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 2000) 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 developed countries (LDCs). Birth rates are falling in most of these countries, but because 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 insight in this area. The topic was discussed with Members of Congress and letters endorsing 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. Permission 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 fertility change. It presents current projections for population growth to 2000 and the implications of this growth; identifies the determinants of fertility change; reviews current reproductive research and contraceptive R&D; discusses the factors that influence the acceptance, distribution, and use of fertility planning technologies in LDCs;

and examines past and current U.S. funding arrangements in support of population assistance requests from LDCs.

Issues and options developed for Congress include Federal support of contraceptive 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, including 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, nongovernmental 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

Abel’s Hill, Chilmark,

Kenneth Boulding

Nathan Keyfitz

Mass. Harvard University Center for

Population Studies

Institute of Behavioral Science

University of Colorado

Wilbur J. Cohen

LBJ School of Public Affairs

University of Texas

Cyril Crocker

Howard University School

of Medicine

Arthur Dyck

Harvard Divinity School

William N. Hubbard, Jr.

The Upjohn Co.

Snehendu B. Kar

School of Public Health

University of California

Marjory Mecklenburg*

American Citizens Concerned

for Life

Deborah Oakley

School of Nursing

University of Michigan

Kenneth J. Ryan

Boston Hospital for Women

Nafis Sadik

United Nations Fund for

Population Activities

Carol Tauer

Department of Philosophy

College of St. Catherine

Faye Wattleton

Planned Parenthood Federation

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

Leslie

Louise

Health and Life Sciences Division

Gretchen S. Kolsrud, Program Manager

Corsa, Project Director through December 1980

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 . . . . . . . . . . . . . . . . . . . . . . . . . . S7

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 abortions per 1,000 women aged 14 to 44 in a given

year.

Age-sex structure.—The composition of a population as determined by the number or proportion

of males and females in each age category. The

age-sex structure of a population is the cumulative result of past trends in fertility, mortality,

and migration. Information on age-sex composition is an essential prerequisite for the description and analysis of many other types of demographic data. (See also population pyramid.)

Amenorrhea.—The absence or suppression of

menstruation; normal before puberty, after the

menopause, during pregnancy and lactation.

Antinatalist policy.–The policy of a government,

society, or social group to slow population

growth through efforts to limit the number of

births.

Artificial insemination.—Introduction of semen

into the uterus or oviduct by other than natural

means.

Baby boom.—The period following World War II

from 1947 to 1961 marked by a dramatic increase in fertility rates and in the absolute number of births in the United States, Canada, Australia, and New Zealand.

Barrier method.—A contraceptive method that establishes a barrier between the joining of sperm

and ovum; e.g., condom, diaphragm, cervical

cap.

Basal body temperature method.-See periodic

abstinence methods.

Billings method.–See periodic abstinence methods.

Birth interval.—The length of time that has

elapsed between one live birth and the next, or

between marriage and the first live birth, or between the time of last live birth and the time of

inquiry; normally measured in months. In contrast to pregnancy intervals, live birth intervals

may include pregnancies that did not end in live

births; for example, a live birth interval could be

a live birth, followed by a stillbirth, followed by

another pregnancy resulting in a live birth. The

live birth interval would include the entire

period between the two live births. (See pregnancy interval.)

Birth rate (or crude birth rate) .—The number of

births per 1,000 population in a given year. Not

to be confused with growth rate.

Census.—A canvass of a given area, resulting in an

enumeration of the entire population, and the

compilation of demographic, social, and economic information pertaining to that population

at a specific time. (See also survey.)

Childbearing years.—The reproductive age span

of women, assumed for statistical purposes to be

15 to 44 in the United States. In other countries,

the range is often set at 15 to 49.

Cohort.—A group of people sharing a common temporal demographic experience who are observed

through time. For example, the birth cohort of

1900 would be the people born in that year.

Completed fertility rate.—The number of children born per woman in a cohort of women by

the end of their childbearing years.

Conception.—Generally the beginning of pregnancy, but in a theological context sometimes

the point at which a new life, in the sense of a

new soul, begins. Conception is usually equated

with the fertilization of the ovum by the sperm,

but is sometimes equated with the implantation

of the fertilized ovum in the uterine lining. The

exact definition is of some significance when attempts are made to classify fertility planning

methods as either contraceptive or abortifacient.

Consensual union.—Cohabitation by an unmarried couple for an extended period of time.

Crude birth rate.—See birth rate.

Continuation rate.—The proportion of those

adopting a method of contraception who continue with it for a given period.

Contraceptive.—An agent or device used to prevent conception.

Contraceptive failure rate.—The ratio of the

number of conceptions occurring during a given

period to the number of person months lived by

a group of women or couples during which contraception or a particular contraceptive is used.

Contraceptive prevalence rate.—A measure of

the extent of contraceptive practice among the

population at risk of conception, calculated as

the ratio of the number of women known or

supposed to be practicing contraception at a

0 . .

Vlll
given time to the total number of eligible women

(generally those fecund, nonpregnant, married

women) in that population.

Death rate (or crude death rate).—The number

of deaths per 1,000 population in a given year.

Demographic transition.—The historical shift of

birth and death rates from high to low levels in a

population. The decline of mortality usually precedes the decline in fertility, resulting in rapid

population growth during the transition period.

Demography (Greek, demos [people] graphic

[studyI).–The scientific study of human populations, including their size, composition, distribution, density, growth, and other demographic

and socioeconomic characteristics, and the

causes and consequences of changes in these factors.

Dependency ratio.—The ratio of the economically

dependent part of the population to the productive part; arbitrarily defined as the ratio of the

elderly (those 65 years and over) plus the young

(those under 15 years of age) to the population in

the “working ages” (those 15 to 64 years of age).

Depo-Provera.—See injectable contraceptives.

Doubling time. —The number of years required

for a population of an area to double its present

size, given the current rate of population

growth.

Effectiveness.–Clinical or theoretical effectiveness is measured by the failure rate of contraceptive methods under conditions as close to

ideal as possible, usually under skilled supervision, with care taken to see that they are invariably and correctly used. Use effectiveness is

measured by the failure rate of contraceptive

methods when used by the general population,

without careful medical supervision, so that failures may be due to intermittent or incorrect use.

Demographic effectiveness is measured by measuring changes in the fertility of a population

after a particular fertility planning method or

program has been introduced.

Emigration.- The process of leaving one country

to take up residence in another.

Emigration rate.—The number of emigrants departing an area of origin per 1,000 population at

that area of origin in a given year.

Estrogen.— Any natural or artifical substance that

induces estrogenic activity; more specifically the

estrogenic hormones estradiol and estrone produced by the ovary; the female sex hormones.

Exponential growth.-A constant rate of growth

applied to a continuously growing base over a

period of time; for example, a savings account increasing at compound interest; a snowball gathering mass; a population growing at 3.0 percent

annually,

Failure rate.—See contraceptive failure rate,

Fallopian tube.—The tube or duct that extends laterally from the lateral angle of the uterus, terminating near the ovary. It serves to convey the

ovum from the ovary to the uterus and spermatozoa from the uterus towards the overy.

.

Family planning.– The conscious effort of

couples to regulate the number and spacing of

births. Family planning usually connotes the use

of contraception to avoid pregnancy, but also includes efforts of couples to induce pregnancy.

Fecundity. —The physiological capacity of a

woman, man, or couple to produce a live child.

Fertility.—The actual reproductive performance of

an individual, a couple, a group, or a population.

Fertility rate.– See general fertility rate.

Fertilization.—Penetration of an ovum by a spermatozoon. Usually occurs in the fallopian tube,

following ovulation in the menstrual cycle, and is

usually considered to be the moment of conception as it is the time when the two sex cells unite.

General fertility rate. (also referred to as fertility rate)---The number of live births per 1,000

women aged 15 to 44 years in a given year. (see

also implantation.)

Gonadotropin.-A substance having affinity for or

a stimulating effect on the gonads. There are

three varieties: anterior pituitary, chorionic

from human pregnancy urine, and chorionic

from the serum of pregnant mares.

Gossypol.-A derivative of the cottonseed plant

known to induce infertility in males; now being

tested as a male contraceptive in China.

Growth rate.—The rate at which a population is increasing (or decreasing) in a given year due to

natural increase and net migration, expressed as

a percentage of the base population.

Immigration. —The process of entering one country from another to take up permanent residence.

ix
Implantation.—Process whereby a fertilized ovum

burrows into the lining of the uterus on its arrival there, and attaches itself firmly. Successful

implantation is essential to the future development of the fetus and is sometimes considered as

the true moment of conception.

Infant mortality rate.—The number of deaths to

infants under 1 year of age in a given year per

1,000 live births in that year.

Infertility.—Failure, voluntary or involuntary, to

produce live born children on the part of an individual, a couple, or a population.

Injectable contraceptives.—The most commonly

used injectable progestins, given at 3-month intervals, are Depo-Provera (DMPA) or medroxyprogesterone acetate, and norethindrone enanthate.

integration. —In the family planning context, integration refers to linkage of family planning

services delivery with some other program,

usually health, MCH, or other rural development

activity (electrification, agriculture, nutrition,

parasite control). The linkage is at either the administrative or the service end. At the administrative level it is the creation of an umbrella

organization with administrative control over a

large array of services; at the service level, specialized services are linked at the point of service

delivery.

In vitro.—Outside the living organism and in an artificial environment.

Less developed country.—For purposes of this

report, all countries, territories, or areas in Latin

America and the Caribbean, all in Africa other

than the Republic of South Africa, all in Asia

other than Japan and the U. S. S. R., and all in

Oceania other than Australia and New Zealand.

LDCs tend to be characterized by low per capita

gross domestic product (GDP), a low share of

manufacturing in GDP, low rates of annual increase in total GDP, low proportions of people

with basic training or technical skills, and low

literacy rates among those 15 or older. (See more

developed country.)

Life expectancy.—The average number of additional years a person would live if current mortality trends were to continue. Most commtmly

cited as life expectancy at birth.

LRF analogs.- Numerous analogs (chemically different but reactively similar to the parent substance) of the luteinizing hormone releasing factor (LRF), a hypothalamus-controlled secretion

from the anterior pituitary gland, are under

study as contraceptives and agents to treat infertility. Both long-acting agonists (stimulators) and

antagonists involve inhibition of ovulation; luteolysis; and inhibition of spermatogenesis and

testosterone secretion. Possible routes of administration include subcutaneous, intramuscular, sublingual, rectal, intravaginal, and intranasal.

Marital fertility rate.–Number of legitimate live

births per 1,000 married women aged 15 to 44 in

a given year.

Maternal mortality rate.—The number of deaths

to women due to pregnancy and childbirth complications per 100,000 live births in a given year.

Menarche.-The beginning of menstruation; i.e.,

the first menstrual period. This occurs during

puberty but does not signify the beginning of full

adult fecundity as ovulation may be irregular or

absent for some time.

Menopause. —Cessation of menstruation; i.e., the

last menstrual period or the end of a reasonably

regular menstrual pattern. After the menopause

is completed a woman is permanently sterile.

Migration.- The movement of people across a

specified boundary for the purpose of establishing a new permanent residence. Divided into international migration (migration between countries) and internal migration (migration within a

country).

Mini-laparotomy. —Female sterilization procedure

in which the fallopian tubes are ligated or cauterized through a small abdominal incision.

Mini-pill.—Oral contraceptive containing no

estrogen and generally less than 1 mg of a progestational agent.

Morbidity. —The frequency of disease and illness in

a population.

More developed country.—For purposes of this

report, all countries of Europe, North America

(Bermuda, Canada, Greenland, St. Pierre and Miquelon, and the United States), Australia, New

Zealand, Japan, and the U.S.S.R. (See less

developed country.)

Mortality.—Death as a component of population

change.

x
Natural family planning.–See periodic abstinence.

Natural fertility.—The fertility of persons or

populations in which deliberate control of childbearing (through use of abstinence, contraception, induced abortion, sterilization, etc.) is not

practiced. Sometimes used loosely to signify the

maximum fertility biologically possible; i.e., that

of a normal healthy person or group of persons

engaging regularly in sexual intercourse during

the reproductive span with no attempt to restrict childbearing. The fertility of such populations will be determined by such factors as

marriage customs, breastfeeding practices, and

similar social and economic factors, and will

therefore probably fall short of the biological

maximum of fertility.

Natural increase.–The surplus (or deficit) of

births over deaths in a population in a given time

period.

Negative population growth.-A net decrease in

the size of a population.

Net migration.—The net effect of immigration and

emigration on an area’s population in a given

time period, expressed as increase or decrease.

Net migration rate.—The net effect of immigration and emigration on an area’s population, expressed as increase or decrease per 1,000 population of the area in a given year.

Oral contraceptives.—Various progestinlestrogen

or progestin compounds in tablet form taken sequentially by mouth; the ‘(pill.” Estrogenic and

progestational agents have contraceptive effects

by influencing normal patterns of ovulation,

ovum transport, implantation, or placental attachment.

Ovulation.—The release of an ovum from the

ovary during the female menstrual cycle.

ovulation method.—See periodic abstinence

methods.

Parity .–The number of live births a woman has

had; a woman of zero parity has had no live

births, a woman of parity one has had one live

birth, etc.

Periodic abstinence methods.—Contraceptive

methods that rely on timing of intercourse to

avoid the ovulatory phase of a woman’s menstrual cycle; Natural Family Planning. The Basal

Body Temperature (BBT) method uses daily temperature readings to identify the time of ovulation; in the ovulation or Billings method, women

are taught to identify the relationships of

changes in cervical mucus to fertile and infertile

days; the Sympto-Thermal method charts both

changes in temperature and cervical mucus and

teaches recognition of other symptoms of ovulation (i.e., intermenstrual pain).

The “pill.”—See oral contraceptives.

Population.— A group of objects or organisms of

the same kind.

Population density.– population per unit of land

area; for example persons per square mile, or

persons per square kilometer of arable land.

Population distribution.—The patterns of settlement and dispersal of population.

Population increase.—The total population increase resulting from the interaction of births,

deaths, and migration in a population in a given

period of time.

Population momentum.—The tendency for population growth to continue beyond the time that

replacement level’ fertility has been achieved because of a relatively high concentration of people

in the childbearing years.

Population policy.—Explicit or implicit measures

instituted by a government to influence population size, growth, distribution, or composition.

Population projection.—Computation of future

changes in population numbers, given certain assumptions about future trends in the rates of

fertility, mortality, and migration. Demographers often issue low, medium, and high projections of the same population, based on different

assumptions of how these rates will change in

the future,

Population pyramid.—A special type of bar chart

that shows the distribution of a population by

age and sex. Most countries fall into one of three

general types of pyramids: 1) Expansive-a

broad base, indicating a high proportion of children and a rapid rate of population growth;

2) Constrictive—a base that is narrower than the

middle of the pyramid, usually the result of a recent rapid decline in fertility; and 3) Stationary—a narrow base and roughly equal numbers

in each age group, tapering off at the older ages,

indicating a moderate proportion of children

and a slow or zero rate of growth.

xi
Pregnancy interval.–Length of time that has

elapsed between the end of one pregnancy and

the end of the next, or between marriage and the

end of the first pregnancy or between the end of

the last pregnancy to occur and the time of inquiry; normally measured in months (See birth

interval).

Prevalence rate.—See contraceptive prevalence

rate.

Progesterone.— A steroid hormone obtained from

the corpus luteum, adrenals, or placenta. It is responsible for changes in uterine endometrium in

the second half of the menstrual cycle preparatory for implantation of the blastocyst, development of maternal placenta after implantation,

and development of mammary glands.

Progestin.-A corpus luteum hormone that prepares the endometrium for the fertilized ovum.

This word is now used to cover a large group of

synthetic drugs that have a progesterone-like effect on the uterus.

Pronatalist policy.—The policy of a government,

society, or social group to increase population

growth by attempting to raise the number of

births.

Prosta#andin .—Refers to a group of naturally occurring, chemically related long-chain fatty acids

that have certain physiological effects (stimulate

contraction of uterine and other smooth muscles, lower blood pressure, affect action of certain hormones).

Rate of natural increase.—The rate at which a

population is increasing (or decreasing) in a

given year due to a surplus (or deficit) of births

over deaths, expressed as a percentage of the

base population.

Replacement level fertility.—The level of fertility at which a cohort of women on the average

are having only enough daughters to “replace”

themselves in the population. By definition, replacement level is equal to a net reproduction

SOURCES: E. Grebenik and A. Hill, International Demographic Terminology: Fertility, Family Planning and Nuptiality

(Liege, Belgium: International Union for the Scientific

Study of Population, 1974), IUSSP Papers No. 4.

rate of 1.00. The total fertility rate is also used to

indicate replacement level fertility; in the United

States today a TFR of 2.12 is considered to be replacement level. (See zero population growth).

Reproductive age.–See childbearing years.

Sex ratio.—The number of males per 100 females in

a population.

spermicide.– An agent that kills spermatozoa.

stable population.–A population with an unchanging rate of growth and an unchanging age

composition, because birth and death rates have

remained constant over a sufficiently long period of time.

Stationary population.—A stable population with

both a zero growth rate (because the birth rate

equals the death rate) and an unchanging age

composition.

Steroid hormones.—See estrogen, progesterone.

Survey.—A canvass of randomly selected persons

or households in a population usually used to infer demographic characteristics or trends for a

larger segment or all of the population, (See also

census.)

sympto-thermal method.–See periodic abstinence methods.

Total fertility rate (TFR).—The average number

of children that would be born alive to a woman

(or group of women) during her lifetime if she

were to pass through her childbearing years

conforming to the age-specific fertility rates of a

given year.

Use effectiveness.—See effectiveness.

Vasectomy.—Surgical sterilization of a male by occlusion of the vas deferens.

Zero population growth.-A population in equilibrium, with a growth rate of zero, achieved

when births plus immigration equal deaths plus

emigration.

Arther Haupt and Thomas T, Kane, Population Handbook (Washington, D. C.: Population Reference Bureau,

Inc., 1978).

xii
Acronyms and Abbreviations

AID

AVS

BBT

CBD

CDB

CPR

CPS

CRS

DES

DHHS

DMPA

FAO

FDA

FPIA

FSH

GNP

IBRD

ICCR

IDA

IEC

IEM

IDRC

IFRP

ILO

IPPF

— Agency for International

Development

— Association for Voluntary

Sterilization

— Basal Body Temperature Method

(See Glossary)

— Community based distribution (of

contraceptives)

— Contraceptive Development

Branch, CPR, NICHD

— Center for Population Research,

NICHD

— Contraceptive Prevalence Survey

— Commercial retail sales (of

contraceptives)

— Diethylstilbestrol

— Department of Health and Human

Services (formerly Health,

Education and Welfare)

— Depo-Provera (See Glossary)

— Food and Agricuhure Organization

— Food and Drug Administration

— Family Planning International

Assistance

— Follicle stimulating hormone

– gross national product

— International Bank for

Reconstruction and Development

— International Committee for

Contraception Research, Population

Council

— International Development

Association

— Information, Education, and

Communication

— Information, Education, and

Motivation (See China report,

app. A)

— International Development

Research Center

— International Fertility Research

Program

— International Labor Organization

— International Planned Parenthood

Federation

IUD

IUSSP

JHPIEGO

KAP

LDC

LH

LRF(LHRH)

MCH

MDC

MWRA

NDA

NFP

NGO

NICHD

NIH

PARFR

PMA

PIACT

PRC

R&D

TFR

UN

UNDP

UNFPA

WFS

WHO

— Intrauterine device

— International Union for the

Scientific Study of Population

— Johns Hopkins Program for

International Education in

Gynecology and Obstetrics

— Knowledge, attitudes, and practice

(of contraception)

— Less developed country (See

Glossary)

— Luteinizing hormone

— Luteinizing hormone releasing

factor (See Glossary)

— Maternal and child health

— More developed country (See

Glossary)

— Married women of reproductive

age

— New Drug Application (FDA)

— Natural family planning (See

Glossary)

— Nongovernmental organization

— National Institutes of Child Health

and Human Development

— National Institutes of Health

— Program for Applied Research on

Fertility Regulation

— Pharmaceutical Manufacturers

Association

— Program for the Introduction and

Adaptation of Contraceptive

Technology

— People’s Republic of China

— Research and development

— Total fertility rate (See Glossary)

— United Nations

— United Nations Development

Programme

— United Nations Fund for

Population Activities

– World Fertility Survey

— World Health Organization

. . . 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 impacts of specific fertility planning technologies

on population grotvth. The influence of direct

factors such as age at marriage and contraceptive use on population growth is relatively well

understood. Less well understood are the indirect influences–the economic, sociocultural,

religious, and political forces—that modify attitudes toward family size. Detailed examination

of these indirect factors is beyond the scope of

this study. Nevertheless, recognition of their importance in determining the use of fertility planning technologies underlies everything that

follows.

The following pages examine the contribution

of fertility planning technologies to reducing

birth rates, improving maternal and child

health, and enabling couples to choose the number and spacing of their children. They also explore future changes in contraceptive use and

birth rates that might be possible. The strengths

and weaknesses of present technologies and

techniques are summarized, and the probable

availability of new or improved technologies

within the next 10 to 20 years is estimated. Also

examined are how the U.S. Government supports international population assistance, both

through its international aid programs and

through contraceptive research and development (R&. D), and how the Food and Drug Administration’s (FDA) regulatory role in assuring

the safety and efficacy of drugs and medical

devices affects U.S. international population

assistance efforts. Finally, this report enumerates options that Congress might consider in the

areas of reproductive research and contraceptive R&D and in furthering the aims of its international assistance programs, and highlights

issues that could benefit from oversight hearings,

Introduction

Following World War II, the world experienced a sudden sustained drop in death rates

which, combined with little change in birth

rates, procluced unprecedented growth in the

world)s population. Today, about 80 million people, the equivalent of an additional Mexico or

Nigeria, afre added to the planet every Year.

More than 90 percent of this growth is in the

developing world. In the United States and

other more developed countries (MDCs), infant

mortality is low and life expectancy exceeds 70

years, yet populations are stable or increasing

only moderately because birth rates are low. In

the less developed countries (LDCs), where infant mortality, although declining, is high, and

life expectancy has not yet reached 5.5 years,

birth rates remain high and populations are increasing, often at dramatic rates.

Rapid population growth in LDCs is a key factor in limiting the ability of these countries to

raise their standards of living. Important obstacles to their socioeconomic development include

limited resources, food distribution problems,

high rates of debilitating disease and infant mortality, lack of proper sanitation, scarcity of investment capital, and shortages of educational

facilities and work opportunities. But each of

these barriers to a better quality of life in LDCs

is intensified by the rapid pace of their population growth.

Because LDC governments that once dismissed rapid population growth as incidental to

their well-being now actively seek help with

their population problems, the United States

and other MDCs provide population planning

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 reducing their birth rates. Such assistance has enabled many of these countries to achieve significant decreases in their population growth rates

during the past decade, and there is now an international consensus that access to contraceptive services is a basic human right.

The issues examined here are not new to Congress. The United States has been a leader in

world population issues since the early 1960’s,

when the Draper Commission recommended

Findings and conclusions

Fertility is declining in most LDCS) but population growth is continuing at high levels because

of the momentum for future growth initiated by

the high birth rates and rapidly falling infant

mortality rates of the recent past. More than 1

billion people will be in their peak reproductive

years (ages 15 to 29) during the next two decades.

Even if growth rates continue their current

decline, the world’s population is expected to increase from 4.5 billion in 1981 to between 5.9

billion and 6.5 billion in the year 2000 (see fig.

1). Almost 92 percent of this growth will occur

in LDCs. Growth will be greatest, according to

current projections, in Africa (76 percent of the

1980 population added in 20 years), followed by

Latin America (65 percent), and Asia (43 percent). But more of the increase in absolute

numbers will occur in Asia (63 percent) than in

Africa (22 percent) or in Latin America (15 percent), simply because many more people

already live in Asia. Three-quarters of all LDC

growth is expected to occur in just 18 countries:

India, China, Brazil, Nigeria, Indonesia,

Bangladesh, Pakistan, Mexico, Philippines,

Thailand, Vietnam, Turkey, Iran, Egypt, Ethiopia, Burma, South Korea, and Zaire, listed here

in the approximate order of the magnitude of

their projected growth.

The striking momentum of world population

growth means that the number of births expected each year will increase despite falling

fertility rates, because the number of people in

that the U.S. Government provide assistance for

population planning, and the governments of a

number of countries began to deal openly with

what they saw as dangers in the sudden disparities between their birth and death rates. In its

1978 review, the House of Representatives

through its Select Committee on Population

issued a series of reports on population and developmental assistance, and identified areas requiring additional study. Foremost among these

was the area of fertility planning technology.

the reproductive ages (15 to 44) is increasing.

The pyramid in figure 2A depicts the age structure that is typical of most LDCS, where populations are predominantly youthful because of

high fertility and declining infant mortality during the past 20 years. If fertility rates were to

fall rapidly, the lower groups of the pyramid

(ages O to 4, 5 to 9, etc.,) would begin to contain

fewer individuals. The older ages (10 to 14, 15 to

19, etc.,) would then form a “bulge,” which

would contribute a disproportionate number of

people of reproductive age some 5 to 10 years

later. This bulge is illustrated in figure 2B by the

U.S. “Baby Boom:” members of this group are

now of reproductive age and, although their

fertility is thus far lower than that of their

parents, the absolute size of this group is

already resulting in an increase in the numbers

of births per year in the United States.

The same cycle will take place in LDCs during

the next 20 years, but on a more massive scale.

Stationary population growth—the stabilization

of deaths and births at near equal levels—would

not be achieved until members of the largest age

group (those now between O and 4 yeas) reach

old age some 60 years from now. The age structure of a stationary population illustrated in

figure 2A describes a typical MDC today.

Current declines in fertility are unevenly

distributed among LDCs but many of those with

the largest populations have achieved the greatest declines. China’s birth rate has declined dramatically. 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 6.5

, ■ 1

A.D. 2000 medium variant 4

projection: 6.2 billion

A.D. 2000 low variant

projection: 5.9 billion

.

P

1

Chart shows world population

growth since 8000 B.C. If

stretched back all the way to

the beginning—300,000 B.C.

—in this scale, the line would

be an invisibly thin one starting 10 feet 71/2 inches to the

left of the graph

6.0

5.5

5.0

4.5

4.0

3.5

3.0

2.5

2.0

1.5

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 200 0

1965 and 1981 range from 17 to 58 percent.

South Korea’s fertility has fallen by 34 percent,

Colombia’s by 34 percent, and Thailand’s by 36

percent during the same period (table 1).

Significant fertility declines are usually

associated with some or all of the following conditions that involve government policy and action with regard to population programs (ordering does not imply relative importance): 1) governmental policies that encourage and promote

equal status and opportunities for women,

higher age at marriage, and more equitable distribution of wealth and educational opportunities, all of which lead to a higher standard of living; 2) programs designed to bring about a decline in infant mortality; 3) a government policy

with explicit goals for reduction of birth or

population growth rates; 4) a strong commitment to population planning by the country’s

leaders; 5) a family planning organizational

structure with executive power to mobilize

more than one government sector and to coordinate with the private sector; 6) population

program funding (usually both external and internal sources); 7) provision of a broad range of

contraceptive methods; 8) sufficient numbers of

well-trained and motivated family planning program personnel; 9) population and family planning information, education, and communication (IEC) efforts that effectively reach all sectors of the population; and 10) direct or indirect

incentives that encourage couples to limit the

size of their families. The relative importance of

these components 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 na-
6 ● world population and fertility Planning Technologies: The Next 20 Years

Female

Age

75+

70

60

50

40

30

20

10

0

1980 and 2

100 140 180 22-J 260 300

Millions

Less developed regions

1

m

000:

Age

75+

70

60

50

40

30

20

10

0

Age

— 75+ ,

— 70

— 60

— 50

— 40

— 30

— 20

— 10

— 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

illustrating the Effects of the Baby Boom

Year

Age

of birth

75+

70-74

65-69

60-64

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

I

r

.,

I

1

1901-05

1906-10

1911-15

1916-20

1921-25

1926-30

1931-35

1936-40

1941-45

1946-50

1951-55

— 1956-60

— 1961-65

1966-70

1971-75

1976-80

5432101234 5

Percent of population

SOURCE: U.S. Bureau of the Census, Illustrative Projections of World Populations to the 21st Century, Special Study Series, p. 23, No. 79, table 2,

pt. V, January 1979.

tional product (GNP), nonagricultural labor

force participation, literacy rates, etc.) affect

the extent to which a program can succeed 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.

Most people in the developing world live in

countries that now consider their rates of population growth higher than desirable and want

help in achieving lower rates. Recent experience has shown that growth rates can be

slowed, often with startling success, despite the

momentum inherent in LDC age structures. Although other development factors influence fertility, both stronger family planning programs

and more effective, safer, and easier-to-use contraceptive methods can make important contributions to slowing population growth in the

next two decades.

If governments decide to take actions to

reduce population growth in addition to those

actions currently planned, the world’s population in 2000 will be closer to the lower estimate

of 5.9 billion than to the upper estimate of 6.5

billion. Even the low projection, however,

means that today’s 4.5 billion world population

will increase by 1.5 billion in just 20 years. For

the longer term, additional efforts undertaken

now can be still more decisive in terms of the

number of people added to the world’s population. The difference between the high and low

projections for 2050 is 4 million people—a

number nearly equal to today’s global total.

Countries that wish to reduce their population

growth rates have three options: raise mortality

rates, encourage emigration (or discourage immigration), or reduce fertility rates. The first is

morally untenable, and the second is not feasible over the long term because there are no

countries left to accept vast numbers of immigrants. The only viable solution is to lower fertility rates. Many LDC governments have already decided to encourage this latter option; in

the last 20 years, the proportion of the world’s

people who live in countries that provide support for family planning services has risen from

about 10 percent to 90 percent.

Most LDCs face similar environmental and

economic problems. In a number of these countries, the need to increase food and fuel production to keep pace with population growth has

led to significant environmental degradation

through denuding of forests, transformation of

productive land into desert, and waterlogging

and salinization of irrigated land, The large

balance-of-payments deficits and increased

debts confronting most oil-importing LDCs in

recent years have depressed their rates of

economic growth, lowering prospects for

meeting basic health care needs, and making

the provision of jobs a formidable task.

The collective effects of these continuing environmental and social problems, exacerbated

by rapid population growth, have led 10 increased international migration and political

instability. U.S. interests are directly involved,

for example, in present immigration pressures
Table 1.—Percent Reductions in Crude Birth Rates From 1965 to 1981 for

Selected Countries

Asia

China a . . . . . . . . . . .

India a

. . . . . . . . . . . .

Indonesia a 

. . . . . . .

Bangladesh a

. . . . . .

Pakistan . . . . . . . . .

Philippines a 

. . . . . .

Thailand a 

. . . . . . . .

South Koreaa 

. . . . .

Sri Lankaa 

. . . . . . . .

Malaysia a 

. . . . . . . .

Latin America

Brazil . . . . . . . . . . . .

Mexico a

. . . . . . . . . .

Colombiaa

. . . . . . . .

Venezuela . . . . . . . .

Chile a

. . . . . . . . . . . .

Middie East

Turkey . . . . . . . . . . .

Egypt . . . . . . . . . . . .

Tunisia a

. . . . . . . . . .

Africa

Nigeria . . . . . . . . . .

Zaire . . . . . . . . . . . .

Tanzania . . . . . . . . .

Kenya . . . . . . . . . . .

MDCs

United States . . . . .

Japan . . . . . . . . . . .

United Kingdom . . .

France. . . . . . . . . . .

969

710

155

91

85

53

49

39

15

14

130

72

28

15

11

46

43

7

80

29

19

17

224

117

56

54

30-40b

43

46

50

48

44

44

35

33

42

42

44

44

42

33

41

42

45

50

47

51

50

19

19

18

18

32

33

29

36

22

32

41

33

50

46

46

53

16

14

13

14

17-58

16

24

—

—

23

36

34

12

26

22

—

27

—

—

10

—

from Mexico, the Caribbean,

and Southeast Asia.

Rapid population growth is

current environmental, food,

South America, Direct fertility determinants

an intensifier of Aside from indirect influences such as levels

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, prevaa term that is itself changing, remain largely lence of induced abortion, and–the most signifunexplored. icant—use of contraception.
Ch. l—Summary, Issues, and Options ● 9

Young age at marriage and near universality

of marriage in the absence of widespread contraceptive use are important causes of high

birth rates in many countries. In Europe and the

United States, reductions in the proportion married and increases in age at marriage have historically helped reduce growth rates. In many

LDCs, high infant, child, and adult mortality in

association with the social stigma attached to illegitimate births has necessitated very young

age at marriage and maximum reproduction to

ensure survivral of the family lineage. Increases

in age at marriage have contributed to fertility

decline in many LDCs in recent years and may

continue to do so in such areas as the Asian subcontinent, where age at marriage remains l0w.

Breastfeeding delays the return of ovulation

after childbirth, sometimes for as long as a year

or more. If large numbers of women breastfeed

for long periods, a natural form of birth-spacing

occurs that can cause a modest reduction in

overall fertility rates. But breastfeeding is an important influence on fertility only in societies

with high fertility rates. Breastfeeding is an imperfect individual contraceptive because the

amount of protection against pregnancy that it

confers is extremely variable. In LDCs, fewer

women are now choosing to breastfeed, and

many women are breastfeeding for shorter

lengths of time.

The limitations of current contraceptive

technologies and lack of access to their use

cause many women in all parts of the world to

seek induced abortion to terminate unwanted

pregnancies. Induced abortion is a medically

safe procedure when performed early in

pregnancy by skilled personnel. But the risk of

maternal death or serious complications increases greatly when it is performed by less

skilled personnel in marginal facilities and when

it is performed later in pregnancy. Rates of induced abortion are high in LDCs, even though

its legal use is constrained in some countries by

religious beliefs. It is rarely a preferred method

of fertility planning, but is resorted to when

other means are not available, or fail.

Of all the means available, contraceptive use is

by far the most important in lowering fertility.

On average, women are fecund (capable of

bearing children) from age IS to 45, about 30

years. In the absence of contraception and allowing for time spent pregnant and infertile

(due to infertility following birth or to breastfeeding), and time not spent in union because of

divorce or widowhood, a woman could expect

to have an average of about 10 children. If

reduction of fertility rates to those associated

with population stabilization (about 2.2 births to

each woman) is desired, it is necessary that

some method of contraception be used for up to

25 years.

The major methods of contraception currently in use are:

●

●

●

.

Sterilization—vasectomy in the male, and

tubal ligation/occlusion in the female.

Steroid hormones—combined (estrogen and

progestin) or low dose progestin oral pills,

or intramuscular, long-acting progestin injections. These synthetic steroids are given

in different combinations and different

doses, depending on the commercial product, but they act primarily by inhibiting

ovulation through suppression of the hypothalamic hormones that stimulate the

release of follicle stimulating hormone

(FSH) and luteinizing hormone (LH) from

the anterior pituitary. The synthetic

steroids also cause endometrial changes

that make the uterus inappropriate for implantation should breakthrough ovulation

and fertilization occur. other changes that

contribute to the contraceptive effect include scant and thick cervical mucus, reduced sperm transport and penetration into the uterus, and altered sperm and ovum

transport within the fallopian tubes.

Intrauterine devices (IUDs)—the insertion

of a foreign body, made either of an inert

substance or impregnated with other materials (copper, progesterone). Although the

IUD prevents implantation in some mammals, its mode of action is unknown in the

human being. There are several possible

modes of action, from interference with

sperm transport, to interference with ovum

transport, to interference with implantation in the uterus. There is also some evidence 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

in the fallopian tube.

Barrier devices—the condom for the male

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

day of ovulation.

Postcoital douches-water

solutions that flush out anci

vagina,

The effectiveness and order

coitus near the

or spermicidal

kill sperm in the

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 available by 1990 are:

● Steroid hormones: safer oral contraceptives, improved long-acting steroid injections, and two new methods of administraTable 2.—Theoretical and Use Effectiveness of

Various Means of Contraception

(by pregnancies per 100 woman-years In MDCs)

Theoretical Use effectiveness

Method effectiveness Rantae Average

Sterilization:

Tubal . . . . . . . . . . . . . . . . . — —

Vasectomy . . . . . . . . . . . . — —

Steroidal contraceptives:

Injectable progestins (3-

month regimen of

medroxyprogesterone

acetate). . . . . . . . . . . . . 0.24 –

Orals . . . . . . . . . . . . . . . . . 0.1 0.2-4.5

IUDs:

Lippes loop. . . . . . . . . . . . 1.9 —

Copper T . . . . . . . . . . . . . . — —

Diaphragm and jelly. . . . . . . 3 3.3-33.6

Condom . . . . . . . . . . . . . . . . 3 6-30

Aerosol foam . . . . . . . . . . . . 3 3.0-35

Jelly or cream . . . . . . . . . . . . 2.0-45

Coitus Interrupts . . . . . . . . 8 10-38

Periodic abstinence. . . . . . . 2.5 5-40

Suppositories. . . . . . ., . . . . 14 17-27

Douche . . . . . . . . . . . . . . . . . 16 21-40.6

●

tion—steroid implants (e.g., capsules in the

forearm) and steroid vaginal rings.

IUDs: three improved types are anticipated.

Table 3.—Future Fertility Planning Technologies

Highly likely before 1990

induction of menses

Monthly steroid-based contraceptive pill

Improved monthly steroid injection

New types of drug releasing IUDs

Mini-dose vaginal rings

Antipregnancy vaccine for women

Improved barrier contraceptives for men

Sperm suppression contraceptives for men

Reversible female sterilization

Simplified female sterilization techniques

Simplified male sterilization techniques

LRF analogs for self-administered induction of

menses

Uniikely by 1990 but possible by 2000

Antifertility vaccine for men

Antisperm drugs for men

Antisperm maturation drugs for men

Lactation-linked oral contraceptives for women

Ovulation prediction methods for use with periodic

abstinence

New types of antiovulation contraceptive drugs for

women

Contraceptive drugs for women that disrupt ovum

transport

Reversible male sterilization

Pharmacologic or immunologic sterilization for

women

Pharmacologic or immunologic sterilization for

men

Agents other than LRF analogs for selfadministered induction of menses

SOURCE: Office of Technology Assessment Survey; S. B. Schearer and M. K.

Harper, 1980.
Ch. l—Summary, Issues, and Options ● 1 1

●

●

●

●

of women in LDCs who otherwise might

lack access to the medical personnel needed

for insertion of other types of IUDs.

Barrier devices for women: one-size-fits-all

diaphragms, disposable diaphragms, spermicide-impregnated diaphragms, vaginal

films, vaginal sponges, vaginal rings that

release spermicides, and cervical caps that

can be left in place for weeks or months.

Improved ovulation-detection procedures

for use with periodic abstinence methods: a

wide varietv of biological and biochemical

parameters-are altered when a woman ovulates, and researchers are endeavoring to

improve or simplify the physical tests that a

woman can use herself to determine when

she ovulates. Improved methods of evacuating changes in cervical mucus, hormones in

urine or saliva, and basal body temperature

would enable greater numbers of users of

periodic abstinence to know with certainty

when they could safely engage in sexual intercourse during the second half of the

menstrual cycle without risk of pregnancy,

although the prediction of ovulation is likely to remain problematic. *

New hormonal methods: methods that

would reversibly inhibit ovulation using

synthesized agonists or antagonists to one

of the hormones that controls ovulation,

luteinizing-releasing factor (LRF).

Drugs that induce menstruation: prostaglandin analogs that depend on uterine

muscle contraction for their action. Administered as vagina] suppositories, these

drugs can also induce abortion during the

first 8 weeks of pregnancy in about 90 percent of cases.

Most R&D on contraceptives has been conducted by MDC governments and the pharmaceutical industry. Prior to 1967, contraceptive

R&D was financed largely through the private

sector. In the 1970’s, however, of funds spent

worldwide on reproductive research and contraceptive development, private industry provided about 10 percent, and governments and

philanthropic and nonprofit organizations pro-

● Such methods would also benefit couples with infertility}’ problems l)j pinpointing the fertile period.

Vialed $10 percent. The U.S. Government is the

major current funder of research on improved

contraception, providing nearly 60 percent of

worldwide expenditures. Approximately 70 percent of worldwide funds go to basic research,

20 to 25 percent to contraceptive development,

and less than 10 percent to safety evaluation.

The market approval process of the FDA affects population planning assistance, because

the U.S. Food, Drug, and Cosmetic Act prohibits

pharmaceutical manufacturers from exporting

drugs for uses not approved for marketing in

the United States. This policy is based primarily

on the premise that one standard of drug approval is necessary, and under this premise, the

United States would be promoting a double

standard if it exported drugs not approved for

use in the United States.

The FDA approval process for all drugs

averages 7.5 years. FDA requirements for the

specific types of tests and test animals to be

used in providing safety and efficacy data for

contraceptives usually make the average length

of the approval process for contraceptive drugs

longer than for other drugs by about a year.

The reason for these more stringent testing requirements for contraceptive drugs over other

classes of drugs is that contraceptives are given

to young, healthy individuals and can potentially be administered over a period of 30 years,

whereas other drugs are usually used to treat

diseases and/or are often administered only for

a few weeks at most.

Drug patents run for 17 years, but effective

patent life is shortened by the regulatory process. For oral contraceptives, however, short.

ened patent life has not affected the original

manufacturers’ abilities to retain a large share

of the market even when prices were increased

after the patent period had expired.

But expanding product liability has escalated

costs and made the prediction of future costs

uncertain for both the pharmaceutical industry

and its insurers. As in the case of patent life,

these difficulties are being experienced by all

drugs (and products in general), but the contraceptive market has been especially affected

by product liability problems.
12 . world population and Fertility P/arming Technologies: The Next 20 years

Rising product liability costs and the ability of

manufacturers to retain their market share

even after patents expire signify higher prices

for contraceptives and reduced purchasing

power for family planning programs.

International population assistance

International population assistance evolved in

response to growing awareness of the problems

that accompany rapid population growth and to

requests from LDC governments for technical

assistance in addressing these problems. The

purposes for which population assistance funds

are expended include: 1) development of population planning policies appropriate to the recipient country; 2) contraceptive commodities;

3) systems for contraceptive distribution and

use; 4) information, education, and communication activities; 5) research on the delivery of

family planning services, on the development

and application of improved or new contraceptive methods, on the social, economic, and

cultural conditions that affect their acceptance

and use, and on those social conditions that

directly affect birth rates (e.g., age at marriage);

and 6) the gathering, evaluation, analysis, and

dissemination of demographic and other information.

Less than 2 percent of official development

assistance from all MDC donors is currently allocated to population activities, a proportion

that represents a small decline since 1970. The

United States provides just under 4 percent of

its total development assistance for international population activities.

In 1980, total resources (excluding China)

committed to population and family planning

programs in LDCs amounted to about $1.0 billion. Of this total, LDC contributions accounted

for about $450 million, private sources about

$100 million, and MDC sources about $450 million. ” Donor governments (including the United

States) are the principal source of MDC

assistance; funds are channeled: 1) through

nongovernmental organizations (NGOs) such as

the International Planned Parenthood Federa-

● China’s expenditures in 1980 for its intensive birth planning campaign

are estimated to ha~’e approached $1.0 billion; see app. A.

tion (IPPF) and Family Planning International

Assistance (FPIA); 2) directly to LDC governments (bilateral assistance); and 3) through

multilateral organizations such as the United

Nations Fund for Population Activities (UNFPA).

Private sector donors channel money primarily

through NGOs such as IPPF. MDC and private

contributions arrive in LDCs as money, contraceptives, information, and technical assistance

in developing and administering family planning

programs and in collecting and analyzing population data. Agencies administering the largest

amounts of population assistance are the U.S.

Agency for International Development (AID),

UNFPA, and IPPF (fig. 3).

The United States supports population

assistance through two main channels, AID (Office of Population) and the World Bank. The

World Bank receives moneys in the form of general development appropriations, about 1 percent of which are directed toward population

projects. AID, in turn, channels funds bilaterally

to LDC governments, multilaterally to UNFPA,

and through private intermediary organizations, such as IPPF, FPIA, etc. World Bank

support is exclusively loan assistance; AID programs are largely grant assistance but include

some loans as well.

The Foreign Assistance Act states that the

population planning component is “to increase

the opportunities and motivation for family

planning and to reduce the rate of population

growth.” It authorizes the President “to furnish

assistance . . . for voluntary population planning. In addition to the provision of family planning information and service and the conduct of

directly relevant demographic research, population planning programs shall emphasize motivation for small families.”

In recent years this has been translated by

AID into program expenditures of about 50 percent for family planning services, 15 percent for

institutional development and training, 10 percent for information and education, 10 percent

for biomedical and operations research, 10 percent for demographic analysis, and 5 percent

for policy development and research into factors that increase the use and acceptance of

family planning services.
Ch. l—Summary, Issues, and Options ● 1 3

Figure

Channel of

assistance

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

3 .–Channels Through Which AID Population Assistance Arrives in LDCS, 1979

Number of countries receiving assistance

o 20 40 60 80 100 120

The amount of U.S.

channeled through AID

100 120

Middle East

population assistance

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 provide the most population assistance to LDCs, its

proportion of the total amount has decreased

over the last 14 years. The United States provided 50 percent or more of all primary source

assistance until 1974, when this proportion

leveled off to about 40 percent, where it has remained. This decrease is largely due to increased 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

to maintain the 1972 level.

International population programs

Population assistance has had diverse impacts,

including a heightened awareness of the problems associated with rapid growth. Government

officials, scientists, and informed lay people in

LDCs and MDCs are working together to develop, test, and disseminate new contraceptive

methods. Many women of reproductive age in

LDCs have at least heard of family planning

even though some may not fully understand

what it means or may not yet have convenient

access to contraceptive methods. More data of

better quality are available to enable governments to formulate policy, set demographic

goals, and monitor program effectiveness. Each

of three decennial census rounds from the

1960’s to the present has been characterized by

substantial improvements in data collection

techniques and data processing and analysis capabilities in LDCs. The World Fertility Survey

and Contraceptive Prevalence Surveys are providing important data on fertility trends and differentials, levels of contraceptive knowledge

and use, and program evaluation. Operations

research projects are testing innovative approaches to the delivery of fertility planning information and methods. Social marketing programs have put contraceptives, on the road to

being self-financing in some LDCs. And the mass

media campaigns associated with social marketing programs have played a major role in enhancing public awareness and acceptability of

family planning.

The need for greater sensitivity to and

knowledge of the role of the sociocultural factors that motivate people to adopt family planning is clear. Social settings that allow women

few options beyond raising large numbers of

children, and negative attitudes of peer groups,

relatives, and spouses can be important constraints to contraceptive use, Thus population

and development programs that are multifaceted and address relevant social, economic,

and health needs along with delivery of family

planning services are most likely to be successful.

Family planning programs contribute significantly to improved health of women and children and have made a substantial difference in

accelerating the rate at which fertility declines,

as shown in table 1. (The countries noted with

asterisks in table 1 are those that have strong-tomoderate family planning programs efforts.) In

countries with strong family planning efforts

for which data are available, fertility declined

an average of 30 percent between 1965 and

1975. This compares with declines of about 4

percent in similar countries with weak family

planning programs and 2 percent in countries

with no programs. On balance, about 15 to 20

percent of the declines in fertility between 1965

and 1975 in 94 LDCs is attributable to the family

planning component of population program

effort. Thus, although family planning programs are not the only factors at work in countries experiencing substantial fertility declines,

such programs clearly make a difference.

The use of contraceptive technologies can

substantially lower birth rates, but their availability and acceptability vary. Delivery systems

may be inadequate or culturally inappropriate

so that family planning services are in fact not

effectively available. The contraceptive methods

used in a particular country may not be the

ones preferred but the ones available. People

may become dissatisfied and discontinue the

methods used because of side effects, the need

for repeated application, costs, medical contraindications, contraceptive failure, and concerns

about long-term safety, A realistic goal is for

each country to have enough technologies appropriate for local conditions so that each individual has access to at least one method that

meets his or her current needs. Improved and

new technologies could enhance family planning effectiveness and efficiency by reducing

side effects, permitting easier administration,

and simplifying delivery system requirements.

At present, of 374 million couples of reproductive age in LDCs (excluding China), some

one-fifth, or about 74 million, are using contraception. By 2000, there will be at least 638 million couples of reproductive age (889 million

couples if China is included). Because about 80

percent of these couples would need to use

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

achieved. The total difference between the high times the current United

and low variants is sizable—650 million per- just 20 years.

Issues and options —-.

the addition of three

States population in

The breadth of purpose of international population assistance, the range of its activities, and

the variety of U.S. governmental involvement in

these activities result in many issues of congressional interest. Not all of these issues require

legislative action, and many can be examined

through the congressional oversight process. In

this section, the principal issues and related

legislative options for: 1) Federal involvement in

contraceptive R&D, and 2) international population assistance support are addressed.

In the biomedical research area, the issues

center on the U.S. Government’s key role in support of reproductive and contraceptive R&D

and on reconciling how the United States regulates the drugs and medical devices industries

with the need to diffuse these technologies to

countries that may have different risks or perceptions of risks.

Contraceptive technologies

The U.S. Government’s role in the development and dissemination of contraceptive technologies is mediated through two avenues: 1)

the R&.D activities of the National Institutes of

Health and AID; and 2) the regulatory policies of

FDA. Peripheral to contraceptive technologies,

but possibly affecting them, are U.S. patent laws

and their interrelationships with FDA’s regulatory process and the direction that product

liability legal doctrines have taken in the United

States.

