraceptives, which occurs in some family planning progra ms, is a more subtle form of coercion. Ensuring full and informed consent and true choice in the decision on whether to use family planning services is neither easy nor simple, but is necessary and of the highest priority from both the U.S. and the international perspectives.

As for the specter of cultural imperialism, preventive voluntary family planning programs are specifically designed with the full input and participation of indigenous groups, women in particular. The charge that these women are availing themselves of contraceptive services as a result of the imposition of Western values is belied by worldwide survey data. Indeed, women in developing countries are seeking out family planning services and having fewer children because they want smaller families.

Over the past 30 years, what people consider ideal family size has declined steadily, according to extensive surveys of married women of reproductive age. Kenyan women in the 1980s, for example, said they wanted about seven children, but today they say they want no more than four. The same downward trend is evident in every region of the world, regardless of religion and culture, and in such diverse places as Senegal, Egypt, Morocco, Bangladesh, Colombia and Peru. While overall fertility rates have also fallen over the same period, large gaps remain between the number of children women say they want and the number they actually have.

Large proportions of women throughout the world report that their most recent birth was unplanned—either unwanted or mistimed: 25­40% in much of Asia, North Africa and the Middle East, and 50­65% in some Latin American countries. The same phenomenon is also evident in several areas of Sub-Saharan Africa, even though women there generally want larger families than in other parts of the world.

Maternal and Child Health

Given that infant mortality is one of the world's most glaring and preventable tragedies, it has been argued that increasingly scarce U.S. resources might be better spent if family planning funds were redirected toward prenatal care, childhood immunization and disease control progra ms. The reality is that family planning is as integral to an effective maternal and child health strategy as these other necessary activities. The facts show that family planning saves lives, of women and children.

Infants born less than two years after their sibling are almost twice as likely to die as those born after a longer delay. This occurs because they are more likely to have a low birth weight, making them more vulnerable to illness. Births too close togeth er frequently affect the older children as well; premature discontinuation of breastfeeding, for example, can lead to malnutrition, dehydration or infection. Further, illnesses in a family with many young children can spread rapidly and be severe, especially in poor countries with inadequate sanitation and crowded living conditions.

Birthspacing is one of the main reasons cited for the promotion of family planning in developing countries. In many such countries, one in five infant deaths could be averted by birthspacing alone. No one is suggesting the abandonment of other available programs known to help save the lives of children; rather, the data show that further progress in child survival would only be impeded if investment in such a low-cost, low-tech strategy as family planning were not sustained.

If family planning's contribution toward lower infant mortality and better child health were its only health rationale, that would be enough. It is not, however. The tragedy of maternal death and disease receives far less attention than the plight of children, but its impact reverberates throughout the developing world. Increased access to family planning can go a long way toward helping women avoid pregnancies that too often and in too many countries are still life-threatening.

The World Health Organization estimates that close to 600,000 women die each year of causes related to pregnancy and childbirth; 99% of these women live in developing countries. Among them, 75,000 die from unsafe, illegal abortion—often self-induced& #151;that leads to infection or hemorrhage. Furthermore, as the United Nations Children's Fund (UNICEF) points out, for each woman who dies, about "30 more...incur injuries, infections and disabilities which are usually untreated and unspoken of, and whic h are often humiliating and painful, debilitating and lifelong."

UNICEF notes that "the first and most obvious step towards reducing the toll of maternal mortality and morbidity is to make high-quality family planning services available to all who need them.... Meeting only the existing demand for family planning would reduce pregnancies in the developing world by up to a fifth, bringing at least an equivalent reduction in maternal deaths and injuries."

Prevention or Abortion?

Family planning means pregnancy prevention. Since 1973, U.S. law has expressly prohibited federal funds provided under the Foreign Assistance Act from being used to perform or advocate abortion as a method of family planning. Confusion persists, nonetheless, about the international family planning program's relationship to abortion. There is no evidence, however, nor any credible reason to suspect, that U.S. funds are being used contrary to the dictates of the law. Instead, the argument has shifted to one that alleges "indirect" support for abortion or the "promotion of abortion." Program skeptics even claim that family planning causes more, not fewer, abortions.

It is indisputable that increased reliance on effective contraception results in fewer abortions. Common sense leads most people to that conclusion, and so does the research. The only question is how quickly lower levels of abortion are attained. That question pertains because there are situations where both contraceptive prevalence and abortion rates rise, creating confusion about cause and effect. In reality, what this phenomenon reflects is the strong desire for smaller families, which then motivates people to seek out all available means to achieve their desired family size. As preventive family planning programs become better established in the culture, and as couples begin to shift to more effective contraceptive methods, recourse to abortion declines.

The experiences of cities in Mexico and Colombia illustrate the point. For example, as contraceptive use rose from the mid-1970s onward in Mexico City, so did the abortion rate, which peaked in the mid-1980s at 41 per 1,000 women aged 15­49. As the culture of effective contraceptive use has taken hold, however, the abortion rate has declined to 25 per 1,000 women. A similar pattern has been observed in Bogotá, where the abortion rate has fallen from 50 per 1,000 women to 30 per 1,000 since the mid-1970s.

The highly organized national family planning programs in these two countries may be credited with the current downward trend in abortion rates. This trend is in stark contrast to the situation in Brazil, where no national family planning program exists but desired and actual family size are relatively small. The abortion rate, now 39 abortions per 1,000, is likely to remain high until Brazil too makes the transition to the widespread availability and more effective practice of contraception.