THE ROLE OF THE U.S. GOVERNMENT IN

CONTRACEPTIVE R&D

The Federal Government not only supports

contraceptive R&D, but also regulates the drug

and medical devices industries through FDA’s

market approval process in which efficacy and

safety requirements must be met. The development and dissemination of contraceptive technologies thus can be influenced through Federal

funding of contraceptive R&D, and through

governmental actions that could stimulate or

restrain expanded or renewed interest in contraceptive products by private industry.

ISSUE: Federal support of contraceptive

R & D

In 1979, governmental agencies throughout

the world provided approximately 80 percent of

funding for reproductive research and contraceptive development. The United States provided nearly 60 percent of all funds, or about

$89 million. Approximately 70 percent of worldwide expenditures were devoted to basic research, training, and institutional support;

about 23 percent to contraceptive development;

and approximately 7 percent to evaluation of

current methods.

Federal support is provided by the Contraceptive Development Branch of the National Institutes of Child Health and Human Development’s

(NICHD) Center for Population Research and, to

a lesser extent, by AID. AID is a major funder of

the Program for Applied Research on Fertility

Regulation (PARFR) and the International Fertility Research Program (IFRP). Federal funds are

also provided indirectly through AID’s contribution to the International Committee for Contraceptive Research (ICCR), to the UNFPA, and

the Program for the Introduction and Adaptation of Contraceptive Technology (PIACT).

OPTIONS:

A. Sustain financial support of R&D at current

levels.

If Congress continues to judge that governmental action is warranted to continue the development of improved contraceptives for use

at home and abroad, the minimum action would

be to sustain support of existing programs at
Ch. l—Summary, Issues, and Options . 17

current levels. Although the dollar amount for

reproductive research and contraceptive development increased from $80 million in 1972 to

$112 million in 1979, inflation has meant, in

terms of constant dollars, a cut of about 20 percent from the 1972 funding level.

With limited research dollars, individual

investigator-initiated research that may not be

part of a larger program might have higher priority and be more likely to be funded than large,

goal-oriented, contract research of the type

needed for stimulating contraceptive development.

B. Substantially increase financial support.

Arguments for increases in contraceptive

research include the following: Present contraceptive development programs may develop

many useful new and improved contraceptives

over the course of the next two decades if additional money is available. Because many LDCs

are actively pursuing policies to reduce population growth and there is increasing concern in

MDCs about the side effects of current fertility

planning methods, there is a strong need for improved contraceptive methods both in the

United States and abroad. The potential impact

is enormous in terms of improved family planning effectiveness, reductions in numbers of unwanted pregnancies and induced abortions, improved maternal and family health, alleviation

of human suffering, and opportunities for economic progress. Without such added investments, emergence of many new contraceptive

products is likely to be either prevented or very

substantially delayed.

Congress can authorize and appropriate more

funds for the entire field of reproductive research, using the presently available funding

channels, NICHD and AID. This action could

strengthen this field in a balanced, comprehensive fashion and thereby increase scientific

prospects for discovery and development of improved contraceptives in the future.

Alternatively, Congress may wish to increase

funding only for contraceptive development.

Added investments in this specific area are

highly likely to produce payoffs in the form of

useful new technologies. As total public funding

for such development is currently less than $20

million annually, present funding levels could

be significantly increased at relatively low cost.

An additional $20 million annually in this specific field could have a substantial impact.

The budget of AID’s Office of Population also

could be augmented and earmarked or recommended for contraceptive development, which

would enable AID to increase funding for both

the three U.S.-based international contraceptive

development programs and other groups that

could contribute to this endeavor,

Increases in NICHD’s budget would need to be

earmarked for the Contraceptive Development

Branch. Such action would greatly increase the

volume of goal-oriented R&D being conducted

under contract by NICHD. This action would

contribute directly to the development of new

contraceptives for U.S. use and indirectly to the

work of international programs seeking to

develop and introduce new contraceptives in

LDCs.

C. Reduce financial support.

Although it could be argued that industry invests little in contraceptive R&D because government funds are available, and that one impact of this option would thus be increased industry participation, such factors as product

liability are major deterrents to greater industrial participation in contraceptive R&D. For

basic reproductive research, the additional factors of longer time for return on investment and

greater risk further deter industrial participation in fundamental research.

For government research, reduction or

elimination of Federal funding for basic research and contraceptive R&D would produce

different effects depending on how the reductions were carried out.

A reduction exclusively in NICHD’s budget

would rapidly result in a discontinuation of

research by many U.S. research centers now

working in this field under NICHD support.

Much of the Nation’s safety research on contraceptive methods currently in use would also

be eliminated. At least initially, the direct effect

on the U.S.-based contraceptive development

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

not funded by NICHD. But because these other

programs utilize basic research and goaloriented research findings that emerge from

NICHD-funded projects, over the long term

their prospects for successful development of

new methods could be reduced significantly.

A reduction exclusively in AID’s contraceptive

development program likely would be detrimental for at least three of the four nongovernmental contraceptive development and dissemination programs, Three programs—IFRP,

PARFR, and ICCR—are highly dependent on

AID funding, and any substantial reductions in

their budgets would essentially put them out of

business. While PIACT might continue its work

independently if its budget were maintained

under such circumstances, it could not replace

the clinical research and applied R&D work of

the other three organizations as PIACT concentrates largely on providing product information

to LDCs.

STIMULATE THE INTEREST OF PRIVATE

INDUSTRY IN CONTRACEPTIVE R&D

Most of the numerous factors that might

stimulate more private industry interest in contraceptive R&D concern removing apparent disincentives against developing and marketing of

contraceptive products. But as these factors also

involve major issues in their own right, trying to

change these factors to promote contraceptive

R&D quickly impinges on other substantial interests. Hence, although options for some factors are discussed here, it should be kept in

mind that the effects of these changes would

reach beyond contraceptives to other drugs and

other products.

ISSUE 1: product Liability and the

Contraceptive Industry

According to representatives of companies actively researching new contraceptive products,

product liability is as great a negative factor in

making a business decision regarding new contraceptives as meeting the FDA requirements

for safety and efficacy.

The primary effect on a manufacturer from

product liability is financial; i.e., compensation

for claimants and defense of claims. A secondary effect is the adverse publicity accruing to

the product and its manufacturer. Because of

increasing frequency of claims and escalating

size of successful judgments against contraceptive manufacturers, pricing of liability insurance has become so uncertain that insurers are

either withdrawing from the field, mandating

that manufacturers self-insure larger and larger

amounts of first-dollar costs, or placing contraceptive drugs and devices in special categories of risk separate from product liability insurance for the manufacturer’s other products.

As liability costs are business expenses that

are incorporated into the price of the affected

product, manufacturers may be increasingly reluctant to devote research and development efforts to products such as IUDS. Once the sale is

made, there is less opportunity to recoup liability costs, as sales are not as frequent and continuous as they would be for oral contraceptives. With the latter, liability costs can be

passed on, which may explain in part the large

price increases of oral contraceptives (discussed

next) in comparison with other drugs. Thus,

product liability may be affecting not only the

propensity of private industry to develop new

contraceptives but also the kinds of contraceptives to be developed in the future.

Because the product liability problem is of

concern for products in general, the contraceptive field may well be an inappropriate forum

for congressional consideration of this larger

liability issue. But recognition by the Congress

of liability problems with contraceptives might

encourage the congressional committees that

have jurisdiction over laws governing commercial products to consider changes in these laws,

ISSUE 2: Effective Patent Life

The current process through which drugs and

medical devices are cleared for commercial distribution and sales takes a number of years.

However, in order to protect its interest in the

potential new product, a company must apply

for and be granted a patent long before the

product has been approved by FDA. Drug

patents run for 17 years, but it takes an average

of 8.5 years for a contraceptive drug to clear the

regulatory process, cutting its effective patent

life to less than 9 years. Whether this situation
Ch. l—Summary, Issues, and Options . 19

inhibits the development of new drugs and medical devices is not clear.

Wyeth Laboratories and Ortho Pharmaceutical share approximately 70 to 80 percent of

the U.S. market for oral contraceptives. Wyeth’s

patent on norgestrel is still in effect, but the

patent on norethindrone expired in 1973. Since

the patent expiration, only Mead-Johnson and

Lederle have entered the market, and Lederle

no longer markets its oral contraceptive. No

generics (nonbrand name drugs) have entered

the market. The Pharmaceutical Manufacturers

Association also reported in August 1980 that

oral contraceptives had the greatest price increases of all classes of pharmaceuticals in the

periods 1969 to 1979 (187 percent) and 1978 to

1979 (23.7 percent), as compared to only a 37.4

percent increase in price during 1969 to 1979

and a 6.5 percent increase in 1978 to 1979 for a

sample of over 1,000 drugs. Although other factors (e.g., product liability) may be at work,

shortened patent life has not had a significant

effect on the oral contraceptive market. After

patents have expired, prices have remained

high and new firms have not been able to enter

the market on a competitive basis.

ISSUE 3: Export of Non-FDA Approved

Drugs

The market for U.S. manufacturers of contraceptives could be expanded if the law on the export of non-FDA approved drugs were changed.

Current law prohibits the export of drugs for

uses that are prohibited in the United States.

Two categories of drugs are at issue: 1) drugs

unevaluated for use; and 2) drugs evaluated but

not approved for use. There are some exceptions to the drug exportation ban; e.g., investigational drugs can be exported for investigational

purposes, provided that the importing country’s

government has approved such imports. In addition, medical devices not approved for marketing in the United States can be exported if: 1)

they conform to the laws and specifications of

the importing country; and 2) their export is not

considered by the Secretary of Health and Human Services to be contrary to the public health

and safety of the importing country.

Changes in the export provision of nonFDA approved drugs have been considered by

Congress. In the 96th Congress a bill adopting

the medical devices export law for drugs was

passed by the Senate but died in the House of

Representatives.

OPTIONS

A. Keep the status quo, where drugs not approved

for marketing in the United States cannot be exported to other countries but medical devices

can be exported under certain conditions.

By keeping the status quo, Congress prevents

the foreign marketing of drugs that have not

been adequately tested or whose safety has not

been established by U.S. standards.

Current law does not affect the foreign production and use of contraceptives that are not

approved for use in the United States. For example, medroxyprogesterone acetate (Depo-Provera) is manufactured and used as a contraceptive abroad, although approved only for the

treatment of endometrial and renal cancer in

the United States.

Keeping the status quo helps to avoid the

danger of “unsafe” drugs being manufactured in

the United States and then “dumped” on other

countries as some critics have charged. Existing

law protects the United States from being criticized for subjecting other people to risks to

which it does not allow U.S. citizens to be exposed.

However, the relative risks and benefits of a

drug are not the same for people in LDCs,

where health conditions, including the risks of

pregnancy and childbearing, are quite different

from those in the United States. Further, the

wide range of contraceptives available to U.S.

women may not be available to women in LDCs,

a factor that affects the risldbenefit assessment

of a particular contraceptive. Thus, the United

States may be depriving women in LDCs of

drugs that would have a greater benefit than

risk for them.

B. Adopt the medical devices export law for drugs.

As in the case of medical devices, non-FDA approved 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

country were met, and the Secretary of HHS

determined that the importing country’s public

health and safety were not compromised.

C. Adopt the medical devices export law for

drugs, and add one or more of the following

provisions:

1, Require that the risk/benefit analysis for an

unapproved drug take into consideration

conditions of the drug's use (and other health

risks) to individuals in the importing country

This provision is based on the assumption that

the risks and benefits of a given drug can

change from country to country. Some advocates of this provision believe that a risk/benefit

analysis of a drug should be based on data actually obtained in the importing country and in

response to requests from that country, Determination of a drug’s benefits would be based on

the prevalence and severity of the target

medical condition, and safety assessments could

consider such items as the extent to which the

drug user could be monitored for adverse reactions. Other user conditions—e.g., nutritional

status—that could affect a drug’s safety and efficacy could also be studied,

Instead of actually collecting data from clinical

trials conducted in the importing country, it

may be more feasible to adjust data collected

from other countries to reflect user conditions

and disease prevalence in the importing country. It is very difficult to collect data from a sufficient number of women within any given

country when low-incidence, but very important, medical events are to be assessed. Many

importing countries would lack the capacity to

conduct such assessments.

Z. Establish industrial standards of conduct.

Procedures could be developed in which officials–and perhaps the public–in importing

countries could be informed of the risks, benefits, and costs of the drugs they wish to import.

Written verification of such an informed consent process, signed jointly by company executives and importing country officials, could

be filed with the Secretary of Health and Human

Services (HHS). Violation of that document could

serve as a basis for withdrawal of approval.

D. Develop international standard-setting mechanisms on the use, safety, and effectiveness of

contraceptive drugs and devices.

If modifications of existing export laws on

drugs along the lines of the current medical devices export law (options 2 and 3) are adopted,

such international standards would be helpful

to the Secretary of HHS in determining whether

or not the importing country’s public health and

safety are compromised.

WHO could be encouraged to develop international standards for safety and efficacy and/or

for labeling and promotion standards for contraceptive drugs and devices. These standards

—in conjunction with safety data specific to the

importing country—could provide the basis for

the Secretary’s decision.

INTERNATIONAL POPULATION ASSISTANCE

Because the momentum for large increases in

the world’s population is clearly present and

recognized, many LDCs now actively seek population assistance. They recognize the implications of their high growth rates, and their requests for population assistance have risen to

the point that donor agencies can meet only a

fraction of current requests for such aid. Further, the people who will contribute to the anticipated surge in world population gorwth in

the next few decades have already been born

(see fig. 2A), and a very substantial increase in

the use of fertility planning methods is required

in LDCs in order to slow population growth.

There are two issues to be addressed in U.S.

international population assistance efforts—

level of funding, and the distribution channels

through which U.S. funds are dispensed.

ISSUE 1: Level of Funding

Because there are many competing demands

on Federal funds, careful examination of the impact of various funding levels is essential.

OPTIONS:

A. Reduce financial support.

Reduced support from the United States for

population programs would force LDCs to reduce their programs, cut back on supplies that

require foreign exchange, eliminate training
Ch. l—Summary, Issues, and Options ● 2 1

programs, and probably decrease program outreach to rural and other hard-to-reach areas,

Because the momentum for population growth

already exists, spending for population programs deferred now would still be necessary at

higher funding levels because of inflation, loss

of trained personnel, and duplication of start-up

costs. The capability of LDCs to finance their

own family planning programs through such

promising avenues as commercial retail sales

(CRS) programs would be postponed. (CRS programs provide oral contraceptives, condoms,

and spermicides at low cost and can effectively

extend to hard-to-reach areas. However, they

require substantial initial funding for bulk procurement of contraceptives, subsidizing of retail

prices, and technical assistance in the establishment of backup medical services, ) Also, if the

U.S. level of support were to be decreased now,

self-sufficiency of LDCs in population planning

and progress in economic development might

be further delayed, resulting in: 1) deteriorating

social and economic conditions including increased death rates in LDCs; 2) need for significant future increases in general economic

developmental assistance from MDCs to LDCs;

or 3) if the United States were to abstain from

future increases in economic developmental

assistance, widening of the economic chasm between MDCs and LDCs, with all of the political

implications that are associated with these differences.

Overall, U.S. cuts would disrupt the current

working balance among private organizations,

intergovernmental agencies, and government

donors, with particularly adverse effect on the

private agencies that are likely to suffer major

reductions yet are often the most cost effective.

Under current budgets, AID and the multilateral donors cannot meet current commitments. With further cuts, many countries and

agencies would have to reconsider their ability

to implement effective programs.

The U.S. Government, as the largest single

donor to international population assistance,

has been able, to some degree, to coordinate

population assistance efforts and influence the

direction of funding. A reduction in population

assistance funds would reduce U.S. influence on

program strategies and design.

B. Increase financial support,

population and family planning programs

have been a key factor in recent fertility

declines. The needs of many LDCs for population assistance and the current shortfall of

funds for these purposes are well-documented.

Congress has in fact increased its appropriation from $190 million in fiscal year 1981 to

$211 million in 1982; $230 million has been authorized for 1983. These current and potential

increases represent a significant step and underscore the importance of population assistance at a time when many high priority social

programs are being cut. However, inflation has

reduced the purchasing power of these funds to

below that of the total amount provided for population funding in the peak year of 1972 ($121

million, or about $239 million in 1982 dollars).

At a time of rising requests for assistance, the

AID population commitment is decreasing in

purchasing power.

AID’s fiscal 1982 budget is about $200 million

below levels of documented need and insufficient to the point that: 1) most AID-supported

projects and programs will receive less than the

funds needed to satisfy demand for family planning services or otherwise function optimally

(this includes inability to meet shortfalls at

UNFPA, IPPF, and other major private voluntary

organizations); 2) there will be few new initiatives in Africa (where governments are now beginning to ask for assistance) and the Near East;

and 3) projects are being terminated prematurely, before recipient countries become self-sufficient.

UNFPA’s 1982 calendar year budget of $135

million represents a shortfall of $40 million to

$100 million. ” The $40 million represents the

‘on the basis of its 1979-80 projections of 15 percent per year

gro~~h in contributions from hlLX: donors, LJNFPA set up multi.

year commitments for various LDC and international progran15,

both new and ongoing. AS 1980-81 unfolded, a plateau in the U.S.

contribution occurred, and the l], S. dollar strengt Iwned in for~~ig[l

markets, making other currencies relati~’elj’ weaker. These etrents

combined with inflation to gi~re NIDC donations less actual value

(Footnote continued on p. 22)
22 . World population and Fertility Planning Technologies: The Next 20 Years

gap between available funds and established

needs for ongoing programs and commitments

previously made. The $100 million includes new

programs that have been requested and merit

funding, but for which funds are not available.

However, a much larger number of countries

now wish populaiton assistance, and there has

been a 20 percent increase in couples of childbearing age in LDCs since 1972. This argues for

an even greater increase in assistance commitments in the coming years.

Excluding China, only 20 percent of couples of

reproductive age are currently using contraception in LDCs. Efficient programs cost an average

of $15 per user annually (new programs can

cost as much as $100 per user). Many countries

are only beginning to implement family planning programs so start-up costs are very high. If

fertility is to fall to replacement levels, contraceptives must be used by about 80 percent of

couples in the childbearing ages. The growth in

the population, the need for increased use of

fertility planning methods, and higher costs of

programs that cannot be fully implemented

until LDCs themselves can contribute more support all argue for major incremental increases

in population assistance in the coming years.

One approach to steady incremental increases

in funding would be to meet the recommendation of the International Conference of Parliamentarians on Population and Development

held in Colombo, Sri Lanka in 1979. Delegates

representing 58 countries unanimously called

for a total annual allocation of $1 billion in international population assistance (exclusive of LDC

commitments) by 1984.

More recently, at the International Conference on Family Planning in the 1980’s held in

April 1981 in Jakarta, Indonesia, participants

from 76 African, Asian (including China), Latin

American, and Middle Eastern countries joined

representatives of major international agencies

in calling for a rapid increase in overall national

and international expenditures for population

and family planning programs to $3 billion annually. LDC representatives stressed the urgency of reducing high fertility rates, slowing the

momentum for further growth, raising

women’s status and economic opportunities,

and providing family planning services as a

basic human right.

Assuming that the United States wishes to

maintain its 40 percent share of the total assistance budget and that other MDCs and private

sources increase their contributions, the goals

set by these international representatives might

be attained, although the timing is likely to be

delayed. If the United States were to increase its

contributions by 30 percent per year (assuming

an annual inflation rate of 15 percent), its contributions could keep pace with inflation and incremental funding would be available for increasing needs. The United States would thereby 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 ● 2 3

LDCs. A change in the present distribution system would affect the type of aid available and

hence would have different impacts on different regions,

Because of differences among regions, varying approaches are required. In general, Asia’s

primary needs are for efficient and effective

services delivery to very large rural populations, a large volume of supplies, and additional

training in health care and program management.

In Latin America, some governments are

reluctant in the face of religious and conservative opposition to give rigorous support to

family planning programs, but public demand

for family planning services is growing rapidly.

As a consequence, support for private agencies

and expansion of family planning within health

care systems are increasing.

In the Middle East, the limitation of opportunities beyond childbearing for women is a major barrier to fertility change. Expansion of

government and private services, and of broad

social programs, is needed. The continuation of

innovative efforts by private population and

family planning agencies to change perceptions

of the role of women is crucial.

Birth rates in some countries in Africa are the

highest in the world, but few African countries

have formulated policies that make a direct connection between their serious economic and social problems and rapid population growth. As

most of these countries do, however, favor the

provision of family planning services in the context of maternal and child health activities, emphasis should be on support for family planning

as a component of health programs. Improved

collection and analysis of demographic and

other data would make an important contribution to increased understanding of the magnitude of population growth and its impact on

economic development and the environment.

Expansion of the role of existing private voluntary agencies would facilitate delivery of family

planning services and improvements in maternal and child health.

There is thus a major difference between

Asia, for example, where governmental programs are established but where support is

needed to make them comprehensive and effective, and Africa, where there is much less appreciation of the implications of rapid population growth and less governmental commitment

to extend family planning services widely.

However, these broad generalizations mask

the variability that exists among countries,

which is at least as great as that among regions.

Different countries have different cultural

values and development goals and thus require

different forms of assistance. Different forms of

government and different political alliances also

make some forms of assistance more appropriate to one country than another.

Technical assistance and commodities for

population planning and family planning programs are currently channeled through several

major international agencies and many private

nongovernmental agencies. The largest agencies, AID, UNFPA, IPPF, and the World Bank

provide technical assistance in varying degrees

in the areas of family planning services (including commodities); information, education,

and communication; institutions and training;

research and evaluation; policy development;

and data collection.

Each agency tends to have different emphases

and priorities within a broad range of support

activities. For example, UNFPA provides technical assistance for basic population data collection, and channels assistance for family planning services primarily through health ministries incorporated into maternal and child

health programs. AID is the largest supplier of

commodities and places strong emphasis on

family planning services delivery. IPPF emphasizes family planning services delivery in private

sector clinic settings. Because each agency has

different emphases and countries have differ-
24 . world populatjon and Fertility Planning Technologies: The Next 20 Years

ent priorities, the agencies can cooperatively

tailor their support to individual country needs.

About 28 percent of AID funds are currently

dispensed to the multilateral agencies (UNFPA

and IPPF), 26 percent are dispensed bilaterally,

and 46 percent dispensed to and through private intermediaries and organizations, Changes

in present proportions of assistance would have

uncertain effects on the balance that has been

achieved among these agencies and there are no

compelling reasons for considering changes at

this time. Given current shortfalls, duplication

of efforts is not an issue, but if funds are increased, efforts to promote greater coordination among agencies at administrative and country levels would need to be examined more

closely.

Additional issues for

congressional oversight

Several additional issues that Congress may

wish to consider for oversight are as follows:

●

●

Although population issues are the jurisdiction of several congressional committees,

there is no single congressional mechanism

for continued oversight of international

population assistance. A prime issue, therefore, is whether population growth in LDCs

and its implications for their progress

toward economic self-sufficiency should

continue to be addressed within the general

subject of international economic developmental assistance, or whether a committee

or subcommittee should be formed to focus

directly on issues related to national, regional, and world population growth.

Present criteria for determining which

countries receive population assistance are

established by AID, except for-the following

provisions: limitation of assistance to the

poorest countries (currently interpreted as

yearly income below approximately $300

per capita), prohibition of aid to Communist

bloc countries, and prohibition of funding

of abortion services. A review of Congress’s

legislative guidelines and the ways in which

AID has interpreted them would be a necessary corollary of changing the current

●

●

●

levels of funding and of the current apportioning of aid between multilateral and

other channels through which assistance is

funneled.

As summarized earlier in looking at the differences among Asia, Latin America, the

Middle East, and Africa, the pace of population change in different regions of the

world varies greatly. Each region requires

different types of assistance and runs on

different timetables, and in some settings

immediate results cannot be expected. Priorities and restrictions in addressing these

various aspects of global population growth

require clarification. For example, current

restrictions prohibit aid to China. The

result of this action toward the country

which contributes the largest proportion of

global growth may be that U.S. population

assistance is oriented less toward having

the greatest impact on total world population growth than to slowing population

growth in those regions of the world and in

those countries where the United States has

a strong interest. Congress may want more

extensive reviews of these priorities and the

reasons behind them.

If governmental support for social programs, including economic aid to LDCs, is

reduced, there will be a need to accelerate

the pace of self-sufficiency of LDCs, and for

additional support from the private sector

in both LDCs and MDCs. Congress may

therefore wish to explore the extent to

which this support can be encouraged, and

how governmental actions can facilitate

greater activity by the private sector in

LDCs.

Factors that may be inhibiting the development, manufacturing, and marketing of

medical products—e.g., product liability

suits, shortened patent life, and FDA’s export provisions on drugs–are not unique to

the contraceptive market, but are representative of problems that have arisen generally for all types of consumer products. Addressing these generic consumer product

problems through the issue of fertility planning 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 projections for the year 2000 is roughly three times the size of the current U.S. population. 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 population 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 opportunities than did MDCs in the past, and LDCs have higher levels of unemployment that were experienced earlier in MDCs. LDCs do have three major new advantages, 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 organized.

Trends in population growth

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

ized nations. This historic transition from high

to low rates, which began in western Europe

some 200 years ago, combined with the industrial revolution to sharply divide the world into

one-quarter rich and three-quarters poor. A

number of terms—more and less developed; developed and developing; North and South; First,

Second, and Third Worlds; industrialized and

underdeveloped—describe this division. This

report uses those terms most commonly used by

international agencies: more developed countries and less developed countries.

Although the dichotomy is real, the terms

oversimplify. The two groups of nations are

vastly different in terms of income, health, education, and rates of natural increase, but differences within each group are also wide, as

shown in tables 4 and 5. Awareness of the heterogeneity and individuality of LDCs is vital to

understanding their levels of development and

population growth.

Table 4.—Selected Population Data for

the 25 Most Populous LDCs

(Medium variant)

population 1981 1981

(millions) rate of doubling

Country 1981 2000 natural increase tim e

a

China . . . . . . .

India . . . . . . . . . .

Indonesia . . . . . .

Brazil . . . . . . . . .

Bangladesh . . . .

Pakistan . . . . . . .

Nigeria . .

Mexico . . . . . . . .

Vietnam . . . . . . .

Philippines. . . . .

Thailand . . . . . . .

Turkey. . . . . . . . .

Egypt . . . . . . . . .

Iran . . . . . . . . . . .

South Korea. . . .

Burma. . . . . . . .

Ethiopia . . . . . . .

South Africa. .

Zaire . . . . . . . . . .

Colombia . . . . . .

Argentina . . . . . .

Afghanistan . . . .

Morocco . . . . . . .

Algeria . . . . . . . .

Sudan . . . . . . . . .

All LDCs . . . . . . .

All MDCs . . . . . .

World . . . . . . . . .

969

710

155

130

91

85

80

72

54

53

49

46

43

39

39

36

33

30

29

28

27

23

21

19

19

3,357

1,138

4,495

1,190

1,040

221

212

153

145

149

132

79

83

76

6 9

65

65

51

55

55

48

46

42

33

37

36

36

31

4,926

1,272

6,199

0.8 59

2.1 33

2.0 35

2.4 29

2.6 27

2.8 25

3.2 22

2.5 28

2.8 25

2.4 29

2.0 35

2.2 32

3.0 23

3.0 23

1.7 41

2.4 29

2.5 28

2.4 29

2.8 25

2.3 33

1.6 43

2.7 26

3.0 23

3.2 22

3.1 22

2.1 34

0.6 113

1.7 41

Table 5.—Selected Socioeconomic and Quality of

Life indicators for the 25 Most Populous LDCs and

Selected MDCs

1975

adult 1981

1978 literacy life 1981

G N P rate expectancy infant

Country (dollars) (percent) (years) mortalit y

China . . . . . . . . .

India . . . . . . . . .

Indonesia . . . . .

Brazil . . . . . . . . .

Bangladesh . . .

Pakistan . . . . . .

Nigeria . . . . . . .

Mexico. . . . . . . .

Vietnam. . . . . . .

Philippines . . . .

Thailand . . . . . .

Turkey . . . . . . . .

Egypt . . . . . . . . .

Iran . . . . . . . . . .

South Korea . . .

Burma . . . . . . . .

Ethiopia. . . . . . .

South Africa . . .

Zaire . . . . . . . . .

Colombia . . . . .

Argentina . . . . .

Afghanistan . . .

Morocco . . . . . .

Algeria. . . . . . . .

Sudan . . . . . . . .

United States . .

Japan . . . . . . . .

UnitedKingdom

. . . . . . . .

230

180

360

1,570

90

230

560

1.290

’170

510

490

1,210

400

2,160 b

1,160

150

120

1,480

210

850

1,910

240

670

1,260

320

9,590

7,280

5,030

8,260

68

52

50

55

56

46

74

76

73

73

133

127

aNumbe o y r f 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 experienced a sudden, sustained drop in deaths

which, combined with little change in births,

produced unprecedented growth in numbers of

people. Today, about 80 million persons—the

equivalent of an additional Mexico or Nigeria—

are added to the planet every year (7). By the

end of the century, despite reduced birth rates,

this annual increase is expected to reach 95

million. Most of this increase in numbers is taking place in the LDCs, where expectations of a

better life are also rising.

The timing, intensity, and effects of population changes have varied greatly among LDCs)

but, beginning with India in the early 1950’s,

more than 40 percent of LDC governments have

become concerned about their rapid growth

and its detrimental impact on national development, and have sought means to reduce their

birth rates.

Although the most immediate effect of rapid

population growth in LDCs has been to limit

their ability to raise living standards, the negative consequences of population growth are

not confined to these countries. MDCs are increasingly concerned about their own population growth. The congressionally established

Commission on Population Growth and the

American Future concluded in 1972 that: “the

stabilization of our population could contribute

significantly to the Nation’s ability to solve its

problems.” National assessments in Great Britain and Japan have reached similar conclusions.

A few countries in Europe are worried about

their s1OW population growth, but overall there

is growing concern that world population is

pushing against the Earth’s carrying capacity.

The Independent (Brandt) Commission on International Development (4) warned of the global

consequences of population growth and its increasingly severe pressure on many basic

resources.

The demographic transition

Although the timing of the transition from

high to low birth and death rates varies among

countries, the chronology of the phases is

similar:

1. an early phase of rising growth as death

rates fall and birth rates do not;

2. a peak growth phase as death rates continue to fall and birth rates begin to fall;

3. a falling growth phase as death rates stabilize at lower levels and birth rates continue

to decline; and

4. a stabilization phase of low, nearly equal,

death and birth rates. (See Tech. Note A, ch.

4)

Differences in timing have produced much

higher growth rates at the beginning of the

transition in LDCs than those experienced by

M D CS (fig. 4). Conditions in Africa, Asia, and

Latin America today therefore differ from those

of the MDC demographic transition in several

very important ways:

● Death rates declined much faster in LDCs

than they did earlier in MDCs. The decline in

●

●

annual death rates from 30 to 15 per 1,000

population that took 150 years in Great Britain, Sweden, and the United States, took

only about 35 years in India. Declines in

LDC death rates from major causes such as

cholera, malaria, and smallpox have been

facilitated by new large-scale international

transfers of health and agricultural technologies from MDCs.

As a result, population growth has been much

more rapid in LDCs in both rates and absolute numbers than it was in MDCs. Great

Britain’s growth rate fell slowly from 1.4 to

0.4 percent between 1800 and 1921; the annual increase in numbers did not deviate

greatly from 200,000. By contrast, India’s

annual growth rate rose from about 1.5 to

2.5 percent between 1950 and 1970 as its

annual increase in numbers soared from

about 5 to 11 million in just 20 years.

LDCs have greater momentum of population

growth built into their age structures than

MDCs had earlier. Sustained higher birth
32 • World Population and Fertility Planning Technologies: The Next 20 Years

Figure 4.—Comparisons of the Demographic

50

40

30

20

10

0

MDCS

--- Assumed trend in the absence of

World Wars I and II

1 1 I I

1750 1800 1850 1900 1950 2000

In MDCs death rates declined slowly beginning in the late

18th century. Birth rates followed closely. - Population

growth rates rarely exceeded 1.5 percent per year.

LDCs

Birth rate

In LDCs birth and death rates remained high through the

first decades of the 20th century. Then death rates began to

drop. Birth rates stayed high and populations grew at 2.5,

3.0, and 3.5 percent or higher a year. Since the mid-1960’s

some countries’ birth rates have begun to decline.

SOURCE: State Department Bulletin, “The Silent Explosion,” fall 1978.

●

●

●

rates have produced large proportions of

children who will soon reach reproductive

age. Thus, even if average family size is

reduced dramatically in this generation, national birth rates will fall more slowly

because such a large proportion of people

are of reproductive age.

International migration can no longer serve as

an outlet for rapidly growing populations as it

did for much of Europe. There are no more

‘(empty” lands to colonize or to accept great

numbers of immigrants. Nevertheless, population pressures in LDCs and income opportunities in MDCs are likely to result in

sizable illegal migration and its attendant

problems as long as rapid population

growth in LDCs continues.

LDCs have far fewer opportunities for

development than did MDCs. Most LDCs

have little unutilized arable land, are

unevenly endowed with natural resources,

and face stiff competition from MDCs in international markets for industrial products.

LDCs face higher levels of unemployment

than were experienced earlier in MCs. The

opportunities for employment (or migration) that were available earlier in MDCs

are not available in LDCs, where unemployment and underemployment are widespread.

In sum, LDCs have not only encountered population growth unlike anything in MDC experience, but have fewer opportunities for accommodating 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 earlier, are taking direct actions to reduce birth

rates by utilizing new fertility planning technologies and by other means. Although family planning programs vary greatly in effort

and effects and most governments allocate

less than 1 percent of governmental expenditures to them, more than 92 percent

of the world’s population live in countries

whose governments provide some form of

family planning services for their people.

(See ch. 7.)
Ch. 2—Popu/ation Growth to the Year 2000 ● 33

Z. There are more effective technologies for the

planning of births than existed in 1800 or

even 1950. These technologies—the pill,

IUD, and new voluntary sterilization techniques–have replaced less effective methods in MDCs and are beginning to be used

in LDCs. (Technological development is

now lagging, however; although concerted

research efforts to develop better contraceptive technologies increased appreciably during the 1960’s, financial support

for such efforts has fallen in real purchasing

power since 1970.) (See ch. 6.)

3. international transfer of knowledge and technologies to reduce birth rates is now organized. The proportion of total international

development assistance devoted to population activities rose from virtually none in

1960 to 2 percent in 1979. MDCs now provide about $450 million annually for population assistance. (See ch. 9.)

This assessment focuses on policies of the U.S.

Government now and during the next 20 years,

which will be a pivotal period in global population history. LDCs receive greatest consideration because problems arising from rapid population growth are particularly acute in these

countries and because their population growth

between 1980 and 2000 will account for more

than 90 percent of the rise in world numbers.

How fertility can be changed takes precedence

because it is the most viable option for countries

that wish to lower population growth rates.

Projections of world population growth

The size of world population during the next

20 years can be predicted with greater certainty

than most future events because about 60 percent of the people who will be on Earth in 2000

A.D. are already here, and—barring a possible

global nuclear catastrophe or unexpected great

epidemic or famine—experts differ little on how

many will die in the coming two decades. The

uncertainties lie in how many people will be

born. Their numbers will depend to a great extent on what the LDCs do to modify their national birth rates. There is a consensus that

population growth has such a powerful, built-in

momentum that actions taken or not taken now

will determine the size of world populations far

into the future.

World population is projected to grow from

an estimated 4.5 billion in mid-1981 to 6.2 billion

(between 5.9 and 6.5 billion; much will depend

upon the rates at which fertility declines) in

mid-2000. Despite decreasing growth rates, the

total number of persons added to the world’s

population each year is expected to increase

from some 80 million in 1981 to about 95 million

(between 70 and 120 million) in 2000. This

growth will be distributed very unevenly among

different regions and countries. Close to 92 percent is expected to occur in LDCs, cutting the

MDC proportion of world population from 26

percent in 1980 to 21 percent in 2000 (and the

U.S. proportion from 4.9 to 4.0 percent).

The LDCs differ greatly in population size and

growth both by individual countries and by geographic regions. Growth will be greatest, according to current projections, in Africa (76 percent of the 1980 population added in 20 years),

Latin America (65 percent), and Asia (43 percent), However, more of the increase in absolute

numbers will occur in Asia (63 percent) than in

Africa (22 percent) or in Latin America (15 percent), simply because many more people already live in Asia. Three-quarters of all

1980-2000 LDC growth is expected to occur in

just 18 countries: India, China, Brazil, Nigeria,

Indonesia, Bangladesh, Pakistan, Mexico, Philippines, Thailand, Vietnam, Turkey, Iran, Egypt,

Ethiopia, Burma, South Africa, and Zaire, listed

here by the magnitude of their projected

growth. Much of future world population

growth thus depends upon what happens in

these few large countries.

The interval during which some of these

countries will double their populations, if present fertility trends continue, is very brief: Kenya

may double the numbers of its people in 18

years, India in 33, Bangladesh in 27, and Egvpt

in 23 (table 4). (See Tech. Note B.)
Sources and bases of population projections

The projections used here are those of the

United Nations (U.N.), the principal source of information about world population. Its Population and Statistical Divisions publish current

population, birth, and death data annually and

prepare periodic global assessments and projections.

Projections based upon a 1978 assessment

were published in 1979; revised projections

based upon a 1980 assessment were published

in 1981. The projections include high, medium,

and low variants. The medium variant is designed to represent likely demographic trends

based on past demographic changes, expected

social and economic progress, ongoing government population policies, and prevailing public

attitudes toward population issues. The high

and low variants are intended to represent the

effects of plausible variations in these factors.

The U.N. projections are similar to those produced by five other major sources (table 6).

Each set of projections starts from estimated

1975 base populations, fertility rates, and life

expectancies. Each uses similar assumptions

about death rates and assumes no major wars,

famines, or epidemics, and all except the U.N.

exclude international migration. All depend on

data from individual nations—sources whose

frequency, accuracy, and completeness of information vary greatly. (See Tech. Note A.)

The projections prepared by the U.S. Bureau

of the Census also include high, medium, and

low series, and are based on current levels of

fertility, development, and family planning; government policy on population matters; and experience in countries with similar social, economic, and political settings. These projections

assume that fertility will decline more or less

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 1,210b1,131 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

planning program by 2000, and that the effectiveness and coverage of such programs will increase.

The World Bank’s single population projection

was prepared by estimating, for each country,

the year in which fertility would reach replacement level. For all countries except those in subSaharan Africa, fertility decline toward the replacement level is assumed to have started in

1975 if not before. For the sub-Saharan countries, the declines are expected to begin in

1980-85.

The University of Chicago projections also include high, medium, and low variants. The projected fertility rates are based On specified relationships between the rate of fertility decline

and the strength of family planning efforts. The

high projection assumes that each country

maintains its present level of family planning effort. The medium projection assumes that

strong family planning efforts eventually are implemented in all nations by the year 2000. The

low projection assumes that all countries have

strong family planning programs by 1995.

The Harvard University projections assume

that fertility will decline to replacement levels

by 1990-95 in MDCs and by 2000-05 in LDCs.

The Population Council projections assume attainment of replacement level fertility at varying times from 1980-85 to 2040-45. Differences

among the six sets of projections summarized in

table 6 are mainly in base data used, in assumptions about future LDC birth rates, and in interpretations of incomplete data about China and

central Africa. Despite these differences, the

outcomes in world, LDC, and MDC population

estimates for 2000 are quite similar among the

first five. The university scholars and the World

Bank expect slightly less growth in LDCs than

do the U.S. Census Bureau and the U.N. Population Division.

Much of the uncertainty about China should

be resolved by its 1982 census and pending improvements in and availability of its birth,

death, and birth planning program data. Meanwhile, special population projections for China

(l)—based upon China’s new emphasis on the

one-child family to achieve population stabilization by 20()()-come close to the low estimates in

table 6.

The U.N. projections have been used as standard reference figures in most of this report but

have been supplemented by new national data

where available and relevant.

For policy makers concerned with modififying

population growth, the most meaningful population information is the difference in numbers

of people added to the world’s population if

governments do or do not take feasible actions

to reduce birth rates in addition to those

already under way. The actual amount attributable to additional governmental actions that

reduce birth rates is neither accurately’ known

nor explicitly stated by most demographic experts who make projections. There is general

agreement, however, that if gotvernments intensify current actions to reduce growth rates, the

low variant projection is more Iikely to be

achieved. The total difference between the high

and low variants is sizable-650 million persons—and is equivalent to the addition of three

times the current U.S. population in just 20

years (table 6 and fig. 5).

The tendency of demographers to follow past

trends and to underestimate changes in birth

rates means that the low variant projections for

2000 are probably not low’ enough. New information has already led to downward revisions

of these low variants. The 1980 Census Bureau

low series projection for lvorld population i n

2000 was 2-percent lower than in 1977. Some of

this change in predictions can be attributed to

governmental actions.
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

A.D. 2000 medium variant A

m

\

projection: 6.2 billion

A.D. 2000 low variant

projection: 5.9 billlon I

The difference in numbers of people added to the world’s popula- 1

tion by 2000 will depend to a significant extent on the actions

taken by governments to modify birth rates. The difference between the high and low projections—about 650 million persons

—is equivalent to the addition of three times the current U.S.

population within 20 years. Close to 92 percent of population W ;

growth projected by 2000 is expected to occur in LDCs.

Chart shows world population

growth since 8000 B.C. If

stretched back all the way to

the beginning—300,000 B.C.

—in this scale, the line would

be an invisibly thin one starting 10 feet 71/2 inches to the

left of the graph

1945 L2.3 billion

r 1850 1

I 1 billion I I

6000 B.C.

5 million

6.0

5.5

5.0

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

The built-in momentum of population growth

Population growth in the next 20 years has

enormous momentum that will affect later population size. This momentum comes from the

combination of high fertility and rapidly declining infant mortality in LDCs that followed

World War II. The result is a subtle, very powerful built-in inertia, resulting from the age

structure of LDC populations (fig. 6A).

In LDCs, far more people are in the younger

age groups than in the older ones. Because the

number of people entering the reproductive

ages each year will be more than 150-percent

greater that the number leaving them, the number of births will be greater each year, even if fertility rates fall dramatically. Because the younger

age groups will be so much larger than the older

age groups, the number of people being born

each year will be much greater than the number of people dying. Even when fertility approaches replacement levels, the number of

deaths will not equal births until the largest cohort of births reaches old age, some 60 years

later.

In contrast to the LDCs, by 2000 the MDCs

will have a very even distribution of population

by age (fig. 6A). The number of people in each

5-year age group between birth and 50 years

will be between 87 and 93 million. Each year

just as many people will move out of their reproductive years as will enter them. With births at
Ch. 2—Popu/ation Growth to the Year 2000 ● 37

Fiaure .g=—. –6A.—Aae.Sex Composition of More Developed and . Less Developed Regions, 1980 and 2000:

Medium Series Projections

A _ - More developed regions

75+

70

60

50

[

Male Female

I I I 1 I I I

Age

75+

— 70

— 60

— 50

— 40

— 30

— 20

— 10

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

number of children will be born each year. Furthermore, because the size of the older age

groups will be about the same as the younger

age groups, the number of children born each

year will be about the same as the number of

persons dying each year. By 2000, many MDCs

are expected to have achieved population

stabilization—or zero population growth—with

low birth rates equal to low death rates, if their

immigration is in balance with their emigration,

One effect of the population momentum in

LDCs is to foreclose future options if actions are

not taken in time. Frejka and Mauldin (2) conclude that the range between the high and low

variants, and thus the range for plausible government options for the eventual size of world

population toward the end of the next century,

was narrowed by 3 billion people in a single

decade. Taking certain actions to reduce birth

rates lowered the plausible upper level; not taking other actions raised the plausible lower

limit, because by 1980 population momentum

had become a part of the built-in growth projection.

How actions taken now can affect the future

size of world population is shown in figure 6B.

Despite all feasible efforts to reduce birth rates,

the world’s population will almost certainly double from 4.4 billion to well over 8 billion persons

in the next 70 years. But if the world instead

chooses a path of high growth by doing nothing

further to change trends, an additional population roughly equivalent to that of the entire world

in 1981 will be on Earth in 2050. Most of these

people would be born in the LDCs, where the

initial direct impact of their numbers would be

most keenly felt.

The United States is expected to grow from

226 million in 1980 to about 260 million in 2000,

and to about 290 million in 2050, while at the

same time dropping from 4.9 to 4.0 to 3.5 percent of the world’s population. The impact of

global population growth on the United States

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 inaccurate 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 projected 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, projections 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 sixon 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 individuals in this population are reproducing at a constant

rate, the rate at which the population increases depends on the number of people at the beginning. A

population with 10 females at the beginning increases faster than a population with two females at

the beginning even though each is reproducing at

the same rate. This kind of population increase,

known as exponential growth, is also referred to as

geometric or logarithmic growth. If exponential

growth were to continue unchecked, the world

would soon contain more living organisms than

atoms in the universe. The factors that keep this

growth in check are the number of deaths in a population (growth rates slow if death rates rise), the time

between generations (age at marriage in human populations), and the number of offspring each couple

has (fertility). (Migration is a factor only for individual countries.)

Chapter 2 References

1. Chen, P., contractor’s report to OTA, 1980.

2. Frejka, T., “~$~orld Population Projections: A Concise History, ” Population Council Center for

Policy Studies, Working Paper No. 66, Ne\v York,

1981.

~. Futures (h’OUp, “The Impacts of Population

(;rowth on Less Developed Countries,” (ITA

working paper, 1980.

4. Independent Commission on International Development Issues (Winy Brandt, Chairman), NorfhSouth: A Program for Sur\~iva/ (Cambridge, Mass.:

NI. I.T. Press, 1980).

5. I.ittman, (;., and Key fitz, N., The Next 100 Years,

(Mter for Population Studies Working Paper NO.

101 (Cambridge, itlass.: Har\’ard LJni\’ersity,

1980).

6. Tsui, A. ()., and Bogue, D. J., Population Projections .fbr the World, 1975-2000: Summary Report

of the 1978 Assessment, New York, 1979.

7. United Nations, World Population Trends and

Prospects by Country, 1950-2000: Summary Report cf the 1978 Assessment, Ne\v York, 1979.

8. U.S. Commission on Population Growth and the

American Future, “Population Growth and the

Anlerican Future” M’ashington, D. C.: Government Printing Office, 1972).

9. IJ.S. Council on Environmental Quality and Department of State (G. O. Barney, Study Director),

The Global 2000 Report to the President

(Washington, D. C.: Government Printing office,

1980).

lo. tJ. S. Department of Commerce, Bureau of the

Census, illustrative Projections of world Population in the 21st Centurey, Current Population

Report, Special Study Series P-23, No. 79

(Washington, DC.: Goiernrnent Printing Office,

1979).

11. , 1980. Re\~ised table to above.

12. World Bank Development Economics Department, prepared by K, C. Zachariah and Aly Thi

V Ll , Popu lat ion Pro ject ions, 1975-

2000 and Lon~ Term (Stationary Population)

(Jt’ashington, D. C.: ~ToI.]C~ Bank, 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 consumption 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 governments 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 production 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 potential 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 disputes over water rights are likely to intensify. International energy demands indicate a difficult future for LDCs; high oil prices, dwindling fuelwood supplies, and use of needed fertilizers (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 by 18 to 20 percent 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 capability 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 political 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 governments 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 population 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 generated a new category of national security concerns, the implications of which remain

largely unexplored.

43
LDCS are experiencing selrere entironrnenta]

and resource pressures. hlDCs contribute Substantially to these pressures because their far

fe~ter numbers consume the greatest proportion of’ the ~i’orld’s resources. Effective efforts to

curb consumption lelre]s in NIDCS combined

\\’ith agricultural and other det’elopmental aici

to LDCS ~vould ease some of the most serious

stresses faced by the det’eloping }vorlci. *

In man~~ LDCS, farmers suilsist ily clearing

forestland that has marginal productit~it~~,

quickly \%’earing out the soil, and mo~ring on to

clear more forest. The traditional use of wood

and charcoal for cooking cuts further into the

tree co~~er, and forested areas rapidly disappear. The Philippines lose an estimated 200,000

hectares of forest each ~ear and Thailand’s forests are i’anishing at the rate of 2s0,000 hectares annually. Droughts hai’e become mor[? frequent and sei’ere; floods are unmoderated by

forest buffers; erosion is extensile; irrigation

and hydroelectric sJ~stems are silting in. India,

Brazil, Indonesia, Costa Rica, Burundi, the I\JOI’}r

coast, Burma, Haiti, HOndUI’aS, and Nepal are

among the nations facing similar problems. }’et

these countries must achim’e huge increases in

agI’ iCLl h L1l’al ~l’Od LICt iOI~ i II the )’~~a I’s ahead to

keep pace \~’ith their rapid popLllation gro\~th.

AlthoLlgh its most direct effect is se(?n in the

pressures exertecl on agricultLlral systems, rapid

pOpLlhitiOIl gro~~th eXaCtS a hea\r} toll on OtheI’

important resources. It also points to complex

interrelationships bet~~’een the demands on

food, ~$rater, and fuel resources and their resulting impacts on the en\rironment, on the social

and economic p regress of delwloping nations,

and on the political stabil itf’ of the ~$rorld at

kWge.

Food

hlost experts estimate that \troI’ld food resources \\’ill be aclecluate to 2000, t)ut man y

countries ~~’ill ha\’e setrere production ancl

+ 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)ii1’(>(1 !01” ( ) [ \ t)\ ‘1 111> t’ 111111’[’ S

(;r(wp (!)}, I\ h(h(I t(lllreport is pul)listled as a lt [Jrhing })apt’1’

distribution problems. NIDCS presentl:r ha\re

sLlfficient SLlt-plUS production to be able to export to 1,DCS, but clistribution s~stenls in these

countries are inadequate to ensure the receipt

of food t]}’ those in greatest need. In the future,

some of the ~~wilthier I.D[;s \\’ill be able to inlport food, but nlan~r poor LDCS t~rill hale insufficient financial resources and are Iikel}’ to experience continued food c~eficits.

Food prociuction to 2000 is projected to increase bv 2.8 percent per ~’ea r in Africa, 3.0 per- .

cent per year in Latin America, and 2.6 percent

per year in Asia (6). 11’hether LD(;s can t]~~ thf311

be relatitwl~f self-sufficient ~iill depend to a

great extent on the IIKi#litLldC of their pO]3Ll]ation gro~$rth. In ,~frica, domestic food production can currently meet 86 percent of calorie re-

(~ LliI’enleIlt S. Depending on \\ fhether the high or

loLIr population projection becomes realit}r b)r

~0()(), this proportion f?ith[?r decreases to 80 pCl’-

cent or increases to 92 percent. In I,at in America, domestic production, CllI’I’(?llt]J’ Lit 84 percent of food liec~Llir’(?IlleIltsl ~1’ould increase in

either the high or ]mtr Population projections,

bLlt the difference \l’OLlld be b[?tll’e(?ll Ill[X?tillg

87 or 101 percent of food I’[;[ltlil’(trllf?rlts. In Asia,

the increase L\rOLlld be from 9.5 percent todi~~’ to

either 110 or 120 percent b~’ 2000.

E\ Fen ~%hen total production approaches 100

percent of food I“(?[]llil’etllellts, caloric intake is

often insufficient among large s(?gments of the

~O~LdatiOIl t)eCaLIS(? Of k)sses iIl StoI’:ig(? :111(] t l’allsit and the proportion of thos(? Lt’hose intake is

at)o\’e a\’erage. ~]thOLlgh food production Illti)’

rise suffic ientl~’ to meet minimum calori~? rccluirements in sonx? poor” IJD(~s, Smrerc ])robIems of distribution are likel~~ to continue.

Nlost L[](k are in one of fOur situations:

1. Countries \\rith se\’er[?l\~ limited resources

(land and technology) t;) increase food” prodLICt ion, most of Lf’h ich face heavy ])op Llk ItiOIl pI’eSSLII’eS :iIld ha\’e Iitt](? UIILIS(X] ;I1’at)l[?

kind (e.g., Bangladesh, Pakistan, ~;gjrpt).

Countries that ha\’e potential l)ut are sIOLI”

to exploit it. ‘rh(;~’ ha\’C ]aIKi a\’aiklbk? [01”

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 increasing 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 increase production will fall on marginal lands,

with consequent need for far-higher use of irrigation, 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 million metric tons by 2000, through the exploitation of new species and the emergence of a

large marine-culture industry, the world’s population will increase at a slightly higher rate.

Water

An adequate supply of water is the most important factor in raising agricultural production

in large areas of the world, Global water supplies 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 percent 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 densities are low (the Nile River valley is an exception), but water is very scarce because people

are crowded close to the few available water

Photo credit Agency for International Development

Haitian farmers plant tree seedlings in efforts to

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

The global energy situation signifies a difficult

future for much of the developing world. While

many of the industrialized countries have raised

the prices of their exported goods, thereby buffering the impact of higher costs for oil imports,

most LDCs have not been able to effectively do

so. They have suffered a double hardship by

paying higher prices for both oil and other imports.

Consumption of commercial energy (oil, gas,

coal, etc.) is more closely tied to economic

growth and level of development than to population growth. But the demand for “noncommercial” fuels is directly related to population

growth.

Wood is the most widely used noncommercial

fuel and supplies the majority of all energy used

in many LDCs. Worldwide, wood burned for

fuel provides energy equal to that derived from

all hydroelectric sources. LDCs consumed about

90 percent of all fuelwood used in 1974, which

provided between 30 and 60 percent of their

total energy (l).

Wood can be a renewable resource, but encroachment on forests for farming and fuel has

resulted in widespread shortages. Charcoal is

frequently adopted as a fuel when deforestation

extends beyond distances from which fuelwood

can be economically transported, because charcoal contains about four times the energy per

unit weight as wood. But because much of the

energy value of wood is lost in the process of

charcoal manufacture, intensified charcoal use

will accelerate the problem of deforestation.

Rising commercial fuel costs and diminishing

supplies of fuelwood are forcing many people in

LDCs either to greatly reduce fuel consumption

or to find alternative fuel sources. Among these

are dried dung and crop residues. Because of

fuel shortages, increasing numbers of people

have only these materials to burn. Yet they are

needed to maintain soil productivity, as subsistence farmers can rarely afford commercial fertilizers, and when they are burned, energy is

gained at the expense of land productivity.

Burning of dung and crop residues is already

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 difference 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 standards 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.

Commercial energy requirements have historically been closely linked with growth in GNP. A

l-percent increase in GNP is associated with a

0.95-percent increase in commercial energy requirements. The tremendous oil price increases

that most oil-importing LDCs have had to pay

have meant large balance-of-payment deficits

and increased debts to finance decreasing,

rather than increasing, rates of economic

growth. The World Bank has estimated that

GNP growth rates collectively fell by more than

60 percent in LDCs between 1973 and 1975,

from an annual growth rate of 7.6 to 3 percent.

Higher rates of population growth require more

commercial energy, necessitating more rapid

growth in GNP-growth that cannot always be

assured and that appears unlikely to occur in

some countries.

Environmental effects

Forests now cover about one-fifth of the

world’s land surface but are being depleted at a

rate of 18 million to 20 million hectares per

year, a reduction rate of about eight-tenths of 1

percent per year. If this rate were to persist to

2000,” forests would be reduced by 18 to 20 percent, or to one-sixth of the world’s land surface.

very little forested area remains in such heavily

populated countries as India and Pakistan.

Deforestation has razed about 10 percent of

Brazil’s forests, 30 percent of those in HonPhoto credit; Agency for /nternat/ona/ Developrnenf

Makeshift housing characterizes the outlying areas

of most cities in LDCs

duras, and over 90 percent of those in Haiti. The

removal of the forest canopy results in largescale soil erosion, decreased soil fertility, landslides, silting-in of reservoirs and irrigation

channels, drought, desertification, and the extinction of forest plant and animal species.

Direct human intervention has caused the

transformation of some 9 million square kilometers (kmz

) of savanna to desert; 600).00 km2

of forest to fields, grassland, or salvanna; and 1

million kmz of fields or forests to paved areas

and urban buildings-a total alteration of some

15 to 17 percent of the Earth’s land area (8).

Much of the best agricultural land lies near urban centers and is being used for urban and industrial development. These alterations are important because only 30 to 36 percent of the

Earth’s total land area is fit for agricultural activities or has significant life support capabilities

with present technologies.

The U.S. Department of Agriculture estimates

that the rapidly rising growth of cities in the

developing world is cutting arable land in LDCs

by 0.03 hectare per capita per year (1 hectare

equals 2.47 acres). If the most likely population

projection becomes reality, this rate ivoulcd lead

to a loss of 49 million hectares of arable land
48 ● Wor/d population and Ferti/ity p/arming Technologies: The Next 20 years

from food production by 2000, an amount presently calculated to feed some 165 million people.

If the low projection is achieved, the quantity of

land lost would fall to 41 million hectares, but if

population totals rise to the high projection, this

loss would reach 56 million hectares by 2000) an

amount that could have fed 188 million people.

The impact of converting arable land is graphically illustrated by the case of Egypt, where the

current total of 25)000 hectares of cultivable

land lost each year is expected to rise as the

pace of urbanization quickens. Despite large investments to expand the country’s irrigated land

area with water from the Aswan Dam, irrigated

land totals remain essentially unchanged because old producing lands are lost at about the

same rate that new hectares are irrigated. If

its present population growth rate continues,

Egypt’s goal of food self-sufficiency will be difficult to achieve.

The increased pollution that accompanies

rapid urbanization has overwhelmed the ability

of many LDC governments to provide sanitation

and other public services. In 1976, fewer than

one-third of LDC city dwellers lived in housing

connected to sewer systems and less than 4 percent of this housing was connected to some

form of sewage treatment facility. Air pollution

problems have become critical in the urban centers of such cities as Mexico City, Sao Paulo, and

Bombay.

The leading cause of the transformation of

productive land into deserts is overgrazing.

Overgrazing and overcropping, combined with

drought, are rapidly expanding deserts in the

Sudan and Sahelian regions of Africa.

Irrigation often causes long-term problems of

loss of soil productivity through waterlogging,

salinization, and alkalinization. These problems

occur when irrigation systems provide poor

drainage or where there is improper use of fertilizer. Evaporation of water from soil surfaces

leaves residues of salt that form a mineral crust

on the surface that can kill plants or inhibit

their growth.

Anthropogenic land-use changes are said to

have played a role in depressing the global temperature by about 0.20 C over the past 25 years,

and this temperature could fall by another full

degree by the end of the century (8). Other

studies suggest that the release of chemicals,

particulate) and carbon dioxide into the

air—the most serious human-induced threat to

climatic stability—could instead result in a

gradual warming trend (7). Still others project

little or no effect on global temperatures. There

is no doubt that humans have caused significant

changes in the environment, but whether these

changes extend beyond the microclimates of

specific regions is still being debated.

Economic and social impacts

The numerous pregnancies, closely spaced

pregnancies, and additional pregnancies at comparatively late ages that are associated with

rapid population growth are also associated

with higher rates of illness and death for both

mothers and infants.

An important health side effect of high fertility is nutritional deficiency. Each additional

child in a poor family may be believed by the

family to provide greater social security for the

parents’ old age, but available food must also be

divided among a larger number of people. Malnourished children are more vulnerable to disease and their physical and mental growth may

be retarded.

When women are malnourished during pregnancy, they are likely to develop maternal depletion syndrome, * and while infants derive important benefits from breastfeeding, the practice further compromises the nutritional status

of malnourished mothers. There is a high incidence of infant mortality and low birth

weights in almost every part of the world where

* Klaternal depletion syndrome is characterize~i b}r smwral disease states including anemia, osteonudacia, and iodine-deficiency

goiter. It is caused hy multiple repregnancies occurring while the

woman is suffering protein/calorie ciepri~~ation, Its effects are

cumulatit’e and contribute to lo\4’ birth \i’eight infants, failure to

gain sufficient l~x?ight during pregtMncy, and a drrreaw in subcutaneous fat and muscle tissue. The process undouhtedl!’ plays a

part in the premature aging and early death often seen among

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 active years during the next 15 years. But the International 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. Reductions in fertility and mortality for the African

countries will be particularly significant because of the difference between the high and

low projections of population growth (table 8).

In Kenya, for example, annual new job requirements 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 exceeds the rate of population growth. But rapid

population growth requires high rates of investment 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. . . . . . . . . . .

Kenya . . . . . . . . . . . .

Nigeria. . . . . . . . . . . .

Tanzania . . . . . . . . . .

Zaire. . . . . . . . . . . . . .

Asia:

Bangladesh. . . . . . . .

India. . . . . . . . . . . . . .

Indonesia . . . . . . . . .

Malaysia . . . . . . . . . .

Pakistan . . . . . . . . . .

Philippines . . . . . . . .

Sri Lanka . . . . . . . . . .

Latin America:

Argentina . . . . . . . . .

Brazil . . . . . . . . . . . . .

Colombia. . . . . . . . . .

Mexico, . . . . . . . . . . .

Venezuela . . . . . . . . .

North Africa and

Middle East:

Egypt ., . . . . . . . . . . .

Iran. . . . . . . . . . . . . . .

Morocco . . . . . . . . . .

1.8

2.8

2.0

2.3

1.9

2.3

1.7

2.0

3.6

2.4

2.1

2.1

1.2

2.8

3.5

3.3

3.3

2.2

2.5

2.7

1.9

2.7

2.8

2.5

2.1

2.2

1.3

1.3

1.1

2.2

1.6

0.7

0.5

1.6

1.2

2.5

1.7

1.6

2.0

2.3

2.7

3.4

3.4

3.2

2.4

2.6

1.6

1.7

1.3

2.6

1.9

0.8

0.7

2.3

1.9

2.9

2.1

1.8

2.3

2.6

3.1

3.9

3.7

3.5

2.9

3.0

1.9

2.0

1.6

2.9

2.3

1.1

0.9

2.9

2.4

3.2

2.6

2.2

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

1970’s illustrates this point. World population

growth, at an average annual rate of 1.9 percent, was greater during these two decades

than at any other period of human history, and

the economic growth rate of more than 5 percent per year was also unparalleled in human

history. World income per capita grew rapidly,

averaging about 3.2 percent per year.

Although economic performance in terms of

aggregate growth of output was about the same

for LDCs and MDCs, a substantial difference in

demographic growth gave MDCs a marked advantage in per capita income. The LDC population grew by 1.2 billion people during this

period, at an annual rate of more than 2 percent, while MDC numbers rose by fewer than

200 million, at a rate of less than 1 percent. MDC

per capita income growth exceeded 4 percent

annually, but LDC growth remained below an

annual rate of 3 percent. The absolute income

gap between LDCs and MDCs widened

significantly between 1960 and 1978, but the

relative gap—as measured by per capita income—widened to a far greater degree (4).

Thus, population growth, even when rapid by

historical standards, does not necessarily prevent significant and even very high rates of per

capita income gain. But to overcome the economic burden of rapid population growth requires rates of economic advance that exceed

the rate of natural population increase by a substantial margin. Given the demands for services,

employment, etc., by constantly rising numbers

of people in the next two decades, declines in

rates of economic growth are likely. Thus, population growth aggravates the economic problem of many countries that have had to borrow

from outside sources, and their increasing debts

are now becoming a hindrance to development.

The combined benefits of slowing population

growth–on health, education, and the economy—are all interrelated. A smaller child population makes it easier to provide quality education and health care to young children. It also

reduces dependency ratios, which can lead to

increased savings. A healthier, better educated

work force is more productive. Increased savings can lead to more investment, more capital

per worker, and, again, higher worker productivity. The resulting higher output and income

can, in turn, make it possible to provide still better health care and education to the young population.

Political consequences

The impact of population growth on political

stability depends on its interaction with the

social, economic, and political structure of the

society involved. The ability of any government

to meet the needs and demands of its people is

clearly a critical element in that government’s

medium- and long-term survival. There is general agreement that political stability is jeopardized when the expectations of individuals and

groups are not fulfilled. Resultant frustrations

can then lead to political and social unrest as increasing numbers of people place ever greater

demands on the limited capacity of national governments and economies to provide desired

goods and services.

Although demographic factors such as rapid

population growth do not act alone or directly

cause conflicts, conflicts that have been viewed

as primarily due to political causes can have

demographic roots (2). Religious, social, and

racial differences are important contributors to

violence and conflict, and differential rates of

population growth among separate ethnic, linguistic, or religious groups can generate serious

political strains.

Rapid population growth in rural areas can

jeopardize political stability in several ways. As

rural population densities rise, existing agricultural acreage must either be divided into ever

smaller parcels or an increasing proportion of

the rural populace must be left landless. Either

result can lead to political unrest as living standards decline and frustrations grow. Rural population growth also stimulates migration from

rural to urban areas, as people search for the

better economic and educational opportunities

that urban centers are more likely to provide.

Explosive urbanization in turn strains service
Ch. 3—/replications of World Population Growth ● 5 1

----
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 atime 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

Bolivia

Brazil

Central America

Egypt

India

Indonesia

Kenya

South Korea

Mexico

Morocco

Nigeria

Pakistan

Philippines

Somalia

Thailand

Turkey

Venezuela

Zimbabwe

Collapse or political realignment

would have destabilizing effect

on Indian subcontinent . . . . . . . . .

Source of tin, antimony, tungsten . .

Source of manganese ore,

columbium and iron ore; size;

leadership role in Latin

America . . . . . . . . . . . . . . . . . . . . .

Panama Canal; excessive

emigration to U. S.; proximity . . . .

Key to U.S. strategies for peace

in Middle East . . . . . . . . . . . . . . . .

World’s second largest country;

key to stability Indian Ocean

region and U.S.-Soviet balance . .

Major source of U.S. oil imports;

fifth largest country in world;

strategic location as U.S. ally

in Southeast Asia . . . . . . . . . . . . .

Leader of pro-Western African

states; U.S. military access

agreement . . . . . . . . . . . . . . . . . . .

U.S. military ally; potential

staging area; possible North

Korean threat . . . . . . . . . . . . . . . . .

Size; proximity; major source of

strontium, cadmium, and major

potential source of oil and gas;

large labor migration to theU.S. . . . . . . . . . . . . . . . . . . . . . .

Major source of potassium; U.S.

friend in North African

conflicts . . . . . . . . . . . . . . . . . .

Second largest source of U.S. oil

imports; one-fourth of total

African population. . . . . . . . . .

Principal bulwark against

Russian move into Gulf of

Oman and Indian Ocean . . . . .

Source of chromite and copra;

military ally with key U.S.

bases; strategically important

Strategic location; U.S. friend in

conflicts over Horn of Africa .

Source of tin, tungsten and

tantalum; military ally; strategic importance in Southeast

Asia. . . . . . . . . . . . . . . . . . . . . .

Eastern anchor of NATO; strategic window on the U.S.S.R. , . .

Source of oil and vanadium . . . .

Major source of chrome; key to

political stability in Southern

Africa . . . . . . . . . . . . . . . . . . . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

91.4

5.7

130.0

95.9

43.1

709.8

155.4

17.0

38.6

72.4

21.0

79.7

85.1

52.5

3.8

49.0

46.5

15.4

7.7

2.60/.

2.5

2.4

2.7

3.0

2.1

2.0

3.9

1.7

2.5

3.0

3.2

2.8

2.4

2.8

2.0

2.2

3.0

3.4

27

28

29

26

23

33

35

18

41

28

23

22

25

29

25

35

32

23

21

440/0

42

41

46

40

41

42

50

38

46

46

47

46

43

44

43

40

43

47

6.70/, 10

4.3

4.0

4.1

3.4

3.8

4.2

7.1

4.1

4.4

4.8

5.6

4.7

4.1

5.4

4.2

4.3

3.9

6.3

16

17

17

20

18

17

10

17

16

14

12

15

17

13

17

16

18

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,

[Jses and Resources in Dmreloping Countries,” prepared for the (1.S. Agency for International Deirelopment under PASA NO. F. RDA/TAB-995-18-76

m’ith the LI. S. Department of Energy, Nlarch 1978.

2. Choucri, N,, Population D-vnamics and Inlerna?iona/

i’iolence; Proposition, !nsights and Evidence (Lexington Itlass.: Lexington Books, 1974).

~. Council on Em’ironmental Quality and the Department of State, The (Johal 2000 Report to the President: Entering the ~vent}r-First Century, The Technical Report, \rol. 2 (i$’ashington, D. C.: U.S. Go\rernment Printing Office, 1980).

4. Demeny, P., “The North-South Income Gap: A

Demographic Perspecti\re, ” Population and Dew/-

oprnent Revietfrl \rol. 7, No. 2, June 1981, p p .

297-310.

5. Draper Fund, “World Population Growth and U.S.

6

7

8

9

Security Interests” (Washington, D. C.: Draper

Fund, 1981).

Food and Agricultural Organization, Agriculture:

Toward 2000 (Rome: FAO, 1979).

National Academy of Sciences, Understandin g C/imatic Change: A Program for Action, U.S. Committee for the Global Atmospheric Research Program,

National Research Council (M’ashington, D. C.:

NAS, 1975).

Sagan, C., Toon, O. B., and Pollack, J. B., “Anthropogenic Albedo Changes and the Earth’s Climate,”

Science 206(4425): 1363-1367, 1979.

The Futures Group, The Impacts qf Population

Growth on Less Developed Countries, report prepared for the Office of Technology Assessment,

Washington, D. C., 1980.
Chapter 4

The Direct Determinants of

Fertility Change
Contents

\ Page

i

. . . .— “ . . -. . .-

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 advocates 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 family 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 influences of the remaining direct factors—frequency of intercourse, natural sterility,

spontaneous abortion and fetal mortality, and duration of the fertile period during a woman’s menstrual cycle—are likely to change only slightly. Because lactation 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 important 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 replacement 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

start of thei I’ reprodLlctive vea I’s (menarc he )

.

and to CO Iltill Lle \trithoLlt inter rLlpt ion until they

t$’(?l’[? no longer t’tK;LHId (IllwIop:ILN?), then, in

the ahsence of limiting faders sLI(:h as iariat ions

in fI’c:(~LIt?IIC:\T ot intercx)LIIw?, nat LII’ttl sterility’,

fetal 11101 ’td~tJ’, and k(:tation, they wLIl(i @[?lltial]~ hak’e 30 to 40 children Olrer their reprodLlcti\’t? li\’es. BLlt no knoW’11 p(lpLll:l tioll—t?\’e Il

those that ha\Te maintained high f’ertilit~f

~o~~ls-h~~s ~3\rf;I. I’f31Chd this ;i~wage. ‘rht; highest fertilitt’ rate (total marital f(?rtilitk’ ratt?) el’(?r

. .

confirmed \tras for the North American rt?ligious

sect kno~t’n as the I+ Lltt(?I’i t(?s—ll(?ii I’l\’ 1:1 (tat)le

lo). hlor(? I’WX?lltlJ’, (; Ll;ItCIll;lkI (lfl;()-~~) and

S~I’ia ( 1 $)Y3) ha\’L? recorded marital fcrt ilit~ rates

of nearly 10 (tat)lc 1 1).

As ~1’OLl~S desiring hII’fje IILIIllt)[?I’S of offspring

ha\w Ix?(;I1 able to achimw f’w~rer than half of the

possit)k? total p[?r ~tronmn, nat L]ral limiting i’a(;-

tors are clearl~T at Jvork. FIqLlenql of inter-

(: OLII”Se, IlatUI’1~1 StWi]itJ’, IMtLII’ti] f(?tii] INOI’tL~]it ~’,

anci duration of the fertile period redLI(x; fertili -
Ch. 4—The Direct Determinants of Ferti/ity Change ● 5 9

ty from the potential level of 30 to about 15. To

reduce fertility rates further to those actually

observed in most populations, the most important limiting direct factors are: 1) lactation, 2)

proportion married and age at marriage, 3) induced abortion, and 4) contraception (3).

Table 10.–Total Fertility Rate and Total Marital

Fertility Rate for Selected Populations’

Total

Total marital

fertility fertility

Historical populations rate rate

11.9

9.9

10.7

13.0

12.1

10.6

12.7

10.2

9.9

9.4

Table il.—Total Fertility Rate and Total Marital

Fertility Rate for Selected Countries*

Total

fertility

Year rate

LDCs

Bangladesh . . . . . . . . . . . .

Colombia . . . . . . . . . . . . . .

Guatemala (rural) . . . . . . .

Indonesia . . . . . . . . . . . . . .

Jordan . . . . . . . . . . . . . . . .

South Korea . . . . . . . . . . .

Panama . . . . . . . . . . . . . . .

Peru . . . . . . . . . . . . . . . . . .

South Lebanon . . . . . . . . .

Sri Lanka ., . . . . . . . . . . . .

Syria . . . . . . . . . . . . . . . . . .

Turkey. . . . . . . . . . . . . . . . .

MDCs

Denmark . . . . . . . . . . . . . . . 1970

Finland, . . . . . . . . . . . . . . . 1971

France . . . . . . . . . . . . . . . . 1972

Hungary. . . . . . . . . . . . . . . 1966

Poland . . . . . . . . . . . . . . . . 1972

United Kingdom . . . . . . . . 1967

United States . . . . . . . . . . . 1967

Yugoslavia . . . . . . . . . . . . . 1970

1.8

1.6

2.2

1.8

2.1

2.4

2.3

2.1

Total

marital

fertility

rate

7.4

7.5

9.7

6.6

8.6

7.1

6.8

8.9

8.9

6.9

9.6

7.2

3.2

3.1

4.3

2.9

4.8

3.9

3.7

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 begin

menstruating again 4 to 7 months after childbirth, 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 become 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 breastfeeding are declining. In Bangladesh, Nepal,

Pakistan, Indonesia, and Kenya, more than 95

percent of women breast-feed. In other countries, most mothers still breastfeed, but percentages 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 breastfeed, 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 between 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

by lengthy periods of postpartum abstinence in

some LDCs, especially in Africa. This norm was

virtually universal in sub-Saharan Africa during

the 19th century, when in 55 percent of the 131

societies for which records are available the

custom of abstinence was observed for longer

than 13 months (14). As traditional cultural supports for these norms are breaking down, the

overall contraceptive effect of breastfeeding

and breastfeeding accompanied by abstinence is

decreasing.

Where fertility rates are high, breastfeeding

acts to prevent maximum fertility, For example,

in the Philippines in 1973, it was estimated that

the additional 5.5 months protection afforded to

women who breastfed provided approximately

590,000 “couple years” of protection from

pregnancy, nearly equaling the 600,000 couple

years of protection provided to the then 2 million participants in the family planning program

(4).

Age at marriage and

proportion married

Because most births take place within some

form of relatively stable union in most LDCS)

age at marriage and proportion married have a

significant impact on fertility. In the absence of

premarital sexual activity, a woman who marries at a later age is exposed to the possibility of

pregnancy for fewer years.

Later age at marriage can also have an impact

on population growth even when the number of

children is the same for later marrying women

as for those who marry at younger ages. InPhoto Credit: Agency for International Development

Many women in LDCs become mothers while in their teens

creasing age at marriage shifts births from one

age group and time period to a later one, temporarily lowering the birth rate. Although this increase in age at marriage cannot be repeated

once it has taken place, its effects continue. For

example, when other factors are equal, a family

in which all women marry at age 15 and produce daughters every 5 years until age 40 will

have more than five times as many living members after a period of 60 years than a family in

which all women marry at age 25 and also produce daughters every 5 years until age 40 (see

Technical Note C). This substantial difference

occurs because women married at age 15 would

average five children apiece in 60 years,

whereas women married at age 25 would average only three children apiece in the same

period.

In many countries, both rising age at marriage

and contraceptive use have contributed to fertility decline. Table 12 lists 26 of the 80 LDCs of

more than 1 million population where data are

available on fertility and marriage trends. Of

the 80 countries, only these 26 have also experienced appreciable fertility declines. The 13

indicated by the letter “a” already record high

ages at marriage (in Taiwan and Korea, fewer

than 10 percent marry before age 20). In seven

of these countries (marked a and b), fertility

among women 15 to 19 or 20 to 24 has dropped

significantly, confirming the impact of higher

age at marriage on fertility. In the other countries, substantial declines in fertility have occurred even though age at marriage has not
Ch. 4—The Direct Determinants of fertility Change • 61

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

fallen appreciably in Brazil, the Dominica n

Republic, El Salvador, Panama, Peru, Trinidad

and Tobago, and Venezuela (7). But as patterns

of marriage in these countries make age at first

marriage difficult to define, how much of the

decline in fertility is due to rising age at marriage and how much to increased contraceptive

use is unclear.

Age at marriage is influenced by the sociocultural context in which marriage takes place. In

China, Sri Lanka, and Tunisia, age at marriage

has risen and fertility has declined, but for very

different reasons.

CHINA

In the People’s Republic of China (PRC), where

the government has embarked on a major campaign to slow population growth, young people

are now expected to defer marriage well beyond the minimum legal ages of 18 for women

and 20 for men. In the cities, the norms for age

at marriage are 24 for women and 26 for men;

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 marriage of 5 to 7 years since 1950 (table 13).

Later age at marriage is helping to reduce fertility in the PRC, but age composition and population momentum play significant roles in the

country’s continuing population growth. Despite China’s lowered birth rate and a contraceptive 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 population goals difficult to achieve. As this strong

momentum for future growth is inherent in

China’s age composition, the government is taking steps to curb third (and higher) births by

1985 and is moving toward a one-child family

norm (table 14).

SRI LANKA

In Sri Lanka, 63 percent of the decline in birth

rates between 1963 and 1971 is attributable to

changing patterns of marriage in the absence of

a government policy designed to encourage

such change. Age at marriage has risen as a

result of:

● Continuing adherence to cultural practices.

prospective mates are expected to be of the

same caste and ethnic group; elaborate procedures are undertaken to assure that the

Table 13.—Mean Age at Marriage for Women in

Shanghai 1950 to 1979

Period of City Suburban

marriage proper county

1950 -54..... 19.9 19.8

1955-59 . . . . . 24.9 20.6

1960-64 . . . . . 26.3 23.9

1965-69 . . . . . 26.6 24.1

1970-74 . . . . . 26.8 24.6

1975 -79..... 27.9 25.0

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

must be a virgin; the groom must be older,

and his potential job security and the dowry

provided by the young woman and her

family must be acceptable.

Increasing economic and job opportunities

for women. In 1971, 71 percent of Sri

Lankan women were literate, and 26 percent were in the labor force.

A stagnating economic climate. Employment is difficult to obtain, agricultural land

shortages have intensified, and males have

migrated, leading to

“Marriage squeeze,” a sex ratio imbalance

among those in traditional marriageable

ages. In 1974 there were 75 males aged 25

to 34 for every 100 females aged 20 to 30

(l).

TUNISIA

In Tunisia, both government intervention and

unanticipated economic changes have contributed to rising age at marriage. Age at marriage

has risen as a result of:

● Marriage squeeze. In 1975, there were 77

males ages 20 to 24 for every 100 females

ages 15 to 19, and 58 males ages 25 to 29 for

●

●

●

every 100 females ages 20 to 24. Tunisian

men are migrating to Europe and to other

Arab countries to seek employment.

A minimum age at marriage law passed in

1964 set the minimum age at marriage at 17

for women and 20 for men. An antipolygamy law passed in 1956 also guaranteed a

voice in marriage decisions and other legal

rights to Tunisian women.

Committed leadership. President Bourguiba

has made a strong commitment to the

emancipation of women.

Increased educational and job opportunities

for women. By 1971, female literacy had

reached 40 percent, and 7 percent of Tunisian women had entered the labor force (l).

When contraceptive use becomes extensive,

age at marriage will lose importance as a causal

mechanism in fertility change. Nevertheless, age

at marriage will continue to be an important

factor for the next 20 years, because of the

number of people entering the marriageable

ages in LDC populations:

During the 1980’s and 1990’s, there will be

more young adults in their peak reproductive

and marriageable years (age 15 to 29) than ever

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

15 years of age. By 1990, there will he 40 percent more potential parents age 15 to 29 than

there were in 1975, and more than twice as

many as in 1960—in other words, a total of

more than 1 billion potential husbands and

wives, fathers and mothers. If this new generation marries young and then begins to reproduce at an earl.v age, it will he difficult for many

countries to reduce population growth to desired levels even if marital fertility is sharply reduced (7).

Induced abortion

Biological events such as life and death are

culturally defined. For example, in some cultures, a child is not considered “born” until its

naming ceremony, which can take place as long

as a month after the child’s birth. Where neonatal mortality rates are high, various “neglect”

behaviors are rationalized. In the view of those

societies, if the child hasn’t been “born” yet,

then it didn’t ‘(die. ” Although cultural and ethical issues are inexorably entwined in any discussion of induced abortion, it is a direct means of

fertility regulation, and certain facts pertaining

to abortion can be analyzed separately from

ethical issues,

An estimated 55 million abortions are performed throughout the world each year, or

about 70 abortion procedures for every 1,000

women of reproductive age. More than half of

these occur in LDCs (10,16).

In 1980, 9 percent of the world’s population

lived in countries where induced abortion was

illegal. An additional 19 percent lived in countries where the procedure was officially permitted only to save a woman’s life, Some 10 percent lived in countries authorizing abortion on

broader medical grounds, and an additional 24

percent lived where social factors were also

considered. The largest group—38 percent—

lived in countries where induced abortion during the first trimester of pregnancy was legal

and available at the request of the pregnant

woman (16).

Changes in abortion laws over the past 15

years have taken place for four reasons: 1) public health, to combat the maternal mortality and

morbidity associated with illegal abortion; 2)

social justice, to give poor women the access to

induced abortion previously available only to

wealthier women; 3) women’s rights, to provide

women greater control over their reproductive

lives; and 4) in a few countries (China, Singapore) government population policies, to encourage women to utilize the procedure in the

event of contraceptive failure.

In the United States, the 1978 abortion rate as

reported by the Center for Disease Control was

23 per 1,000 women of reproductive age. New

estimates of induced abortion in China place

that country’s rate at 25 in 1978. Eastern bloc

countries have very high rates. In the U. S. S. R.,

there were 180 abortions per 1,000 women of

reproductive age in 1970, the latest year for

which data are available, There were 88 abortions per 1,000 women of reproductive age in

Romania and 68 per 1,000 for the same group in

Bulgaria (1979). The latest data from Japan

(1975) show an equivalent rate of 84 per 1,000

(16).

In countries where induced abortion is illegal,

maternal mortality from complications of improperly performed procedures can be as high

as 1 in 100 procedures (16). When abortion is

performed during the first trimester under

medically supervised conditions, maternal mortality rates are very low. (In the United States in

1978, 11 times more women died as a result of

pregnancy and childbirth than as a result of

legal abortions). In the United States, where

changes in abortion laws to allow more legal

abortions began in 1967, maternal mortality

from abortion (spontaneous and induced) fell at

a rate of 18 percent per year from 1968 to 1978.

Maternal deaths attributed to illegal abortions

declined 34 percent per year during the same

period (16) (fig. 7).

Induced abortion occurs in all societies,

whether legislation permits it or not. The frequency of abortion procedures can often be reduced by making effective contraceptive methods readily available. The introduction of contraceptives can also reduce the maternal mortality that accompanies illegal abortions. This

was the justification for establishing official

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

Abortion, by Type of Abortion: United States, 1958-78

Illegal and Illegal Spontaneous Legal

spontaneous

SOURCE: C. Tietze, Induced Abortion: A World Review, 1981, Population Council, 4th ed.

taken in the early 1960’s, when these efforts

began, found that at least 25 percent of women

in Chile acknowledged having had an illegal

abortion. Between 1964 and 1978, the number

of women of reproductive age using contraceptives increased from 3 to 23 percent. During the

same period, the number of women admitted to

hospitals for complications from illegal abortions declined from more than 56,000 to 37,900.

Mortality among women undergoing illegal

abortion also decreased markedly, from 11.8

per 10,000 live births to 4.2 per 10,000 live

births (10).

Although induced abortion can be an effective

method of fertility regulation for an individual

because it prevents a live birth, it is not an “efficient” way for a society to reduce the total number 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 interval 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 because 7 months of pregnancy and 1 to 11

months of postpartum infertility are interrupted. The period between induced abortions

is about 9 months (1 month of postpartum infertility, 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 reproductive years (i.e., two abortions for each

full-term birth averted). The number of induced

abortions would be still higher were there no

changes in natural sterility with age, divorce,

widowhood, coital frequency, etc. (12,13,16).

Contraception

Contraceptive prevalence rates are reliable

predictors of crude birth rates despite the effects of the other factors that directly affect fertility” rates. In figure 9, the line relating the contraceptive prevalence rate and the crude birth

rate 1 year later indicates that every 2.4-percentage-point increase in contraceptive prevalence (X-axis) is associated with a l-point decline

in the birth rate (Y-axis) (11).

Knowledge of the relationship of various factors with the use of contraception is increasing
Ch. 4—The Direct Determinants of Fertility Change ● 65

Figure 8.— Birth Intervals and Induced Abortion

SOURCE: Office of Technology Assessment.

rapidly, as illustrated by the following examples

of the relationships between contraceptive use

and place of residence, age, and education.

Contraceptive prevalence rates tend to have

similar patterns in geographic regions. Contraceptive practice is relatively high in Southeast

Asia and in Latin America, low in Middle South

Asia, and lowest in Africa.

The proportion of couples using particular

contraceptive methods differs widely among

countries (table 15 and figs. 10, 11, and 12), The

causes of these differences include cultural factors, the strength and historical antecedents of

the program effort, the methods available in the

country, and the socioeconomic setting. Fiftyseven percent of women who use contraceptives in Indonesia (Java and Bali), a relatively

poor country, use oral contraceptives. Orals require fewer personnel with less medical support than other methods such as IUDs and sterilization. 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 countries except China; Colombia (16 percent) and

Korea (20 percent) have relatively high proportions of IUD users, while IUD use is now estimated 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 paramedical 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 contraceptive use rate in 1979 was attributable to

sterilization. In Thailand, a concentrated effort

to increase the availability of sterilization services markedly changed the country’s contraceptive use rate in just 2 years. A significant portion

of the increase in overall contraceptive use in

Colombia is also attributable to an increase in

male and female sterilization; sterilization accounted for 9.4 percent of all contraceptive use

in 1976 and 17 percent of all use by 1978.

Contraceptive use varies with age and with

the number of children a woman has. Except

for Bangladesh, Pakistan, Kenya, and Nepal, of

the countries shown in table 15, 40 percent or

more of women with four children are using

contraception. In many countries, contraceptive

use decreases when women have five or more

children. This may be due to the fact that older

women may resist the adoption of family planning or may believe they are no longer capable

of bearing children. older women who do use

contraception are more likely to use more efficient methods, especially sterilization where it

is available.

Rural-urban differences in contraceptive use

follow the same pattern in all countries; a higher percentage of urban women use contraception. 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 ● 6 7

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

MWRA

total Orals/

Source Year Age prevalence Barrier Sterilization IUD injection Othe r

Pakistan . . . . . . .

Philippines . . . . .

WFS

PC

WFS

WFS

WFS

CPS

1975

1972

1977

1975

1975

1978

15-49

15-44

15-44

15-49

15-49

15-49

— 1.0

0

5.4

10.2

7.9

16.5

2.5

1.3

20.2

15.8

3.6

4.1

3.5

Sri Lanka . . . . . .

Thailand . . . . . . .

2.2

Latin America

Colombia . . . . . . WFS

CPS

CDC

WFS

CPS

CPS

WFS

CDC

Government

WFS

1976

1978

1978

1976-77

1978

1979

1977-78

15-49

15-44

15-44

15-49

15-49

15-49

15-49

3.9

7.8

6.3

2.9

7.1

9.1

2.8

8.4

7.4

1.3

5.7

6.5

6.1

1.5

13.4

17.0

5.4

12.5

16.6

15.0

5.7

16.0

13.8

5.0

8.2

8.8

7.0

22.4

Guatemala . . . . .

Mexico . . . . . . . .

Peru. . . . . . . . . . .

Brazil, . . . . . . . . .

Sao Paulo , . . .

Piaui . . . . . . . .

Africa/Middle East

Egypt b 

. . . . . . . . .

Kenya . . . . . . . . .

MDCs

United Kingdom.

France. . . . . . . . .

United States . . .

1978

1979

15-44

15-44

64

31

16.1

15.4

27.8

10.0

13.4

5.4

?

15-49

20

9

0.3

—

o

1.3

1.7

0.9

16.5

1977-78 3.4

WFS

WFS

WFS

1976

1978

1976

16-49

20-44

15-44

75

79

68

16.0

4.7

19.0

6.0

9.5

6.1

25.0

30.8

22.4

30.0

34.0

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.

CDC - Center for Disease Control Survey.

FPS - Family Practice Survey of Korean institute for Family Planning.

MWRA - Married women of reproductive age.

WFS - World Fertility Survey of international Statistical institute.

SOURCE: Office of Technology Assessment.

factors and on the availability of contraceptive

methods. In many countries family planning

programs effectively reach only urban women.

In Pakistan, for example, 15 percent of urban

women but only 3 percent of rural women are

currently using contraception. Yet the country’s

population is predominantly rural–74 percent

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 countryside. Here the difference is less extreme; 40

percent of urban women are contraceptive

users as compared with 36 percent of rural

women. Where government programs make no

special effort to reach rural couples, socioeconomic factors such as educational level and income substantialy influence contraceptive use,

but where governments provide services in

rural areas, the influence of these factors becomes less important.

I Latin America I

WFS

1977-78

(15-44)

Colombia Guatemala Mexico Peru

Methods

SOURCE: Off Ice of Technology Assessment
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

WFS

1974

(15-49)

Asia I

Other

Methods

❑ Other ■ Sterolda ■ lUOa ■ Barrier ■ Sterlll.atlon (U) Unavailable

Key

WFS – World Fertility Survey (Int’1. Statistical Institute)

CPS – Contraceptive Prevalence Survey (Westinghouse Health Systeme)

CDC — Center for Disease Control Survey

Pc – population Council

WFS

1977-78

(15-49)

Philippines Kenya

Methods

Steroids IUDs

Barrier Sterilization (U) Unavailable

WFS –

CPS –

CDC –

PC –

Key

World Fertility Survey (Int’1. Statistical Institute)

Contraceptive Prevalence Survey (Westinghouse

Health Systems)

Center for Disease Control Survey

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 measured in populations and reflects the effects of

these fertility inhibiting factors. If only married

people are counted, the rate is higher than the

total fertility rate and is called the total marital

fertility rate. If the inhibiting effects of contraception 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

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

of each of the four primary factors in lowering

the potential rate. The horizontal axis represents 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-inhibiting factor as replacement fertility levels are approached.

Figure 14 summarizes the historical contribution of each of the fertility inhibiting factors as

population fertility rates have changed. When

fertility rates are high, breastfeeding is found to

have a significant impact, reducing potential

fertility by 37 percent. At replacement levels of

fertility, however, breastfeeding is not significant, contributing only 7 percent of the inhibiting effect on the total fertility rates (fig. 14).

By contrast, the fertility-inhibiting effect of

the other factors has been found to increase as

fertility approaches replacement levels. The effect of proportions not married (later age at

marriage) rises from 25 to 47 percent as total

fertility rates fall. Induced abortion is insignificant when total fertility rates are above 3 but

has some impact when these rates are at replacement levels.

The pattern of the fertility-inhibiting effects

of these variables changes slightly when different countries are used in calculating the rates.

For example, because Eastern European confFigure 13.—Fertility4nhibiting Impact of

Selected Factors

Fertility Inhibiting

impact of:

Breastfeeding

ICOntraception

Induced abortion

Nonmarriage

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,

tries were included with LDCs and other MDCs

in this analysis, induced abortion was shown to

have a significant impact at replacement levels.

(Eastern European countries have total fertility

rates at or below replacement levels and induced abortion is used extensively.) In populations with higher total fertility rates and similar

rates of induced abortion, the demographic effect of induced abortion may be more significant than shown here.

The demographic transition in Europe was a

relatively slow process by comparison with the

current transition in LDCs, and the effects of

these four direct factors—proportions married

and age at marriage, contraceptive use, induced

abortion, and lactation—were different in the

relative degree of their impact on declines in

total fertility rates. Today, however, the finding that contraception has a markedly intensified capability to reduce potential fertility as

total fertility rates approach replacement levels

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

765432 1

Total fertility rate

765432 1

Total fertility rate

60

40

765432 1

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, coninhibiting 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 Europe, a general “theory of the demographic transition” was developed, which held that fertility decline

follows only after, and as the result of, a decline in

mortality (particularly infant mortality) and improvement in socioeconomic conditions, or “modernization.” Because much of Europe’s fertility decline took

place before modern contraceptives or safe medical
Ch. 4—The Direct Determinants of Fertility Change ● 7 1

abortion were readily available, it is argued that

couples who limited their family size must have done

s. by practicing withdrawal or abstinence. Induced

abortion was rarely resorted to because of the

dangers associated with the procedures then in use.

The demographic record has now been examined

more closely. New information sources and analytical methods indicate that sustained fertility declines

in Europe began under a much wider variety of social, economic, and demographic conditions than had

been thought, appeared to follow cultural and linguistic lines, were remarkably concentrated as to

onset—mostly between 1880 and 1910—and became

irreversible processes once under way. Large families were not necessarily desired in pretransition Europe, according to these new findings, and high infant and child mortality may have been partly the result of high fertility rather than the other way

around. The then-available fertility planning methods—withdrawal, abstinence, and induced abortion—may not have been used because they were unthinkable for married couples, ineffective, or simply

unknown.

The European demographic transition can be visualized by contrasting the typical childbearing experiences of 100 women married in the middle of the

19th century with those of a similar group at mid20th century (fig. 15). Much of 19th century Europe’s

high fertility was neutralized by high mortality, patterns of delayed marriage, and lifetime celibacy.

Because of late marriage and widowhood, mothers

averaged only five children apiece, a number well

below their potential total. By the mid-20th century,

a substantial decline in fertility reduced the number

of children per family, but the likelihood that these

offspring would survive to reach childbearing age

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

fewer to emigrate. The net result was a 10-percent

gain in population over a generation in contrast to a

gain of 25 percent a century earlier.

Information on these occurrences has been drawn

from three principal sources: censuses, parish registers, and contemporary accounts. Family histories

are reconstructed from parish registers, compared

with censuses where available, and analyzed by new

techniques, Contemporary accounts of socioeconomic conditions are then used where possible to confirm the results.

The concepts of natural fertility and family limitation are central to descriptions of the demographic

transition. “Natural” fertility occurs among couples

who make no attempt to limit or terminate childbearing during the biological reproductive lifespan. Family limitation describes couples who make a deliberate

effort to terminate childbearing once a desired number of offspring have been born. Such limitation is

not synonymous with “birth control” but refers instead to behavior designed to halt childbearing altogether. Birth control, or family planning, refers to

spacing and limiting the total number of births. Birth

spacing can occur under conditions of natural fertility, as when couples deliberately space births but are

unconcerned with their total number. This practice

has been common in sub-Saharan Africa, where it

Figure 16.—Trends in Average Age of

persists in many regions. The techniques used to

study historical data can detect stopping behavior

but cannot detect deliberate spacing behavior. This is

important because the introduction and spread of

stopping behavior characterized the onset of the fertility transition.

Because the decline in fertility in Europe resulted

from a shift from natural fertility to family limitation,

the age of women at last birth becomes an index for

the degree of family limitation behavior being practiced. These trends are seen in two cultural groups in

figure 16. The transition from natural fertility to

family limitation began relatively early in the town of

Grafenhausen, Germany. The bourgeoisie of Geneva,

Switzerland, were an elite group who began practicing family limitation early in the 17th century, long

before most other European couples did so. In both

groups the shift is clearly evident: before the fertility

decline, women had their last birth at about 40 years

of age; toward the latter part of the decline they gave

birth for the last time nearer 30 years of age.

In general, although predecline levels of fertility remained relatively constant within cultural or geographic areas, there was considerable variability in

fertility levels among groups, due to a mix of physiological factors, social customs, health conditions, and

differences in breastfeeding patterns. Evidence is

strong that, despite regional differences in overall

— Women at Last Birth: Grafenhausen and

Genevan Bourgeoisie, 17th-19th Centuries

B

Year of husband’s birth
Ch. 4—The Direct Determinants of Fertility Change ● 7 3

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. . . . . . . . . . . . . . .

Belgium. . . . . . . . . . . . . .

Switzerland . . . . . . . . . . .

Germany . . . . . . . . . . . . .

Hungary . . . . . . . . . . . . .

England and Wales . . . .

Sweden . . . . . . . . . . . . . .

Scotland . . . . . . . . . . . . .

Netherlands . . . . . . . . . .

Denmark . . . . . . . . . . . . .

Norway . . . . . . . . . . . . . .

Austria. . . . . . . . . . . . . . .

Finland . . . . . . . . . . . . . .

Italy . . . . . . . . . . . . . . . . .

Bulgaria. . . . . . . . . . . . . .

Spain . . . . . . . . . . . . . . . .

Ireland . . . . . . . . . . . . . . .

Developing countries

Costa Rica . . . . . . . . . . .

Taiwan. , . . . . . . . . . . . . .

Chile . . . . . . . . . . . . . . . .

Thailand . . . . . . . . . . . . .

ca. 1800

1882

1885

1890

ca. 1890

1892

1892

1894

1897

1900

1904

1908

1910

1911

1912

1918

1929

1962

1963

1964

ca. 1970

185C

161

165

221

250

149

102

124

153C

131

76

205

114

146

159

158

69

70

30

33

38

73

15

49

13

29

42

37

40

66

46

70

66

48

81

56

78

68

84

28

81

27

26

61

72

7

22

9

21

11

57

11

49

42

23

18

19

9

28

7

26

20

0.89b

0.50b 74 58 66 20

0.70 0.70 49 47 42 31

0.65b 0.50b 103 37 29 53

ca. 0.75 0.75 77 75 85 12

High

30

Low

Low

49’

Low

Low

Low

Low

Low

Low

21

44

39

60

46

Low

14

30

15

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

population, which is a measure of the proportion of a

population practicing contraception at a particular

point in time, is analogous to taking a snapshot of the

reproductive behavior of that population. The prevalence rate is the percentage of all women of reproductive age (15 or 20 to 44 or 49) currently living in

some type of stable union (“married”) who are currently using contraception. For example, 23 percent

of such women in India are currently using some

form of contraception while only 5 percent of their

counterparts in Pakistan are doing so. These figures

are snapshot views for 1979 and 1975, respectively

(table 15).

Although prevalence rates appear straightforward,

reliable prevalence rates are difficult to obtain for

several reasons. If there is extensive use of contraception outside of marriage, this use will not be

measured since rates are calculated on the basis of

women currently in some type of stable union. Unless the survey is truly representative of the population and the quality of research, questionnaire design, and fieldwork are adequately controlled, the

data will be questionable. Even with good quality

control, contraceptive use can be underreported

because respondents may be shy, may wish to hide

the truth, or may misunderstand the questions.

Prevalence rates can vary depending on the contraceptive methods included in the index of current

contraceptive use. Traditional methods such as

herbs, withdrawal, or abstinence can augment the

percent of women who report using contraception.