The states of the former Soviet Union present a compelling case for how the introduction of high-quality contraceptive services can reduce abortion rates dramatically. In Russia, abortion is legal and has been used—in the absence of any contraceptive s—as the major method of birth control. In fact, it was the only choice available in answer to the prevailing desire for smaller families. While abortion rates are still very high, the recent introduction of family planning has already resulted in a significant drop in the abortion rate (see Table 1). Similarly, abortion was the primary means of birth control in Hungary until the late 1970s, by which time contraceptive use had risen to about 50%. Once reliance on family planning became more the norm in Hungary, the abortion rate dropped by more than two-thirds.

These patterns suggest reason for concern about the impact of suddenly withdrawing family planning programs just as contraception is beginning to replace abortion. It is especially troubling for regions such as Africa, where the fertility transition is in its earliest stages. As increasing numbers of people feel more strongly about having fewer children, the absence of quality family planning services will inevitably encourage more abortions—legal or not, safe or not.

Public Support for Aid

A recent survey confirms that foreign aid is unpopular among Americans, apparently because most people think the United States is spending far more than it actually is. Most people questioned estimated that the United States is spending 15% of the federal budget on foreign aid, 15 times the actual amount of 1%. When asked what they thought the appropriate amount should be, most respondents indicated a level that turned out to be five times the present spending level. Less than half of the 1% the federal government spends overseas is reserved for development aid, which provides support for population, health, nutrition and environmental programs.

Americans cite protection of the global environment as one of the most compelling reasons for the United States to support development assistance. And "overpopulation" is often volunteered as a significant factor contributing to environmental degradation. So, international population aid should be, according to most Americans, a central component of U.S. humanitarian programs overseas. Indeed, this rationale supports the U.S. position that its population program is the cornerstone of its approach to sustainable development, a process whose objective is to enhance the quality of life for people today without unduly compromising the resources necessary to sustain future generations.

Many public opinion surveys have shown that population growth is an issue of concern to most Americans. A 1994 Time-CNN poll found that 55% of Americans view "overpopulation" as a "very serious" problem; an additional 31% view it as "somewhat serious." Four-fifths of those surveyed believe this is a problem that will eventually affect the United States.

Perhaps for this reason, 72% of Americans support U.S. subsidies "to make birth control and family planning" more available in developing countries. Why do so many people support family planning assistance, even assistance overseas? According to a 1994 survey conducted for the Pew Global Stewardship Initiative, 91% of Americans do so because they believe that "all men and women in the world who want birth control should be able to get it."

The Future at a Crossroads

Even though the world's population growth rate appears to be slowing down, the world's population promises to continue to grow significantly over the coming decades as the largest cohort in history enters its reproductive years. The greater the degree to which women's increasingly prevalent and ever-stronger desire for smaller families can be addressed today, especially through better access to effective contraceptive services, the more likely that world population will stabilize at fewer than 10 billion people by the middle of the next century.

The United States has played a major role in raising worldwide awareness about individual family planning needs and global population trends, and through its strong financial and policy leadership, has established its prominence in addressing those challenges. Its relatively small investment pays significant dividends in strengthening the global economy, protecting the environment and saving the lives of women and children throughout the developing world. As First Lady Hillary Rodham Clinton noted recently in La Paz, Bolivia, in reaction to that country's extremely high maternal mortality rate, "Family planning campaigns at work in Bolivia and elsewhere represent sensible, cost-effective and long-term strategies for improving women's health, strengthening families and lowering the rate of abortion."

Despite being a program that is popular with Americans and one that provides services that people in the developing world need and want, this worldwide effort is in doubt. U.S. participation in the international program has been under siege over the last two years, largely in the name of opposition to abortion. It is a sad irony, since the research shows unequivocally that family planning leads to fewer, not more, abortions. Indeed, a consortium of research organizations (including The Alan Guttmacher Institute) concluded that the recent cuts imposed by Congress could be expected to result in 1.6 million more abortions.

Thus, whether the motivation is reducing abortion, improving the health of women and children, enhancing women's status, helping to alleviate world poverty, promoting economic development overseas, protecting the global environment or pursuing the economic self-interest of the United States, restoring a strong U.S. commitment to international population assistance will be essential to future progress.

Information Sources

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Alan Guttmacher Institute (AGI), Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, New York, 1995.

Conly, S., and J. Rosen, "International Population Assistance Update: Recent Trends in Donor Contributions," Population Action International, Washington, D.C., 1996.

Gelbard, A., "Global Population: An Overview," Population Reference Bureau, Washington, D.C., 1996.

Klitsch, M., and S. Singh, "Are Women Achieving Their Childbearing Goals?" Issues in Brief, AGI, Nov. 1996.

Kull, S., "Americans and Foreign Aid: A Study of American Public Attitudes, Summary of Findings," Center for the Study of Policy Attitudes and Center for International and Security Studies at Maryland, College Park, MD, 1995.

McDevitt, T., World Population Profile: 1996, U.S. Agency for International Development (USAID) and U.S. Bureau of the Census, Washington, D.C., 1996.

Population Reference Bureau, Family Planning Saves Lives, second ed., Washington, D.C., 1991.

Singh, S., and G. Sedgh, "Trends in Abortion, Contraception and Fertility in Brazil, Colombia and Mexico," International Family Planning Perspectives, Vol. 23, No. 1, 1997 (forthcoming).

Sollom, T., R.B. Gold and R. Saul, "Public Funding for Contraceptive Sterilization and Abortion Services, 1994," Family Planning Perspectives, 28:166­173, 1996.

Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization (WHO), Reproductive Health Activities in WHO, Geneva, 1994, p. 7.

Turnbull, W.R., "Endangered: U.S. Aid for Family Planning Overseas," Issues in Brief, AGI, Nov. 1996.

United Nations Population Division, "World Population Growing More Slowly but Could Still Reach 9.4 Billion by 2050," press release, New York, Nov. 4, 1996.

USAID, The Role of Family Planning in Preventing Abortion, Washington, D.C., 1996.

© 1997, The Alan Guttmacher Institute, 1/97