Traditional methods, however, are not usually reliable and such women are in effect at risk of unwanted pregnancy. Menstrual regulation and induced abortion as post coital methods are usually excluded from calculations of the percentages of

women using contraception, but their use may represent a significant proportion of the effective contraceptive protection in a population. Thus, the prevalence rate may be lower than expected when compared with the birth rate because women are relying

on postcoital methods in cases of contraceptive

failure. For example, because pills or IUDs may not

be as available as spermicides or condoms in some

countries, menstrual regulation and/or induced abortion are used in the event of method failure.

It is necessary to distinguish between sterilization

for contraceptive purposes and sterilization for

health reasons. The basis for the sterilization procedure is ascertained from women survey respondents. It is often difficult for a woman to distinguish

the primary cause for sterilization when she has as

many children as she wants, her doctor has advised

her that having more would probably threaten her

health and well-being, and when the couple’s income

is inadequate for the support of another child.

Thus, there is always a margin for error in the

determination of contraceptive prevalence rates. In

surveys such as the World Fertility Survey and the

contraceptive prevalence surveys currently being

undertaken by Westinghouse and the Center for Disease Control, z this “sampling” error is being calculated and prevalence rates are shown with calculations of probable ranges of error (e.g., a rate of 50

percent plus or minus several percentage points).

These sampling ranges have not been included in this

document, but may be obtained from the sources

cited in the text tables of contraceptive prevalence.

‘F”or drtaiis on (wllrwf,pt itf,prtII alwlw suI.I (,}sw{, Sir klauricr Kendall,

“’1’tl(’ L\’()[’lfi E’ertililj, Sur\q\ (;llrrw}t Slat LIs and h’indings, ” PqJ[//atj{Jn Rf..

porfs, Series 11, No 3, Populiilk]n Information Program, The Johns Hopkins

( 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>

Sill’\ (>~s’ /\ N(It\, %)lll.(i(~ (It p’illl)llj, l)!iillllillg [>illii, ” /’(J/llJ/;lfi(Jfl Hfporl,s, Srrim

hl, NO .5, Nlii}-Jtill[, 1981, Popuklkm Ir]lo[m)iition” Program, [h, J[)llns

tlophins [ 11111 (>l’s[l}, Billlilllo[,(,, kid.

Technical Note C: Age at marriage3

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 possigraphic reasons: bility of pregnancy, and thus, in the absence of

● they are likely to have sexual intercourse frequently throughout their most fecund years

(later-marrying women will have sexual inter- !t’’ol ” f’lil’th(, r (I(,tilils \lW> ,\ ~{ fIlll-\I :Illd ]) ]]i[)tlX)\! , “ A#’ ii[ Alill’l’iiig[} .111(1

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 ● 7 7

contraception, are apt to have more children

than women who marry later; and

● by their early childbearing, they shorten the interval before the next generation is born.

Figure 17, which illustrates the effect of age at

marriage (in the absence of contraceptive use), assumes that a woman gives birth to a daughter every

5 years until she reaches age 40. If her age at marriage is 15, she gives birth to a daugher at age 20 (at

left of figure). By the time this woman reaches age

40, she has had 5 daughters and the eldest has given

birth to her first daughter. After a period of 60 years,

if age at marriage is 15, the resulting female population would total 22. Using the same assumptions, but

changing age at marriage to 20 (as shown in the central portion of the figure), the total female population

would rise to only 11 after 60 years. If age at marriage is raised to age 25 (as shown at the right of the

figure), the female population would consist of only 5

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

Nlarriage: The Cases of Tunisia, Sri Lanka, Malaysia, and Bangladesh, ” PRB Report, vol. 13, No. 4

(Washington, D. C.: Population Reference Bureau,

1977).

2. Bongaarts, J., “The Fertility Inhibiting Effects of

the Intermediate Fertility Variables, ” paper prepared for the IUSSP and WFS Seminar on the

Analysis of klaternity Histories, London, April

1980.

3. ‘(A Framework for Analyzing the Proximate Determinants of Fertility, ” Population and

Development Review 4(l), March 1978, pp.

105-132.

4. Buchanan, R., “ Breast feeding, Aid to Infant

Health and Fertility Control, ” Population Reports,

Population Information Program, The Johns

Hopkins University, Series J, No. 4, July 1975.

5. Chen, P., OTA working paper, 1980.

6. Davis, K., and Blake, J., “Social Structure and Fertility: An Analytic Framework,” Economic Dc\’elopment and Cuhural Change, vol. 4, No. 4, 1956, p.

211.

7. Henry, A., and Piotrow, P. T., “Age at ~larriti~e

and Fertility, ” Population Reports, Population Information Program, The Johns Hopkins [Jni\ersity, Series M, No. 4, November 1979.

8. Jain, A. K., and Bongaarts, J., “Socio-Biological

Factors in Exposure to Child-Bearing: Breastfeeding and Its Fertility Effects, ” paper presented at

the k$rorld Fertility Sur\ey Conference, London,

July 1980.
78 . World Population and Fertility Planning Technologies: The Next 20 years

9. Kent, M. M., “Breastfeeding in the Developing

World: Current Patterns and Implications for Future Trends,” Reports on the World Ferti/ittiv

Surve-v, No. 2 (Washington, D. C.: Population Reference Bureau, June 1981).

10. Liskin, L. S., “Complications of Abortion in Developing Countries, ” Population Reports, Population

Information Program, The Johns Hopkins Unik~ersity, Series F, No. 7, July 1980.

11. Nortman, D. L., and Hofstatter, E., Population and

Fami/y P/arming Programs, A Population Council

Fact Book, New York, IOth edition, 1980.

12. Potter, R. G., “Additional Births Averted When

Abortion is Added to Contraception, ” Studies in

Fami/eY Planning, vol. 3, No. 4 (New York: The Population Council, April 1972).

13. Potts, M., Diggory, P., Peel, J., Abortion (New

York: Cambridge University Press, 1977).

14. Schoenmaeckers, R., et al., “The Child-Spacing

Tradition and the Postpartum Taboo in Tropical

Africa: Anthropological Evidence,” paper prepared for the IUSSP Workshop on Child Spacing

in Tropical Africa: Tradition and Change, Brussels, Apr. 17-19, 1979.

15. Scrimshaw, S. C. M., “Infant Mortality and Behavior in the Regulation of Family Size,” Population and Development Review 4(3), September

1978, pp. 383-403.

16. Tietze, C., Induced Abortion: A World Review,

1981, Population Council Fact Book, 4th cd., New

York, 1981.

17. \’an Ginneken, J. K., “The Impact of Prolonged

Breastfeeding on Birth Intervals and on Postpartum Amenorrhea,” Nutrition and Human Reproduction, W. Henry Mosley (cd.) (New York:

Plenum Press, 1978), pp. 179-196.

18. Wray, J. D., “Maternal Nutrition, Breastfeeding,

and Infant Survival)” IVufrition and Human Reproduction, W. H. Mosley (cd.) (New York: Plenum

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. . . . . . . . . . . . . . .

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. . . . . . . . . . . . . . . . . . . . . . . . . . .

20. Annual Number of Birth-Related and Method-Related Deaths per 100,000

Nonsterile Women, by Fertility Planning Method, Age,

and Development of Country. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21. Future Fertility Planning Technologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LIST OF FIGURES

85

89

90

92

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; inexpensive; 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 access 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 components–birth, death, and migration-of population growth. medical, agricultural, and sanitation technologies are essential to the reduction

of death rates. Communication and transportation technologies play key roles in all aspects of

population change. This report, as stated

earlier, focuses on the technologies that help to

change birth rates, and this chapter deals with

the specific fertility planning technologies that

human beings use to affect the numbers and

characteristics of births.

wanted pregnancy: contraceptive technologies.

Less common but important at present are

those used for early termination of unwantecl

pregnancy. Still less common but very important in some societies are technologies used to

prevent or correct unwanted infertility, uncommon and little developed are the sex selection

technologies used to determine an infant’s sex at

conception. Techniques to detect pregnancy or

important abnormalities of pregnancy or to preselect genetic characteristics are not included in

this study.

The most common

these technologies are

and most important of

those used to prevent unThe human reproductive process

Sperm are produced continuously in the testes 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. Sperm production takes

about 72 days. The fina1 stages of sperm maturation take place in the small ducts and long

epididymis at the back of the testes. The sperm

are ejaculated by 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

spermatogenesis. LH regulates the secretion of

testosterone by the Leydig cells. Testosterone

Figure 18.—Human

Male Reproductive Organs

Bladder

Penis

and other male hormones act as the feedback

mechanisms. Figure 18 summarizes the human

reproductive cycle.

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

Human reproduction, as for other mammals,

is characterized by relatively long intervals of

natural infertility in the female. Fertilization can

only take place within a few days after ovulation. Pregnancy occurs following fertilization of

the ovum by the sperm, usually in the fallopian

tube, and implantation of the embryo in the

uterus. When pregnancy occurs, the corpus luteum is maintained by another hormone,

human chorionic gonadotropin (HCG), secreted

by the implanted embryo, and estrogen and progesterone continue to be produced. Once

delivery has taken place, further ovulation is

temporarily blocked by the hormonal changes

induced by the infant’s suckling, including a rise

in the level of another pituitary hormone, prolactin.

Contraception

Methods

The major methods of contraception currently in use, listed in order of their use effectiveness in preventing pregnancy, are:

●

●

●

Sterilization—vasectomy in the male, and

tubal ligation/occlusion in the female.

Steroid hormones–combined (estrogen and

progestin) or low dose progestin oral pills,

or intramuscular, long-acting progestin injections. These synthetic steroids are given

in different combinations and different

doses, depending on the commercial product, but they act primarily by inhibiting

ovulation through suppression of the hypothalamic hormones that stimulate the release of FSH and LH from the anterior pituitary. The synthetic steroids also cause endometrial changes that make the uterus inappropriate for implantation should breakthrough ovulation and fertilization occur.

Other changes that contribute to the contraceptive effect include scant and thick

cervical mucus, reduced sperm transport

and penetration into the uterus, and altered

sperm and ovum transport capabilities

within the fallopian tubes.

Intrauterine devices (IUDs)—the insertion

of a foreign body, made either of an inert

substance or impregnated with other materials (copper, progesterone). Although the

IUD prevents implantation in mammals, its

mode of action is unknown in the human

being. There are several possible modes of

action, from interference with sperm transport, to interference with ovum transport,

●

●

●

●

●

to interference with implantation in the

uterus. There is also some evidence that

IUDs lead to increased sperm damage and

affect the motility of the ovum in the fallopian tube.

Barrier devices—the condom for the male

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

solutions that flush out and kill sperm in the

vagina.

*The tJasal bod~’ temperature (BBT) method of periodic coital abstinence uses daily temperature-taking to identifj’ the temperature shift that occurs at or shortly after mwlation to determine the

‘(safe” days of the menstrual c~’cle. B~~ the evening of the third da~

of sustained high temperature readings fo]louring the shift, which

may be abrupt or gradual, the posto~wlatory infertile phase is

assumed to be under w’a~l. [ntermurse must be limited to this

phase for highest effectiveness. Ctl~][~s during which ovulation

does not occur and there is no tem~erature shift can be a problem

during postpartum and premenopaosal periods, [n the (]\wlation-or Billings—method, a woman is taught to identifJ/ the

precise characteristics of the cer~’ical mucus produced at ~arious

stages of her menstrual cycle and their relationship to her fertile

and infertile da~ls. In the S~wlpto-Thernlal method, which charts

both temperature changes and changes in \Iolunw and viscosity of

cerlica] mucus, women are also taught to recognize such subjective symptoms of ovulation as intermenstrual pain.
Ch. 5—The Technology of Fertility Change: Present Methods and Future Prospects . 85

Characteristics

The potentials of present contraceptive technologies and the limitations that future technologies will need to overcome depend upon how

well their characteristics meet the requirements

of such diverse groups as users, providers, program administrators, physicians, scientists, theologians, and politicians in various countries

and cultures.

Contraceptive technologies are judged by the

degree to which they are:

●

●

●

●

●

●

●

●

●

●

●

effective—prevent pregnancy;

safe—are free of deleterious side effects;

reversible—permit subsequent pregnancies

upon discontinuation of use;

easy to produce—do not require complex

industrial processes;

easy to provide—do not require frequent

resupply or specialized personnel;

easy to use—do not require periodic application or interfere with coitus;

inexpensive—have low economic costs to

user or society;

acceptable to governments—are permitted

or encouraged by laws and regulations;

acceptable to cultures—are consonant with

local beliefs and customs;

acceptable to religions—are consonant with

religious beliefs; and

acceptable to individuals—promote general

well-being, enhance sexual enjoyment, fit

lifecycle, and protect privacy.

How well any characteristic of a contraceptive

technology meets individual and societal requirements depends not only on the technology,

but on the views and actions of the society in

which it is used and of the individuals who use

it.

The myth of the ultimate, “ideal” contraceptive is precisely that. The perfect contraceptive

would be completely effective in preventing

pregnancy, have no harmful effects, be fully reversible, 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

lives. No such method exists or 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 access to at least one that meets current

needs.

Effectiveness

Contraceptive failure rates are usually quantified according to theoretical v. use effectiveness, because contraceptive failure under average conditions of use can be significantly higher

than when methods are used correctly and consistently. The effectiveness of the contraceptive

methods listed above is summarized in table 18,

where they are listed in descending order of effectiveness under ideal and actual conditions of

use, The failure rates represent the number of

pregnancies among 100 nonsterile women using

the method for 1 year in the United States. If

they were to use no contraceptive method,

about 90 percent of these women would become pregnant within a year.

Sterilization is the most effective contraceptive method. Use effectiveness equals theoretTable 18.—Theoreticai and Use Effectiveness of

Various Means of Contraception

(by pregnancies per 100 woman-years in MDCs)

Theoretical Use effectiveness

Method effectiveness Range Average

0.06

0.15

0.24

0.7
86 . World Population and Fertility Planning Technologies: The Next 20 Years

ical effectiveness because the procedure is usually performed adequately in the United States

and there is no need for additional contraceptive practice once the surgical procedure is performed. The obvious drawback of sterilization

is its permanence. For female sterilization, although individual surgeons have reported reversal rates as high as 60 percent, it is estimated

that only about one-fifth of all women sterilized

by current techniques could have their sterilizations reversed (8). For reversal of male sterilization, the rate of anatomical success as determined by the reappearance of sperm is in the

range of 40 to 90 percent, but functional success

as determined by the pregnancy rate is much

lower, on the order of 18 to 60 percent (3); new

microsurgery techniques are reported to have

increased the upper range to 70 percent (21).

The steroid hormones and IUDs are very effective in preventing pregnancy, but the degree

of prevention depends on how correctly and

consistently they are used. Barrier devices (condoms, diaphragms) approach the IUD in theoretical effectiveness but have three to four times

the failure rate of the IUD in use effectiveness.

The use of vaginal spermicides, coitus interrupts) and periodic abstinence also significantly

lower pregnancy rates, but about 20 percent of

users will still become pregnant within a year.

Postcoital douching also has a preventive effect

but will protect only about 35 percent of users.

New techniques are now being employed to

evaluate pregnancies that occur during use of

periodic abstinence methods. Unintended pregnancies are analyzed in terms of when in the

woman’s cycle they occurred and whether the

couple proceeded with a particular act of intercourse despite advance knowledge of the reasonable likelihood of conception; which of these

pregnancies can be attributed to the methods

themselves; and which pregnancies are likely to

have resulted from difficulties in teaching or

learning the various methods (10).

Most determinants of effectiveness are inherent in the technology, but variations occur

depending on the conditions and behavior of

the user. The closer a couple are to the number

of children they want, the more effective is

their use of barrier methods or periodic abstinence. Couples who are using contraception to

prevent any future births achieve much higher

effectiveness than couples merely spacing the

next birth. Highly motivated and experienced

couples can prevent pregnancy much more effectively than less motivated couples.

Risks

Risk estimates attempt to compare the relative

risks of each contraceptive method not only

against other methods but also against the risk

of using no contraceptive method. The latter

risk is in becoming pregnant and the morbidity

and mortality associated with pregnancy and

childbirth. The risks of each contraceptive

method are the morbidity and mortality associated with use of the method and with those

pregnancies that the particular method does not

prevent. For these comparative estimates, the

measure of risk used is the death rate, comprised of method-associated (use of a particular

contraceptive method or failure of a contraceptive method) and birth-associated (use of no contraceptive method) deaths.

A further distinction must be made between

absolute and relative risks. For example, relative

incidence in the population is important.

If the incidence of a disease is 1 per million

among non-exposed persons, and the use of a

particular drug increases the relative risk of

disease tenfold, then one would anticipate 10

cases per million users of the drug. On the other

hand, if the incidence of another disease is 100

per million, and drug exposure increases the risk

only twofold, then one would anticipate 200

cases per million among users of the drug. The

latter situation would clearly entail a much

greater public health problem, even though the

relative risk is much smaller (24).

Language is also important when studies of

risk are discussed. For example, the conclusion

that oral contraceptive users have a five times

greater risk of dying from circulatory disease

than nonusers can be rephrased to point out

that pill users decrease their chances of survival

during a year from 99)995 per 100,000 to 99,974

per 100,000-a reduction of only two-hundredths 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

are largely confined to oral contraceptives and

IUDs. Some morbidity and mortality are also associated with sterilization procedures, but these

are limited to the time at which the procedure is

performed. Barrier devices and spermicides are

relatively risk-free except for the risks associated with pregnancy from the higher degree

of contraceptive failure with these methods.

Barrier devices, principally those used by the

woman, have been associated only with minor

side effects—allergic reactions, vaginal irritation, and infections (26).

Spermicides, apart from local reactions such

as tissue irritation to either partner, have been

considered very safe insofar as method-related

risks are concerned. Such risks might be incurred from: 1) systemic effects on the woman

resulting from absorption of the spermicide

through the vagina; 2) damage to a developing

fetus from spermicide components or metabolites in the woman’s circulation; and 3) genetic

damage to conceptions involving sperm damaged by spermicides (5). A recent study has

shown a positive correlation between spermicide use in the 10 months prior to conception

and the prevalence of certain major congenital

anomalies (9). The prevalence of such abnormalities as limb-reduction deformities, neoplasms,

and syndromes associated with chromosomal

abnormalities was 2.2 percent, compared to an

incidence of 1 percent in infants born to mothers who had not used spermicides in the 10

months prior to conception. The rate of spontaneous abortion requiring hospitalization was

also 1.8 times more common. The investigators

considered these findings tentative, as these abnormalities were diverse and did not appear as

a well-defined syndrome. This area clearly warrants further investigation.

The basic risks of IUDs are: 1) increased

menstrual bleeding or spotting; 2) perforation of

the uterus; 3) increased frequency of pelvic infection; and 4) unwanted pregnancies that are

more likely to be ectopic (implanted outside the

uterus in the fallopian tube or abdominal cavity)

or to result in septic midtrimester abortion than

pregnancies in nonusers (17). Method-related

mortality from IUDs stems principally from ectopic pregnancies—a life-threatening emergency–and septic abortions.

Circulatory system diseases associated with

oral contraceptives have caused the most concern. Venous thromboembolic disease—

principally of the legs—was the first recognized

circulatory system risk associated with oral contraceptive use. Excess mortality has been

estimated at 2 to 3 per 100)000 women annually,

with no increase of risk associated with duration of use. Heart attacks and subarachnoid

hemorrhage–a type of stroke probably from

rupture of congenitally weak cerebral blood

vessels—are the other circulatory system risks.

The risk of heart attack depends on other predisposing factors, e.g., cigarette smoking, hypertension, diabetes. The chances of heart attack

thus increase with age, smoking, and other predisposing factors, The risk of subarachnoid

hemorrhage increases with smoking and duration of use (17).

Together, these circulatory system diseases

would theoretically account for a fivefold increase in deaths, but questions have arisen as to

why such an increase has not been reflected in

vital statistics trends. A researcher at the U.S.

Center for Disease Control estimates that 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 was indeed fivefold. Such a high propulation

of cardiovascular deaths attributable in oral

contraceptive use should have been reflected in

dramatically increased rates of cardiovascular

deaths in women of reproductive age since the

onset of oral contraceptive use, but such increased rates have not appeared. In addition, instead of the death rate from these diseases

diverging for men and women as would be expected, U.S. cardiovascular disease death rates

have been falling nearly equally and steadily for

men and women of reproductive ages since

1950 (13). (See fig. 19 for circulatory system

death rates for U.S. women.)

Research on long-term risks of oral contraceptives has found no statistically significant in.

crease in the cancer rate. A rare type of benign

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

Diseases,a Females, Aged 10-84, by 5-Year Age

Groups, United States, 1951-75

Age

group

80-84

75-79

70-74

65-69

W-64

A11 ages

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-

lo19

14

formed in medically approved Settings)) either

alone or in conjunction with barrier methods, is

included.

In MDCs, between ages 25 to 35, the risk for

oral contraceptive users who smoke is about the

same as for those using no method, but is 50

percent higher between ages 35 to 39 and about

three times higher after age 40. For nonsmoking

oral contraceptive users, the risk is much less

under age 40. Barrier methods in combination

with access to legal abortion in the event of contraceptive failure are the safest, but induced

abortion is a controversial method which is

morally unacceptable to many, or, if acceptable,

may not be readily available. IUDs have low risk

rates throughout the reproductive years.

This model has been extended to the LDCs

and is summarized in table 20. The principal

assumptions are: 1 the ability to become pregnant is the same in more developed countries

(MDCs) and LDCs but lactational amenorrhea

following childbirth is 8 months longer in LDCs

because of the higher prevalence of breastfeeding; 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) maternal 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) method-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 included.

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 contraceptive 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

supervision in the event of contraceptive failure

are the safest, but the higher maternal mortality

rates make all methods—with the exceptions

noted above—safer than no method at all. Thus,

in LDCs, the risks of the different methods are

relatively less significant than in MDCs because

of much higher maternal mortality rates, and

the choice of methods depends more on different legal and medical circumstances, kinds of

methods available, and the convenience and acceptability of particular methods.

Future technologies

The following forecasts are based on four

major elements. The first is the past rate of

innovation in reproductive and contraceptive

research. Between 1960 and 1970 a revolution

in contraceptive technology occurred, and more

than a dozen new technologies—oral contraceptives, IUDs, and new sterilization and abortion

techniques— reached the public. This rapid pace

of innovation continued through the 1970’s)

which saw the widespread introduction and

adoption of new types of vaginal spermicides,

contraceptive injections, drug-releasing IUDs,

outpatient sterilization methods, and low-dose

oral contraceptives.

A second element is the present base of

knowledge available to researchers. As early as

1974, it was evident that the field of reproductive biology was benefiting from the explosion

of basic research in biology and especially from

fundamental new discoveries in biochemistry

and genetics made during the 1960’s (2). The

consolidation of knowledge about these new discoveries that took place during the 1970’s has

been extensively applied in the areas of scientific methodology, medicine, and fertility.

A third element is the magnitude of current

applied research and development efforts. A

worldwide network of facilities is engaged in

the development of fertility planning agents

with government and private foundation support. Private companies are also working to

develop new methods.

The fourth basis for these forecasts is expert

opinion on both the overall likelihood of innovation 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 predisposing 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 predisposing 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

Method-associated a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 predisposing 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 predisposing 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

Method-associated a . . . . . . . . . . . . . . 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

(4,7). These views, from personal consultations,

mail surveys, and reviews of literature, were

brought together in a comprehensive assessment of prospective technologies by a senior

scientist as a working paper for this study,

which was in turn submitted for critique by external reviewers. The paper reviews each major

category of fertility planning technology and examines its current level of development, nature

of action, mode of administration, probable effectiveness, probable side effects and safety,

delivery requirements, probable cost, probable

extent of use, likely time frame for development, and obstacles to development (7).

The predictive power of these forecasts depends on the assumption that current trends

continue. Such unforeseen developments as

funding changes, toxicity findings, or alterations

in cost factors could intervene to retard or even

curtail the development of particular technologies. It is also impossible to foresee the scientific discoveries that almost certainly will

emerge during the next two decades, giving rise

to entirely new opportunities for technology development or to greatly accelerated development of methods now under study.

Developments arising from one category of

methods—folk methods—deserve special mention. They are not treated further in the discussion to follow because the methods are diverse,

and their bases poorly understood. The World

Health Organization (WHO) is conducting a collaborative global effort to identify and develop

the potential antifertility agents present in

plants believed (and used) in numerous LDCs to

prevent pregnancy. Among the compounds thus

far isolated are extracts from the plant Montanoa tomentosa, which has been used as an early abortifacient in Mexican folk medicine for

centuries, and from the roots of Trichosanthis

kirilowii maxim, which has long been used in

Chinese medicine to induce menstruation. The

likelihood of developing new fertility planning

techniques from these sources is unknown, but

the potential is unquestionably present. Gossypol, a derivative of the cottonseed plant, induces

male infertility and is currently under clinical

investigation in China as a male contraceptive,

but significant side effects, including potassium
92 ● World population and Fertility Planning Technologies: The Next 20 Years

depletion and delayed return to fertility, have

been encountered in studies of the extract.

Between now and the end of the century,

more than 20 new or significantly improved

technologies for contraception could become

available. They have been classified in table 21

in three categories: 1) technologies highly likely

to become available by 1990; 2) technologies

that could become available by 1990) but for

which prospects are in doubt; and 3) technologies that are unlikely to become available by

1990, but which could emerge by 2000 (19,7).

Table 21 .—Future Fertility Planning Technologies

Highly Iikely before 1890

Safer oral contraceptives

Improved IUDs

improved barrier contraceptives for women

improved long-acting steroid injections

Improved ovulation-detection methods for use with

periodic abstinence

Steroid implants

Steroid vaginal rings

LRF-analog contraceptives for women

Prostaglandin analogs for self-administered induction

of menses

Possible by 1990 but prospects doubtful

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Monthly steroid-based contraceptive pill

Improved monthly steroid injection

New types of drug releasing IUDs

Minidose vaginal rings

Antipregnancy vaccine for women

improved barrier contraceptives for men

Sperm suppression contraceptives for men

Reversible female sterilization

Simplified female sterilization techniques

Simplified male sterilization techniques

LRF analogs for self-administered induction of

menses

Unlikeiy by 1990 but possible by 2000

Antifertility vaccine for men

Antisperm drugs for men

Antisperm maturation drugs for men

Lactation-linked oral contraceptives for women

Ovulation prediction methods for use with periodic

abstinence

New types of antiovuiation contraceptive drugs for

women

Contraceptive drugs for women that disrupt ovum

transport

Reversible male sterilization

Pharmacologic or immunologic sterilization for

women

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.

METHODS HIGHLY LIKELY TO BE

AVAILABLE BY 1990

All of the technologies listed below meet two

conditions. They are already in advanced stages

of research and development, and the scientific

and technical knowledge required to complete

their development and to permit their manufacture and distribution appears either to be in

hand or easily attainable.

Safer Oral Contraceptives.—New versions of

the contraceptive pill are being tested that will

cause fewer changes in the body metabolism,

either because they utilize a smaller amount of

contraceptive drug (e.g., the triphasic pill), because they avoid the peak blood levels of drug

that occur following ingestion of current pills,

or because the effect of the drug is more focused on a specific target or end point. It is assumed that this will reduce the incidence of circulatory system disease, liver hepatomas, and

other rare long-term side effects shown to be associated with current formulations of oral contraceptives.

Improved IUDs.—Three improved types of

IUDs are anticipated before 1990. The first are

advanced versions of the copper-releasing IUDs

introduced in the mid-1970’s. The improved versions will be effective longer than current IUDs

and will not require replacement during the

lifetime of the user. The second are advanced

versions of the progestin-releasing IUD introduced in the late 1970’s. By employing different, more potent contraceptive steroids, the

new versions will be much more effective—possibly equaling the pill—and will not require

replacement more often than every 5 to 10

years. These new IUDs may cause much less

bleeding than existing models, but questions of

long-term safety will be present because they

release drugs. The third new types are postpartum IUDs—devices that can be safely inserted

immediately following delivery without excessively high expulsion and pregnancy rates. They

would enable intrauterine contraception to be

made available to large numbers of women in

LDCs who otherwise might not have access to

the medical personnel needed for insertion of

other types of IUDs.
Ch. 5—The Technology of Fertility Change: Present Methods and Future Prospects ● 93

Improved Barrier Contraceptives for

women.-Improvements center on two areas:

increases in convenience of use and increases in

contraceptive efficacy. Among the former are

one-size-fits-all diaphragms, disposable diaphragms, spermicide-impregnated diaphragms,

vaginal films, vaginal sponges, vaginal rings that

release spermicides, and cervical caps that can

be left in place for weeks or months. Increases

in contraceptive efficacy include new formulations of existing spermicides and new types of

spermicides. Which of these are likely to survive

the R&D process and become new products is

uncertain. Because the level of resources being

devoted to this work is very low, progress is

likely to be slow, and major improvements are

unlikely. A substantially increased level of effort

would be required to develop highly effective

new spermicides or radically improved barrier

devices by 1390.

Improved Long-Acting Steroid Injections.—A

wide variety of improved injections under development make use of controlled release of

contraceptive steroids from biodegradable polymers. Which polymer systems will prove most

useful is not certain, but prospects are excellent

that one or more will provide the basis for a

new form of contraceptive injection. Effectiveness should be extremely high, and duration of

action is likely to be between 1 and 6 months,

depending on the properties of the polymer system eventually selected. Side effects are expected to be moderately reduced over existing

long-acting injections because of a more stable,

controlled release of contraceptive steroid.

However, the nature of side effects, including

alterations in menstrual bleeding patterns in

many users, is expected to be similar to those of

existing products.

improved Ovulation-Detection Procedures for

Use With Periodic Abstinence Methods.–Although R&D investments continue to be small,

technological prospects for development of a

routinized, simple test for ovulation appear

good. A wide variety of biological and biochemical parameters are altered when a woman

ovulates, and researchers are endeavoring to

improve or simplify the physical tests that a

woman can use herself to determine when she

ovulates. Improved methods that provide clearcut evaluation of, for example, changes in cervical mucus, hormones in urine and saliva, and

basal body temperature would enable larger

numbers of users of periodic abstinence to

know with certainty when they could safely engage in sexual intercourse during the second

half of the menstrual cycle without risk of pregnancy, although the prediction of ovulation is

likely to remain problematic. Such techniques

would also free users of barrier contraceptives,

withdrawal, or coitus reservatus from the need

to employ these methods during the second half

of the cycle. The excretion pattern of urinary

metabolizes of estrogen and progestogen has

been identified and has been successfully used

to determine when ovulation has occurred, according to studies conducted by the WHO Special Programme of Research, Development and

Research Training in Human Reproduction,

which reports that the measurement of these

substances in early morning urine was indicative of ovulation in 90 percent of women tested.

A number of firms are working to develop a kit

for women to use at home, and at least one of

the methods is expected to be ready for testing

when final analysis of the studies is completed

later this year (10).

Steroid Implants.—This new, reversible contraceptive method is likely to undergo several

rounds of technological innovation between

now and 1990. The first generation product—six steroid-releasing capsules implanted in

the forearm providing extremely effective contraception over 5 years—is likely to be either

supplemented or supplanted by second generation products employing fewer and smaller capsules that are biodegradable. The first generation product is now being introduced in LDCs

and will offer an alternative to sterilization for

women who wish to terminate births, as well as

a new contraceptive option for long-term spacing between births. While the second generation implants will not require removal, thus

eliminating a major drawback of the silicone

rubber implants, they will probably need to be

replaced at much more frequent intervals than

the six-capsule silicone-rubber method. It is likely 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

methods are expected to be at least as effective

as oral contraceptives and to have a similar incidence and range of side effects. They are expected to have the disadvantage of causing irregular patterns of menstrual bleeding in most

users, much the same as do the injectable.

Steroid Vaginal Rings.—As for the implants,

this new reversible contraceptive method

employs a previously unused system to administer steroid hormones. A one-size-fits-all silicone rubber ring that releases an ovulation-suppressing dose of contraceptive steroids is left inside the vagina for 3 weeks, then removed for 1

week, during which time menstruation occurs.

Because this is a monthly schedule and

estrogens as well as progestins are used, menstrual bleeding patterns are not greatly altered.

This new method offers an alternative to the

pill: it is self-administered, highly effective,

potentially available over-the-counter, and has

the advantage of simplified administration in

comparison with daily pill-taking. The method is

likely to have at least some of the rare long-term

side effects of pills, As with implants, this

method is in advanced development, and second

generation products are therefore also likely to

emerge before 1990. Second generation vaginal

rings are likely to have improved administration

schedules, such as continuous wearing of the

ring for long periods, and new ring designs that

offer advantages in price and convenience,

LRF-Analog Contraceptives for Women.

—Although this prospective new contraceptive

method has only recently entered clinical testing, relatively extensive R&D investments and a

high level of technological promise may make it

available during the next 10 years. Many modes

of antifertility action for new chemical analogs

of LRF are being investigated. The one that

stands out as most clearly feasible is reversible

inhibition of ovulation using chemically synthesized agonists or antagonists of the naturally occurring LRF. It is not yet clear whether these

drugs will be given by injection, nasal spray,

suppository, buccal insert, or oral capsule, nor

is the duration or frequency of administration

that will be required yet known. It is anticipated, however, that these new contraceptives

will offer a major new alternative to the pill,

with the advantages of many fewer short-term

side effects and, at least potentially, many fewer

long-term health hazards. Depending on which

chemical analogs are employed and their precise mode of action, the new contraceptives

could also offer the advantage of monthly in

place of daily administration.

prostaglandin Analogs for Induction o f

Menses.–After more than a decade of R&D, the

first prostaglandin analogs for inducing menstruation are now being introduced in clinical

trials. These drugs, which are administered as

vaginal suppositories, successfully induce abortion during the first 8 weeks of pregnancy in

about 90 percent of cases. Side effects—transient fever, nausea, vomiting, and cramping—are generally manageable, although disagreeable. Second and third generation products are likely to emerge over the course of the

next decade: new uterotonic prostaglandin analogs and formulations that are effective in bringing about a complete abortion in over 95 percent of cases and that cause fewer side effects,

However, it is doubtful that these agents, which

depend on uterine muscle contraction for their

action, will ever be 100 percent effective or

completely free of gastrointestinal side effects.

These drugs can be used in place of surgical

abortion during early pregnancy if surgical facilities are available to treat severe complications and to surgically complete the abortion

procedure in cases where the medication fails to

do SO.

METHODS THAT COULD EMERGE BY 1990, BUT

FOR WHICH PROSPECTS APPEAR DOUBTFUL

The following technologies are possibilities

currently being investigated or seriously considered by R&D groups. Some of them are in advanced stages of development.

It is likely that the majority will be eliminated

as realistic prospects during the next 10 years as

new information and R&D findings become

available, A number will survive as continuing

prospects and be carried forward into the following decade for additional R&D to complete

their development. A few might meet with

greater success and emerge as new technologies

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

developments in technology for formulating

sustained-release preparations of contraceptive

steroids may be put to use to develop a pill that

need only be taken monthly. Effectiveness

would be expected to be about equivalent to daily oral contraceptives. Short-term side effects

would be similar, although a somewhat greater

incidence of altered menstrual patterns might

occur. Long-term effects would also be similar.

The primary advantage of this new pill would

be the added convenience offered by monthly

use.

Improved Monthly Steroid Injection.—As for

the pill, a monthly injection would use new sustained-release formulation techniques to deliver

a monthly dose of estrogen and progestin sufficient to block ovulation and produce a hormonally induced menstrual bleeding at the end of

the month. Such new monthly injections might

be superior to existing ones in their much lower

incidence of menstrual bleeding alterations, in

their use of steroids compatible with U.S. Food

and Drug Administration toxicity standards,

and perhaps in a slightly reduced incidence of

such short-term side effects as headaches and

weight gain. Effectiveness and the general spectrum of short- and long-term side effects would

be similar to those associated with daily oral

contraceptives. Costs would likely be somewhat

higher.

New Types of Drug-Releasing IUDs.—Several

current R&D projects are testing drugs that

reduce menstrual bleeding and uterine cramping associated with the IUD. It is likely that one

or several of these drugs will eventually be incorporated into a drug-releasing IUD that will

cause significantly less bleeding and discomfort

than existing IUDs. Another type of drug that

may be incorporated into IUDs is antibiotics.

Low doses of such agents released locally into

the uterus would reduce the incidence of pelvic

infection associated with IUDs, thus overcoming

one of the major drawbacks of this contraceptive method, especially for young women. None

of the new varieties of drug-releasing IUDs is

likely to incorporate the improvements in effectiveness anticipated for the new copperreleasing and steroid-releasing IUDs.

Minidose Vaginal Rings.—Minidose rings, while

similar to the steroid-releasing vaginal rings that

inhibit ovulation described earlier, would employ much lower doses of progestational steroid

and no estrogen. Like the minipill, they would

exert their contraceptive action primarily

through effects on cervical mucus instead of on

ovulation. Minidose vaginal rings would offer

the advantage of reduced short- and long-term

side effects except with respect to menstrual

bleeding patterns, which would probably be significantly changed in most users. Another major

advantage of this method over the ovulationsuppressing rings would be its continuous use

by a woman, avoiding the complexities of a

3-week in, l-week out schedule. A major drawback would be lower effectiveness, probably in

the range of the present-day minipill or inertIUD contraceptives.

Antipregnancy Vaccine for Women. —

This prospective, reversible contraceptive

method uses a vaccine to immunize women

against the hormone in a specific component of

the fertilized egg, such as the zona pellucida.

Initially, a series of injections would probably be

needed over a period of several weeks or

months to establish immunity. Immunity might

last from 1 to several years and then disappear

unless a booster injection were given. Effectiveness of a vaccine contraceptive is theoretically

very high. A number of different antigens are

being investigated for use in developing such a

vaccine, and tests in monkeys and women have

shown the feasibility of several of these. This is

one of the prospective future methods that

could benefit from greatly expanded R&D efforts, since feasibility appears good, but a wide

range of technical problems needs to be overcome to realize this potential.

Improved Barrier Contraceptives for

Men.—Although very little R&D is currently

under way in this area, a growing market for

barrier contraceptives could stimulate significant innovation over the course of the next decade. Present R&D centers on biodegradable

condoms, spermicide-impregnated condoms (already marketed in Great Britain), and penile

films. The goal is to overcome the drawbacks of

decreased sensation, problems of disposal, and
96 • World Population and Fertility Planning Technologies: The Next 20 Years

variable effectiveness associated with existing

condoms. The scale of this effort is very small,

however, as condoms are already an acceptable

and effective method. But it is possible for radically improved condoms to be available by 1990

if private sector companies respond to the new

market demand by investing in R&D using new

synthetic materials.

Sperm Suppression Contraceptives for

Men.—For almost a decade, different drugs have

been tested for their capacity to suppress sperm

production in men. At least two types of

drugs-steroids and LRF analogs–are currently

under clinical study, and other agents are being

investigated in the laboratory. A future spermsuppressing contraceptive based on one of these

agents would for the first time offer men a

means of contraception similar to the pill for

women. Depending on the type of drug used, it

could take the form of a daily, weekly, or

monthly pill or, possibly, a long-acting injection

or implant. Concerns about possible rare or

long-term safety hazards (e.g., teratological effects in any offspring) associated with such a

new form of treatment will be important and

difficult to overcome.

Reversible Female Sterilization. -Short of extremely expensive and highly uncertain tubal

reconstruction surgery, female sterilization is

rarely reversible. This major limitation could be

overcome if current R&D efforts using fimbrial

hoods, tubal plugs, or other methods that permit easy reversal of sterilization are successful.

Numerous technical problems remain to be

solved, however, before a highly effective, safe,

and reversible means of female sterilization is

developed.

Sirnplfied Female Sterilization Techniques.—At

least three major lines of R&D work are being

undertaken in hopes of developing an outpatient method for female sterilization that could

be performed by ancillary medical personnel.

All of the methods require entry into the uterus

via the vagina and cervix in order to apply sclerosing (scarring) chemicals or to use freezing

temperatures to destroy a portion of the fallopian tubes. Technical problems in assuring high

effectiveness, safety, and freedom from subsequent ectopic pregnancies stand in the way of

successful development of these methods.

These methods could make sterilization much

more widely available to women in LDCs at

lower cost and in a manner not requiring

hospital stays or surgery.

Simplified Male Sterilization Techniques.—

Vasectomy is already performed as a simple outpatient technique with very low rates of morbidity or medical complications. One modest improvement being studied entails the injection of

a sclerosing chemical into the vas deferens, thus

eliminating the need for opening the scrotum

and cutting and tying off the vas.

LRF Analogs for Self-Administered Induction of

Menses.—A pill that can be taken each month at

the expected time of menstruation to ensure

that bleeding will occur whether or not a pregnancy has been established is under study. Such

a self-administered, menses-inducing agent

might also be effective as an abortifacient if

taken up to a week or two after a missed period.

New uterotonic prostaglandin analogs are likely

to offer some but not all of these features. For

complete effectiveness, a luteolytic agent (one

that destroys the corpus luteum) will probably

be needed, and current research findings point

to LRF analogs as the most likely future candidates.

METHODS UNLIKELY TO EMERGE BY 1990,

BUT WHICH COULD BE AVAILABLE BY 2000

The following methods are either in the early

stages of development or still the subject of mission-oriented research. All appear unlikely to

emerge as new fertility planning methods earlier than 1990, but could become available over

the course of the following decade. For several,

greatly expanded R&D programs could accelerate their development. For several others, it is

likely that substantial additions of knowledge from basic research will be needed as a

precondition for successful R&D efforts.

Antifertility Vaccine for Men.—Although little

R&D has yet been conducted on a male contraceptive vaccine, this area could benefit very

substantially from work on a vaccine for

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

that would render the man infertile. Suitable

antigens for such a vaccine have not yet been

identified. Whether such a vaccine would be a

reversible contraceptive or a permanent sterilization technique is not known.

Antitisperm Drugs for Men.—A moderate

amount of goal-oriented research has been conducted to identify enzymes essential to the

metabolism of sperm, and research for inhibitors of these enzymes has been undertaken. It

is possible that specific metabolic processes in

sperm could be halted by certain drugs that

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

principle.

Antisperm Maturation Contraceptive Drugs for

Men.—Such drugs would act on maturing sperm

rather than on fully active sperm. If specific

steps in the maturation process can be identified that could be blocked by specific drugs, a

reversible contraceptive could be developed.

Administration would need to be on a daily or

weekly basis or by means of a sustained-release

formulation such as an implant or injection.

Lactation-Linked Oral Contraceptives for

Women.—Efforts to develop a drug regimen that

could be administered to breastfeeding women

to extend both the duration and ovulation-suppressing intensity of their lactation after childbirth have been unsuccessful. In view of the

great health benefits of breastfeeding and the

very widespread reliance on this as a means of

birth spacing by women in LDCs, this remains a

high priority technological goal. Recent findings

about LRF and other gonadotropin-releasing

factors may make it feasible.

Ovulation Prediction Methods for Use With

Periodic Abstinence.—The development of simple techniques for predicting when ovulation

will occur would permit the rhythm or natural

family planning methods to be practiced with

full effectiveness. The development of such

techniques is beyond the capacities of current

scientific knowledge, but prospects a decade

from now should be much better.

New Types of Antiovu/ation Contraceptive

Drugs for Women.—Intensive basic and goaloriented research is under way on factors required for maturation of the ovum in the ovary.

If maturation could be prevented, either

through direct action or via inhibition of FSH release by the pituitary gland, ovulation would not

occur. Prospects that future contraceptives

employing a synthetic “inhibin” or chemical analog of an ovum maturation factor will eventually

emerge from this research appear good. If such

efforts are successful, a new type of nonsteroidal monthly pill or injection for women could

result.

Contraceptive Drugs for Women That Disrupt

Ovum Transport.—It is known that the transport

of the newly fertilized egg and its implantation

in the uterus can be disrupted by high doses of

estrogens, and this is believed to be the mode of

action of the current postcoital pill. A radically

improved postcoital pill that could be taken after every coitus without unpleasant side effects

or disruption of the menstrual cycle might be

developed in the future, using new drugs that

interfere with fertilization, ovum transport, or

implantation. Despite considerable research,

however, no promising agents have yet been

identified, and extensive basic and goal-oriented

research will be required to achieve this goal.

Reversible Male Sterilization.—Vasectomy is

safe, easy to perform, and highly effective. Easy

reversal of this procedure to restore fertility

would probably have great impact in making

the method more widely used. Unfortunately,

numerous R&D projects to develop tubes,

valves, plugs, and other devices that could be

implanted in the vas deferens and reversibly

block sperm from passing have ended in failure,

so the biological feasibility of a reversible technique is uncertain. New surgical techniques

coupled with new biocompatible synthetic

materials are likely to be required for development of such a method.

Pharmacologic or Immunologic Sterilization for

Women.—A pill or injection that confers permanent 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

would have to be resolved, if sufficient R&D

were devoted to a careful selection of proper

pharmacologic or immunologic agents, high

safety and effectiveness should be attainable.

The method could be based on drugs that destroy the capacity of the ovaries to produce

viable ova or on an immunization against a body

protein that is essential for reproduction. Although the method could be effective following

a single administration, it is more likely that a

series of administrations of the drug or vaccine

would be needed. Such a method would offer a

low-cost, noninvasive alternative to surgical

sterilization.

pharmacologic or Immunologic Sterilization for

Men.—Analogous to the method for women

summarized above, this prospective future technology would produce sterility in the male by

using drugs that permanently eliminate sperm

production or a vaccine that permanently

blocks male fertility. Both types of agents are

already known, but no significant R&D program has been established to develop them into

a male sterilization technique. As for the female

method, considerable research would be

needed to assure both safety and effectiveness.

Since vasectomy is already a simple technique,

the advantages of a pharmacologic or immunologic male sterilization method are less dramatic

than those associated with a similar method for

women.

Agents Other Than LRF Analogs for SelfAdministered Induction of Menses.—A variety of

agents are being investigated for this purpose:

luteolytic prostaglandin analogs, plant extracts,

chemicals that bind to different types of hormone receptors, and antibodies that could be

administered by injection as a one-time, passive

immunization.

Induced abortion

Natural or spontaneous abortion occurs in

about one in five known pregnancies. However,

the loss of fertilized ova prior to or immediately

following implantation is much higher. The

combined total may be as high as 70 percent of

all fertilized ova (20). Many of these spontaneous abortions are due to defective fetuses,

such as those with chromosomal abnormalities.

Induced abortion is a medically safe procedure when performed early in pregnancy

(first trimester) by skilled personnel. Simple suction equipment, such as that developed in rural

China, and manual syringe equipment for office

use, such as that developed in the United States,

have begun to replace the primitive methods

traditionally used in less developed regions. But

the risks of maternal death or serious complications increase greatly when induced abortion is

performed later in pregnancy, and also when

the quality of personnel and facilities is lowered.

Although induced abortion is ubiquitous, its

legal use is constrained in some countries by

religious beliefs. The limitations of current contraceptive technologies, particularly lack of

access to their use, cause many women in all

parts of the world to seek induced abortions to

terminate unwanted pregnancies. Abortion is

not a preferred method of birth control but at

times is the only means of preventing an undesired birth. The large numbers of women who

seek abortions are more an index of how strongly births are not wanted and contraception is

needed than an indication of the preference for

abortion.

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

or improperly conducted abortions, such as injury to the cervix; etc.

Except for a few congenital defects, the principal criterion for the diagnosis of sterility is

failure of a couple to achieve pregnancy after a

significant period (e.g., 2 years) of cohabitation

without practicing contraception. Worldwide

infertility has been estimated as involving 5 to

10 percent of couples (25). The prevalence of

sterility rises from a low of 3 to 4 percent among

young couples, to 20 percent among couples in

their early 30’s, and rapidly to 100 percent

(menopause) during the woman’s 40’s. In some

areas, as in parts of sub-Saharan Africa, sterility

from infectious diseases is common enough to

lower birth rates and to be a major reason for

seeking medical care. In Zaire, for example, the

high prevalence of sterility caused by venereal

infections was documented in the 1950’s in association with lower than expected birth rates.

Following effective efforts to reduce venereal

diseases, the occurrence of sterility was

markedly reduced and birth rates rose (18).

Several technological innovations could have a

major impact on the capacity to diagnose the

causes of infertility. These include development

of reliable, simple techniques for predicting as

well as for confirming ovulation; development

of similar tests for determining the level of functioning of the male seminiferous tubules; and

further development of ovulation-inducing

Sex selection -— —

Sex selection is included as a fertility planning

technology in this study because a strong preference for sons persists in many LDCs, scientists

are working on new technologies, and the probable impacts of effective technologies could be

highly disruptive and contrary to rising expectations of sexual equality.

The evidence for sex preferences in different

parts of the world is well documented in descriptions of the divisions of power and labor

between men and women and in such practices

drugs to verify the woman’s capacity for

ovulating.

In women, the major preventable cause of infertility is infection leading to damage of the

fallopian tubes. A variety of public health

measures can reduce the incidence of such infections, including control over the transmission of venereal disease and, in some countries,

prevention of tuberculosis. Two technological

developments could be significant: the development of IUDs associated with a lower risk of

pelvic inflammatory disease, and the development of vaccines against venereal diseases.

New technologies likely to be extremely useful

for inducing fertility in couples are LRF agonists

for inducing ovulation and LRF agonists and

other possible releasing-factor analogs for increasing sperm production. For some couples,

infertility in one partner cannot be treated, and

assistance will only be possible in the form of

adoption, use of another person’s sperm via artificial insemination, or use of in vitro fertilization followed by embryo transfer to the uterus.

These technologies now exist but are expected

to benefit from improvements in sperm banking

and techniques for artificial insemination, and

from new developments in ovum extraction, in

vitro fertilization, and embryo implantation.

These techniques, however, are expected to

have little global impact on the treatment of infertility.

as female infanticide (see ch. 7). Despite political

actions of a few countries like China to eliminate preference for males by raising the status

of women, it seems likely that a simple, effective

technology for sex selection would be widely

used.

Current technologies are highly ineffective

for sex selection short of performing amniocentesis to ascertain the sex of the developing embryo and then carrying out a second trimester

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

early embryos might emerge in the next 20

years, enabling much earlier determination of

sex. This would make possible the choice of first

trimester abortion if the sex were unwanted,

but any such technological advances would face

strong social, political, and ethical pressures

against the use of induced abortion for what

most perceive to be a trivial purpose.

A second approach to sex selection that has

been the subject of limited research entails

separation of sperm into male-determining

sperm (those bearing Y chromosomes), and

female-determining sperm (those bearing X

chromosomes), followed by artificial insemination with the desired sperm. While this approach might be more acceptable, prospects for

developing highly effective sperm separation

techniques are limited and even if these existed,

the need to employ artificial insemination would

almost certainly prevent this from becoming a

generally used procedure.

Claims that certain chemicals present in the

vagina at the time of ejaculation or that the timing of intercourse during the menstrual cycle

could affect the sex of the offspring have proved

largely unfounded. Nonetheless, there exists a

remote possibility that a chemical or immunological agent might be discovered that

would differentially destroy male- or femaledetermining sperm. If such a substance were to

be developed, a male pill or injection or a

vaginal preparation for selecting the sex of the

offspring could become a practicable reality. In

view of the lack of research aimed at this objective, the serious social questions about

of sex selection, and uncertainty of

market for sex selection products, it

unlikely that a product for general

become available by 2000 A.D.

the value

an MDC

is highly

use will

The need for better fertility planning technologies

Each existing fertility planning method has

one or more serious limitations, such as mode of

administration, interference with coitus, need

for frequency of use, cost (a significant factor in

LDCs), requirements for special personnel and

facilities, and conflicts with cultural, religious,

and medical norms. Side effects of IUDs and

steroids are sufficient to discourage adoption by

some women and discontinuation of use by

many,

One-year discontinuation rates in LDCs are

high for both the pill (60 percent) and the IUD

(40 percent) (11). These and other methods can

be inappropriate for use in many settings. Pills

can be misused by being taken irregularly or in

the wrong sequence, resulting in low effectiveness, and because the mode of action of

IUDs is not well understood, the devices are

sometimes suspected of “migrating” to other

parts of the body by women in LDCs. Changes

in menstrual duration and flow sometimes

cause fears, as do reports of death and injury

from various methods. Requirements of vaginal

methods for clean water and a degree

privacy can deter their use in LDCs.

of

Many methods require medical personnel for

delivery and follow-up care, and because their

use is not well-researched for LDC groups, relative risks are unknown. A number of methods

require logistical support systems that are

beyond the capacities of many LDCS) where

refrigeration, transport, and storage facilities

may be inadequate. The complexities of many

methods require high levels of scientific and

technical sophistication for their selection, procurement, and delivery. The difficulty of sterilization reversal remains a principal drawback

despite improvements in surgical techniques,

and no method other than periodic abstinence is

acceptable to the Roman Catholic Church.

The failure rate, or inability of the method to

accomplish its primary purpose of preventing

unwanted pregnancy, is a critical shortcoming.

Even in MDCs, where levels of use of the most

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

unwanted births and large numbers of induced

abortions, Some 500,000 babies are born in the

United States each year to parents who did not

want them, and an approximately equal number

of induced abortions are reported for married

women (6).

It is clear that although current fertility planning methods are far superior to those of just 20

years ago, they remain inadequate to the needs

of MDC users and fall critically short of the

needs of couples in LDCs. When the lifetime

needs of both MDC and LDC couples—who will

require an effective, safe, reversible, easy-to-use

contraceptive method for 20 to 25 years of their

lives–are taken into account, the disparity between technology and need is greater still. Current methods have considerable unused potential for lowering LDC birth rates in the next 20

years, but cannot yet adequately meet the needs

and desires of people either in MDCs or LDCs.

When the urgent desire to reduce the incidence

of induced abortion is also taken into account,

the magnitude of need for better contraceptive

technologies cannot be underestimated.

Chapter 5 references

1. Armed Forces Institute of Pathology, Hepatic

Branch, and Center for Disease Control, Bureau

of Epidemiology, Family Planning Evaluation Division, “Increased Risk of Hepatocelhdar Adenoma

in Women with Long-Term Use of Oral Contraceptives)” Morbidity and Mortality Weekly Report,

26(36): 293-294, 1977.

2. Barnes, A. C., Schearer, S. B., and Segal, S. J.,

“Contraceptive Development,” in Working Papers:

The Be/lagio Conference on Population (New York:

The Rockefeller Foundation, 1974).

3. Bradshaw, L. E., “Vasectomy Reversibility–A

Status Report, ’’Population Reports, Series D, No. 3,

May 1976. Population Information Program, The

Johns Hopkins University, Baltimore.

4. Cain, P., “Future Prospects for the Development

of Birth Planning Technology: What the Experts

Think,” report prepared for OTA, Washington,

D. C., 1980.

5. Coleman, S., and Piotrow, P. T., “Spermicides

—Simplicity and Safety are Major Assets,” Population Reports, Series H, No. 5, September 1979,

Population Information Program, The Johns

Hopkins University, Baltimore.

6. Forrest, J. D., Sullivan, E., and Tietze, C., “Abortion in the United States, 1977 -1978,” Family P[anning Perspectives, vol. II, No. 6, November-December 1979, Alan Guttmacher Institute, New York,

pp. 329-341.

7. Harper, M. J. K., “Prospects for New or Improved

Birth Control Technologies by the Year 2000

A. D., “ report prepared for OTA, Washington,

D. C., 1980.

8. Henry, A., Rinehart, W., and Piotrow, P. T., “Reversing Female Sterilization, ” Population Reports,

9.

10,

114

12.

13,

14,

15.

16.

Series C, No. 8, September 1980, Population Information Program, The Johns Hopkins University, Baltimore.

Jick, H., et al., “Vaginal Spermicides and Congenital Disorders,” Journal of the American

Medical Association, 245(13): 1329-1332, 1981.

Kane, L. J., Executi\re Director, Human Life and

Natural Family Planning Foundation, Alexandria,

Va., personal communication, 1981.

Mauldin, W. P., “Experience With Contraceptive

Methods in Developing Countries,” in Contraception: Science, Technology, and Application, Proceedings of a Symposium, National Academy of

Sciences, Washington, D. C., 1979.

May, D., “Mortality Associated With the Pill” (letter to the editor), Lancet, 2(8044): 921, 1977.

Ory, H, W., “The Health Effects of Fertility Control,” presented at the Symposium on Contraceptive Technology, National Academy of Sciences,

Washington, D. C., May 19, 1978.

Piotrow, P. T., Rinehart, W., and Schmidt, J. C.,

“IUDs-Update on Safety, Effectiveness, and Research,” Population Reports, Series B, No. 3, May

1979, Population Information Program, The

Johns Hopkins University, Baltimore.

Potts, M., Speidel, J. J., and Kessel, E., “Relative

Risks of Various Means of Fertility Control When

Used in Less Developed Countries, ” in Sciarra, J.,

Zatuchni, G., and Speidel, J. J. (eds.), Risks, Benefits, and Controversies in Fertility Control (Hagerstown, Md.: Harper & Row, 197’6).

Ravenholt, R, T., and Rinehart, W., “Mortality

From Circulatory System Disease in Four Countries,” January 1978 (unpublished). Reproduced

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

A, No. 5, January 1979 (reprinted May 1980).

17. Rinehart, W., and Piotrow, P. T., “Oral Contraceptives–Update on Usage, Safety, and Side Effects,” Population Reports, Series A, No. 5, May

1980, Population Information Program, The

Johns Hopkins University, Baltimore.

18. Romaniuk, A., “Increases in Natural Fertility During the Early Stages of Modernization: Evidence

From an African Case Study, Zaire)” Population

Studies, 34:293-310, 1980.

19. Schearer, S. B., “Future Birth Planning Technologies)” report prepared for OTA, Washington,

D.C. 1980.

20. Schlesselman, J. J., “How Does One Assess the

21

Risk of Abnormalities From Human In Vitro Fertilization?” American Journal of Obstetrics and

Gynecology, 135:135-148, 1979.

Silbur, S. J., and Cohen, R. S., “Microsurgical Reversal of Female Sterilization: Techniques and

Comparison to Vasectomy Reversal)” in S. J. Silber (cd.), Microsurgery (Baltimore: Williams &

Wilkins, 1979), p. 185-242.

22. Tietze, C., Induced Abortion: A World Review,

23,

24.

25,

26,

1981 (4th cd.) (New York: The Population Council, 1981).

Wheeler, R. G., Duncan, G. W., and Speidel, J. J.

(eds.), Intrauterine Devices: Development, Evaluation, and Program Implementation (New York:

Academic Press, 1974).

World Health Organization, Special Programme

of Research, Development and Research Training

in Human Reproduction, Seventh Annual Report,

1978.

World Health Organization, Special Programme

of Research Training in Human Reproduction,

Eighth Annual Report, 1979.

Wortman, J., “The Diaphragm and Other Intravaginal Barriers—A Review,” Population Reports,

Series H, No. 4, January 1976, Population Information Program, The Johns Hopkins University,

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 institutions, 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 Research and the Agency for International Development’s (AID) Office of Population were created. Although worldwide expenditures for reproductive research and contraceptive development rose from $31 million to $155 million between 1966 and 1979, when adjusted for inflation 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 percent 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 individuals 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 marketing 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 patent life, leaving manufacturers too little time to recoup their investments. Drug patents run

for 17 years, and the market approval process averages 71⁄2 years-81⁄2 years for hormonal

contraceptives. However, for the oral contraceptives, patent holders have been able to increase prices and retain a dominant share of the market even after their patents have expired. Liability insurance costs have risen, and, in some cases, pharmaceutical manufacturers have had difficulty in obtaining satisfactory insurance coverage. These product liability problems may be deterring some pharmaceutical manufacturers from the contraceptive 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 investigation, reproductive research and contraceptive

development are comprised of the following activities:

●

●

●

●

basic research (in both the reproductive

process and in related fields; e.g., immunology);

training of scientists;

applied research (i.e., goal-oriented R&D);

and

evaluation of the safety and effectiveness of

methods already in use.

These activities and, in some cases, the introduction and marketing of contraceptives, are

carried out in varying degrees by the following

entities:

. academic institutions;

● the pharmaceutical industry;

● private foundations;

● the U.S. Government;

● foreign governments; and

• international agencies.

In the following analysis, recent trends in the

financing of reproductive research and contraceptive development are discussed. The major

public sector organizations involved are described, and selected factors that affect reproductive research and contraceptive development are examined.

Support of reproductive research and

contraceptive development

Trends in financial support

Throughout the 1940’s and 1950’s, contraceptive development was not directly supported by

the U.S. Government. Oral contraceptives, for

example, were developed with the support of

private philanthropy (particularly the Rockefeller Foundation) and the pharmaceutical industry,

In the late 1960’s, the U.S. Government created agencies that eventually began allocating

relatively small amounts of research funds to

contraceptive development. In 1967 the Office

of Population was created within AID, and in

1968 the Center for Population Research was established in the National Institute of Child

Health and Human Development within NIH. On

the international level, the United Nations Fund

for Population Activities (UNFPA) was created in

1969, and in 1972 the Special Programme for

Research, Development and Research Training

in Human Reproduction was established within

the World Health Organization (WHO).

In 1979, worldwide funding for reproductive

research and contraceptive development totaled approximately $155 million, an increase

from $31 million in 1965. However, expressed in

constant (1970) dollars, this $155 million was

equal to $82.6 million, and the high point in

funding was 1972-73 (fig. 20). There has thus

been a decline in these funds of about 20 percent since 1973 (table 22).

During the 1970’s, the U.S. contribution remained at approximately 70 percent of the

worldwide total; the remaining 30 percent was

provided largely by other industrialized nations

and by the LDCs (table 22). The U.S. contribution in 1979 was $111.6 million (actual dollars),

or 72 percent of worldwide expenditures.

U.S. contributions consist of funds from the

U.S. Government, philanthropic and nonprofit

organizations, and industry, and there has been

a shift in relative contributions among these

sources. In the 1960’s, these three sources provided roughly equal percentages of the total

.
Ch. 6—Reproductive Research and Contraceptive Development ● 107

Figure 20.—Worldwide Expenditures for

Reproductive Research, 1965-79

150

140

130

120

110

100

90

80

70

20

10

0

SOURCE: L. Atkinson, et. al., “Prospects for Improved Contraception,” family

P/arming Perspectives, 12(4), pp 173-192, 1900.

U.S. contribution, but by the late 1970’s, the U.S.

Government was by far the major contributor,

providing 70 to 80 percent of the total U.S. contribution (table 23). The U.S. Government is

thus the major current contributor to reproductive research and contraceptive development,

providing more than 50 percent of total worldwide expenditures.

The components of worldwide total expenditures for reproductive research and contraceptive development are summarized in table 24

and figure 21. Worldwide public sector expenditures, by governments and philanthropic and

nonprofit organizations, constitute about 85 to

90 percent of total expenditures (table 23). The

components of these public sector expenditures

are summarized in table 25. Approximately 70

percent of total funds go to basic research and

training, 20 to 25 percent to contraceptive development, and less than 10 percent to safety

assessments. In contrast, about 80 percent of

public sector funds are spent on basic research

and training, 10 to 15 percent on contraceptive

development, and 10 percent on evaluation of

current methods (compare tables 24 and 25).

The public sector thus allocates proportionately

more funding to basic research and less to contraceptive development than does the private

sector.

The proportionate distribution of public sector expenditures in 1978 for contraceptive development (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 methods (such as sterilization) for female or male

use. Of the 71 percent of expenditures on methods for women, 37 percent was spent on new

approaches to use of steroids, including subdermal implants, improved oral products, injectable, 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,

menses-inducing and abortifacient drugs, and

barrier methods.

Major agencies involved in

reproductive research and

contraceptive development

The following organizations or scientific institutions currently either finance or conduct

reproductive research and contraceptive development, largely for LDCs:

The Center for Population Research (CPR)

was established in 1968 within the National

Institute of Child Health and Human Development at NIH. In turn, CPR established its

Contraceptive Development Branch, which

in 1979 spent about $7 million.

The International Fertility Research Program (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 $13.7 $16.3 $21.2 $24.7 $24.4 $23.3 $24.8 $25.8 $24.3

a $22. 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 71.8

a 73.8a 68.0 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

Year Total

1969 . . . . . .

1970 . . . . . .

1971 . . . . . .

1972 . . . . . .

1973 . . . . . .

1974 . . . . . .

1975 . . . . . .

1976 . . . . . .

1977 . . . . . .

1978 . . . . . .

1979 . . . . . .

Research to

evaluate

current

methods

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 conof 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 supported by AID, NIH, and private donors (primarily the Hewlett Foundation).

● The Program for Applied Research on Fertility Regulation was established in 1972

and, through subcontracts, has established

its own clinical testing network for new

contraceptives. Its annual budget is about

$1.9 million, approximately 90 percent of

which is provided by AID.

● The International Committee for Contraception Research was founded in 1971 by

the Population Council for contraceptive

product development. Its $2.7 million annual budget is funded in roughly equal portions by the Rockefeller Foundation, the

Ford Foundation, the International Development Research Centre (IDRC) (a Canadian

Government agency), and AID.

● The Special Programme of Research, Development, and Research Training in Human

Reproduction was established by WHO, a

U.N. agency, in 1972. A little over $4 million

of its 1979 budget of $16.9 million was

allocated to applied contraceptive R&D.

Other activities include developing scientific institutions and manpower in LDCs,

setting scientific and technical standards,

providing supplies and equipment for research, and providing information about

the performance of existing family planning

programs.

● The Program for the Introduction and

Adaptation of Contraceptive Technology

(PIACT) was founded in 1976 to serve as a

bridge between the clinical researcher and

the family planning program manager, and

a significant part of its program effort is

directed toward introducing new and improved contraceptive technologies into public sector family planning programs. It is

currently helping several countries, including the People’s Republic of China, establish

the local capability to produce the contraceptives they require. PIACT was initially

financed largely by the Ford Foundation.

About 50 percent of its 1981 budget of over

$4 million is provided by UNFPA, approximately 15 percent by IDRC, approximately

30 percent by American private foundations (primarily the Ford Foundation, the

Andrew W. Mellon Foundation, and the

Hewlett Foundation), and the remainder

from other sources.

Factors affecting reproductive research and

contraceptive development

Availability of R&D funds from

public sector sources

Government agencies now provide most of

the funds for reproductive research and contraceptive development. The U.S. Government

provides over 50 percent of worldwide funds;

other nations contribute about 25 percent (table

27). Philanthropic institutions, nonprofit organizations, and industry provide the remaining

25 percent in roughly equal proportions. Support from U.S.-based philanthropic and nonprofit organizations peaked in 1971-72, while

nonprofit organizations in other countries have

increased their contributions since that time

(table 23). Industry’s contributions have remained fairly stable, but its share of total funding has decreased from about 20 to 10 percent

(table 27) while government contributions have

increased.

Public sector funding has historically been

largely devoted to basic research and training.

Because funds from these sources increased

from about two-thirds of the worldwide total in

1965 to about 90 percent in the late 1970’s,

funds for this purpose were adequate to keep

pace with inflation. However, funds for contraceptive development did not increase enough to

offset inflation. Funds for research on safety

and other evaluations of current methods rose

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

(see fig. 21).

Basic research is

at approximately that level

primarily investigator-initiated and administered through grants. The research enterprise has historically emphasized

investigator-initiated research, and this emphasis is likely to continue. Contraceptive development and safety and other evaluations of current methods are goal-oriented and usually administered through contracts. In addition, concerns over the safety of drugs and medical devices—concerns that are especially acute in the

contraceptive field—translate to pressures to increase safety testing. Contraceptive development thus faces competition for funds not only

from basic research activities but also from the

burgeoning field of safety assessment.

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 incorporate these research findings into

their product development activities. This avenue has recently been enhanced by a new patent law (Public Law 96-517), which contains

more liberal provisions for the transfer of patent rights arising from inventions sponsored by

the Government. This law creates a uniform set

of procedures by which small businesses can

gain licenses to develop federally sponsored inventions to which the Government retains title

but that were previously left undeveloped. The

new law seeks to: 1) use the patent system to

promote the utilization of inventions arising

from federally sponsored research; 2) encourage maximum participation of small business

firms; 3) promote collaboration between commercial concerns and nonprofit organizations

(including universities); 4) ensure that inventions made by nonprofit organizations are used

to promote competition and free enterprise; (5)

promote the commercialization and public availability of inventions made in the United States

by U.S. industries and labor; 6) retain by the

Government sufficient rights to protect the public against nonuse or nonreasonable use of inventions; and 7) minimize the cost of administering policies in this area.

Second, Federal agencies can directly finance

selected research projects that normally would

be financed by the industry itself. For example,

the National Cancer Institute will conduct animal toxicity tests and clinical trials of anticancer

drugs developed by the industry. This is also

true for vaccines. The National Institute of

Allergy and Infectious Diseases will finance

basic and epidemiologic research, as well as

clinical trials, to stimulate vaccine manufacturers to develop and market new vaccines (10).

The agency within NIH that finances contraceptive development is CPR in the National
Ch. 6—Reproductive Research and Contraceptive Development ● 113

Institute of Child Health and Human Development. In 1979, CPR's Contraceptive Development Branch (CDB) spent about $7 million,

about 14 percent of CPR’s research budget. Currently, CDB is helping the industry develop

three contraceptives (3). For the past 6 years,

CDB has jointly financed long-term animal toxicity tests and clinical trials of norethindrone

enanthate with Schering A. G., a German pharmaceutical company. CDB will probably continue to help finance clinical testing of this drug

through completion of the new drug application

(NDA) process. For 3 years, CDB, Alza Pharmaceutical, and WHO have jointly financed the

development of a biodegradable implant of a

progestin-type contraceptive. CDB began financing a joint effort with Syntex pharmaceutical

company in June 1980 to conduct early animal

toxicity tests and clinical trials with a luteinizing-releasing factor agonist.

The market approval process

Before U.S.-manufactured drugs and medical

devices can be marketed, they must meet the

minimum standards of safety and effectiveness

established by Congress through a series of legislative actions. The principal laws are:

● The 1906 Food and Drug Act;

● The 1938 Food, Drug, and Cosmetic Act;

● The 1962 Drug Amendments; and

● The 1976 Medical Devices Amendment.

The interpretation of these laws and the enforcement of the standards set are the responsibility of the FDA.

Although postmarketing surveillance is also

conducted, U.S. laws are designed to screen

drugs and medical devices before they are used

by the public, so premarket testing is used to

predict whether or not significant harm could

occur with human use. FDA regulations thus

emphasize the use of predictive methods which,

given the state of current scientific knowledge,

depend heavily on tests in laboratory animals.

The issues concerning the market approval

process and its effect on contraceptive development are generic to FDA’s role in the regulation

of drugs and medical devices in general, but

these issues are especially sensitive in the contraceptive area.

TESTING METHODS

FDA regulations specify the kind and length of

tests that must be completed for market approval. Testing requirements for oral contraceptives are more stringent than for other types

of drugs because they are used for long periods

by healthy individuals rather than by individuals with disease. Table 28 summarizes the animal tests that must be completed before testing

in humans can take place and an NDA is submitted. In each phase of testing, the regulations

require longer testing periods and more animal

species for oral contraceptives than for other

drugs: 90-day studies in rats, dogs, and monkeys, v. 2- to 4-week studies in two animal

species prior to Phase I; l-year studies in rats,

dogs, and monkeys v. 90-day studies in two animal species prior to Phase II; 2-year studies in

rats, dogs, and monkeys, and initiating 7-year

Table 28.—Preclinical and Clinical Requirements

for Oral Contraceptives in the United States

Phase 1:

Phase 11:

Phase Ill:

Market ing

approval:

Ninety-day studies in rats, dogs, and monkeys

must be completed prior to Phase I studies,

which involve 10-20 individuals for up to 10

days. (For other drugs, Phase I studies can be

initiated after 2-4 week studies in two animal

species.)

One-year studies in rats, dogs, and monkeys

must be completed prior to Phase II studies,

which involve approximately 50 women for

three menstrual cycles. (For other drugs,

Phase II studies can be initiated after W-day

studies in two animal species.)

Two-year studies in rats, dogs, and monkeys

must be completed and 7-year dog and

10-year monkey studies must be initiated

before Phase Ill testing may begin.

Progress reports on long-term studies in dogs

and monkeys are required at the time of new

drug application (NDA) submission. (For other

drugs, chronic toxicity studies—including

l-year dog, 18-month mouse, and 2-year rat

studies—must be completed by the time of

NDA submission.)

SOURCES: M. Finkel: “Contraceptive Regulation in the U.S.,” paper presented

at the PIACT Workshop on Developing Countries and the Regulation of Contraceptive Drugs and Devices, Seattle, Wash., July 24,

1978; E. 1. Goldenthal, “Current Views on Safety Evaluation of

Drugs,” FDA Papers, May 1988, pp. 13-18; E. 1. Goldenthal, “Contraceptives, Estrogens, and Progestogens: A New FDA Policy on Animal 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,

18-month mouse, and 2-year rat studies before

an NDA can be submitted.

FDA regulations also require that the beagle

be the breed of dog used to test oral contraceptives for safety. This requirement has raised the

most controversy, because the appearance of

breast tumors in beagles when given depot medroxyprogesterone acetate (Depo-Provera) was

one of the reasons why the FDA denied Upjohn

Co.’s supplemental NDA in 1978.

The reasons given for FDA’s nonapproval

included more than the appearance of breast

tumors in beagle dogs. The complete list of

reasons was:

●

●

●

●

●

malignant breast tumors in beagle dogs;

estrogen may be administered to women receiving Depo-Provera in order to control

the irregular bleeding disturbances often

caused by this drug. In FDA’s opinion, the

added risk of cancer from the simultaneous

use limited the benefits that might be associated with a progestin-only contraceptive;

the patient population originally targeted

for Depo-Provera had diminished substantially as other methods of contraception

and sterilization became increasingly available and accepted;

doubts that the proposed postmarketing

studies on breast and cervical carcinomas

would yield meaningful data; and

progestin and estrogen-progestin drugs increase the risk of congenital abnormalities

in the fetus. Depo-Provera is a progestin,

and a failure of contraception or an error

made by injecting a woman already pregnant would result in exposure of the fetus

to this hormone (9).

Depo-Provera is currently approved for use in

the United States only for inoperable cancer of

the uterus and renal cancer, a use approved

since 1972. It is manufactured and used as an injectable contraceptive in other countries. Drugs

produced abroad for use abroad are beyond

FDA’s regulatory reach.

Contraceptive drugs are given to young,

healthy individuals and can potentially be administered over a period of 30 years. FDA requires testing in both the beagle and the monkey because the beagle is highly susceptible to

spontaneous breast tumors, the monkey is relatively resistant, and the human female falls between the beagle and the monkey in the incidence of spontaneous breast tumors. FDA also

points out that no contraceptive currently approved for marketing has shown a carcinogenic

potential in the beagle dog assay similar to

Depo-Provera (14).

In contrast, other internationally recognized

agencies have taken the position that the beagle

dog is not predictive of any risk of breast cancer

in women using steroid hormones. These agencies include the Special Programme of Research,

Development, and Research Training in Human

Reproduction of WHO (october 1978); the Committee on the Safety of Medicines in the United

Kingdom (February 1979); and the International

Planned Parenthood Federation (IPPF) (November 1980). In addition, a recent review of DepoProvera concluded that “a great deal of human

data have been collected and these show no

evidence of human risk at present” (7).

The Depo-Provera issue has focused much attention on the beagle dog, but this specific controversy should be viewed in its broader context. Safety testing for contraceptives is understandably more stringent than for other drugs

in both the length of testing required and in the

kinds of laboratory animals subjected to testing.

Both requirements increase the time and expense incurred in contraceptive product development compared with product development

for drugs in general.

EXPORT OF DRUGS AND MEDICAL DEVICES

A large, expanding market for contraceptives

no longer exists in the United States but does in

the LDCs, where large percentages of people

are either in their reproductive years or about

to enter them.

In general, the U.S. Food, Drug, and Cosmetic

Act prohibits U.S. pharmaceutical manufacturers from exporting drugs not approved for

marketing in the United States. Two categories
Ch. 6—Reproductive Research and Contraceptive Development ● 115

of drugs are at issue: 1) drugs unevaluated for

use; and 2) drugs evaluated but found unacceptable for use. A few exceptions to this provision

exist; e.g., investigational drugs can be exported

for investigational purposes, provided that an

importing country’s government has approved

such imports.

Medical devices that are not approved for

marketing in the United States can be exported,

provided: 1) they conform to the laws and specifications of the importing country; and 2) their

export is not considered by the Secretary of

Health and Human Services to be contrary to

the public health and safety of the importing

country.

Changes in the export provision of non-FDA

approved drugs have been considered by Congress. In the 96th Congress, a bill adopting the

medical devices export law for drugs passed the

Senate but died in the House of Representatives.

The U.S. Government’s policy of prohibiting

the export of non-FDA approved drugs is based

on safety and efficacy concerns. FDA recognizes

that different standards may exist elsewhere

but does not know which ones to apply when

U.S. standards are not met, Some importing

countries also do not have mechanisms to either

evaluate or regulate the quality of drugs they

import (18), so the United States is unable to

defer to or apply these standards. There are

also documented episodes of “drug dumping;”

i.e., situations in which drug companies promote products in LDCs deemed unsafe or ineffective in more developed countries (MDCs),

The analgesic drug Dipyrone, for example, was

removed from the U.S. market because of its

documented toxicity, yet it is marketed overthe-counter in several Central and South

American countries (4). In addition, substantial

differences in product labeling—e,g., indications

for use and precautions—have been noted for

selected products marketed in different countries (15), but attempts to develop international

uniform labeling standards have been only partially successful.

Those who advocate exportation of drugs unapproved in the United States base their arguments on the right of a country to make its own

risk/benefit analyses, differing risk/benefit ratios in other countries, and economic concerns.

The belief that an importing country has a

right to assess the risk/benefit ratio for a drug’s

use among its people is consistent with the international legal principle of comity, which

states that countries have a duty to respect the

sovereign rights of other nations. Further, because of international variatio~s in life expectancy, standards of living, prevalence of diseases,

and availability of health care, the relative risks

and benefits of a given drug are different

among different populations.

In order to market products unapproved in

the United States, several American pharmaceutical companies have either established, purchased, or used manufacturing facilities in

foreign countries, where their products are

either approved for use or where laws permit

the export of unapproved products. Some U.S.

manufacturers argue that if they were able to

export their nonapproved products from the

United States, they would manufacture such

products in this country rather than abroad.

They further argue that such manufacturing

would contribute to the U.S. economy (in terms

of capital formation and employment) and thus

help improve the United States’ international

balance of payments.

The Depo-Provera controversy has also contributed to this debate over current law on the

exportation of drugs not approved for use in the

United States. Because it is approved for U.S.

use for the treatment of endometrial and renal

cancer but not for use as a contraceptive, DepoProvera manufactured in the United States cannot be exported as a contraceptive. But it is

manufactured abroad, and in 1977 was in use in

42 countries (13).

AID has received requests from LDCs for

financial assistance to purchase Depo-Provera

for contraceptive purposes. But AID’s usual

position has been to refrain from providing

other countries with drugs not approved by the

FDA for use in the United States. A panel of external advisors to AID recommended in 1980

that the agency make Depo-Provera available to

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

1981, FDA had chosen the members of a Public

Board of Inquiry to evaluate the findings on

Depo-Provera; AID is awaiting the Board’s recommendations. However, AID does help finance

UNFPA and IPPF, both of which purchase DepoProvera. Because UNFPA commingles its funds,

money from a particular donor cannot be earmarked for specific uses. IPPF, however, itemizes its expenditures by donor so that AID is

assured that its funds are not used for purchasing Depo-Provera.

Here again, as with the case of the beagle dog

findings for Depo-Provera’s carcinogenic potential, the specific controversy surrounding the

ban on export of U.S.-manufactured Depo-Provera for contraceptive use should be viewed in

its broader context. That is, it should be taken as

illustrating, and not controlling, the difficult

issues surrounding current U.S. policy on the

exportation of U.S.-manufactured drugs.

Patent life

Drug patents run for 17 years, but the industry has expressed concern that the FDA market approval process takes so long–an average of 71/2 years— that effective patent life is

shortened and too little time is left for them to

recoup their investments (6). Patent life could be

legislatively extended beyond the current 17-

year limit, or effective patent life could be

lengthened if the FDA approval process were

shortened. How significantly does the shortening of effective patent life diminish incentives

to research and develop new contraceptives?

The first company that puts a product on the

market has the advantage of capturing a larger

proportion of potential users than a company

entering the market later. Its initial investment

is also greater, since it must underwrite the research costs. Once its patent runs out, if other

companies then enter the market and manage

to cut into its sales, its return on investment is

diminished.

In the field of oral contraceptives, Wyeth Laboratories and Ortho Pharmaceutical share approximately 70 to 80 percent of the market in

the United States. Wyeth’s patent on norgestrel

is still in effect, but the patent on norethindrone

(the progestin in the products marketed by Ortho, Syntex, Parke-Davis, and Mead-Johnson) expired in 1973. After the expiration of the patent

on norethindrone, only Mead-Johnson and Lederle entered the market with oral contraceptives. Even though competitive pricing was utilized by these companies, they did not capture a

substantial share of the market, and Lederle

subsequently withdrew. No generic pharmaceutical house has entered the market.

The Pharmaceutical Manufacturers Association (PMA) reported in August 1980 that of all

classes of pharmaceuticals, oral contraceptives

experienced the greatest increases in price for

the reporting periods 1969-79 (187 percent) and

1978-79 (23.7 percent). In contrast, for over

1,000 ethical drugs, PMA reports only a 37.4-

percent average increase in price for the period

1969-79 and a 6.5-percent increase for 1978-79.

Attractive profits would be expected from such

price increases and would be expected to lead to

price competition or the entry of new competitors. But these price increases occurred primarily after the patents on norethindrone and norethynodrel (Searle’s progestin) had expired and

during Mead-Johnson’s and Lederle’s entries

into the oral contraceptive market.

PMA estimates that between 8 and 9 million

women in the United States now use oral contraceptives, and a substantial number of women

(between 500,000 and 1 million) currently initiate use of oral contraceptives each year. But because the U.S. birth rate is close to replacement

level, the U.S. market is relatively static as new

users of oral contraceptives replace those aging

beyond the reproductive years and those who

discontinue use for other reasons. Thus, pharmaceutical companies that seek to market generic versions of brand name contraceptives

after patents expire must compete in a limited

market, with high advertising costs the probable entry price.

Oral contraceptives have also had difficult

product liability problems. These contribute to

uncertainties in business profit/loss projections

and project a negative image that may affect the

public’s confidence in a pharmaceutical com-
Ch. 6—Reproductive Research and Contraceptive Development “ 117

pany’s other products as well as in its contraceptive products. The ability of the original oral

contraceptive manufacturers to retain their

market share and raise prices significantly

despite expired patents may not be completely

explained by a limited U.S. market and the

negative image that may be keeping other pharmaceutical companies out of the field. However,

this ability to keep the market captive in the

face of patent expiration and rising prices does

lead to the conclusion that, at least for the oral

contraceptive market, initial entry into the

market seems to be the determining factor, not

the length of patent life as affected by the FDA

market approval process.

Product liability

Product liability, its costs to business, and

possible inhibition of new product development

have been prominent issues in recent years.

While not limited to the pharmaceutical and

medical devices industries, its most visible impacts have been through the national swine flu

immunization program of 1976 and in lawsuits

involving the hormone diethylstilbestrol (DES),

oral contraceptives, and intrauterine devices

(IUDs).

Product liability problems, and the ability of

manufacturers to pass on their insurance and

litigation costs to purchasers, may affect the

kinds of future contraceptives developed. Products that involve a single sale or limited repurchase, such as IUDs, provide little means to adjust for increasing liability exposure once the

device is sold. Oral contraceptives, on the other

hand, require periodic purchases. A. H. Robins

ceased selling its Dalkon Shield IUD in 1974, and

in 1980 some of the devices were still in place,

so some users maintained the device in place for

at least 6 years. An oral contraceptive would

have required repeated purchases during that

period of time, and the price of the monthly

dose package could have been adjusted to reflect changing product liability risks. Or if the

sale of the contraceptive had been terminated,

existing supplies of the contraceptive would

have been disposed of or consumed.

Although oral contraceptives represent only

about 4 percent of the total ethical pharmaceutical market, more suits are filed on oral contraceptives per year than on any other class of

ethical pharmaceutical products. Several manufacturers of oral contraceptives reported to

OTA that they have more product liability

claims for contraceptives than for all of their

other pharmaceutical products combined.

Injuries from these causes do not usually

result from negligence in their manufacture,

distribution, or administration, but rather are

statistically rare injuries that will inevitably occur in a few people. In legal parlance, these are

“unavoidably dangerous” though socially useful

products, and the U.S. courts have developed

many legal doctrines as possible avenues

through which the injured person might obtain

compensation for the injuries suffered. That is,

rather than leaving the economic burden of the

injury on the injured persons, courts have tried

to shift the economic loss to the “deep pockets”

of the product manufacturers; for example, by

imposing a “duty to warn” of serious side effects

on the manufacturer and developing a test of

whether the product user had given his/her “informed consent” to use the product after being

warned of the possible side effects that could

occur with use. But legally adequate “duty to

warn” and “informed consent” do not avoid injury. Successfully meeting both tests simply

means that the already injured plaintiff will fail

in the lawsuit.

Product liability is part of business costs for

manufacturers and has traditionally been covered by insurance. Expansion of product liability has led to uncertainties in pricing such insurance, which in turn has led insurance companies to treat such products as special risks or

to move out of the market, leaving manufacturers to self-insure such losses by pooling

funds among several manufacturers or by establishing “captive” insurance companies. These

product liability and insurance problems have

been examined in a previous OTA report, “A

Review of Selected Federal Vaccine and Immunization 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 elements that would constitute a Federal compensation program for injuries caused by vaccines.

That report, “Compensation for Vaccine-Related

Injuries, ” was released in November 1980.

Does product liability have an inhibitory effect on the propensity of the pharmaceutical industry to research and develop new contraceptives, to continue to produce proven contraceptives, and to enter established markets after the

developer’s patent has expired? These are difficult questions to answer for the contraceptive

products field in isolation from what is happening in product liability in general (e.g., football

helmet manufacturers) and in liability per se

(e.g., professional malpractice, whether in medicine, law, engineering, the clergy, etc.), but the

evidence does point to an inhibitory effect.

Whether product liability does or will fundamentally affect the contraceptive field is speculative, but the following findings indicate that it

is a significant problem.

product liability and the adverse publicity that

attaches to a specific product can affect contraceptive development and use in two ways.

First, product liability affects the predictability

of business expenses and what profit margins

can be expected. If these costs are predictable,

the product’s price can be adjusted. If not, the

manufacturer cannot limit its exposure except

by taking the product off the market. In addition, however, such costs may become so large

that they affect the price to the extent that demand may be depressed. And adverse publicity

about a specific contraceptive may: 1) turn consumers to other contraceptives (which would be

justified if the information is correct; i.e.,

market forces and “informed consent” would be

working appropriately); and 2) affect the manufacturer’s decision on what kinds of contraceptives to develop and continue to sell (e.g., oral v.

injectable contraceptives, IUDs v. oral contraceptives).

Predictability and the spreading of costs are

fundamental insurance tenets. But two developments have affected their stability in recent

years. Lawsuits are usually filed and contested

in State courts, whose supreme courts develop

and follow their own legal doctrines. However,

a State’s supreme court may adopt the doctrine

of another State, and it is difficult to predict

when and if this will happen.

Recently, the California Supreme Court (16)

decided that an injured party who does not

know which manufacturer made the product

that led to the injury can sue any of those who

act in ‘(conscious parallelism” and who may have

produced the drug used by the patient. The

plaintiff had developed cancer alleged to be

caused by the hormone DES, taken by her

mother 26 years earlier to prevent a miscarriage. No evidence existed as to which of the

defendant companies manufactured the DES

used by the mother. More than 200 companies

manufactured DES at that time. Michigan has

reached a similar result but on different legal

reasons (l).

The variance in damages for a successful lawsuit may literally be millions of dollars. Spokespersons for manufacturers of oral contraceptives estimate that most jury verdicts for death

or severe injury range from $100,000 to $4 million, and a suit involving its Dalkon Shield IUD

resulted in a $6.2 million verdict against A. H.

Robins.

In addition to judgment costs, there are administrative costs of handling claims, the great

majority of which never reach the courtroom

stage. For instance, A. H. Robins marketed its

Dalkon Shield IUD from 1970 to 1974 and sold

approximately 2 million. According to Robins,

the first reports of problems (septic abortions)

occurred in late 1973. As of September 30, 1980,

there had been 4,660 claims filed against

Robins, with 1,482 pending and 3,178 closed.

Total settlements and judgments paid were $69

million, and Robins estimates its legal fees and

expenses to be about $20 million, or a total of

about $45 (and still growing) for each IUD sold.

Robins was receiving 100 claims per month at

the end of 1980, Robins’ insurer increased premiums and deductibles for IUD coverage to the

extent that Robins rejected the policy in 1978.

Robins found that its loss record on the Dalkon

Shield prejudiced its ability to obtain coverage

on other pharmaceutical products. In order to
Ch. 6—Reproductive Research and Contraceptive Development • 119

obtain product liability insurance on other

pharmaceutical products, Robins had to pay a

$1.4 million surcharge (8).

These escalations in the scope of liability costs

have had two effects: raising the price of contraceptives that have remained on the market,

and leading insurers to treat contraceptives as

special risks. For example, one oral contraceptive manufacturer estimated that product liability expenses for a 20- to 30-percent share of the

market have totaled about $15 million for the

past 10 years and have been escalating at about

$3 million to $4 million per year. Another oral

contraceptive manufacturer estimates that 10

percent of its sale price is earmarked for product liability claims (10).

As for contraceptives as special risks, standard product liability policies for pharmaceuticals now specifically exclude only four types of

products—swine flu vaccines, DES, oral contraceptives, and IUDs. Also, insurance usually

comes in a trifurcated form—a deductible, the

standard policy, and excess insurance—and

these components have changed. For example,

the deductible may have been several hundred

thousand dollars, the basic policy for the next

$5 million to $15 million, and the excess insurance up to a specific limit; e.g., $25 million to

$30 million. This excess insurance would be

provided at a separate premium, either through

a pool of several insurance companies to spread

the risk, or through a high-risk insurer such as

Lloyd’s of London. Today, the self-insurance requirement may be up to $5 million, the premium itself for the standard policy in the millions,

and the excess insurance either not available or

with a premium in the million-dollar range.

Organizations supporting R&D of contraceptive products are not immune to liability. For instance, the Ford Foundation and the Population

Council both carry liability insurance. Even

though such organizations may not manufacture or sell contraceptives in the United States,

the fact that a contraceptive product that causes

harm was developed under their support could

subject them to liability.

The developer of a new contraceptive product

also bears the risk of liability during clinical

trials. The standards for liability are in general

more varied with respect to clinical trials and

often the doctrine of product liability does not

apply. Uncertainties nevertheless exist. While

many developers of pharmaceuticals and medical devices have asserted in an OTA telephone

survey that they have had no liability problems

in clinical trials, there have been reports of difficulties for contractors and developers in obtaining affordable and meaningful insurance.

Liability problems arise when the research is

sponsored at institutions that do not belong to

the pharmaceutical industry (3). The cost of

liability insurance is included in contracts when

necessary, but it is expensive and difficult to obtain. WHO has reported difficulty in securing

contractors for clinical trials because insurance

was not available to the contractor. In at least

one instance, a potential NIH contractor could

not procure adequate liability insurance for a

phase I clinical trial. In another NIH-funded

phase I clinical trial, the insurance for a 1-

month, 12-woman study was in the neighborhood of $30,000, and the policy required considerable amounts of time and effort to procure.

There are clear indications that current product liability in the contraceptive field is more

severe than for other classes of products, has

raised costs, and is severe enough in cost escalation and unpredictability to have affected the insurance companies’ way of doing business with

pharmaceutical manufacturers. This situation is

conducive to diminished interest in future contraceptive research by profitmaking companies.

In addition, liability insurance in the clinical

trial phase of development has become expensive and sometimes hard to obtain, thereby adding to developmental costs and, because of difficulty in purchasing such insurance, imposing

another impediment to the developmental

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.

2d 20 (1980) (Michigan Court of Appeals).

2. Atkinson, L., et al., “Prospects for Improved Contraception,” Familwv P/anrzing Perspectives, 12(4):

173-192, 1980.

3. Bialy, G., Chief, Contraceptive Development

Branch, Center for Population Research, National

Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, personal

communication to the Office of Technology Assessment, 1981.

4. Bueding, E., Professor of Pharmacology and of

Pathohiology, School of Hygiene and Public

Health, The Johns Hopkins [University, letter to

Dr. Donald Kennedy, Commissioner, Food and

Drug Administration, dated Feb. 5, 1979.

5. Cook, R., “U.S. Drug and Devices Regulation and

Contraceptive Innovation, ” and “Laws Regulating

the LJ.S. Export of Drugs and Devices: Options for

the Future, ” OTA working papers, 1981.

6. Demkovich, L. E., “Drug Companies Plead With

Congress: Don’t Shortchange LJs on Patents, ” National Journal, 12(47): 1980-83, 1980.

7. Fraser, I. S., and Weisberg, E., “A Comprehensive

Review of Injectable Contraception with Special

Emphasis on Depot Medroxyprogesterone Acetate, ” “l%e A4edica/ Journal of Ausfraiia, 1(1) (special supplement): 3-19, 1981.

8. Grayson, G. S., A. H. Robins Co., personal communication with the Office of Technology Assessment, 1980.

9. Hubbard, W. N., Jr., President of the Upjohn Co.,

testimony before the U.S. House of Representatives, Select Committee on Population, in Select

Committee on Population, U.S. House of Representatives, hearings on The Depo-Provera Debate,

95th Cong., 2d sess. (Washington, D. C.: U.S.

Government Printing Office, 1978).

10. Huff, S., G. D. Searle and Co., personal communication with the Office of Technology Assessment, 1980.

11. Office of Technology Assessment, U.S. Congress,

A Review of Selected Federal Vaccine and immunization Policies (Washington, D. C.: U.S. Government Printing Office, 1979).

12. Office of Technology Assessment, U.S. Congress,

Compensation for Vaccine-Related Injuries: A Technical Memorandum (Washington, D. C.: LJ. S. Printing Office, 1980.)

13. Sai, F. T., former Assistant Secretary General of

the International Planneci Parenthood Federation

before the [J.S. House of Representatives, Select

Committee on Population, in Select Committee on

Population, [J.S. House of Representatives, hearings on 7’he Depo-Provera Debare, 95th Cong., 2d

sess. (Washington, D. C.: U.S. Go\~ernment Printing Office, 1978).

14. Select Committee on Population, U.S. House of

Representatives, hearings on The Depo-Provera

Debate, 95th Cong., 2d sess. (Washington, D. C.:

U.S. Government Printing Office, 1978).

15. Silverman, M., The Drugging of the Americas (Berkeley and Los Angeles, Calif.: University of California Press, 1976).

16. Sinde// v. Abbott Laboratories, 26 Cal. 3d 588, 607

P. 2d 924 (1980) cert. denied, 49 USLW 3270

(198,0).

17. U.S. Agency for International Development, f?eport to USAID of the Ad Hoc Consultative Panel on

Depot Medro~+vprogesterone Acetate, 1980.

18. Wegman, M. E,, Professor of Public Health, University of Michigan, testimony before the U.S.

Senate, Select Committee on Small Business, Subcommittee on Monopoly, hearings on the Present

Status of Competition in the Pharmaceutical Industry; Pharmaceutical Company Practices in Labeling

and Promoting Prescription Drugs Sold in Latin

America, 94th Cong., 2d sess. (Washington, D. C.:

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 direct and important impact on the reduction of

population growth. LDC government leaders,

aware of the potential benefits of family planning programs and faced with the prospect of

the doubling of many of their populations over

the next 25 years, are giving greater attention to

the status of family planning in their countries.

The findings are often contradictory:

● An average of 50 percent of married

women in LDCs report that they want no

more children, yet from 25 to 90 percent of

these women do not now practice contraception. (Asian and Latin American estimates; data from Africa are not yet available.)

● Variations in contraceptive use are enormous. Contraceptive prevalence rates

range as high as 70 percent and as low as 2

percent of currently married women in

LDCs.

● Many women in LDCs report having from

one to as many as three more children than

they wanted. The policy implications of this

acknowledged unwanted fertility—of children already born–are important in that

resulting fertility rates are one-third to onefourth higher than these women desire.

Most women are fecund (capable of bearing

children) from age IS to about age 45 and most

men are able to sire children throughout adult

life. The decision to have a child, or to use a contraceptive, is influenced by both past and present conditions. Recent research centers on the

four factors that have the greatest direct impact

on fertility (see ch. 4):

● age at marriage and proportion married;

. lactation (breastfeeding);

. induced abortion; and

● contraceptive use.

Efforts to change fertility rates by changing the

relative influence of these factors, which are in

turn influenced by such indirect determinants

as community attitudes about contraception,

levels of education, income, and family relationships (fig. 22) can have unanticipated results.

The socioeconomic determinants affect fertility

in ways that are only partially understood. Nevertheless, their influence is extremely important. For example, fertility has declined at a

more rapid rate in Colombia, Thailand, and

South Korea, which have relatively high socioeconomic settings, than it has in the lower income countries of Bangladesh, Pakistan, and

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

rapid fertility decline.

Because contraceptive use has become increasingly important in reducing fertility, family planning programs focus on this intervention. Yet policies and programs that are multifaceted–that simultaneously take account of

both the other primary factors and the indirect

influences listed in figure 22—are the most likely to be successful. This chapter examines the

results of directed or undirected changes in the

four direct factors listed above.

At least five separate levels of interaction can

be distinguished. Each is a point of both intervention and choice. At each point choices are

available and decisions must be made (fig. 23).

At the government level, a point of intervention/choice is the formation of population policy. The type of policy and the rationale and

support for that policy influence the country’s

population growth rate. A second crucial point

of intervention/choice is the determination of

the structure, form, and function of a family

planning program. Some governments choose to

keep programs and their implementation entirely under official control; others choose to keep

programs exclusively in the private sector; still

others choose a combined approach. A third

point of intervention/choice is the selection of

delivery system or systems used to implement

the program. These systems include IEC efforts.

Intervention and choice also operate at the community level. Social structure, culture, personal

networks, and voluntary groups all come into

play, but the most important decision is that of

the individual, who chooses whether to adopt

family planning. All governmental or orgaFigure 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

the degree that they affect individual behavior.

Fertility change is an interactive, dynamic

process in which individuals, groups, and governments seek to modify the attitudes, customs,

and behavior that surround the most personal,

intimate part of human life. Awareness of the

individual and social factors impinging on this

process can help to avoid the mistaken view of

modern contraceptive methods as “technological fixes” that can, by themselves, lower fertility rates. one of the most important and encouraging findings of recent years is that family

planning attitudes and behavior can change

rapidly. Population programs thus need to be

designed to take account of individual rights

and cultural values while educating individuals

and helping them to change. This chapter highlights the complexity of this process.

Individual concerns: the user perspective

When I think of all the things I ate or swallowed, hoping that they would prevent me from

having another child! But they didn’t work. Now

it is better because I have an IUD. (A village

woman, Mexico) (10)

The perceptions of the individual—based on

the degree of benefit expected from contraceptive use, and the expected duration of that benefit—determine whether he or she will use a

fertility planning method. Because individual

fertility behavior is both the impetus for and the

target of family planning systems, individual

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 situation is unlikely to change greatly in the near

future. This section is thus devoted to the individual 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 attitudes of her husband, family, and social networks but also the availability and cost of

methods. Moreover, the impact of various factors is different depending on her status, age,

and the number of children she already has.

Once she decides to use a method, her perceptions and attitudes influence her choice. (See

table 29 for categories of influences.) For example, a woman might perceive the side effects (irregular menstrual patterns) of a contraceptive

injection as intolerable over a long period. Yet

she might find them tolerable when she and her

husband have agreed that she will be sterilized

but she must wait 6 months until a sterilization

team visits the village.

Table 29.-Types of Influences That Pertain to

the Acceptance and Continued Use of

Contraceptive Methods
128 . Wor/d Population and fertility Planning Technologies: The Next 20 Years

Latent demand for family planning

WFS data provide good evidence of the latent

demand for contraception in their measurement of the percentage of women who want no

more children yet use no contraception. Although this measure may be inflated because

some women who want no more children

would not use contraception even if readily

available because of pressures from peer group,

family, or spouse, it does provide a useful

estimate of unmet demand for family planning

services.

The proportion of “exposed” women (those

currently married, nonpregnant, and fecund—

capable of childbearing) who want no more

children varies from a low of 17 percent in

Kenya to a high of 74 percent in Korea (table

30). The estimates of unmet demand are contained in column 2 in table 30; they range from

Table 30.—Percentage of Exposed” Women Who

Want No More Children, Percentage Not Currently

Using Contraception, and Estimates of Unmet Need

for Effective Contraceptive in 15 LDCs

Of all currently

married women,

percent who are

exposed and want

no more and are

Of exposed women, not using

percent who want Any Modern

no more children method method

Asia ● nd Pacific

Bangladeshb . . . . . . . .

Indonesia . . . . . . . . . . .

South Korea . . . . . . . . .

Malaysia . . . . . . . . . . . .

Nepal. . . . . . . . . . . . . . .

Pakistan . . . . . . . . . . . .

Sri Lanka. . . . . . . . . . . .

Thailand . . . . . . . . . . . .

Latin America

Colombia . . . . . . . . . . .

Costa Rica . . . . . . . . . .

Dominican Republic . .

Mexico . . . . . . . . . . . . .

Panama. . . . . . . . . . . . .

Peru. . . . . . . . . . . . . . . .

Africa

Kenya . . . . . . . . . . . . . .

64

40

74

46

30

42

62

61

17

22

7

17

21

14

25

NA

47

: :

22

21

27

31

22

NA

a high of 47 percent in Bangladesh and more

than 30 percent in Korea, Sri Lanka, and Peru to

a low of 12 percent in Costa Rica.

Rates of contraceptive knowledge–knowledge of at least one modern family planning

method—are high in these countries, with the

exception of Nepal, where only 21 percent of

women know of a modern method. Rates in

Bangladesh and Indonesia (81 percent), Kenya

(88 percent), and Pakistan (71 percent) fall into

the middle range, but in all other countries for

which data are available, 90 to 100 percent of

women know of modern contraceptive methods

(15).

Women in countries where WFS surveys

were conducted were also asked if their most

recent pregnancy was desired. Although their

answers provide a conservative estimate of unwanted fertility because many women are likely

to rationalize a child as wanted after it is born,

the levels of admitted unwanted fertility are

striking (fig. 24). For example, when women in

Peru and Colombia complete their childbearing,

they have an average of 2.75 and 2.19, respectively, more children than they wished to have

(table 31). In national terms, the percentage of

unwanted births constitutes about a third of all

births in Peru and Colombia and a quarter of

those in Panama and Sri Lanka. The lowest rates

of unwanted fertility are observed in Indonesia

and Korea. In Korea, high rates of induced abortion make unwanted fertility rates correspondingly low (50)0

Cultural values and the adoption of

family planning

Why do large numbers of women admit to

wanting no more children or to having more

children than they wanted, yet use no contraception despite high levels of knowledge of

contraception? Among the many possible constraints to contraceptive use—lack of supplies,

fear of side effects, antipathy of the husband—personal attitudes and customs appear to

play a major role. Individual cultural traditions,

sexual taboos, and attitudes toward menstruation, 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

Sc

5.40 RC SC RC

5.34 SC

6;.16

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

Photo credit: Agency for International Development

Village family in a remote sector of Madhya Pradesh, India

Years since

last wanted South Sri

birth Colombia Panama Peru Indonesia Korea Lanka

Cumulative unwanted fertility rate

1. . . . . . . . 0.03

2 . . . . . . . . 0.31

3 . . . . . . . . 0.55

4 . . . . . . . . 0.73

5 . . . . . . . . 0.89

10 . . . . . . . . 1.48

15 . . . . . . . . 1.93

20 . . . . . . . . 2.19

0.04 0.05 0.01 0.01 0.02

0.20 0.30 0.07 0.09 0.17

0.39 0.80 0.21 0.31 0.37

0.52 0.82 0.32 0.43 0.52

0.64 1.04 0.39 0.53 0.62

1.06 1.82 0.59 0.91 0.98

1.33 2.41 0.72 1.06 1.16

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

ceptance and continued use of contraceptive

methods.

Women in the Philippines, Korea, Indonesia,

and Mexico rated the four most important attributes of a contraceptive as: 1) effectiveness;

2) absence of side effects and convenience;

3) route of administration (oral, injectable, or

vaginal); and 4) frequency of use. There were

cultural differences in preference for route of

administration, with the vaginal route generally

least preferred (11). As the most frequent reason cited for discontinuing use of a method is

the presence of side effects (20), priorities may

depend on whether women are simply rating

their preferences for attributes of contraceptives in the course of a survey or actually using

a method.

Women’s perceptions of menstruation vary

widely. Because many contraceptives change

menstrual patterns, these perceptions can hinder—or sometimes enhance—acceptance of particular methods. Rural and urban women from

14 cultural groups in 10 countries—Egypt, India

(Hindu High and LOW Caste), Indonesia (Javanese, Sudanese), Jamaica, Korea, Mexico,

Pakistan (Punjab, Sind), Philippines, United

Kingdom, and Yugoslavia (Moslem, nonMoslem)–expressed reluctance to use a method

that produces amenorrhea. They feel that

menstrual bleeding offers regular reassurance

that they are able to bear children and denotes

youth and femininity, provides evidence that

they are not pregnant, and indicates that the

body is eliminating impure blood. Many women

feel that if “bad blood” is not removed, disease,

failing eyesight, and mental illness are likely to

ensue. Women tend to confuse the duration of

their menstrual periods with the amount of

flow. Light bleeding was equated with 1 to 3

days duration and heavy bleeding with 6 or

more days duration (52). If family planning providers are to be sensitive to individual concerns,

they must be certain that side effects that produce amenorrhea are fully understood by the

user and that she is aware that she will not suffer disease or hold ‘(impure” blood in her body if

she adopts a particular method. If a method

decreases the duration of flow, the user needs

to be reassured that the flow will not necessarily be less, or that the shorter duration is not

harmful.

Although some women in this 10-country

study believe that menstruation is like an illness,

they do not necessarily behave as though

unwell. Conversely, those not holding this belief

were found to exhibit the greatest behavioral

changes during menstruation. Even though the

women studied said they wanted no changes in

their bleeding patterns, many of them—and

many women in other countries—are currently

using injections and orals that do in fact change

the volume and duration of blood loss and do

sometimes cause amenorrhea. Among the tradeoffs in the process of deciding whether to use an

injection method, efficacy and ease of administration may be more important than

changes in menstrual cycle. Such considerations

as need for surreptitious use of a method or unavailability of other contraceptive methods may

also come into play.

The knowledge that beliefs are often inconsistent with behavior can be put to creative use

in the delivery of services. The IUD was unacceptable in the Indian village of Bunkipur

because the indigenous interpretation of its

mechanism of action conflicted with cultural

definitions of health. The people of Bunkipur

divide their world (food, religion, medical

system, etc.) into “cold” and “hot” attributes,

which must be properly balanced in order to

maintain equilibrium. Villagers believe that the

IUD functions by “increasing the heat in a

woman’s genital region above the threshold at

which conception can occur.” Under normal circumstances this heat production is perceived as

acceptable, but should the individual contract a

disease perceived as hot—such as smallpox,

diarrhea, or venereal disease—the combination

would induce too much body heat and the individual would die (38). By contrast, perceptions

of hot and cold can evoke a positive reaction to a

device such as the IUD. In one Mexican village,

where the IUD is interpreted as cold and the

uterus as hot, villagers believe that after about 3

months the IUD takes on heat and becomes

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 contraceptive into local cultural religious practices

and beliefs comes from the Indonesia family

planning program. A family planning official of

West Sumatra, a physician, became interested

in giving birth control pills to women in such a

way as to prevent menstruation during the

sacred observance of Ramadan, when Muslims

fast from sunrise to sunset. A menstruating

woman is regarded as ritually unclean and thus

may neither participate in the fast nor pray in

the mosque. He reasoned that many women

would wish to inhibit menstruation during

Ramadan, and having overcome their initial reluctance to use the pill would be motivated to

continue its use. According to custom, women

may “pay back” missed days after Ramadan is

over but receive less pahala (grace from God)

for these days. A three-cycle pill had been used

elsewhere; this pill was approved for use and as

the “Ramadan pill” has become a part of the program (9).

Decreased sexual desire, especially among

males, is perceived as one of the most salient

disadvantages of any method, yet a method that

increases sexual desire is not necessarily more

acceptable. Some Indian males, for example, believe that vasectomy increases sexual desire, but

this factor is unacceptable because Hindus believe that semen is an important source of

strength that should not be depleted by high

frequency of sexual intercourse (38). Nevertheless, vasectomy becomes acceptable when

Indian men are informed that vasectomy allows

the semen to remain in the body, thereby preserving virility, youth, etc. (23).

In some instances, attitudes.likely to prejudice

people against a method can be mitigated by

more pervasive beliefs. In one Mexican village

where, except for postpartum amenorrhea,

amenorrhea is greatly feared and is widely believed to cause ill health, hemorrhage, and

tumors, women often resort to herbal teas and

injectable medications to induce menstruation.

Contraceptive agents that induce amenorrhea

would thus be expected to be totally unacceptable in this setting. Yet the villagers there accept

a 3-month injectable that causes amenorrhea

because other beliefs supersede these basic

fears: they believe that conception occurs

through the union of male and female blood or

liquid. As oral contraceptives are thought to

prevent conception either by weakening the

blood of one of the partners, which causes “ill

health,” or by destroying the joined male and

female blood in the uterus, many women hesitate to use them. And since the pill must be

taken daily, it is believed that its constant action

allows no time for recuperation. The injectable,

however, is administered every 3 months, and is

thought to give sufficient time for the blood to

regain its strength. These beliefs, which reinforce a desire to curb family size, and effective

instruction regarding the harmless effects of

possible amenorrhea, account for much of the

success of the injectable in this setting (37).

Misinformation about reproductive anatomy

and function can also cause resistance to the use

of fertility planning methods. Some women in

Mexico and the Dominican Republic voiced

fears that an IUD would either be lost, appear in

various openings in their bodies, or cause them

to interlock with their mates during intercourse

(38).

Clinic locations and hours of operation are important, though sometimes in unexpected ways.

Women in a Barbados village, ignoring the clinic

specifically set up for them, journeyed instead

to a clinic an hour’s bus ride away in order to

keep their attendance a secret. Clinics should

also be open at hours other than those during

which women must do their chores.

Lack of privacy is a major problem in family

planning clinics in many countries. A study in

Equador found that clinic personnel failed to

take account of their women patients’ sense of

modesty. Women in Guayaquil are shy about

their sexuality. They are expected to be chaste

at marriage, and to display no enjoyment of sexual activity. Menstruation is not discussed, and

undressing in front of their husbands causes

embarrassment. A clinic visit is at best a difficult

undertaking for these women, but the clinics in

question made it virtually impossible by interviewing them within hearing distance of other

patients, by requiring them to undress in front

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

asking irrelevant personal questions. Preference for female physicians is documented in

India, Puerto Rico, Honduras, Brazil, and

Muslim countries (37, 38).

The kind of information clients are

given–how much or how little they are told,

and the attitudes of those giving the information—can also hinder adoption of contraceptive

methods. Women seated in a room where clinic

staff members lecture to them, who are given

no chance to ask questions, may feel too uncomfortable about the subject matter to acquire the

motivation needed to successfully use a method.

In one clinic in the Dominican Republic, prospective pill users were told:

You cannot take them in a disorganized manner, or ever stop taking them, or lend them, or

borrow them because these pills are hormones

and every one has a distinct function in the body

and if you take them incorrectly, a tremendous

lack of control will occur and it will be a long

time before it is corrected. Ladies, do not stop

taking the pills at any time. If you do stop, it will

cause hemorrhaging. (37).

The necessity for clinic administrators and

staff members to fully understand both the level

of their patients’ knowledge of reproductive

functions and local attitudes toward sexuality

cannot be overstated. Program planners must

also be aware of the importance of waiting time

for clinic patients. In many LDCs lengthy

waiting times are apt to lead to client dissatisfaction, but in some cases this interval may provide

pleasurable social contact for village women, becoming an inducement to visit the clinic and to

accept and continue to use family planning.

As providers of family planning services often

favor different methods than do their clients,

the distribution of types of methods used in

particular countries may be less a function of

what is preferred than of what is available. In a

recent study of user preferences in India,

Korea, the Philippines, and Turkey, the pattern

of contraceptive selection differed from the

previous pattern in each clinic after providers

were trained to give balanced presentations of

the three methods available—pills, IUDs, or injectable. For example, in Korea for a year prior

to the study, 36 percent of the patients had used

IUDs and 64 percent pills. When freedom of

choice was encouraged, 50 percent chose the

IUD. There were also rural-urban differences;

rural women in India and Turkey preferred injectable, while these differences were not

significant in Korea.

Community concerns: The sociocultural perspective

I am tired. Look at me. I am nothing but a beast

working in the fields and bearing all these

children. I don’t want any more children, but my

husband says I must have as many as come (A

village woman, Kenya).

As for religion, its importance in this connection varies. Just 1 week ago, a woman came and

said that she wanted to have her IUD removed

because she wanted to take communion in

church. The priest had told her that if she had

an IUD he would not give her the sacrament (A

Mexican doctor) (10).

Most people in LDCs live in rural communities, which provide excellent settings for

many development efforts, including family

planning programs. As the pace of rural to urban migration accelerates, governments are increasingly attempting to provide people with alternatives that will allow them to remain in

rural areas. Because the community is usually

the local economic, political, cultural, and social

base, existing organizations and structures can

be utilized to promote family planning acceptance, and community level interactions will continue to have a significant impact on the adoption of small family norms and the utilization of

fertility planning methods.

It is extremely difficult to predict the most important factors in people’s decisions to use contraception. In comparing Venezuelan and Kenyan 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 dominant role in the major decisions of everyday life.

This decisionmaking power—and the extent to

which women share in it—has a significant impact 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 influences of male dominance, male decisionmaking, and spousal communication in the motivation 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 children restricted their activities. In questions on

attitudes toward children, women more frequently 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 lnstitute, No. 60A, Current Studies on the Value of Children, March 1979, Honolulu, Hawaii.

tives, there will be substantial pressures for

high fertility.

In a comparison of attitudes toward family

size in Malaysia and Thailand, Malaysian husbands and wives were found to differ frequently about ideal family size and especially about

the desired sex distribution of children. In

Thailand, interestingly, spousal attitudes tended

to be very close. When asked whether they

wanted additional children, 71 percent of the

couples agreed (in 51 percent of the couples neither wanted more and in 20 percent both

wanted more) (43). In Thailand, men and women

have relatively equal status, especially in

comparison with other LDCs.

During a 1977 conference in West Africa, the

participants, predominantly African women,

emphatically stated that ‘(African women did

not need to be reminded of the benefits of smaller families; African husbands did.” At another

meeting a West African man stated, “Men here

are never sterile, only women are.” That is, a

woman who is barren for a certain amount of

time will take a clandestine lover to assure her

husband of offspring, Both will derive status

from offspring but the responsibility is hers. If

she fails to produce she will be divorced or her

husband will take an additional wife.

Husbands and wives sometimes disagree as to

whose decision is final. Results from surveys in

Santiago and São Paulo note that although the

men feel that husbands and wives are about

equally concerned with the number of children

and most men report sharing in decisions on

family size with their wives, women are more

likely to state that the men make the final decision. This same pattern prevails in Mexico,

where more women felt that men had the ultimate say (20 percent) than did men (12 percent).

Although there is disagreement as to who initiates the discussion of whether to use contraceptives and who makes the final decision,

there is ample and consistent evidence that the

role of the husband is extremely important in

the adoption and continuing use of a method.

In the WHO study of user preferences (53),

when women were asked why they were using

or would use particular methods, one of the

most frequently cited reasons was that the husband liked or would like the method. More than

half of the women in India and Turkey reported

that the choice of method was made with or by

the husband. In the Philippines and Korea,

fewer than half of the women reported a joint

decision. Joint decisions were more often associated with IUD use, which may be because the

husband can sometimes feel the IUD string during intercourse.

In Iran, where women at selected clinics who

were given oral contraceptives showed very low

continuation rates (only 12 percent after 6

months), husbands were asked to participate in

family planning and encouraged to supervise

pill use; during the next 6 months the continuation rate rose to 93 percent (35). In Jamaica, the

primary reason given by women for discontinuing contraceptive use was the objection of their

male partner. In Santiago, Chile, among couples

in which the husband was in agreement with

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

husband was opposed to the use of contraception the figure was only 40 percent. In Kenya,

Venezuela, and the Philippines, spousal communication was critically important in decisions

to use contraceptive methods. The frequency of

discussions on such topics as household budget,

education of children, and contraceptive use is

less important than the wife’s role in the decisionmaking process and her degree of

autonomy in various family decisions. Women

with more independence are more likely to use

contraception (12,13,14).

Women can manage to “beat the system”:

Juana was in her late thirties or early forties.

Of her 15 pregnancies 8 children were currently

living. Although all her children had been delivered by a midwife, discomfort after her fifteenth delivery sent her to a regional health

clinic, where she was told that another pregnancy would endanger her life. She had an IUD inserted and then proceeded to figure out how to

involve her husband. She felt both guilt at having

taken such a step without consulting him and

fear that he would find out and be angry. She approached an American woman, who was a clinic

outreach worker, and asked her to help. She had

her “drop by” on a specific day, just when

Juana’s husband would get home. She coached

her in great detail on bringing the subject up,

beginning with a discussion of the new baby, the

doctor’s health warning, and then working

around to family planning. She warned her

friend that she would not speak up in support of

the idea; all the approval had to come from her

husband. The actual conversation took place just

as Juana had predicted. When the discussion on

contraceptive methods began, Juana’s husband

listed many concerns, not the least of which was

that Juana’s personality would change. Juana did

not speak except to say, “whatever he wants”

and to bring up potential problems the health

worker had not covered. The conclusion was

that Juana should have an IUD inserted, but only

if the health worker accompanied her. The

woman had to fake a trip to the doctor for the insertion (36).

Women who appear to play a secondary role

may actually be very good at manipulating their

husbands. In one African clinic, women are

asked whether their husbands know that they

are using a contraceptive method. If not, when a

worker comes to give the woman supplies, or

during the course of an acceptor survey, the interviewer can use a pretense for her visit if the

husband is at home. Although the use of subterfuge between spouses raises difficult questions,

some women in LDCs are willing to take extreme measures to avoid or delay pregnancy,

and welcome innovative means of introducing

family planning into their lives. Women who are

innovators in the use of contraception often

become enthusiastic supporters of family planning in their communities.

When men agree that their wives should use

family planning they often have reservations

because of misinformation about the safety, effectiveness, and potential side effects of particular methods. In one village in Mexico, 46 percent of the women thought that their husbands

would approve of their using contraception,

usually for economic or health reasons. But

some were concerned that their husbands

might change their minds while intoxicated, as

there had been episodes in the village when

drunken husbands had attempted to remove

their wives’ IUDs. Twenty-one percent of the

women had never discussed the issue with their

husbands and did not know what their reactions might be. One-third of the women

reported such negative attitudes as the desire to

have many children to gain prestige and to ensure the couple’s future economic security, fear

that if the wife used contraceptives it would

undermine the husband’s authority and encourage her sexual autonomy, and fear that illness and even death might result from using

contraception. Men’s fears, based on rumor and

misinformation, are also recorded in a study in

Guayaquil, Equador, where some men felt that

the pill would “eat the red blood cells” or change

a woman’s temperament, or that withdrawal

would make a man’s head swell up (36).

Studies of male contraceptive use indicate that

use of current methods (condoms and vasectomy) can be expanded and new methods would

find considerable acceptance. In Ghana’s Danfa

project, men’s continuation rates were higher

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

which there is strong motivation to prevent

pregnancy. There is some reserve among men

in many groups toward the use of condoms because of their association with prostitutes.

Groups of 150 rural and 200 urban men in Fiji,

India, Iran, Korea, and Mexico were asked to

evaluate the attributes of existing male methods

(condoms and vasectomy) and potential male

methods (a daily pill and a monthly injectable).

Willingness to use a daily male pill if available

ranged from 48 percent in Fiji to 77 percent in

India. Somewhat lower proportions of men

stated that they would use an injectable. Approximately one-third of the men reported that

they were currently using no method (11).

As better methods are made available to men,

their responsibility for and involvement in family planning is likely to increase. For the short

term, it is important that family planning administrators be aware of the influence men

have on their wives’ fertility decisions and of the

need to include men in family planning educational efforts.

Son preference

“A daughter lets you down twice, once when

she is born and again when she marries. ” Korean

proverb (26)

The evidence that couples prefer sons is consistent across all countries, including the United

States. In many countries this preference is

even more marked in women than in men.

The importance of son preference to fertility

rates changes as fertility begins to decline.

Several factors are involved. Unless preferences

are strong there will be no fertility effect. The

amount by which the desired ratio within the

family diverges from the natural ratio is important; if the ratio is three or more boys to each

girl the effect will be greater than if it is just two

boys to one girl. Preferences for family size are

related; if family size is large—four or more

children—son preference will not have an appreciable effect on fertility because most

families will have at least one son, And if contraceptives are unavailable, families will not be

able to stop having children when their ideal

family size/sex ratio composition is attained (51).

In Japan, Singapore, and Hong Kong fertility is

low and son preference has diminished, largely

as a result of social and economic development,

urbanization, and increased opportunities for

women. The birth rate has fallen sharply in

China, where, in a radical reversal of traditional

attitudes, campaigns are now under way to encourage the one-child family. In these campaigns, a major emphasis is on reducing the

preference for sons by raising the status of

women.

The implications of son preference are direct

and powerful. In societies where son preference is strong, women are directly affected

from birth to death. For example, in India in

1972, mortality among girls from birth through

9 years of age was 8 to 23 percent higher than

among boys, depending on the region of the

country and the 5-year age group (7). Although

girls die from the same causes as boys, boys

tend to be given better quality medical care and

probably more food. As boys are also preferentially educated, they have a better chance

to become economically self-sufficient. Women

often suffer from anemia and poor health

because they must undergo many pregnancies

in rapid succession in order to assure sons for

their husbands. This cycle of female deprivation

is unlikely to be broken until women are given

opportunities to increase their self-sufficiency.

This can be accomplished when governments

undertake active campaigns to educate women

(and men concerning new roles for women),

assure them equal economic opportunities and

legal protection, and convince society that

daughters can be as reliable as sons in assuring

the old age security of their parents.

Social networks and organizations

Many existing networks and organizations

can have marked impact on adoption and use of

contraceptives when they incorporate family

planning efforts into their activities, especially

women’s organizations and traditional midwives 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,

where the local infrastructure is well

developed, the family planning program has

specifically targeted community leaders and

local women’s groups as elements of the family

planning effort.

Mothers’ clubs in Korea are an outstanding example of the role of voluntary organizations-and of women—in family planning adoption and rural development. Groups called Kae

had traditionally been formed by Korean

women as revolving credit associations and lotteries to provide opportunities for women to accumulate funds for special purposes. The

Korean National Family Planning Program

decided to distribute contraceptive information

and supplies through these mothers’ clubs.

Their goals were to encourage family planning

practice and continuation by example and

through social and emotional support to users,

to aid overburdened fieldworkers in recruiting

new users and supplying contraceptives (pills

and condoms), to aid in the introduction of a

new method (the pill), and to encourage participation of women in community development

activities. These efforts were highly successful

both in increasing family planning acceptance

Photo credit: Agency for International Development

Family planning worker explains IUD-use

to Korean mothers

and use and in improving the status of women

in the community. The clubs have branched out

and now encompass cooperative agricultural efforts, community construction projects, and

income-producing activities (28).

Similar women’s organizations are becoming a

part of family planning program efforts in

Nepal, Thailand, and Egypt. Their leadership includes women professionals who join together

to help poorer women, and community political

activists who are selected and trained to help

deliver family planning information and contraceptives, usually pills (3). Women’s credit

organizations in Nigeria and other African countries are expanding their functions to include

family planning. These grassroots women’s

groups can be encouraged to aid both family

planning efforts and rural development programs (27).

Sixty to 80 percent of births in LDCs occur at

home. Hospitals are likely to be too far away or

too expensive, and many women prefer to have

their babies delivered by local women whom

they know. Midwives thus already play a vital

role in the community, and with training can

improve and expand their services to include

prenatal and postnatal care and family planning. 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 planning aspects of this effort may have limited

results, improvements in overall maternal and

child health care are expected to be significant

(8).
138 . World Population and Fertility Planning Technologies: The Next 20 Years

National concerns: The role of governments

Significant fertility declines are usually

associated with some or all of the following conditions that involve government policy and action with regard to population programs (ordering does not imply relative importance): 1)

governmental policies that encourage and promote equal status and opportunities for women,

higher age at marriage, and more equitable

distribution of wealth and educational opportunities, all of which lead to a higher standard of

living; 2) programs designed to bring about a

decline in infant mortality; 3) a government

policy with explicit goals for reduction of birth

or population growth rates; 4) a strong commitment to population planning by the country’s

leaders; 5) a family planning organizational

structure with executive power to mobilize

more than one government sector and to coordinate with the private sector; 6) population

program funding (usually both external and internal sources); 7) provision of a broad range of

contraceptive methods; 8) sufficient numbers of

well-trained and motivated family planning program personnel; 9) population and family planning information and communication efforts

that effectively reach all sectors of the populace;

and 10) direct or indirect incentives that encourage couples to limit the size of their families. The relative importance of these components 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 participation, literacy rates, etc.) affect the extent to

which program implementation efforts can succeed 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 perceptions of whether population growth rates are

satisfactory differ greatly. Nearly all governments allow access to modern methods of contraception as a health measure, and as a human

right, but as some actively encourage family

planning while others take no direct role, the

actual availability of family planning information and supplies varies widely. Most of the

world’s 50 most populous countries are in

Africa and Asia. But only 35 percent of African

countries with high growth rates consider their

rates too high, while 75 percent of their Asian

counterparts hold this view. By contrast, 13 of

the 15 most populous countries consider their

fertility rates too high (table 33).

The process of policy formulation varies

among countries because of differing political

and historical factors. In many countries, both

the private sector and the demographic community have been instrumental in influencing

governments to formulate population policies

and implement family planning programs.

Even when rapid population growth is seen

by government leaders as a problem, cultural

and/or historical constraints may mitigate

against the adoption of a specific policy of fertility reduction and the implementation of a government-sanctioned family planning program,

The contrast between Latin America and Asia

Photo credit: Agency for International Development

Family planning slogan that has become famous

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

Perception a 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,

political, and cultural traditions. In general, Asia

has had a relatively long tradition of government family planning programs while Latin

America has traditionally relied on the private

sector. Government policies have not always

been explicit in Latin America but government

support has been unobtrusively provided to

private family planning efforts. Ness and Ando

(22) argue that Latin America has implemented

few government programs because there must

be a perceived “legitimacy” for the government

to implement such efforts. This legitimacy stems

from underlying value sets of the nation’s

cultural groups. In Latin America there is deepseated antipathy toward governmentimplemented family planning among diverse

groups: conservatives oppose contraceptive use

because of commitment to Roman Catholic

values; social reformers have supported limiting

population growth but have been suspicious of

the U.S. emphasis on family planning; and

revolutionaries oppose population growth

limitation either from strict Marxist opposition

to Malthusian theory or from objection to any

social reform that reduces pressures for radical

change. Because Latin America has a high proportion of countries that support fertility reduction without specific public policies for fertility

planning, successful family planning programs

require a substantial degree of commitment on

the part of strategic groups of leaders. Latin

America’s general public appears to be in a

greater state of readiness for serious collective

population growth limitation than do some of its

leaders (22).

By contrast, Asia has taken the lead in

government-sponsored fertility reduction programs. The greater penetration of modern colonialism in Asia produced strong nationalist

movements which led to strong political and

organizational commitment to economic development and centralized economic development

planning. These antecedents led, finally, to

political decisions for population growth limitation by planning authorities, justified largely on

economic arguments. These decisions led in

turn to government organizations to promote

fertility planning (22).

There are clear differences in outcome between policies with demographic objectives and

those aimed primarily at improving general

health care. About two-thirds of the countries

with policies to reduce population growth have

either strong or moderate programs. when the

effects of social setting and population program

are compared, more specific policies are shown

to be associated with greater declines in the

crude birth rate after controlling for social setting (table 34); only a high social setting can

overcome a weak policy position. (Social setting

is an index of socioeconomic development level

used by Mauldin and Berelson,)

Three very important considerations lie

behind policy as a level of intervention–the

country’s degree of political commitment, its administrative capability, and the ability of

government planning and statistical agencies to

analyze projects and programs with respect to

their population dynamics. Experience to date

indicates that a nation’s political elite must be

committed to population planning efforts to the

extent that it supplies the program—whether

public, private sector, or both—with ample

resources, Highly qualified personnel must be

chosen to administer the programs, bureaucratic impediments to program effectiveness must

be removed, and program goals given high

visibility in the government’s development plan.

Administrative capability is generally correlated

with the country’s level of development; if levels

of skills are low and basic infrastructure is

weak, institution-building must be a part of the

program. This is a slow, expensive undertaking.

If infrastructure and skills are in place and only

Table 34.–Decline in Crude Birth Rate (percent) by

Social Setting and Nature of Family Planning Policy

1965=75

To reduce For other than

population demographic No program

Social setting growth rate reasons and unknown

High . . . . . . . . . . . . 28(1 1) 21(7) 3(6)

Upper middle. . . . . 15(14) 4(6) 2(4)

Lower middle. . . . . 7(4) 4(8) 2(1 1)

Low . . . . . . . . . . . . . 1(2) 1(4) 2(17)

Number of countries In parentheses.

SOURCE: P. W. Mauldln, B. Berelson, Z. Sykes, “Conditions of Fertility Decline

in Developing Countries, 1905-75,” Studies in Fare//y Planning 6(5):

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

training programs can be very cost effective.

When the social setting is less than congenial to

the idea of family planning, political commitment and administrative capability are crucial

(40).

Decline in infant mortality

In the ongoing debate over the relationship

between infant mortality and fertility, it has

generally been believed that infant mortality

rates must begin to decline before fertility rates

will do so. The underlying assumption is that

couples will continue to try to replace children

who die in infancy until they have a sufficient

number to insure the survival of at least several.

Now, however, new evidence from the European demographic transition and from many

LDCs shows that fertility can begin to decline in

countries with high rates of infant mortality.

When various neglect behaviors are implemented toward unwanted children, their

risks of dying rise, and high infant mortality

may be associated with high fertility (see also

Tech. Note A, ch. 4). Although the relationship is

complex, both MCH and family planning programs respond to an important humanitarian

need to reduce death rates among infants, their

siblings, and their mothers.

Demographic information, education,

and communication efforts

Up-to-date demographic information and

statistics for program evaluation are crucial to

policy development, and to the implementation

and functioning of family planning programs.

Reliable demographic information from censuses and surveys must be available to inform

government leaders of the dimensions of

population growth in their countries. Data collection to document the initiation, growth, and

change of programs is essential, as is the capacity to analyze demographic data and recognize

the consequences of population growth in terms

of a country’s economic and social goals.

Parallel to this demographic support are IEC

efforts to increase awareness of the effects of

rapid population growth on socioeconomic

goals, and to explain what family planning is

and where services are available. IEC efforts

range from mass media campaigns to the information that individual family planning workers

give personally to their clients. Knowledge of

the ability to control one’s fertility favorably influences use of fertility planning methods; this

use, in turn, increases knowledge and receptivity to education efforts which, in turn, increase

use of family planning methods (49). This constant feedback process can occur quickly—as

evidenced by the rapid spread of family planning in Mexico, Indonesia, Colombia, Brazil, and

Thailand-and can establish family planning as

a subject of open and free discussion.

Strategies for the structure and functioning of family planning programs

Contraceptives have usually been available on

a limited basis prior to the establishment of

government programs. Often the private sector,

including the medical profession and social

scientists, has been active in alerting government officials and the population’ in general to

the need for family planning services, These

services have in may cases been provided by

local affiliates of IPPF.

In Colombia, the medical community and

voluntary organizations played a major role in

encouraging the government to adopt a population policy and to sponsor and implement a

family planning program. The Colombian

Association of Medical Schools (ASCOFAME)

through its division of Population Studies (DEP)

demonstrated the existence of the country’s

population problems by gathering data on fertility and rates of illegal abortion and by

generating awareness of Colombia’s demographic situation among both medical and academic professionals and the Colombian people.

Through the combined efforts of ASCOFAME,

Profamilia (IPPF’s Colombian affiliate), other

government and private organizations, and external support, public health personnel were

trained in the delivery of family planning services, these services were made available, and

the government was encouraged to undertake a

national program. Much of the institu-
142 ● World Population and Fertility Planning Technologies: The Next 20 Years

tionalization of family planning was thus taking

place while the government was formulating its

policy.

Governments must consider not only the

structure of their official programs but the

relative contributions and continuing roles of

those organizations whose family planning efforts precede the implementation of a national

program. ASCOFAME, Profamilia, and the

health ministry continue to deliver services in

Colombia; each organization fulfills varying

roles according to its individual strengths. A

parallel experience is seen in Malaysia, where

the private family planning organization and

government-run program work hand-in-hand.

Most government family planning programs

are located in health ministries or in the maternal and child health sections of health ministries. This is more likely to be the case when

policies are primarily aimed at health care,

although many policies with specific

demographic objectives are implemented

through programs in the health ministry. Countries also have the option to rely heavily on the

private sector. In these cases the private sector

can include the medical community as well as

affiliates of such nongovernmental organizations as IPPF. Brazil is a country where cultural

and religious factors mitigate against a strong

population policy at the national level while

family planning activities proceed in various

sectors through state governments and through

extensive use of the medical community and

nongovernmental organizations. The national

government simply does not bar these activities.

Family planning programs located in health

ministries can encounter problems when family

planning priorities are submerged by the demand for basic health services. In Kenya, where

there are fewer than 15 doctors for each

100,000 people and it is impossible for doctors

to reach all patients even for the most basic of

health services, family planning becomes a low

priority health measure. In Korea, by contrast,

there are enough doctors to provide basic

health care and they have been trained in family

planning, incorporated into the system, and

paid for delivery of family planning services.

Locating a program in the health ministry can

cause problems if there is no vehicle (an executive governing board or some form of coordinating and executive power) to expand the

program beyond the ministry. For example,

health ministries are not usually equipped to

launch major education and information campaigns, nor do they have the marketing skills to

launch projects to distribute contraceptives

through commercial channels. In addition, the

health ministry usually focuses on maternal and

child health, which is important but often limits

male access to and involvement in family planning.

One strategy used by several countries is to

establish a coordinating board that has executive power to coordinate the various activities of

a family planning program. Thus, as in the case

of Mexico, such a board can coordinate the activities of various ministries and the private sector in order to reach populations with different

characteristics. Mexico’s coordinating board

consists of the directors of the major sources for

health care and family planning in the country.

The board, called Coordination General del Programa Nacional de Planificacion Familiar, is

under the direction of an executive coordinator

within the Ministry of Health, and is composed

of all cabinet members and heads of institutions

in the health sector, the Directors-General of

the Mexican Social Security Institute and Institute of Social Security for Government

Workers, the Undersecretaries of Planning and

of Health and Welfare, and the Director-General

of the National System for the Integral Development of the Family. The board coordinates and

streamlines the family planning effort of the existing public health infrastructure in order to

expand services, especially to rural and marginal zones, and is responsible for setting standards, creating new programs, and monitoring

the activities of all family planning service

organizations, public and private, in Mexico. It

is a semiautonomous state agency with close access to the President through the Executive

Coordinator and the Secretary of Health and

Welfare.

Indonesia also has an autonomous coordinating 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

million family planning users by 1973-74. The

National Family Planning Coordinating Board

(BKKBN) was set up as a separate board with

direct responsibility for reporting to the president on family planning activities. This board

does not directly provide contraceptive services

to the public; instead, it coordinates the work of

the various ministries and private institutions

that provide contraceptives and conduct informational and motivational campaigns. BKKBN

employs fieldworkers who complement staff

from other ministries.

Unfortunately, few data are available on how

the structure of family planning organizations

relates to the effective functioning of the family

planning system. Some data are available from

structure charts of organizations, but how communication channels work or don’t work and

the implications of structure for the functioning

of the system remain to be investigated (24).

Integration of family planning with

other development programs

The belief that integrating family planning

into other development and welfare efforts is

essential to the success of family planning programs is being given wide currency at a time

when the success of nonintegrated family planning programs is being well-documented

around the world. Questions thus arise about

the evidence supporting the efficacy of integrating family planning with other programs.

The rationale for integration and the criteria

used as evidence for its need must be carefully

examined. A government considering an integrated program must first consider its goals, its

target population, the existing infrastructure,

and how the integration is to be carried out.

The process must be carefully planned because

different procedural actions are required when

integration occurs at the service delivery level

than when one ministry is to become a part of

another.

“Integration” usually means integrating family

planning with health or MCH. An inherent problem is that the addition of a new program to an

already fragile program is apt to weaken both.

Ministries of health are typically weak in LDCs

because of the severity of health problems and

the lack of trained personnel. In the MCH approach, sick women and children are given priority. If special hours and specific personnel are

not delegated for family planning, services will

not be delivered. If the family planning budget

is integrated into that of the health ministry,

funds earmarked for family planning may be

diverted to more acute health needs. As MCH

clinics primarily serve women, there is little

motivation or opportunity to incorporate men

into family planning activities. Services tend to

remain clinic based as health ministries rarely

command the educational or marketing expertise necessary to launch non-clinic-based programs, The rationale for integration into other

sectors—that a plateau is reached in a clinic

based approach—may be valid but it may also be

true that a weak administrative infrastructure

causes a leveling off of new users of contraception.

Even when there is a definite goal the process

of integration crosscuts several organizational

concerns. Are the linkages to be temporary or

long term? Which development sectors are to be

linked? Is the linkage to be along administrative

or service lines, or both? Does the target

group-rural or urban, male or female, married

or single—warrant an integrated approach?

UNFPA has made a number of recommendations based on their examination of the experience of several types of integration in

several countries.

Integration of family planning with rural

development activities can help to improve the

program in specific circumstances:

●

●

Because many rural people are extremely

poor and isolated, current clinic-based programs are unlikely to reach them, and linking family planning with other development

activities—especially with existing structures and with the rural community itself—can increase the availability of all services.

Where there are politically influential

groups who are averse to family planning,

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

more acceptable.

It is preferable to focus on integration that

links specialized services at the point of service delivery, and to approach with caution

integration that creates large umbrella activities. Experience has shown that the

delivery of other services can be added

after the delivery of family planning services is established, e.g., addition of oral

dehydration kits to family planning outreach workers. Care must be taken not to

overburden workers with too many interventions in settings where unmet health

needs are acute.

Although integrated programs may achieve

some long-run efficiencies and cost reductions,

they require large investments in resources, especially in the beginning. Integration cannot be

effective when existing personnel are given

heavier workloads without being given the necessary additional resources (23)41,47). In general, integrating family planning with other development interventions works best at the service

delivery level, when the needs of the target

group are carefully considered, and when interventions are simple and straightforward.

when a family planning service delivery system

is strong, other interventions can strengthen

the total program. In Thailand, for example, the

local production of methane gas is among a

number of program interventions incorporated

into the family planning commodities delivery

system. In Mexico, the distribution system set

up for the government’s PROFAM brand of contraceptives-was so successful that a major pen

manufacturer asked to include the PROFAM

network of pharmacies in its distribution

system,
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs • 145

Considerations governing the contraceptive methods provided

Among the most crucial choices a government

must make is that of the methods to be provided

in the country, both within and outside the program. Legal considerations and cultural and individual preferences must be carefully assessed.

Each method has its logistical requirements:

supply considerations, warehousing support,

transport, need for specially trained personnel,

specific types of information and education

campaigns, knowledge of brands available, shelf

life, and cost. Import regulations apply or are

determined by a government’s decision regarding manufacture of contraceptives within the

country, which must take into account the number and kinds of methods to be distributed. Product safety and reliability considerations are important, as is cultural acceptability, and who

will prescribe and who will use the methods.

Six major factors—in addition to cultural considerations—generally determine the adoption

and use of fertility planning technologies by

governments and national family planning programs and will continue to do so in the future.

They are: 1) cost of the technologies, 2) adequacy of information about the technologies, 3)

adequacy of sources of supply of technologies,

4) nature of government policies with respect to

importing goods, 5) nature of laws, policies, and

commodity financing arrangements pertaining

to the technologies themselves, and 6) capacity

of program administrators to arrive at and

implement technical decisions about these

technologies.

The fundamental problem that governs technology transfer in the fertility planning field is

the still unresolved question of who will bear

the very substantial costs associated with the

development, distribution, and use of both present and future technologies. Many future technologies that could be of use in LDCs will be

much more costly than existing technologies either because they will be sold at higher prices

than current methods or because it will cost

more to acquire the rights and technical capacities to manufacture them locally. These problems of cost will have to be resolved at both national and international levels among donors

who purchase commodities for LDC programs.

For example, since costs are high, program

managers must have sophisticated knowledge of

the exact contraceptive, packaging, labeling,

and quality control specifications they want if

contraceptives are purchased from privatesector companies. Costs can often be reduced if

bulk purchases are made. Purchasing from the

private sector offers the advantage of a wide

choice of products and, usually, high quality,

prompt delivery, and good service. In contrast,

purchase of contraceptives from manufacturers

that sell to donors such as AID, UNFPA, IPPF,

FPIA, etc., reduces cost and offers high quality

products and arrangement of procurement,

shipment, and customs clearances. However,

only a limited choice of products may be available. Given current high costs and the expected

increases in use of contraceptives, many LDCs

will still prefer this route. It is also likely to be

the best option for procurement of new contraceptive methods because of the high costs

associated with other options.

Another option for an LDC government is to

manufacture the commodities locally. (see app.

D for a detailed description of the logistic requirements and processes involved in establishing local manufacture of contraceptives in

LDCs.) The major advantages of local manufacture include the benefits of increased local employment, technical skills, and output, and,

sometimes, reduced expenditures of foreign exchange currency. packaging and labeling can be

designed to meet local specifications and needs.

The interval between manufacture and use of

product is reduced, which is especially important for products with limited shelf life. Major

disadvantages include the difficulty of retooling

for new technologies, the narrower range of

choices available, and potentially higher costs.

Most importantly, unless a country is able to

commit the technical and managerial resources

necessary for the highly sophisticated production of contraceptives, problems with reliability

of manufacture and product quality can occur.

If a government decides to build up local production capacity through strict foreign exchange controls and import substitution poli-
146 ● World Population and Fertility Planning Technologies: The Next 20 Years

cies, planning and finance ministries will find it

difficult to approve the purchase of new technologies manufactured abroad. And, as was discussed in chapter 6, because new methods are

most likely to be developed in MDCs in the next

20 years, governments will need to import

them, at least until they can establish local

manufacturing capabilities. Because governments are likely to favor local production in the

future, there could be severe delays in local

availability of many new technologies and

blocked access to others.

In addition to these economic considerations,

technical and programmatic factors determine

the method mix in LDCs now and will continue

to do so in the future. The importance of the effective dissemination of information about the

technologies, on which the transfer of technology depends, cannot be exaggerated. For example, there are three major variants among IUDs,

and these are further subdivided into almost

100 specific products or techniques, Oral contraceptives are available in more than 40 different formulations. Brands with different formulations and dosages often differ in packaging,

cost, shelf life, and side effects. Efforts are now

under way to provide program administrators

with up-to-date information on different methods; PIACT, the Program for Introduction and

Adaptation of Contraceptive Technology, is disseminating comprehensive information on contraceptives to LDCs. Once an administrator decides which contraceptives to purchase, the

sources of supply must be chosen. Contraceptives can be purchased from private manufacturers or from special manufacturers that sell to

the public sector, obtained as gifts from international donors, or manufactured locally. Each

source has attendant advantages and disadvantages.

Levels of expertise and infrastructure are important in contraceptive choice decisions. Even

if all the information could be listed in a compendium and constantly updated, people would

need special training in order to adequately

evaluate the properties of various methods (36).

Each decision about the method mix in a particular country is extremely important and has

its ramifications and repercussions. The administrator must not only be aware of user

preferences and logistical requirements, but

have up-to-date information and be able to

assess medical properties of the methods. These

considerations are likely to become more complex as overall prevalence rates increase and as

new methods are introduced.

Commercial retail sales and

community-based distribution systems

When a country has determined the structure

of its program, the development of serviceoriented operational strategies is needed.

Governments can choose clinic-based systems

for government-provided services, heavy reliance on existing health facilities and utilization

of private physicians, distribution through

nongovernmental private voluntary organizations, retail sales distribution systems, or

community-based distribution systems, or they

can mobilize all of these sources. Among the innovative approaches in current use are community-based distribution (CBD) programs, and

commercial retail sales (CRS). These systems incorporate subsidized government sales through

pharmacies, local boutiques, village centers, and

distribution through institutions and individuals, and involve people who are closely

linked to the community and well-known to the

clientele they serve. These workers may be

village elders, midwives, merchants, or volunteers who assume responsibility for any number of tasks, including contraceptive storage,

program administration, and transmittal of

family planning education and information. Approaches differ from country to country, but

several characteristics are common to successful programs. These include prices that are affordable to the target community, culturally appropriate methods, convenient dissemination

techniques, integration of family planning with

other health, nutrition, and socioeconomic

development delivery systems, providing IEC

materials (including population education) along

with methods, efficient and regular systems for

resupply of contraceptives, and adequate

methods of program evaluation.

Innovative advertising has helped make

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.

Buyers would rather ask for a “panther” in

Jamaica, a “Preethi” (“joy”) in Sri Lanka, or a

“Raja” in Bangladesh than a condom.

Raja (the Bengali word for “king”) is the name

of the condom which is characterized by a picture of a playing card king, symbolizing strength

and power. The pill is called Maya (affection) and

is associated with a picture of an attractive

woman. The familiar Raja picture adorns the

sails of sea vessels delivering contraceptives to

outlying areas. The picture has become a part of

the country’s successful mass media campaign,

which has included newspaper, cinema, and TV

advertising. This has resulted in Raja and Maya

being the most heavily promoted consumer

items in Bangladesh, next to cigarettes. The

Maya radio jingle is the most recognizable song

on the radio in Dacca (l).

By April 1981, Raja and Maya were available

in some 69,000 outlets in Bangladesh and

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 programs), or whether a small charge will make the

commodities seem more valuable. Both approaches have been successful, and social

marketing efforts have substantially reduced

consumer costs in’ many countries (table 35).

Social marketing/CRS programs have had a

number of political and administrative problems. The need for mass media advertising

campaigns in support of CRS programs can

create political difficulties in securing government approval of these efforts, and traditional

attitudes toward and laws governing the use

and sale of contraceptives make program implementation difficult. These projects have,

however, expanded existing family planning

programs, have been highly cost effective, and

have spurred increases in contraceptive sales.

Countries with CRS programs are listed in table

36.

while CRS programs are built into existing

commercial marketing networks, CBD programs utilize existing social structures and institutions and were the first extensions, in

Table 35.—Prices to Consumer of Contraceptives

Available Through Commercial Retail Market and

Through Social Marketing Programs in Selected

Countries

(in U.S. dollars)

Country Contraceptive

Price through

social marketing

programa

0.01

0.05

25-45

0.35

0.04

0.40

0.016

0.03

0.17

0.05

0.30

0.11

0.39

1.91

0.013

0.13

0.013

0.15

LDCs, of traditional clinic-based family planning

services, Distribution points include family planning outreach workers, mobile delivery units,

and contraceptive resupply depots. CBD programs evolved from demand for better access to

services and a lack of trained health personnel

and facilities in remote rural areas, and operate

in a variety of ways. Some provide services at a

central point in a village, as in Indonesia, while

others feature door-to-door service by way of

household canvassers, as in Egypt and Bangladesh.

Although some of the CBD projects now active

in 38 countries are relatively small, there are

large-scale operations in Bangladesh, Egypt, Indonesia, India, Mexico, Nicaragua, Thailand,

Colombia, Jamaica, Philippines, Korea, and Sri

Lanka (table 37).

Current evidence shows that many kinds of

household and village distributions can be more

effective than clinic programs. Rates of acceptance, continuation, and prevalence consistently

fall within–rather than below–the “ac84-587 0 - 82 - 11
148 ● World Population and Fertility Planning Technologies: The Next 20 Years

ceptable” range of clinical programs (5). Continuation rates among oral contraceptive users

in Indonesian CBD programs are higher than

those among clinic-based users (table 38).

Although provision must be made for clinical

support for management of side effects of methods, costs of operating CBD programs are competitive with clinical approaches. Because volunteer personnel are extensively used, these costs

are expected to decline.

The availability of family planning

services

Few assessments of the conditions of fertility

decline in LDCs take account of differences in

the availability of contraception among countries because of the paucity of reliable data, Yet

these differences are at least as great as the

socioeconomic differences among LDCs. Therefore, to examine rural-urban and education differentials in contraceptive use without first

ascertaining whether distribution of services to

urban, and better educated, women varies is to

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 Conference on Family Planning in the 1980’s, April 1981, Jakarta, lndonesia. Cosponsored by the UNFPA, IPPF, and the Population

Council.

Table 38.-Continuation Rates for OCs in ClinicBased and Community. Based Programs: Village

Family Planning Program, Indonesia

OC users

Time resupply depot

period Clinic Village

12 months. . . . . . . . . . . . . . . . . . . . 65.9 76.3

24 months. . . . . . . . . . . . . . . . . . . . 47.7 61.5

36 months. . . . . . . . . . . . . . . . . . . . 33.1 47.9

SOURCE: J. R. Foreit, M. E. Gorosh, D. G. Gililespie, C. G. Merritt, “CommunityBased and Commercial Contraceptive Distribution: An Inventory and

Appraisal,” Population Reports, series J, No. 19, March 1978, Population Information Program, Johns Hopkins University, Baltimore

Md.

ignore a causal link in the factors influencing

the use of family planning. In order for contraception to be used, information, services, and

supplies must be available (2). Services and supplies are unavailable if the financial cost is too

high, if clinics are open at hours convenient only to clinic staff, if supplies are insufficient or

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

of recent national fertility surveys has focused

on a single index of availability, the perceived

availability of family planning services and their

relationship to contraceptive use. Rodriguez

(34) analyzed the perceived accessibility (accessibility and availability are used interchangeably) of services in terms of women’s

perceptions of travel distance to the nearest

outlet and the relationship of this distance to

use of family planning methods in Nepal, Colombia, Costa Rica, Korea, and Malaysia. In Nepal,

only 6 percent of currently married women

know where contraceptives are available, and

only 2 percent know of a place less than 2 hours

away from their homes. In Nepal, 27 percent of

those who live within 2 hours of an outlet use a

method in contrast to 14 percent of those who

live within a day or more of a source. In every

country except Costa Rica (where virtually

everyone knows of an outlet nearby), the closer

the source the more likely women are to be using it (table 39). Traditional associations with

education and rural-urban residence are not as

strongly tied to use of contraceptives when the

nearness of an outlet is controlled. The reduction in association is most marked in Nepal,

where sources are rarely available in rural

areas.

The relationship between current use of contraceptives and knowledge of the distance to an

outlet is shown for 10 countries in table 40. The

level of motivation is obvious when even 30 or

40 percent of women who live 30 minutes or

more from an outlet are using contraception. Efforts to provide more accessible services could

result in higher levels of use.

Incentives

Because incentive schemes to increase family

planning vary considerably, their impact on fertility cannot be adequately assessed. Nevertheless, they have engendered considerable controversy—less because the incentives themselves are inherently discriminatory or coercive

than because of the ways in which they have

been implemented. India’s widely publicized

sterilization campaigns are a prime example.

An incentive is here defined as something of

value (usually, though not always, financial)

given by a government or an organization to an

individual, couple, or group to encourage certain fertility planning behaviors. Both the

‘(value” and the ‘(behavior” must be specified for

each type of incentive scheme.

Value is usually specified in terms of

payments in cash or commodities (government

provision of family planning services and/or

commodities is excluded because many governments already provide these services free or at

minimal cost), but can be in the form of indirect

benefits. In Singapore, for example, access to

better education is offered as an incentive to encourage couples to have small families. Education is free for their first two children, but costs

rise for third and higher order births.

The desired fertility planning behavior is

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

Panama, WFS, 1976 . . . . . . . . . . . . . . . . . . . . 59.9

Colombia, WFS, 1976 . . . . . . . . . . . . . . . . . . . 55.2

Thailand, CPS, 1978 . . . . . . . . . . . . . . . . . . . . 52.9

South Korea, CPS, 1978 . . . . . . . . . . . . . . . . . 50.7

Mexico, WFS, 1976 . . . . . . . . . . . . . . . . . . . . . 50.3

indonesia, WFS, 1976 . . . . . . . . . . . . . . . . . . . 47.6

Mexico, CPS, 1978 . . . . . . . . . . . . . . . . . . . . . . 47.4

Philippines, WFS, 1978 . . . . . . . . . . . . . . . . . . 43.9

Malaysia, WFS, 1974 . . . . . . . . . . . . . . . . . . . . 39,3

South Korea, WFS, 1974 . . . . . . . . . . . . . . . . . 39.0

Kenya,WFS,1978 . . . . . . . . . . . . . . . . . . . . . . 13.0

Pakistan,WFS, 1975a.... . . . . . . . . . . . . . . . 7.7

88.8

NA

57.2

56.6

52.0

52.4

NA

51.4

47.2

42.3

41.2

15.5

NA

63.0

NA

51.4

44.8

46.9

48.6

NA

32.2

38.0

34.7

38.9

12.3

NA

providing the incentive, and in most cases is the

adoption of a particular method—the IUD, for

example—or consent to a sterilization. In

Singapore, limiting family size to two children is

the desired birth platining behavior.

In some incentive schemes payment is made

to a “diffuser,” who motivates individuals to use

specific methods, to a ‘(provider,” such as the individual who inserts an IUD, or to a community

when its percentage of couples practicing contraception reaches a target level.

Most current schemes usually include the

following elements: the government is the grantor of incentives; payment is made to individuals

rather than groups; funds come from the program budget; cash rather than in-kind incentives are used; immediate and single, rather

than installment and deferred, payments are

made; payments are of a fixed amount and are

made at the time of adoption of a family planning method; and incentives are positive rather

than negative.

Table 41 contains a listing by country of incentives paid for IUD insertion and contraceptive sterilization (no countries are paying incentives to pill or condom users). In Bangladesh, India, Pakistan, and the Republic of Korea, incentives are paid to the diffusers. In most Asian

countries the medical practitioner who inserts

IUDs is reimbursed on a fee-for-service basis.

Voluntary sterilization has been a traditional

focus of incentive schemes. Many payment

schemes have been tried; clothing was given to

those undergoing sterilization in India and food

rations were offered in India and the Republic

of Korea. In 1974, Singapore relaxed certain of

its disincentives for families who chose sterilization. If one parent is sterilized, the fourth child,

who would otherwise be given lower priority in

primary school admission, is given the same

priority as the first three, and women with two

or more living children, who are not otherwise

entitled to paid maternity leave, receive this

benefit if they choose postpartum sterilization

(table 43).

Governments that elect to implement incentive schemes must plan carefully to avoid compromising individual choice. Incentives cannot

substitute for full availability of services, and

although culturally defined, questions of coercion must be carefully considered. The often

overlooked aspect of coercion is the social coercion 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

Country (1975-77)

Incentives

provided to Fees charged to

Region and diffused user in U.S.

country provider dollars

Africaf

Botswana . . . . . . . . . . . . .

Egypt . . . . . . . . . . . . . . . . .

Gambia a 

. . . . . . . . . . . . . .

Ghana . . . . . . . . . . . . . . . .

Kenya2 

. . . . . . . . . . . . . . . .

Mauritius . . . . . . . . . . . . . .

Morocco . . . . . . . . . . . . . .

Zimbabwe . . . . . . . . . . . . .

Tunisia . . . . . . . . . . . . . . . .

Uganda . . . . . . . . . . . . . . .

Asia and Pacific

Bangladesh. . . . . . . . . . . .

China 3b 

. . . . . . . . . . . . . . .

Fiji . . . . . . . . . . . . . . . . . . .

Hong Kong . . . . . . . . . . . .

India C 

. . . . . . . . . . . . . . . . .

Indonesia . . . . . . . . . . . . .

Malaysia . . . . . . . . . . . . . .

Nepal . . . . . . . . . . . . . . . . .

Pakistan d 

. . . . . . . . . . . . . .

Philippines . . . . . . . . . . . .

South Korea . . . . . . . . . . .

Singapore . . . . . . . . . . . . .

Sri Lanka . . . . . . . . . . . . . .

Thailand . . . . . . . . . . . . . .

Turkey . . . . . . . . . . . . . . . .

Americas

Chile . . . . . . . . . . . . . . . . . .

Colombia . . . . . . . . . . . . . .

Costa Rica. . . . . . . . . . . . .

Dominican Republic. . . . .

El Salvador . . . . . . . . . . . .

Guatemala . . . . . . . . . . . .

Honduras . . . . . . . . . . . . .

Jamaica . . . . . . . . . . . . . . .

Mexico . . . . . . . . . . . . . . . .

Nicaragua . . . . . . . . . . . . .

Puerto Rico . . . . . . . . . . . .

—

0.58-1.15

—

—

3.00-4.00 —

—

0.50-2.00

0.40-0.80 —

0.14-0.27

0.24-0.47

0.25-0.60 —

0.42-1.05

—

—

—

—

—

—

—

—

—

—

SOURCES:

Legal considerations

Legal considerations apply to four major areas

in the implementation of family planning programs:

1.

2.

3.

4.

dissemination of fertility planning information and provision of methods;

distribution of fertility planning methods—whether a prescription is required,

which methods can be sold and where, and

who can provide the services (included

here are laws governing voluntary sterilization and induced abortion);

training requirements for personnel who

will distribute contraceptives; and

who shall be eligible to obtain family planning advice and contraceptives. - -

Eligibility is especially relevant where both

premarital and extramarital sexual activity contribute significantly to fertility rates (30).

Legislation that specifically affects women

and their positions in the family is important

because it affects the options available to them

beyond their traditional roles as wives and

mothers, In some countries, under Moslem law,

a husband can terminate a marriage by simply

declaring his intention to do so to his wife. In

others, married women must be represented in

judicial proceedings by their husbands, cannot

work without their husband’s permission, and

often need the approval of their husbands before they can avail themselves of family planning services (30).

As pointed out in chapter 4, minimum age at

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

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 minimum ages for marriage, these laws are not always strictly enforced, and may not be sufficient to raise the status of women unless

women are given opportunities beyond

childbearing, such as education and paid employment.
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

Tunisia (female)

(male)

Asia and Pacific

Bangladesh (male)

Hong Kong

India

Indonesia

Iran

Malaysia

Nepal

Pakistan (male)

(female)

Singapore

Sri Lanka

South Korea

Thailand

No cash payment

11.65

2.10

No cash payment

2.00-3.00

No cash payment

No cash payment

No cash payment

No cash payment

1.50

2.00

No cash payment

No cash payment

No cash payment

No cash payment

2.35

4.89

2.10’

1.37

0.69’

—

—

1.98

1.50

2.00

—

10.50

(for

31.50

(for

0.74’

0.57

Free

Free

Free b

2o.ood

Free

Free

Free

Free

Freec

0.50’ Free

0.50’ Free

1.68

Free

male)

female) Free

2.50 (male)e

7.50 (female)

When family planning information is

restricted, couples can remain unaware that

they can limit their fertility. In Chad and several

other countries, an old French law makes it a

criminal offense to disseminate “contraceptive

or antinationalist propaganda” through

speeches in public or by placing in “public channels” books, written material, drawings, pictures, or posters. A major restriction on contraceptive distribution in LDCs is the requirement for a prescription. In Nigeria, where a prescription is required for oral contraceptives,

there is one physician for each 40,000 people.

(In some countries where prescriptions are required for the pill, the legal requirement is ignored and they are available on a nonprescription basis in the private sector (48).)

The status of induced abortion is always legislated. Even where induced abortion is legal, access to properly performed procedures can be

impeded because restrictive legal provisions

limit induced abortion to hospital settings or

determine who may perform the procedure. If

only physicians may legally perform first trimester abortions in countries where the number of physicians is limited, illegal abortions

continue to be performed by untrained personnel.

In many LDCs, where marriage is nearly

universal and takes place at a very young age,

premarital sexual activity is negligible and laws

that restrict access of supplies and/or information to married adults are not a problem. In

countries where there is increasing demand

from adolescents and single adults for contraceptive information and supplies, laws that

restrict dissemination of family planning education in schools and other settings can interfere

with the ability of these individuals to plan their

fertility (30).

Do family planning programs make a

difference?

Although there are exceptions, and the

reasons for these exceptions are fairly well

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,

Mauldin, Berelson, and Sykes undertook a major analysis to determine the relative contributions of program effort and social setting (level

of socioeconomic development) to fertility

declines in LDCs. Countries classified by both

strength of family planning effort and level of

socioeconomic development produced the

groupings in table 43. The authors found that:

● In 94 LDCs during 1965-75 there were

significant—some quite spectacular—fertility declines.

● The large countries—those with populations of 35 million or more—showed greater

declines than did the smaller countries

(although Bangladesh, Pakistan, and Nigeria

are exceptions to this).

● The better-off countries, particularly those

near the top in table 43, do better than the

less well-off. But, on balance, family planning programs have a significant, independent effect over and above the effect of socioeconomic factors. Weak programs might

as well not exist, so far as fertility reduction

is concerned.

● The longer a family planning program has

been in operation, the greater its effect

(although several weak programs have existed for many years).

● Countries that have adopted population

policies with demographic goals to reduce

their rates of population growth have experienced much greater fertility declines

than countries without family planning programs or countries whose programs were

adopted for health reasons only.

● There is synergism between social setting

and program effort. Countries that rank

well on levels of socioeconomic variables

and also make substantial program effort

average much greater declines than do

countries that have one or the other, and

far greater declines than those with neither. A country that wants to reduce its fertility should seek a high degree of modernization (which of course all do, and find costly and difficult) and should adopt a substantial family planning program; for countries

at or near the bottom of the socioeconomic

scale, a special kind of determination—as

found in India, Indonesia, and China—is required to implement a strong program effort (19).

The contributions of various factors to observed fertility declines can be separated. These

contributions vary among countries, but on average, about 60 to 65 percent of the decline in

fertility is attributable to social setting, 15 to 20

percent to the family planning effort of the population program, about 5 to 10 percent each to

the age structure of the population and to program efforts to raise age at marriage, and about

15 to 25 percent to various unknown or unmeasured factors (table 44). Program effort thus

accounts for 20 to 25 percent of the observed

declines in fertility between 1965 and 1975.

McGreevey (18) added national income

distribution to the index that Mauldin and

Berelson used (the original index used GNP and

GNP per capita), in an attempt to relate distribution of income to changes in fertility. He found

that fertility is higher when poor people are

much poorer relative to the rich. If the poor

stay poor relative to the rich, fertility will

decline more slowly than if the poor raise their

relative income levels. He also added a government index which was associated with fertility

decline, further confirming the Mauldin and

Berelson finding that program effort may be an

index for effective government in general.

Tsui and Bogue (42) extended the analysis by

adding the total fertility rate at the time the

family planning program was initiated. This additional variable serves as an index for a fertility

decline which may or may not already be in process when the program begins. They found the

greatest effect on the total fertility rate of 1975

to be associated first with this rate for 1968 (the

index of whether a fertility decline may be in

process); second, with family planning program

effort; and third, with socioeconomic variables.

Another approach to assessing the impact of

family planning programs is to first estimate the

fertility change resulting from a particular

change in contraceptive use and then use these

estimates to determine the effect on fertility

rates of a family planning program. Two countries for which these analyses have been carried

out are Thailand and Colombia. Khoo and Park

(16) estimated that some 200,000 births were

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

High

Upper middle

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

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

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

Lower middle

Vietnam, North. ....23 India . . . . .......16 Papua

Indonesia .. .....13 New Guinea . . . ...5

Pakistan . . . . . . . . . . .1

Bolivia . . . . ........1

Nigeria . . . . . . . . ....1

Kenya . . . . . . . . . ....0

Liberia . . . . ........0

Haiti . . . . . . ........0

Uganda . . . . . . . . . .-4

Mean . . . . .......23 Mean . . .......14 Mean. ... ... .....l

Median . . .......23 Median . ......14.5 Median . . . . . . . . ..0.5

Angola . . . . . . . . . ....4

Cameroon . . ........3

Burma . . . . . ........3

Yemen,

P.D.R.of . . . . . . . . ..3

Mozambique ,. ......2

Khmer/

Kampuchea. . . . ...2

Ivory Coast . ........1

Senegal . . . . ........0

Saudi Arabia... .....0

Vietnam,South ......0

Madagascar .. ......0

Lesotho ... ... ....–4

Mean . . . . ........1 3

Median . . . . . . . ....1.5 1

Tanzania . . . . . . . ....5

Dahomey . . ........3

Bangladesh .. ......2

Sudan . . . . . . . . . . ...0

Nepal . . . . .......-1

Mali . . . . . . . . . . . ..-1

Afghanistan . . . . ..-2

Low

Mean. . . . . . . . . . ..1

Median . . . . . . . . . .0

Laos . . . . . . . . . . .....5

Central African

Republic . ........5

Malawi ..,...... ....5

Bhutan . . . . . . . . .....3

Ethiopia . . . . . . . . . ...2

Guinea . . . . . . . . .....2

Chad . . . . . . ........2

Togo . . . . . . . . . . . ....2

Upper Volta . . . . .....1

Yemen . . . . . ........1

Niger . . . . . . ........1

Burundi . . . . ........1

Sierra Leone .. ......0

Mauritania . . . . . .....0

Rwanda . .........0

Somalia ......, .....0

Mean . . . . ........2 2

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 distributed 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)

will need contraception in 2000 (See table 51,

ch. 9). If fertility were to fall to replacement

levels over the short term, there would have to

be a fourfold increase in contraceptive use at a

minimum cost of $4.5 billion in 1980 dollars.

Although there are regional differences, and

countries within regions vary widely, several

policy and program issues will be of concern for

both the short and long term: 1) allocating resources; 2) establishing cost effective, selfsupporting programs; 3) expanding availability

of services to reach rural populations; 4) integrating family planning with other components of development; 5) strengthening program management; 6) increasing opportunities

for women and raising their status; and 7) effectively using present and new technologies (45,

46).

Allocating resources

Although over 90 percent of the population of

the developing world lives in countries that

have formal policies in support of family planning, the financial commitment of their governments to family planning remains a small fraction of current health expenditures. In many

countries, half or more of total government

health budgets are devoted to a few urban hospitals and clinic based medical systems that do

not reach the vast majority of the country’s rural poor. Developing administrative systems to

effectively provide fertility planning services to

rural areas is one of the most important tasks

for the next 10 to 20 years.

Establishing cost effective,

self-supporting programs

Development of the private sector through

social marketing techniques is crucial to the

gradual self-financing of family planning programs in LDCs. These systems not only effectively reach rural areas where clinic coverage is

weak and expensive to maintain, they also allow

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 contraceptive use.

Countries that use multiple delivery

systems—government health services, private

physicians, private family planning clinics, commercial retail sales networks, and communitybased distribution systems—can give couples

the advantages of a comprehensive range of

methods. Moreover, because many of the methods most easily distributed in community-based

systems (condoms, pills, spermicides, etc.) need

only backup medical sew-ices, a

systems is also cost effective.

Expanding the availability

to reach rural populations

multiplicity of

of services

Countries with strong programs where fertility is beginning to fall have been, for the most

part, “easy,” that is, these countries have

relatively high levels of socioeconomic development, a fair degree of infrastructure, and

trained personnel. The countries that will need

support for the next 20 years are “difficult.”

These are countries that will require innovative

approaches to reach rural populations and major efforts to train personnel and develop infrastructure capabilities and support for basic

health services. In most, only small sectors of

urban populations presently have real access to

family planning services.

Rural couples who have sufficient resources

and time can usually obtain some type of contraceptive method, but full access to family

planning services—nearby presence of an outlet

that offers services, information, and supplies,

without major cost or inconvenience—remains

out of reach of all but a few rural populations in

LDCs.

Integrating family planning with other

components of development

Although family planning programs have

traditionally been linked in varying degrees

with other health services, recent efforts have

combined family planning with other community services (e.g., nutrition, nonformal education)

and existing organizations (e.g., cooperatives,

women’s clubs). Because most of these projects

require significant collaboration between agencies in allocation and control of resources,

determination of priorities, and development of

personnel policies, integration attempts often

encounter administrative problems. Their experimental nature can also make them expensive to establish, particularly where few development services are in place. A decentralized

approach that identifies and meets community

level needs, focuses on primary health care, and

capitalizes on local institutions appears to hold

the most promise.

Strengthening program management

As the demand for services grows and programs expand in coming years, a crucial need

will be for well-trained, highly skilled managers

for family planning programs; experience has

shown that expert managers can have tremendous impact on program performance. Senior

management skills, which tend to be in short

supply in LDCs, will be a major need, but

substantial numbers of middle-level managers

and supervisory personnel and a wide range of

family planning workers will also be required.

Governments will have to give high priority to

management recruitment and training and to

devising the new directions and flexible, innovative approaches that will be necessary to

broaden services provision. Decentralized

organizational structures designed to foster

local decisionmaking and community participation will be needed to supplement today’s largely centralized organizational patterns.

Increasing opportunities for women

and raising their status

Women in many LDCs are restricted in their

ownership of property, their ability to marry

and divorce, their freedom of movement and

employment, and their access to education and

other resources. These social and economic constraints adversely affect their status and

strengthen existing cultural pressures for

women to define their lives solely in terms of

their maternal roles. Improving the status of

women through legal change, greater access to

education and income-generating opportunities,

and fuller participation in community life are

key factors in redressing this imbalance. Greater 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,

and/or active members of the community, and

enable them to make important contributions to

the development process.

The needs of adolescent women in LDCs today are particularly acute. There are far more

adolescents in the world at present than ever

before in history because of high fertility in the

recent past, and their potential fertility is far

greater than that of their counterparts of previous centuries because better nutrition has

lowered the age of menarche, making these

adolescents capable of childbearing at much

younger ages.

Their access to contraceptive services is frequently limited, especially in LDCs, and those

who do use contraception tend to use ineffective methods. In Latin America, for example,

most married teenagers have never used a contraceptive method even though they want to

limit their fertiliy. Many use ineffective methods—some by choice—but often because of insufficient supplies or difficult access. Special approaches responsive to the needs of this vast

group of young people will require major family

planning program efforts in coming decades.

Chapter 7 references

1. Altman, D. L., and Piotrow, P. T., “Social Marketing: Does it Work?” Population Reports, series J,

No. 21, January 1980. Population Information

Program, The Johns Hopkins University, Baltimore, Md.

2. Brackett, J. W., “The Role of Family Planning

Availability and Accessibility in Family Planning

Use in Developing Countries,” paper presented at

Effectively using present and

new technologies

Because all of today’s available fertility planning technologies have significant deficiencies

and drawbacks, it will be a continuing challenge

for family planning programs to use these technologies in ways that minimize their shortcomings. Ideally, programs offer a wide range of

methods ,

s have difficulty providing even four or

five. The logistics of distribution, storage, and

backup medical services can intervene to prevent the provision of some methods, as can CUL

tural, religious, and legal restraints. With costs

of supplies expected to increase at the same

time that numbers of prospective users multiply

rapidly, countries will have to carefully consider the costs and benefits of establishing their

own production facilities. Couples will need reliable counseling to enable them to choose fertility planning technologies that are appropriate to

their needs. Governments should thus give high

priority to efforts to communicate accurate information on current methods and on new

methods as they become available.

the World Fertility Survey Conference, London,

July 1980.

3. Bruce, J., “Women’s Organizations: A Resource 8

for Family Planning and Development,” international Family Planning Perspectives and D@est,

8(6), 292-297, November/December, 1976.

4. Bulatao, R. A., “On the Nature of the Transition in

the Value of ChiIdren,” from Current Studies on 9.

19, March 1978, Population Information Program, The Johns Hopkins University, Baltimore,

Md.

6. Greep, R. O., Koblinsky, M. A., Jaffe, F. S., l?eproduction and Human Welfare: A Challenge to Research, Ford Foundation, Cambridge, Mass., MIT

Press, 1976.

7. Gulhati, K., “Women’s Reproductive Health: A

New Perspective for India,” Draper Fund Report

No. 9, October 1980, pp. 26-28.

Simpson-Hebert, M., et al., “Traditional Midwives

and Family Planning,” Population Reports, series J,

No. 22, Population Information Program, The

Johns Hopkins University, Baltimore, Md., May

1980.

Heiby, J. R., Ness, G. D., Pillsbury, B. L. K., “AID’s

the Value of Children, papers of the East West Role-in Indonesian Family Planning: A case Study

Population Institute, Honolulu, Hawaii, No. 60-A. with General Lessons for Foreign Assistance,”

5. Foreit, J. R., et al., “Community-Based and Com- AID Program Evaluation, report No. 2, Agency

mercia] Contraceptive Distribution: An Inventory for International Development, Washington,

and Appraisal)” Population Reports, series J, No. D. C., December 1979.
158 ● World Population and Fertility Planning Technologies: The Next 20 Years

10, Huston, P,, Third World Women Speak Out, New

York: Praeger Publishers in cooperation with the

Overseas Development Council, 1979.

11. Hollerbach, P, E., “Factors that Determine the Appropriateness of New Technologies to Consumer

Needs,” OTA Working Paper, 1980.

12. Kar, S. B., and Gonzalez-Cerrutti, R., “Psychosocial Determinants of Fertility and Contraception:

Report of the Baseline Survey,” Washington, D. C.;

Pan American Organization/World Health Organization, 1978.

13, Kar, S. B., and Talbot, J. M,, “Attitudinal and Nonattitudinal Determinants of Contraception: A

Cross Cultural Study,” Studies in Family PZanni~

11(2): 51-64, 1981.

14. Kar, S., “Consistency Between Fertility Attitudes

and Behavior: A Conceptual Model,” Population

Studies, 32 (l), 1978.

15. Kendall, M., “The World Fertility Survey: Current

Status and Findings,” Population Reports, series

M, No. 3, Population Information Program, The

Johns Hopkins University, July 1979.

16, Khoo, S. and Park, C., “The Effect of Family Planning Programs on Fertility Decline in Four Asian

Countries,” International Famiiy Planning Perspectives and Digest, Vol. 4(3) Fall 1978, The Alan Guttmacher Institute, New York.

17. Londono, J., and Bogue, D. J., “An Estimate of the

Direct Impact of Family Planning Programs on

the Birth Rate of Colombia)” in The Impact of

Family Planning Programs on Fertility Rates: A

Case Study of Four Nations, by J. Teachman, D. J.

Bogue, J. Londono, D. Hogan, Community and

Family Study Center Monographs, The University of Chicago, 1979, pp. 11-37.

18, McGreevey W. P., and von Elm, B., “Socioeconomic Change and Family Planning: Their Impact

on Fertility,” Battelle Population and Development Policy Program Working Paper No. 1, April

1979, in AID Program Evaluation Report No. 1,

Family Planni& Program Effectiveness: Report of a

Workshop, Agency for International Development, December 1979, Washington, D.C.

19, Mauldin, P. W., Berelson, B., with a section by Z.

Sykes 1978 “Conditions of Fertility Decline in Developing Countries, 1965-75)” Studies in Family

Planning 6(5):89-147, The Population Council,

New York.

20. J “Experience with Contraceptive Methods

in Developing Countries,” in Contraception: Science, Technology, and Application, Proceedings

of a Symposium, National Academy of Sciences,

Washington, D.C. 50-104, 1979.

21. Ness, G. D., personal communication, 1980.

22. Ness, G. D., and Ando, H., Population Planning in

Asia: A PoliticaZ-EcoZogica/ Perspective, forthcoming in 1982.

23. Ness, G. D., “On Integration in Family Planning

Programming)” in UNFPA Policy Development

Studies, No. 1, On Integration of Family Planning

with Rural Development, UNFPA, New York, 1979.

24. Nortman, D. L., personal communication, 1981.

25. Nortman, D. L., and Hofstatter, E., Population and

Family Pkmning Programs, A Compendium of Data

through 1978, loth cd., A Population Council Fact

Book, The Population Council, New York, 1981.

26. Newland, K., The Sisterhood of Man, W. W. Norton and Co. (New York: A Worldwatch Institute

Book, 1979).

27. Okonjo, K., “Rural Women’s Credit Systems: A

Nigerian E$ample,” in Studies in Family Planning

11:326-331, November/December 1979.

28. Park, H.J. et al,, “The Korean Mothers’ Club Program,” Studies in Family PZannin~ vol. 7(10):

275-283, 1976.

29. Park, C. B., “Incentives and Disincentives in Population Programmed,” Background Paper for

UNFPA/EWPI Meeting.

30. Paxman, J. M., Law and Planned Parenthood, A

Handbook, compiled and edited for the IPPF

Panel on Law and Plamed Parenthood, International Planned Parenthood Federation, London,

1980.

31. Poffenberger, T., “Fertility and Family Life in an

Indian Village,” Michigan Papers on South and

South East Asia No. 10, University of Michigan,

Ann Arbor, 1975.

32. Polgar, S., Marshall, J., “The Search for Culturally

Acceptable Fertility Regulating Methods,” in Marshall and Polgar, (cd.), Culture, Natality and Family

P/anni~ Chapel Hill, North Carolina Population

Center, University of North Carolina Monograph

21, 1976.

33. Population Council and PIACT de Mexico, ’’Family

Planning in Mexico: A Comprehensive Marketing

Study of Awareness, Attitudes, and Practices

Among Consumers and Retailers” (New York:

The Population Council and PIACT de Mexico,

1979).

34. Rodriguez, G., “Family Planning Availability and

Contraceptive Practice,” International Family P/arming Perspectives and Digest, 4(4): 100-115, 1978.

35, Schearer, S. B., “The Role of Governments in the

Uptake and Use of Future Birth Planning Methods)” OTA Working Paper, 1981.

36. Scrimshaw, S., “Acceptability of New Contraceptive Technology,” paper prepared for the PARFR

International Workshop on Research Frontiers in

Fertility Regulation, Mexico City, Mexico, February 1980.
Ch. 7—Factors That Affect the Distribution, Acceptance, and Use of Family Planning in LDCs ● 159

37. ‘(Women’s Modesty: One barrier to the

use of ~amily planning clinics in Ecuador”, in J. F.

Marshall, and Polgar’s (cd.), Culture, IVatality and

Family Planning Chapel Hill, North Carolina Population Center, University of North Carolina Monograph 21, p. 167, 1976.

38. Shain, R. N., “Acceptability of Contraceptive

Methods and Services: A Cross-Cultural Prospective, ” in Rochelle N. Shain and Carl J. Pauerstein,

Fertility Control: Biologic and Behavioral Aspects

(Hagerstown: Harper and Row 1980, pp.

299-312).

39. Shedlin, M. G,, Hollerbach, P., “Modern and Traditional Fertility Regulation in a Mexican Community: Factors in the Process of Decisionmaking,”

Working Papers 27, Center for Policy Studies,

Population Council, New York, 1978.

40. Sinding, S, W., “Study of Family Planning Program Effectiveness: Summary,” AID Program Evaluation Discussion Paper No. 5, Office of Evaluation, Bureau for Program and Policy Coordination, AID, Washington, D. C., April 1979.

41. Speidel, J. J., Memorandum: Integration of Health

and Family Planning, AID, April 15, 1977.

42. Tsui, A. O., and Bogue, D. J., “Declining World

Fertility: Trends, Causes, Implications,” Population Bulletin, vol. 33(4): October 1978, Population

Reference Bureau, Inc., Washington, D.C.

43, Thailand Fertility Survey, World Fertility Survey,

London, 1975.

44. UNFPA, Policy Development Studies Series, No. 4,

“The Role of Incentives in Family Planning Programmed)” A report of UNFPA/EWPI Technical

Working Group Meeting on the Role of Incentives

in Family Planning Programmed, 1980.

45. UNFPA, IPPF, and the Population Council, Family

Planning in the 1980b: Challenges and Opportunities, Background Document, International Conference on Family Planning in the 1980’s, Apr.

26-30, 1981, Jakarta, Indonesia, The Population

Council, New York, 1981a.

46. UNFPA, IPPF, and the Population Council, Family

Planning in the 1980’s, Review of the Current

Status of Family Plannin~ Annex to the Background Document, International Conference on

Family Planning in the 1980’s, Apr. 26-30, 1981,

Jakarta, Indonesia, The Population Council, New

York, 1981b.

47. UNFPA Policy Development Studies Series, No, 1,

On Integration of Family Planning with Rural Development, a Report on the UNFPA/EWPI Technical

Working Group Meeting on Integration of Family

Planning with Rural Development, UNFPA, New

York, 1979.

48. Watson, W., personal communication, 1981.

49. Westoff, C. F., ‘(The Unmet Need for Birth Control in Five Asian Countries,” International Family

Planning Perspectives and Digest, 4(1):9-17, 1978.

50. “Unwanted Fertility in Six Developing

Countries,” Paper presented at World Fertility

Conference, London, 1980.

51. Williamson, N. E., ‘(Boys or Girls? Parents’ Preferences and Sex Control,” Population Bu//etin, Population Reference Bureau, Washington, D. C., vol.

33, No. 1, January, 1978.

52. World Health Organization, “A Cross-cultural

Study of Menstruation: Implications for Contraceptive Development and Use,” Studies in Family

Planning vol. 12(1), January 1981, pp. 3-16.

53. “A Study of User Preferences for Fertility

Regu]a;ing Methods in India, Korea, the Philippines, and Turkey,” Studies in Family Planning

11(9-10):267-273, September-October 1980.
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 understanding 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 consensus that current fertility planning technologies fall short of ideals of safety, effectiveness, 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 require 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 efforts. 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 policymakers 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 contraceptive 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 applied research where additional effort would be

likely to result in information or products of

value to polivymakers, providers, or consumers.

The focus of this chapter is on research that will

improve the ability of couples to choose the

number and spacing of their children and nations to develop beneficial population policies.

Research needs in the population field are

many. They range from fundamental knowledge of reproductive processes to characterization and development of effective service delivery systems to better understanding of the political processes that give rise to population policies. The breadth and number of research

needs in this field arise from the complexity and

number of factors influencing population

growth and the fact that current understanding

of them is limited.

Basic data and theory

Verifiable reporting of the levels, trends, and

differentials of the three components of population growth-fertility, mortality, and migration—requires careful collection of data. Accurate, descriptive data are needed for countries, 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 differences 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 relationship 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 accomplished,

Better information is needed about the dimensions and consequences of international migration 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 provariables and theories are needed. Most existing gram implementation.

explanatory models fail to consider the variables

Fertility planning technologies

Basic biomedical research is fundamental to

the development of new or improved methods

for regulating fertility and correcting or preventing infertility. Better understanding of reproductive biology will permit identification of

new points of intervention that may lead to

safer, more effective and/or easier-to-use methods than those now available. However, as a

National Science Foundation (NSF) report (10)

points out, “mixed feelings about the value of

pure science have recurred as a theme throughout U.S. history. ” A major reason is that the relationship between basic research and useful

technology is often unclear. The report provides 26 examples of NSF-funded research over

a 30-year period in which the applications were

not anticipated when the research began.

Another factor in the lack of support for basic

research is the long time lag between fundamental work and its application. This is especially true in pharmacologic technologies

where the need to meet Food and Drug Administration requirements adds to the time between

research and application. As in the case of the

contraceptive pill, 20 years may pass before the

fruits of research are realized. Additional deterrents are the high costs of field trials and product liability suits (see ch. 5). These factors make

basic research in reproductive processes aimed

at developing a new method of contraception increasingly unattractive.

Yet there is general agreement that current

fertility planning technology falls short of meeting ideals of safety, effectiveness, acceptability,

and ease of use, In LDCs, family planning is

practiced by fewer than one-fifth of couples

of reproductive age (excluding China). Discontinuation rates are high; after 2 years, nearly two-thirds of oral contraceptive users and

half of those using IUDs have stopped using

these methods. Sociocultural influences and distribution problems contribute to these high

discontinuation rates, but drawbacks associated

with the methods themselves are unquestionably significant. Although the likelihood of an

ideal contraceptive is remote because the characteristics of that ideal differ among cultures

and during different stages in the reproductive

lifespan, new or improved methods can certainly be produced by undertaking the appropriate

research. A variety of improved technologies,

including those for treatment of infertility,

would provide couples with more varied, effective, and safer choices to meet their changing

needs for contraception.

While development of new technology in this

field is often time-consuming and expensive,

this is not always true. Some highly effective instruments and procedures have been developed

for relatively low expenditures of time and

dollars. Examples include minilap sterilization,

syringe equipment for menstrual regulation and

induced abortion, and cautery equipment for

vasectomy. Such new developments generally

depend less on new knowledge than on improvements in technology, which may arise

from other fields (e.g., the fiber optics used in

minilap sterilization). An opportunity for similar

rapid, relatively low-cost development in the

near term may lie in contraceptive delivery systems such as implants, injections, and drug-releasing IUDs and vaginal rings, and in foolproof

methods for detecting the time of ovulation.

The opportunities for basic research are

broad. They range from characterization of the

structure of molecules fundamental to the reproductive process (such as gonadotropin) to

the physiological level (such as the relationship
166 Ž World Population and Fertility Planning Technologies: The Next 20 Years

between sperm development and testicular support cells). The 1976 “Greep Report” (3) lists

more than 230 gaps in knowledge of reproductive processes; most of these still exist.

R&D needs in specific areas of family planning technology include:

●

●

●

●

●

●

Development of better male contraceptives.

Prospective methods include those to suppress sperm production and to intercept

sperm maturation, and simplified sterilization procedures.

Further development of barrier methods.

Highly effective methods that would eliminate the need for coitus-related application

or for privacy during application would be

welcomed not only in LDCs but by the

growing number of MDC women concerned about the side effects of most nonbarrier methods. Better materials, product

designs, and modes of administration could

result from further research in this area.

Improved methods of periodic coital abstinence. The development of means to reliably identify the fertile and infertile phases

of the menstrual cycle could, by sharply increasing use-effectiveness, both increase

the use of such methods and improve their

low continuation rates.

New approaches to female contraception.

Areas of promise include LRF analogs, immunizing antigens, vaginal steroid rings,

and post-coital methods such as menses inducers.

Better methods of nonsurgical sterilization.

The World Health Organization (WHO) (13)

has noted that the demand for sterilization

by surgery cannot be met in some LDCs because of lack of trained personnel, operating rooms, and anesthetics.

Better methods of preventing and correcting

infertility.

Many causes of unwanted infertility could be

eliminated by improved understanding of

reproductive processes.

Evaluation research, as opposed to research

on new contraceptive methods, is also needed.

Of primary concern are the safety and side effects of current contraceptive technologies. Specific interest lies in:

●

●

●

●

●

●

●

●

●

risks for cardiovascular diseases and other

diseases associated with use of oral contraceptives in different populations and under

different dosages of different hormones;

the effect of disease states such as anemia,

malaria, and schistosomiasis on absorption,

effectiveness, and safety of different fertility planning methods;

the hypothesized carcinogenic effects of

spermicides and therefore the need for

safer spermicides to be used with various

methods;

better understanding of how genetic differences, nutrition, and body characteristics

alter method safety, effectiveness, and side

effects;

the safety of contraceptive implants and injections;

whether induced abortion under medically

supervised conditions is associated with adverse outcomes in subsequent pregnancies;

methods to counteract the blood loss associated with nonprogesterone-releasing IUDs

which can result in iron deficiency;

the long-term effects of contraceptive methods, such as the risk of cancer; and

medical bases for high discontinuation

rates.

Finally, there is a need for research aimed at

improving the R&D process itself. Better understanding of species differences between animals

and humans, for example, would improve testing for side effects, safety, and effectiveness of

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

through a broad spectrum and affect the relative acceptability of different fertility planning

technologies. Appropriate technologies also

vary with age, reproductive status, and frequency of sexual activity. The consequences of

an unplanned birth are very different for a

woman with no children than they are for a

mother of five, and for single and married

women. Thus, the relative weight placed on the

criterion of effectiveness, for instance, in selecting among various methods will vary for women

in these different circumstances. Other criteria

vary in relative weight in similar fashion.

Therefore, a fundamental research need is

the relationship between culture-specific (11)

and age-specific factors and various fertility

planning technologies. Theoretically, it should

be possible to develop physiological and psychological self-tests for use by an individual—or as

guides for family planning workers–to help a

man or woman select the contraceptive method

most appropriate to his or her needs and values

at a given point in time. Information on agespecific factors as they affect acceptability

would also be of great value to policymakers in

deciding which drugs or devices to include in

family planning programs.

One of the greatest needs is for development

of a sound theoretical framework describing

the factors that determine fertility. Information

to develop such a framework requires research

on patterns of social organization and their influence on the reproductive and economic decisions of individuals. The economic value of children and institutional factors governing fertility

incentives need elucidation.

Among cultural factors, a very important area

of investigation is women’s beliefs and attitudes

and how these influence their practice of family

planning. These relationships require investigation on both physiological and psychosocial

levels. At the physiological level, understanding

attitudes toward changes in menstrual patterns

is particularly important because these changes

are most frequently cited as reasons for discontinuance of such contraceptives as orals and

IUDs. At the same time, women who state that

they will not tolerate changes in their menstrual

cycles continue to use contraceptive methods

that cause such changes. Much remains to be

learned about what menstruation means to

women of different cultures, whether and how

their beliefs can be modified, and how decisions

are made in selecting among contraceptive

methods.

On the psychosocial level, the relationships

between contraceptive practice and the following areas need investigation:

●

●

●

the role of women in a given class and/or

culture;

women’s autonomy for decisionmaking;

and

women’s perception of themselves, their

bodies, and childbearing.

Male beliefs about different fertility planning

methods and about the responsibility of men for

their use also require clarification. WHO studies

suggest that there is demand for male contraceptives in different cultures, but the very low

usage rates and the difficulty encountered by

investigators in recruiting male volunteers for

clinical studies raise questions about male acceptance of both existing and new contraceptive

technologies.

Decisionmaking with regard to the adoption

of family planning is influenced not only by the

feelings and beliefs of the individual man and

woman in a couple but by considerations of that

couple as a family. Achieved family size and desired family size, the role and status of children

within a culture, male-female communication,

and participation of various family members in

decisions on the number and spacing of births

are all little-understood factors which influence

acceptance and use of family planning and the

methods specific to achieving desired family

size. The same can be said of the relationships

between individual men and women or between

couples and their peers.

To make choices among various fertility planning technologies, individuals must be aware of

the methods that exist and the benefits and consequences of each. How best to communicate

such information both within a given mode (e.g.,

different forms of package inserts) and across

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.

The role of pharmacists, physicians, and others

who provide information on family planning

methods also needs attention.

Many of the conditions that determine acceptance of contraceptive technologies do not lie in

the users themselves but in the political and administrative systems that distribute the technologies. Elites make decisions on what methods to

use, how the distribution shall be organized,

who shall be the distributors and educators,

what price to charge, what the message will be,

and how the methods will be packaged. Yet, the

managing elite and the delivery systems themselves have rarely been the subject of systematic

research. This type of program research is a

major gap on both theoretical and empirical

grounds and may pay high dividends in the

short run.

Finally, some research on the determinants of

fertility has been aimed at increasing the use of

family planning services, thus enabling parents

to have the family size they want. But this is

only one of two fundamental social objectives in

fertility policy. The other is to balance the

numbers of children individual couples want

for themselves with the number the whole society thinks best. Research on how this second objective is accomplished and how it influences

fertility is needed.

Population policy

The relative contributions of availability of

fertility planning methods and of general socioeconomic development to reducing population

growth have been a subject of considerable

controversy, with strong advocates on both

sides. Each undoubtedly contributes and the

relative contribution in a particular case will

vary with culture-specific factors. Further research to bolster either position might better be

directed toward broader based research on the

complex interaction of the many factors that influence population growth, Methodologies are

available for study of these interactions, and

data collection efforts need to be designed so

that these can be used. Data on social, economic, and political variables are often collected

in different ways at different times by different

groups, Coordination of data collection efforts

would also facilitate disaggregated analysis at

the subnational level, which is necessary to

better design family planning programs. The

comparative research within and across countries that is needed to improve predictive ability—which approach to family planning is likely

to work best under what conditions—would be

facilitated as well. Critical analysis of individual

variables is also needed. Assistance to LDCs in

experimental design and use of the new methodologies would be beneficial.

A systematic analysis of “success stories”

—areas where dramatic reductions in population growth have been achieved—could be productive. Through careful analysis, factors that

have led to success might be identified and

ranked in probable importance for further evaluation. The objective of such work would be to

improve predictive capability with regard to the

factors likely to lead to effective programs in

different contexts.

The need for viewing family planning activities in a broader context was recognized by

Congress in 1978 in passage of an amendment

(sec. 104d) to the Foreign Assistance Act of 1961.

Section l04d requires that all assistance programs, not just those specifically directed at

population, be evaluated for their impact on

population growth.

Policymakers attending the workshops held

by the International Review Group to identify

social science research needs for the 1980’s also

identified evaluation of past and present policies

and programs for their impact on population as

one of their most critical needs (8). Evaluation of

both those policies and programs with specific

family planning objectives and those expected to

have indirect impact, such as in the areas of

education and nutrition, was called for. The
Ch. 8—Research Needs ● 169

lack of existing knowledge, however, about how

specific factors interact to influence population

growth makes this an as yet impossible task and

points up the need for research to make such efforts achievable.

Research is needed both on the effect of general policies and programs and on specific interventions. For example, how effective is a program which promotes breastfeeding as a method of limiting fertility likely to be? What is its

cost? What are its nutritional and other effects?

How does such a program compare to one promoting later ages at marriage?

The situational aspect of specific interventions

should not be neglected. A finding of WHO acceptability research is that not enough is known

about the application of various fertility planning methods in specific situations. Though

some might not consider how IUDs are inserted

in women of an Indian village as a subject for research, information on similar situation-specific

applications is considered a significant need in

many LDCs.

How various institutional arrangements influence family planning programs in particular

countries should be further studied. Whether,

how, and under what conditions family planning should be combined with health care or

other socioeconomic programs are the kinds of

questions on which further information is

needed. Such information would permit development of guidelines that administrators could

use in designing family planning programs.

Finally, there is a need to better understand

the political processes that lead to population

policies and the relationship of research to policy formation. Although it is often difficult to

show that a specific piece of research has had

an influence on policy, a number of cases where

the relationship is clear have been documented.

In a review of such work (5), evidence is summarized that clearly shows that research findings have influenced policy in four areas:

● development of antinatalist population policies—definitive evidence comes from Colombia, Thailand, and Taiwan;

●

●

●

service delivery—research has supported

the use of paramedical or nonmedical personnel to provide fertility planning services

and information traditionally supplied by

physicians. Research findings have also had

a major influence on the implementation of

hospital postpartum programs and on selection of particular contraceptive methods

such as the pill and the IUD;

development of population growth targets–research findings have been used to

formulate programs and estimate budgets

necessary to meet specific population

growth goals; and

migration and redistribution of population—a

good example of the influence of research

on policy in these areas comes from Colombia (5).

In a fifth area, that of population education, it

is too early to evaluate the many recently implemented specific programs providing education

on population-related topics in LDC schools, but

a number of these programs include comparisons of the effectiveness of various teaching

methods and the relationship between educational level and material presented. This information is of obvious value to policy makers.

Research, by showing the high mortality rates

associated with abortions performed under inadequate medical conditions in Chile and other

Latin American countries, was of considerable

significance in the establishment of family planning programs in these countries; “programs

were often justified, and sometimes evaluated,

in terms of their effectiveness in preventing induced abortion” (5). Such research has also influenced policy on the legal status of induced

abortion.

Much remains to be learned, however, about

the research most needed by policy makers, how

such research should be done, and especially

how it can be brought to bear on policy. As Miro

and Potter (7) point out, it is widely assumed

that “if research succeeds in identifying the

relationship between demographic variables

and social, economic, and cultural indicators,

then a tool will have been obtained for use in

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 developthat are involved.” They argue that such infor- mants in the field of population.

mation would provide a firmer basis for predictThe relative importance of different

kinds of research

The preceding sections cover three kinds of

research that might be described as basic, developmental, and utilization research. Basic research includes studies of reproductive processes and fundamental studies in apparently unrelated areas (such as in materials science which

may eventually lead to improved contraceptive

devices). Also included are development of basic

demographic data and theory, and development

of explanatory models and new measurement

techniques.

Developmental research links knowledge and

practice and is particularly applicable to such

important aspects of new or improved contraceptive technologies as dosage levels, mode and

frequency of administration, and safety. Regulatory requirements that must be met add to

the expense and risks involved in developmental

research.

Utilization research, as applied to fertility

planning technologies, is the study of cultural,

economic, and political factors that impede or

promote use of technically safe, effective technologies. The objective of utilization research is

to ensure that the technology is distributed and

administered in ways that are consistent with

the cultural, economic, and political values of a

Chapter s references

given society. Despite its importance, utilization

research is often inadequately err hasized in

the process of developing and distributing fertility planning technologies.

Research on delivery systems, institutional arrangements, and evaluation of program effectiveness is included in utilization research. Also

included is development of techniques that can

be used to increase use of family planning methods, usually termed operations or management

research. Although utilization research could be

considered market research, it is broader than

what usually falls under that rubric; hence the

term “utilization research.”

Each of these three categories of research

serves different purposes. Because of the inadequacies of current fertility planning technologies and the acknowledged increase in need

for them in the years ahead, basic and developmental research to develop improved methods

is clearly needed. But because of the long lead

times in development of new methods, current

technologies will have to be used more effectively if population goals are to be met in the

next 20 years. Utilization research will thus be

of key importance in the immediate future.

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. Reproductive and Human Welfare: A Challenge to Research (Cambridge, Mass.: MIT Press, 1976).

4. Harper, M. J. K., “Prospects for New or Improved

Birth Control Technologies by the Year 2000

A.D.,” report prepared for OTA, Washington,

D. C., 1980.

5. Mauldin, W. P., “The Role of Population Research

6

7.

in Policy Formation and Implementation (A Preliminary Note),” working paper prepared for the

International Review Group of Social Science Research on Population and Development, September 1977.

Mertens, W., Research Priorities for Population

and Socioeconomic Development: Recommendations for UNFPA inter-Countrtiy Programmed,

United Nations Fund for Population Activities,

1978.

Mire, C. A., and Potter, J. E., Social Science Research for Population Policy: Directions for the

1980’s, IRG, El Colegio de Mexico, 1979.

8. Mire, C. A. and Potter, J. E., “Social Science and

Development Policy: The Potential Impact of Population Research, ” Population and Development

Review 6(3), 1980, pp. 421-430.

9. National Research Council, Contraception: Science, Technology, and Application, proceedings of

a symposium (Washington, D. C.: National Academy of Sciences, 1979).

10. National Science Foundation, How Basic Research

Reaps unexpected Rewards (Washington, D. C.:

NSF, 1980).

11. Salyer, S. L., and Bausche, J. J., Toward Safe, Convenient, and Effective Contraceptives: A Policy Perspective (New York: The Population Council,

1978).

12. Schearer, S. B., “Future Birth Planning Technologies, ” report prepared for OTA, Washington,

D.C. 1980.

13. World Health Organization, Annual Report 1979,

World Health Program, Geneva, Switzerland,

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 developed countries (MDCS) governments and international agencies, $100 million from private 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 Activities (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 61⁄2 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 components 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 supports information and education activities, policy development, data collection, institutions

and training, and research efforts.

La

1979, Asia received the largest share of population

assistance (60 percent); followed by 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 population growth; data of better quality are available to enable governments to formulate policy;

countries are becomiing increasingly self sufficient and taking greater financial and administrative 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 couples enter their childbearing years. Excluding China, in the year 2000 some 495 million couples of reproductive age (compared, with 300 million in 1980) will need contraceptive protection 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

family planning programs in LDCs today comes

from three major sources: private organizations, national governments, and intergovernmental agencies. Most of these agencies took on

this role during the 1960’s, when the implications of rapid population growth emerged as a

worldwide concern. During the 1970’s, these

agencies, working in a generally cooperative

way, assumed different functions in the complex and expanding field of population assistance. They operate in different ways both

because the LDCs and regions are at varying

stages of their demographic transition to lower

birth and death rates, and because the complexity and sensitivity of population issues require a

mix of programs and agencies to enable each

country to have access to one or more sources

that meet their needs.

Origins of population assistance from the

United States

Awareness of the magnitude of population

growth in LDCs grew gradually during the late

1950’s and early 1960’s. Statements from the

countries themselves heightened this awareness, as did the activities of such organizations

as the Population Council and the United Nations (U. N.). The U.N. published its first Demographic Yearbook in 1949 and its first series of

population projections in 1952, which forecast a

1980 world population of 3.6 billion. This total

was revised upward in 1957 to 4.2 billion.

India adopted a national family planning policy in 1951 and Pakistan included demographic

policy and family planning activities in its national development plan in 1955. Demographer

Ansley Coale and economist Edgar Hoover built

a population growth model in 1958 which demonstrated that family planning expenditures

would, over various intervals, increase per

capita income to a greater degree than any

other type of goverernment investment. Although

this model was developed for India, its message

to other LDCs was clear: a reduced rate of population growth would always mean additional

funds for capital investment because there

would be fewer dependents and smaller expenditures for consumption and social needs.

The actions taken by India and Pakistan, and the

activities of private organizations and the U. N.,

heightened public recognition of the hazards of

rapid population growth.

Until the mid-1960’s, private agencies played

the major role in international population assistance. These agencies were of two types: activist

citizen organizations like the International

planned Parenthood Federation (IPPF), established in 1952, and the Pathfinder Fund, established in the 1930’s, in which business leaders

and community workers merged to promote

public recognition of population problems and

provide family planning services directly to

those who wanted them; and professional scientific organizations like the Population Council,

also established in 1952, which focused on specialized demographic and biomedical research

and then on technical assistance as requested.

Private donors—individual philanthropists and

such major foundations as Ford and Rockefeller—provided financial support for these scientifically oriented programs. Princeton, North

Carolina, Michigan, and Johns Hopkins Universities, with this help, were able to develop training programs for population/family planning

specialists.

Although private agencies had been seeking

Government support for more than a decade,

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

U.S. public support for population assistance.

The 1960 round of censuses showed high rates

of population growth in LDCs, especially in Asia.

The governments of Pakistan and India had by

the 1960’s begun to ask the United States and

other MDCs for help, The U.N. Population Commission and the U.N. Economic Commission for

Asia and the Far East brought population issues

to international attention.

Within the U.S. Government, such expert advisory groups as the Draper Committee (in 1959)

recommended that the U.S. provide assistance

for population planning at the request of LDCs.

The election of John F. Kennedy in 1960 as the

first Catholic President of the United States

helped defuse religious issues and brought to

power an administration that viewed population growth as a national policy matter.

The food crisis that developed in South Asia in

the mid-1960’s also spurred U.S. Government

concern. Members of Congress had initiated the

Food for Peace Program (Public Law 480) in

1954 and were following international food developments closely. The news that food production in many LDCs was failing to keep pace with

population growth was highlighted in House

and Senate hearings. As a result, the Congress

took the initiative in 1963 and again in 1966 and

1967 to provide specific legislative authority for

the United States to assist LDCs with their population growth problems.

The AID population assistance program, first

created by Congress as a part of a concerted

War on Hunger, and then as an important element of humanitarian and social development,

grew from a $5 million effort in 1965 to one of

$190 million in 1981. From the beginning, the

U.S. program has made extensive use of private

organizations. Influenced by both the important

role of private voluntary agencies in other

assistance efforts and by the fact that until the

mid-1970’s many LDC governments were not

yet ready to adopt bilateral assistance for official population programs, AID and other donors

support a network of private agencies that provide family planning services, training, information, and education; demographic and policy

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

assistance to an LDC for family planning, supported pilot projects in Sri Lanka in 1958 and

Pakistan in 1961. The United Kingdom followed

with small-scale assistance programs in India

and Pakistan in 1964. Denmark made its first official grant in 1966 in support of a pilot study to

test the suitability of a Danish IUD for India’s national family planning program. The Netherlands offered bilateral support to a family planning project in Kenya in 1968. The Federal Republic of Germany and Finland followed in 1969

with support to multilateral programs and Canada, Japan, and Norway joined in the effort in

the early 1970’s.

International agencies had meanwhile begun

o respond to LDC needs for population assistance. Although the impetus for response to international population problems came from a

number of U.N. agencies, a viable U.N. unit with

a specific mandate in the field of population did

not exist until 1969 when the U.N. Fund for Population Activities (UNFPA) became a separate

unit within the U.N. Development Programme

(UNDP). Following the unanimous General Assembly Resolution in 1966, a trust fund was established to become UNFPA, and operational activities began 3 years later.

Within the U.N. system different offices and

agencies have different responsibilities for the

execution of population programs: the Statistical Office gathers statistics and the Population

Division conducts research on population issues

and makes demographic projections; the World
178 ● World Population and Fertility Planning Technologies: The Next 20 Years

Health Organization provides technical expertise for assistance to maternal and child health

and family planning services; UNESCO deals

with population education and communications;

UNDP provides general development assistance

on request but relies on UNFPA for population

expertise.

Most U.N. agencies depend on contributions

assessed from member nations on a population/

income formula and are reluctant to start new

programs without additional funds. Their governing bodies and staff were at first apprehensive about the political implications of a program that might be controversial. Established

first as a trust fund of the Secretary-General

and entirely dependent on voluntary contributions from interested governments and on the

technical expertise of other agencies, UNFPA

came into being with a minimal mandate in a

field where responsibilities were fragmented

and bureaucratic rivalries strong.

UNFPA uses a broader definition of population planning than does AID’s Office of Population. UNFPA programs, often in conjunction

with LDC health ministries, focus on migration,

mortality reduction, and maternal and child

health (MCH) activities in addition to fertility

planning, while the AID Office of Population, as

legislated by Congress, is primarily concerned

with family planning activities. Separate accounts within AID handle health activities.

The World Bank initiated a population program in 1969, The Bank, which has more development resources than any other international

agency, deals with high level finance and planning officials in LDCs. Population planners

hoped this influence would be used within LDC

governments to provide more support for population programs, but banking officials have remained skeptical of such programs; less than 1

percent of Bank resources have been directed

toward population projects in recent years.

About 20 population projects totaling $400 million have been initiated since 1969 through the

Bank’s International Development Association

(IDA) and International Bank for Reconstruction

and Development (IBRD), and the Bank is now

working to integrate population, health, and

nutrition projects to provide a broader operating base.

Support for population activities

Channels of assistance

Donor governments are the principal sources

of population assistance. Most smaller donors

contribute only to UNFPA or to other U.N. programs, but larger donors such as the United

States, the Scandinavian countries, Germany,

Japan, Britain, and Canada have contributed in

three ways: I) to private intermediaries or nongovernmental organizations (NGOs), i.e., IPPF

and the Population Council; 2) directly to LDC

governments through bilateral loans and grants;

and 3) to UNFPA. UNFPA contributes in turn to

LDC governments and also provides a small

amount of support for private intermediaries

and for global activities, such as conferences

(see fig. 25).

Private sector donors contribute primarily to

NGOs such as IPPF, the Population Council, the

Pathfinder Fund, and Family P1anning International Assistance (FPIA). These in turn provide

both funds and advisory personnel to local organizations within LDCS. Some international private agencies, like IPPF and the Population

Council, also make expert advisory personnel

available to assist LDC governments or to organize U.N. or global programs such as the 1974

World Population Conference in Bucharest and

the 1981 conference in Jakarta on Family Planning in the 1980’s.

Kinds of assistance

Kinds of population assistance, although not

strictly comparable, can be grouped under six

functional headings (see table 45): I) family plan.

ning services—purchasing and distributing con.

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 flow s

--- Technical assistance flows

SOURCE: Office of Technology Assessment.

Table 45.—Composite of Kinds of Assistance

Assistance Agencies

Provided by Major

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

operations, personnel, and equipment (AID,

UNFPA, IPPF, and World Bank all expend close

to half or more of their population funds for

family planning services, and the Bank includes

clinic construction in this category); 2) information, education, and communication (lEC)—informing or educating the public about family

planning, contraceptive mehtods, and the implications of rapid population growth; 3) institutions and training—teaching and training of

clinic personnel, midwives, and family planning

practitioners; 4) research and evaluation—sponsoring biomedical and social science research

activities, family planning program evaluation,

and operations research; 5) policy deve[opment—conducting leadership awareness activities in the government and private sector in

LDCS (AID also includes research on fertility determinants and women’s roles); and 6) data co/-

Iection–gathering, analyzing, and disseminating

relevant population information through censuses and surveys.

Roles of assistance agencies

The private agencies (Population Council,

IPPF, FPIA, AVS, etc.) are major innovators in

service delivery, training, and research. For example, IPPF, FPIA, and others initiated community-based distribution (CBD) of contraceptives—usually cond’oms and pills—by networks

of local community leaders. The Ford Foundation initiated contraceptive sales activities in

LDCS through retail storekeepers. Private agencies and universities have trained and equipped

physicians in newly simplified techniques of

female sterilization, and were the first to

establish collaborative international research

networks to pool data and evaluate new contraceptive technologies in a pattern now being

expanded by WHO. They have tested new computer techniques for storing and retrieving

population data and presenting these data visually to government leaders, and have experimented with women’s programs to develop

women’s management skills and spread awareness and knowledge of family planning. In countries where population policies are in flux, private family planning associations have provided

a measure of continuity.

The role of international agencies is necessarily different, and less experimental. UNFPA, for

example, works with other U.N. agencies and

national governments to fund efforts to build

national capacity to formulate and implement

population policies and programs. UNFPA has

served three main population assistance functions that supplement and complement U.S.

Government efforts:

1.

2.

3.

As a multilateral agency, UNFPA has been

able to stimulate substantial additional

funding for population assistance. Of the

more than 85 governments that have contributed to UNFPA, fewer than 10 have

separately staffed bilateral population

assistance programs. Most would probably

have made little contribution to population

programs had they not had the opportunity

either to contribute directly to UNFPA or to

support multilateral-bilateral projects combining national funds and UNFPA-U.N. specialized agency monitoring and expertise.

The various international agencies, including UNFPA and the World Bank, have

helped to define rapid population growth as

a global concern, an obstacle to economic

development, and a problem in need of high

level national attention. Their efforts underscore the fact that population assistance

is a cooperative response to an international need. Whether the immediate issue is

rapid urbanization or high levels of unemployment, UNFPA has called government attention to the underlying demographic

causes and made assistance available to address the problem at hand, World Bank officials can articulate the adverse economic

impacts of rapid population growth while

working with the planning and finance ministries that set government budgets.

International agencies can mobilize technical assistance to help LDCs help each other.

Even though national programs may suffer

temporarily if skilled people leave to join

these agencies, these experts can bring
Ch. 9—Financial Support for LDC Population Program ● 181

their specialized experience to bear on similar problems in other LDCs, where it is likely to carry more weight than advice from

MDC governments that have not faced comparable population problems. Through this

process of mutual support, LDCs can move

toward greater self-sufficiency.

Among these channels of population assistance, AID has played a multiple role. As one of

the first and still the largest of government

assistance programs, AID has provided part of

the basic strategy for population programs.

AID’s strategy is based on the established public

health principle of availability-making information, supplies, and services readily available

so that individuals who choose to plan their fertility can do so conveniently. As a result, AID

has been the principal supplier of contraceptives, purchasing in bulk from U.S. firms at low

competitive prices. (For example, AID now pays

$0.15 for a cycle of oral contraceptives that

would otherwise wholesale in an LDC for about

$3.50.) Through the use of intermediary agencies, AID has encouraged CBD of contraceptives

and other cost effective approaches for the

delivery of family planning information and

supplies to rural populations that lack access to

clinic-based services. In addition, AID has been

responsible for many major improvements and

innovations in the field of fertility planning

technology.

The AID program has been both a catalyst and

a stimulus to other agencies in developing such

projects as the World Fertility Survey, which is

also supported by UNFPA and other governments, AID’s efforts have encouraged other governments and agencies to improve their programs, and universities, private agencies, LDC

governments, and the World Bank to undertake

more intensive efforts in program implementation.

U.S. share in international assistance

Less than 2 percent of official development assistance from all MDC donors is currently allocated to population activities, which represents

a small decline since 1970. The United States

provides just under 4 percent of its global development assistance for population activities.

In 1980, total resources committed to population and family planning programs in LDCS

amounted to about $1 billion. LDC contributions accounted for about $450 million in 1980,

excluding China; roughly $55o million originated externally as international population

assistance. (See app. A for China expenditures. )

MDC governments over the last decade have

consistently generated more than 80 percent of

all international population assistance; the remainder has originated with the World Bank

and private sources. Among MDC donor countries, the United States, through AID, continues

to be the largest contributor of population

assistance. The United States provided 50 percent or more of all primary source assistance

until 1973, when the U.S. share of this funding

decreased and the portion provided by other

sources increased (see fig. 26). By the mid1970’s, the U.S. share leveled off to about 40

percent, and has remained at this level for the

last 4 years. This decrease is largely due to increased contributions from other MDCs. Several

of the Scandinavian countries, Japan, and West

Germany have increased their funding over the

past few years by 30 to 60 percent. United

States funding for population assistance has increased only 61/2 percent since 1978 after having

increased by 40 percent between 1975 and 1978

(see table 46). The impact of inflation has cut today’s funding level–in constant dollars–to below that of the peak year of 1972. In that year

Congress provided AID with a budget of $121

million. Inflation has cut the value of AID’s 1981

appropriation of $190 million to about $100 million, and the 1982 appropriation of $211 million

is $28 million below the amount required to

maintain the 1972 level (see fig. 27).

Components of U.S. population

assistance

AID obligates its population assistance

through four channels: 1) direct bilateral from

AID to LDC governments; 2) indirect bilateral

through U.S.-based private organizations to

NGOS in LDCS; 3) intergovernmental muhilateral (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

Assistance, 1975-81 (in millions)

Percent increase

Year Budget over previous year

NOTE: Figures and percentages reflect actual dollar figures, not allowing for

inflation.

pooled and redistributed to LDC governments

and NGOs; and 4) private multilateral (IPPF), in

which donor funds are pooled and redistributed

to IPPF affiliates in LDCs (see fig. 28). The

United States also contributes to the World

Bank, but this separate authorization from Congress is not channeled through AID.

DIRECT BILATERAL

In calendar year 1979, the latest year for

which complete data are available, about $48

million (26 percent of the AID population budget) went directly to 33 LDC governments: 11

each in Africa and Latin America, 8 in Asia, and

3 in the Middle East. In 1979, the largest recipients of U.S. bilateral aid for population activities

were:

Millions of dollars

Indonesia . . . . . . . . . . . . . . . . . . . . . . . . . $11.4

Bangladesh. . . . . . . . . . . . . . . . . . . . . . . . 4.0

Philippines . . . . . . . . . . . . . . . . . . . . . . . . 2.4

Tunisia . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8

Thailand. . . . . . . . . . . . . . . . . . . . . . . . . . 1.7

Nepal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7

INDIRECT BILATERAL

In 1979, some $90 million (52 percent of the

AID population budget) went to private intermediary organizations. Eighty-five percent of

this assistance was channeled through 14 agencies (see table 47), which provide substantial

amounts of technical assistance to countries

where bilateral assistance is not always appropriate. U.S.-based NGOs provided technical

assistance to 64 LDCs in 1979: 22 in Africa, 19 in

Latin America, 14 in Asia, and 9 in the Middle

East.

INTERGOVERNMENTAL MULTILATERAL

In 1979, the United States contributed about

$30 million (16 percent of the AID population

budget) to UNFPA. This constituted 27 percent

of UNFPA’S budget. UNFPA grants went to 116

LDCS in 1979: 37 in Africa, 31 in Latin America,

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

AID Population Funds, 1979

Estimated

expenditures from

AID for fiscal

year 1979

Intermediary organization (in millions)

Family Planning International

Assistance (FPIA). . . . . . . . . . . . . . .

Association for Voluntary

Sterilization (AVS) . . . . . . . . . . . . . .

Johns Hopkins Program for

International Education in

Gynecology and Obstetrics

(J HPIEGO) . . . . . . . . . . . . . . . . . . . . .

Pathfinder Fundb . . . . . . . . . . . . . . . . .

International Statistical Institute

(World Fertility Survey) . . . . . . . . . .

International Fertility Research

Program (IFRP) . . . . . . . . . . . . . . . . .

Development Associates . . . . . . . . . .

Westinghouse Health Systems . . . . .

University of North Carolina . . . . . . . .

Johns Hopkins University . . . . . . . . . .

Population Council . . . . . . . . . . . . . . .

Battelle Memorial Institute. . . . . . . . .

Program for Applied Research on

Fertility Regulation (PARFR). . . . . .

East-West Center. . . . . . . . . . . . . . . . .

$14.0a

7.7a

7.2

6.7a

5.0

4.2

3.0

2.9

2.2

1.6

1.6

1.5

1.1

1.0

nean. Those countries receiving the largest

grants from UNFPA in 1979 were:

Millions of dollars

India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $17.0

Vietnam . . . . . . . ... , . . . . . . . . . . . . . . 4.9

Bangladesh. . . . . . . . . . . . . . . . . . . . . . . . 4.5

Thailand, . . . . . . . . . . . . . . . . . . . . . . . . . 3.0

Egypt . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4

In 1980, the U.S. share of contributions to

UNFPA fell to 26 percent of its budget where it

remained during 1981. This marks the lowest

point of declining U.S. input to this agency (see

fig. 29).

PRIVATE MULTILATERAL (lPPF)

The remaining $22 million (12 percent of the

1979 AID population budget) was channeled

through IPPF. * This represents 28 percent of

IPPF’s total operating budget and, as in the case

● Note: This was not a representative year for the IPPF appropriation from AID. The figures for 1978 and 1980 were about $10

million less.

of UNFPA, is a proportional decline of U.S. input

since 1970 (see fig. 30). IPPF provided grants to

88 private family planning affiliates in LDCS in

1979: 21 in Africa, 32 in Latin America, 20 in

Asia, and 15 in the Middle East.

The countries receiving the largest grants

from IPPF during calendar year 1979 were:

Millions of dollars

Brazil . . . . . . . . . . . . . . . . . . . . . . . . . . . . $3.4

Colombia . . . . . . . . . . . . . . . . . . . . . . . . . 2.9

India. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.0

Mexico . . . . . . . . . . . . . . . . . . . . , . . . . . . 1.4

Republic of Korea. . . . . . . . . . . . . . . . . . 1.2

International assistance to LDCs

The quantification of dollar flows from MDC

governments and international agencies to specific LDCs cannot be precise because:

funds that pass through a variety of agencies are often commingled, making identification of initial donors difficult;

interpretations vary as to what international population assistance is, as opposed

to, for example, MCH assistance;

different accounting methods, fiscal years,

and exchange rates are used; and

commitments span several years and are

often reprogrammed through continuing

evaluation and review processes, making

identification of given-year expenditures

exact.

The relative proportions of all external population assistance to each region were fairly

constant from 1977 through 1979, with Asia receiving the greatest share (see fig. 31), Excluding

funds for regional, interregional, and global

purposes, country-specific dollar expenditures

increased from $208 million in 1977, to $232

million in 1978, to $280 million in 1979 (see table

A-3, app. A) for total amount of external assistance to each LDC).

AFRICA

Total average international assistance to

Africa during 1977-79 for all population activities remained at about $0.09 per capita per

year. Almost half of this aid came from UNFPA.

Among African countries, Kenya and Tanzania

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

20

5

‘/0

Figure 30.–Contributions to IPPF by the United

States and All Donors

International Planned Parenthood Federation income and

expenditures 1970-79

averaging $0.59 and $0.22 per capita per year,

respectively, over the 3-year period. West

African countries received less: Nigeria, $0,03

per capita; Niger, $0.04; Upper Volta, $0.01; and

Cameroon, $0.04.

African countries either do not generally recognize 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 demographic data collection, IEC, and family planning in

the context of maternal and child health. Nevertheless, family planning services and commodities 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 because 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

Provided to Africa, 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.

of government-sponsored programs, more

funds flow into this region. In 1979, 90 percent

of all international population assistance to Asia

came from U.N. agencies and direct bilateral

donors. Bangladesh received $0,49 per capita,

Thailand $0.38, and the Philippines $0,28. A

large portion of assistance to Asia has been earmarked for expansion of services and purchase

of commodities (see fig. 33).

Figure 33.—Kinds of Population Assistance

Provided to Asia, 1979

Data

collection

20% Policy Institutions and training/

development research and evaluation

30/0 7%

SOURCE: Percentages derived from: UNFPA Report on Population Assistance,

1979-Table 3—Assistance to Population Programs by Country and

Region and Major Population Sector.
Ch. 9—Financial Support for LDC Population Program • 187

LATIN AMERICA

Latin American countries rely extensively on

intermediaries for population assistance. In

1979, IPPF and the Ford and Rockefeller Foundations provided 36 percent of population assistance to Latin America. NGOS provided 53

percent of the $9.7 million contribution to

Brazil, 44 percent of the $11.2 million contribution to Colombia, and 65 percent of the $8.3 million contribution to Mexico. Although Latin

American countries received less total population assistance than Asia in 1979, per capita

averages were higher (about $0.19); relative

proportions of assistance were similar, with

most funds spent on family planning services

(see fig. 34).

MIDDLE EAST/MEDITERRANEAN

Middle Eastern and Mediterranean LDCS received the smallest share of international population assistance of all major regions over the

last few years. Although total country-specific

assistance in this region grew 62 percent between 1977 and 1979, from $14.4 million to

Figure 34.—Kinds of Population Assistance

Provided to Latin America, 1979

r evaluation

Policy development 1‘/0

$23.3 million, the relative share of total world

population assistance remained at only 8 percent. Total per capita population assistance in

1979 amounted to about $0.12. UNFPA contributed more than half of this assistance through

large grants to Egypt, Jordan, and Tunisia.

Egypt also obtained substantial World Bank support during the late 1970’s and 1980-81. Tunisia

received one of the largest per capita population

assistance donations in 1979 ($0.78), principally

from AID and UNFPA. Like Africa, the Middle

Eastern/Mediterranean region is at a comparatively young stage of policy and program development, and data collection for increased demographic awareness is a major focus of population activities (see fig. 35).

THE 13 MOST POPULOUS LDCS

External population assistance trend data and

per capita estimates for 1977-79 to the 13 most

populous LDCS are shown in table 48 (for complete list of countries see table A-3, app. A, ch.

9). Thirty-nine percent of all external population

assistance in 1979 went to these countries,

Figure 35.—Kinds of Population Assistance

Provided to Middle Eastern/Mediterranean

Regions, 1979
188 “ World Population and Fertility Planning Technologies: The Next 20 Years

Table 48.—Total Intemationai Population

Assistance Fiows to 13 Most Popuious LDCS,

1977=79, (in millions of dollars)

Cents received

per capita

Countw 1977 1978 1979 1979

China . . . . . . . . .

India . . . . . . . . . .

Indonesia . . . . . .

Brazil. . . . . . . . . .

Bangladesh . . . .

Pakistan . . . . . . .

Nigeria . . . . . . . .

Mexico . . . . . . . .

Vietnam . . . . . . .

Philippines. . . . .

Thailand . . . . . . .

Turkey. . . . . . . . .

Egypt . . . . . . . . .

$0 $ o+

19.5 35.6

42.4 23.8

5.0 9.0

18.0 20.7

4.2 2.3

1.4

i:; 7.6

1.2 0.7

4.3 19.0

7.3 11.7

1.5

;:: 7.3

$0. 4

36.5

24.2

9.7

43.8

3.1

1.9

8.3

5.4

14.5

18.2

2.1

6.6

o+

5

16

8

49

4

2

12

10

28

38

5

16

which comprise 75 percent of the world’s population. If China’s population is excluded from the

total count, the proportion becomes more equal:

39 percent of population assistance goes to 46

percent of the LDC population.

LDC support for population activities

Of the $1.0 billion spent for population activities in 1979, LDCS contributed $450 million.

The LDC commitment is thus a crucial component of support for population programs.

Although data are not available for all countries, there is evidence that some LDCS assume

funding and operational responsibilities in proportion to the length of time the program has

been in operation. In Indonesia, trend data illustrate this growing government commitment as

the family planning program has matured (see

fig. 36). In 1968, 96 percent of Indonesia’s total

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 government’s goal is self-reliance in the production of

orals by 1985-90.

Many populous LDCS are contributing more

than 50 percent of the funds needed for their

population programs. Table 49 shows 16 such

countries for which data are available. Of the 13

most populous countries, China, Bangladesh, InFigure 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

Country

Local dollars

for population As a percent of Years family planning

activities all population services available

(thousands) funding Government Private

Category 1: Countries providing more than 50 percent of all resources (1980)

Bangladesh . . . . . . . . . . . . . $22,000 54 21

India . . . . . . . . . . . . . . . . . . . 175,000 79 29

Indonesia. . . . . . . . . . . . . . . 49,700 65 13

Malaysia . . . . . . . . . . . . . . . 8,000 78 14

Nepal . . . . . . . . . . . . . . . . . . 4,145 54 15

Philippines . . . . . . . . . . . . . 23,500 69

South Korea . . . . . . . . . . . . 16,186 84 ; :

Thailand. . . . . . . . . . . . . . . . 10,914 60 14

Costa Rica. . . . . . . . . . . . . . 2,496 58 13

El Salvador . . . . . . . . . . . . . 4,030 62 13

Jamaica . . . . . . . . . . . . . . . . 1,366 56 14

Mexico . . . . . . . . . . . . . . . . . 48,207 81 8

Panama . . . . . . . . . . . . . . . . 2,562 66 12

Mauritius . . . . . . . . . . . . . . . 800 69 9

Senegal . . . . . . . . . . . . . . . . 2,428 77 —

Morocco. . . . . . . . . . . . . . . . 8,000 73 15

Category 11: Countries providing less than 50 percent of all resources (1980)

Colombia . . . . . . . . . . . . . . . 2,100 33 14

Dominican Republic. . . . . . 317 11 13

Honduras. . . . . . . . . . . . . . . 410 11 15

Paraguay . . . . . . . . . . . . . . . 96 13 8

Botswana . . . . . . . . . . . . . . 106 6 9

Ghana . . . . . . . . . . . . . . . . . 1,235 43 11

Kenya . . . . . . . . . . . . . . . . . . 2,000 16 14

Swaziland . . . . . . . . . . . . . . 130 24 —

Tanzania . . . . . . . . . . . . . . . 1,152 46 —

Egypt . . . . . . . . . . . . . . . . . . 11,283 38 15

Tunisia . . . . . . . . . . . . . . . . . 1,000 10 15

28

32

24

23

23

16

20

26

15

18

24

16

15

24

—

11

16

15

20

15

—

; :

—

—

28

13

dia, Indonesia, the Philippines, Thailand, and twelve countries in which private family planMexico contributed more than 50 percent to ning associations have provided services for 20

their population programs (data are unavailable or more years are now more than 50 percent

for the other most populous countries). Nineof self-sufficient.

Impacts of population assistance

Population assistance has had diverse impacts. at least heard of family planning even though

More people are now aware of the problems as- some may not fully understand what it means

sociated with rapid population growth. Govern- or may not yet have convenient access to conment officials, scientists, and informed lay peo- traceptive methods. Laparoscopic surgical techple from LDCS and MDCS are working together niques incorporating use of plastic rings and

to develop new contraceptive methods. Many clips for voluntary female sterilization (develwomen of reproductive age in many LDCS have oped with population funds) make it possible for
190 ● wor/d popu/atjon and Fertility Planning Technologies: The Next 20 Years

paramedical personnel to carry out this procedure in many countries. More data of better

quality are available to enable governments to

formulate policy, set demographic goals, and

monitor program effectiveness. Each of the

three decennial census rounds from the 1960’s

through the present has been characterized by

substantial improvements in data collection

techniques and data processing and analysis capabilities in LDCS. The World Fertility Survey

(WFS) and Contraceptive Prevalence Surveys

are providing rich information on fertility

trends and differentials, levels of contraceptive

knowledge and use, and program evaluation

data. Operations research projects are testing

innovative approaches to the delivery of family

planning information and methods. Social marketing programs have put contraceptives on the

road to being self financing in some LDCs. Most

importantly, mass media campaigns have made

the topic of family planning and discussion of

contraceptive methods public and acceptable.

Above all, fertility rates have begun to decline and

are declining rapidly in countries with strong family planning programs.

The awareness of rapid population growth as

a problem is now worldwide. At the international Conference of Parliamentarians in Colombo, Sri Lanka, in 1979, delegates from 58 nations

agreed that international population assistance

from donor countries should be targeted to

reach $1.0 billion by 1984. The climate for discussion of population-related issues has

changed dramatically in the past decade. The

topic of the Second International Conference on

Voluntary Sterilization held in Geneva in 1973

was so sensitive that WHO refused to participate. Much conference time was spent trying to

develop a euphemism for the term “voluntary

sterilization”; “surgical contraception” was the

favored candidate. Although the specter of coercion arose during India’s 1976 vasectomy campaign, changing attitudes were evident at the

fourth such conference, held in Seoul in 1979,

where more than 400 delegates from 75 countries shared information on voluntary sterilization techniques and delivery methods developed

with population assistance funds.

Better data derived from the decennial censuses make determination of population growth

rates, bases for economic forecasting, and analysis of population distribution changes much

more reliable. UNFPA has taken a leading role in

providing technical assistance to LDCS to improve the substance and quality of their collection and analysis of census data. These data in

turn are supplemented and complemented with

data derived from surveys on particular topics.

WFS, for example, has provided an extensive

data base on fertility trends and factors

influencing fertility in LDCS, and is making the

first comparable data available from 50 LDCS.

Early results from about 20 WFS countries indicate that:

1,

2.

3.

Levels of knowledge of contraception are

high. Over 90 percent of married women in

many countries and at least 75 percent in

most other countries know at least one

method of contraception. In a few countries

where family planning programs have only

recently been implemented, 25 to 33 percent know at least one method.

There is a large unsatisfied demand for family pZanning. Among women who say they

want no more children, about half are not

currently using contraception. This proportion reaches 90 percent on the Indian subcontinent, where contraceptive practice is

low. As contraceptive use increases, desired

family size decreases, because when

women realize they can avoid unwanted

pregnancies, they are likely to change their

perceptions of ideal family size.

A major reason why women who want no

more children aren’t using contraception is

that contraceptives are not always accessible.

Women cite a number of reasons for not

using contraception, including fear of side

effects, opposition of husband, or weak motivation. Recent analyses, however, have indicated that contraceptive use in some

LDCS would increase markedly with the addition of more family planning outlets, a

wider choice of methods, and a reduction in

traveling time to these outlets.
Ch. 9—Financial Support for LDC Population Program ● 191

4.

5.

Women acknowledge that they have more

children than they want. In 12 of the

15 countries where women were asked

whether their most recent birth was

wanted or unwanted, more than 30 percent

said the birth was unwanted.

Rural and uneducated women do practice

contraception. More than 40 percent of

rural currently married women aged 35 to

39 have used contraception in 13 of the 20

countries for which data are available.

Levels of use are generally lower among

rural and uneducated women but these

differences are reduced if contraceptives

are available at the village level at low cost.

These analyses and others nearing completion

provide information previously unavailable to

scientists and government officials in LDCS, and

have documented trends that many scientists

only suspected. These surveys have also left a

legacy of trained people in LDCS who are now

better able to carry out demographic research.

Funding for the surveys has been cooperative.

The largest portions have been contributed by

AID and UNFPA, but Great Britain’s Overseas

Development Ministry (ODM) has also contributed, and LDCS) on average, bear about onethird of the in-country survey costs.

Photo credit: World Bank

Home visits by field workers provide health and

family planning information in rural Kenya

The International Fertility Research Program

(IFRP) funded primarily by AID and UNFPA has,

since 1971) conducted clinical trials of new fertility planning methods in 200 centers in some

50 countries, primarily in Latin America and

Asia. IFRP has also established national fertility

research programs that now have the capability

to conduct their own research in Bangladesh,

Colombia, India, Indonesia, Sri Lanka, and the

Sudan. This program is continuing its training

function and testing postpartum N.JDs, techniques for nonsurgical sterilization, and barrier

methods and conducting comparative trials on

side effects of different oral contraceptives,

The Johns Hopkins Program for International Education in Gynecology and Obstetrics

(JHPIEGO) has, since 1973, trained physicians

from 70 LDCS in maternal and infant care, infertility, high-risk pregnancy, and voluntary sterilization. Followup studies indicate that each participant in this program has trained an average

of 12 to 14 other LDC physicians upon return to

his or her country.

The impacts of population assistance can be

measured both in terms of successful projects

such as these that cover many countries, and in

terms of successes in individual countries

where a number of projects and often multiple

donors have participated in national efforts.

Indonesia’s success story has become a model

for other population efforts in Asia (see app. B).

Begun in earnest in 1968 with the establishment

of the National Family Planning Board, the country uses Village Contraceptive Distribution Centers and the help of local volunteers to recruit

and supply family planning users. There are

now 25)000 village distribution centers in Indonesia—one for each village on the main islands

of Java and Bali. In 5 years, average completed

family size dropped by one-third in Bali and onefifth in Java. In parts of Bali, about 75 percent of

married women are using contraceptives—a

rate that approaches those of China and MDCs.

This downturn in fertility rates is especially

significant because Indonesia is characterized

by a relatively low level of socioeconomic

development that is often associated with low

success in family planning program efforts: per

capita income is only $180 per year, infant mor-
192 ● World Population and Fertility Planning Technologies: The Next 20 Years

tality rates are nearly 150 per 1,000 live births,

and literacy among adult females is only 50 percent. AID has been the major donor, with contributions from the World Bank and UNFPA.

Mexico’s national family planning program,

announced in 1972, became fully operational in

1974. Between 1976 and 1978, total fertility

rates fell from 6.15 to 5.18—a reduction of one

child per woman. Between 1973 and 1978, contraceptive use increased from 13 to 42 percent

of all married women. Assistance has been provided primarily through private and international organizations.

Thailand has been highly innovative in its

family planning program and is moving rapidly

toward self-sufficiency. It was the first LDC to

experiment with innovative ways to distribute

oral contraceptives in rural villages. Forty-seven

percent of the fertility decline from 1968 to

1975 has been attributed to organized family

planning programs (19)$ Contraceptive use increased from 33 to 53 percent between 1975

and 1978. A major component of this increase

has been the number of women electing voluntary sterilization. The Thai program has

received external assistance from AID and

UNFPA.

Do family planning programs make a difference

or would fertility rates fall anyway? Demographers Mauldin and Berelson showed that in

LDCS with strong family planning programs,

fertility declined an average of 30 percent between 1965 and 1975 (some declines were as

high as 50 percent)(n). This is in contrast to declines of 15 to 30 percent in LDCS with moderate programs and 1 to 8 percent in those with

weak or nonexistent programs. There is synergism between effective programs and the level

of development of a country, but, on balance,

family planning programs have a significant impact over and above the country’s development

level (for details, see ch. 7).

In some countries, population assistance has

been available and programs have been in operation for a number of years but fertility has not

declined appreciably; Pakistan and Kenya are

examples. Renewed efforts are now under way

to solve persistent problems of infrastructure

and give women opportunities beyond childbearing.

Is assistance for family planning cost effective

relative to other interventions to reduce population growth rates? Factors such as increased

female education, reductions in infant mortality, and rises in per capita incomes for the poor

are linked to fertility decline. These interventions are highly justified in both humane and

economic terms. Nevertheless, LDC government

economists and planners faced with tight

budgets must choose those interventions that

are both humane and cost effective. A combined

governmental effort to modify fertility by providing family planning services and raising

women’s educational levels has multiple potential benefits: fertility is likely to decline because

services are available, educated women are likely to have fewer children, and smaller family

sizes mean smaller numbers of children who

will need to be educated in the future. ,But an effort to modify fertility levels solely by raising

women’s educational levels, although the education of women is unquestionably an urgent need

in LDCS, is likely to be extremely costly. Simmons (2o) estimates that such an educational

program would be seven times more costly than

an effort focused primarily on the provision of

family planning services. The relative costs of

other single interventions to modify fertility,

each of which, aside from its impact on fertility,

stands as a critical need in LDCS, vary widely.

Intervening to modify infant mortality in this

context is estimated to cost up to 36 times more

than a family planning effort; the cost of intervening to raise per capita income is estimated

to be 138 times greater.
Ch. 9—Financial Support for LDC Population Program . 193

Future needs

Five major parameters define the future

needs and priorities of U.S. population assistance to LDCS:

1. the types of assistance appropriate to various countries in light of their national policies and priorities, and the needs of their

particular population programs;

2. the number of couples of reproductive age

in LDCS now and in 2000;

3. the estimated costs of population programs

that include provision of family planning

services and supplies for an increasing percentage for these couples;

4. the countries or regions where population

growth will be concentrated in the next two

decades; and

5, political and other considerations governing the distribution of U.S. population assistance.

Types of assistance appropriate

various countries and regions

co

Some LDCS are at relatively advanced stages

of population program development, while

others have taken only preliminary steps

toward organized programs. These wide variations in program development are likely to persist during the next two decades. Countries at

early stages are more likely to emphasize policy

development, IEC efforts, legal changes that affect women’s status, infrastructure development, training, and clinic construction. These

actions tend to be expensive, and are unlikely to

result in early, measurable changes in fertility

and contraceptive use rates. Although population support in countries with longstanding population programs is likely to be more cost effective because infrastructures are more highly

developed, diverse, well-run service delivery

systems are in place, and a wide range of contraceptive methods has been made available,

comprehensive estimates of program costs cannot be made. Some generalizations, however,

can be made by region:

The number of Asian couples who will need

family planning services is immense, but almost

all governments in this region have recognized

the problem and initiated family planning programs, often with specific demographic targets,

Until satisfactory local manufacturing arrangements can be made, contraceptive supplies–orals, IUDS) condoms, and spermicides—will be a major cost, requiring foreign

exchange. U.S. assistance to meet commodity

needs generally involves U.S. procurement,

which has constituted a large portion of U.S.

assistance to Asia. Asian countries also need

support for primary health infrastructures, and

for technical assistance in trying new approaches to minimize per capita expenditures.

In Asia, where programs are well under way,

U.S. emphasis on management training and

cost-effectiveness studies could be particularly

useful.

In Africa, by contrast, present populations are

neither as large nor as dense as those in Asia,

and partly for those reasons, governments have

not yet initiated extensive population/family

planning programs. Assistance in health and

communications infrastructure and in demographic data collection to highlight the implications of rapid population growth is the most obvious need. As with any new programs, per capita start-up costs will be high in terms of family

planning users, and the socioeconomic setting

will make all programs more costly, less efficient, and initially heavily reliant on external

assistance. Expanded support for the work of

existing private organizations is an important

need.
194 . World Population and Fertility Planning Technologies: The Next 20 Years

In the Middle East and Mediterranean region,

cultural constraints that affect the status of

women are a greater deterrent to contraceptive

use than lack of infrastructure or funds. Private

agencies can play a major role in raising such

issues. Where government programs exist, a

major problem is reaching and counseling women on the benefits of family planning.

In Latin America, there is wide acceptance of

family planning by women, but millions still lack

the family planning services they desire.

Greater public and private sector commitment

and support are needed for family planning efforts. Despite rising demand for family planning

services, some governments have been reluctant to offer family planning services and

sometimes limit access to sterilization to those

with large families or immediate health risks. In

those countries, the most appropriate U.S. assistance is probably through the private voluntary groups and medical practitioners who have

often been leaders in increasing public and official awareness of the benefits of family planning to health and development efforts.

Overall, types and levels of U.S. assistance

should be in response to national efforts and

needs. Where national governments are not

ready to commit their own resources to populatiordfamily planning efforts, massive external

assistance can become a target for political attack. Funds provided to private agencies help to

encourage greater local interest and commitment, while funds channeled through professional assistance agencies and universities help

to evaluate program effectiveness and to develop innovative service delivery efforts. In determining priorities for population assistance, U.S.

policy makers need to weigh different regional

needs and the costs of various types of assistance.

The number of couples of

reproductive age in LDCS

The number of couples in LDCS who will be in

their reproductive years—in which the wife’s

age is between 15 and 49—for the next two

decades can be calculated because all but the

youngest members of this group have already

been born, Excluding China (its unique population status and projections are discussed in app.

A), and assuming that about 70 percent of

women are in some form of stable union, there

are now 374 million such women living in LDCS.

If these couples were to have an average total

completed fertility rate of 2.2 children per couple (or replacement fertility), about 80 percent

(300 million) would now need to be practicing

contraception, (This 300 million allows for 10

percent who are naturally sterile and another

10 percent who are pregnant or lactating (see

table 50),)

Table 50.—Basis for Estimates of Population

Support Costs in 1980 and 2000

Target population (In millions)

(2)

(3)

(4)

(5)

(6)

(7)

Minimum per user costsb

(In dollars)

Contraceptive retail sales and community

based services alone. . . . . . . . . . . . . . . . . . . . $ 6

With clinic services and medical backup . . . 10

With other population program

components . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

With infrastructure building and training

necessary for new program . . . . . . . . . . . . . . 50-100

Using the

conservative 1980$15 x 300 million = $4.5 billion

estimate of

$15 per user 2000$15 x 495 million = $7.4 billionc

costs:

a~arried ~Omen of reproductive age.

bchina *Expenditures are included in app. ‘

cln 19s0 constant dollars.

(3)Assumes 70 percent of women 15-49 in union.

(4)Assumes 10 percent MWRA naturally sterile.

(5)Assumes 10 percent MWRA Iactatlnfj or pregnant.

(8) Replacement fertility Is when crude birth rate equais crude death rate.

(7)Assumes a 65 percent increase (medium variant) in number of women

needing contraception In 2000.

SOURCES: AID, “Cost Implications of Population Stabilization,” March 1981;

Population Reference Bureau, 1980; U.N. Medium Variant Projections from World Population Trends and Prospects by Country,

1950-20(.M; U.S. Census Bureau, Illustrative Projections of Wor/d

Population to 21st Cerrfqry.
Ch. 9—Financial Support for LDC Population Program ● 195

Projected population growth in the next two

decades will increase contraceptive needs by 65

percent. But with the exception of China, where

contraceptive use rates are high, only about 20

percent of LDC couples are contracepting.

There would thus have to be a fourfold increase

in current contraceptive use for fertility to

begin to fall to replacement levels. By 2000,

some 495 million couples of reproductive age

are likely to need contraceptive protection if

population growth is to approach stabilization

(see table 50). (If China’s estimated reproductiveage population is added to this calculation, this

number rises to 695 couples by 2000.)

Two key factors will affect the future of these

LDC couples. First, a high proportion of all couples of reproductive age will be young–between 15 and 29 rather than 30 or older—because of the “baby boom” generation in LDCS

that followed World War II. Their family planning needs will thus center around childspacing.

Second, because of this high proportion of

\lounger men and women, age at marriage may

have an important effect on fertility that cannot

yet be precisely assessed. If this generation

defers marriage and/or childbearing for several

years, say from age 17 to age 20, as is now happening in some Asian countries, fertility decline

can be accelerated beyond that expected from

higher rates of contraceptive use.

Estimated costs of providing family

planning services and supplies

Although the number of couples of reproductive age can be estimated, the costs of providing

services and supplies for these couples are more

difficult to predict. Any assessment of costs will

be modified by changing international and national political and economic considerations.

Although population assistance to China from

UNFPA has just begun, China may request more

aid in the future because of the magnitude of its

population growth.

Current per-user costs in LDCS (excluding

China) range from $6 to $100 annuall.v, depending on the type and efficiency of the population

program, on average, these costs are about $15

per user (see table SO). (This cost includes all

program aspects, from demographic data collection and analysis to IEC, administrative support,

and commodity procurements, and is thus a

conservative estimate for an efficiently run program.) Using this estimate, today’s cost to

achieve replacement fertility, with 80 percent of

couples using contraception, would be some

$4.5 billion annually.

Although rates of contraceptive prevalence

are unlikely to exceed so percent by 2000, if

these rates were to rise to 80 percent, program

costs could reach $7.4 billion in 1980 constant

dollars. (This amount rises to $10.7 billion when

China’s childbearing-age population is added.) If

inflation persists at about 10 percent per year,

the dollar would be worth about one-eighth of

its 1980 value, and the increase would be

twelvefold.

Although $15 per user is a conservative estimate, if a program is efficiently run and has a

good mix of methods (heavy reliance on voluntary sterilization, and sliding scales of payment

by users), this figure is fairly realistic. In many

regions such as Africa and the Middle East,

where programs are just beginning, these costs

will be much higher.

The 1982 AID budget request for U.S. population assistance was $253.4 million. Under this

request, UNFPA and AID had projected shortfalls—shortages of funding for requested new

projects in LDCS and for support of continuing

projects–of $40 million to $100 million and

about $200 million respectively. (For the UNFPA

budget request this shortfall assumed that other

MDCS would increase their contributions by 10

percent rather than 15 percent as in the past.

See footnote ch. 1.)

Shortfalls under the actual budget of $21 I million for 1982 and the projected budget of $230

million for 1983 will increase substantially as inflationary effects continue and needs for

assistance rise during the 2-year period.
196 . World Population and Fertility Planning Technologies: The Next 20 Years

The countries in which population

growth will be greatest in the next

two decades

Priorities for assistance for the remainder of

this century might center on the 13 countries

that together now account for 75 percent of the

LDC population and will account for the greater

proportion of numbers added in the next 20

years–India, China, Indonesia, Brazil, Bangladesh, Pakistan, Nigeria, Mexico, Vietnam, Philippines, Thailand, Turkey, and Egypt (listed in

order of their projected population increases).

For political and economic reasons, bilateral

population ‘assistance from the United States

will not be sent to some of these countries, will

be provided only minimally to others, and will

focus heavily on a few. Multilateral agencies are

likely to continue to address the unmet needs of

certain of these countries. For example, because

the Foreign Assistance Act currently prohibits

assistance to Communist countries, China and

Vietnam receive no direct U.S. assistance. Countries like Brazil and Mexico, which prefer not to

receive direct assistance from the U.S. Government, look to UNFPA, IPPF, and other intermediaries to provide external assistance. Indonesia, Bangladesh, the Philippines, Egypt, and

Thailand, on the other hand, welcome U.S. population assistance and have received substantial

aid, both direct and indirect.

Growing U.S. interest in African issues and requests from African countries may also prompt

increased population assistance to Nigeria,

Kenya, Senegal, Burundi, Rwanda, and other nations of the region. overall, the countries that

receive the largest amounts of U.S. population

assistance are not always determined on the

basis of demographic priorities but rather by

other interests and mutually cooperative relationships. The obvious importance of helping

such nations as China, India, Brazil, and Mexico

argues for a continuing multiplicity of donors

and adequate funding for multilateral assistance

programs of UNFPA, the World Bank, and IPPF.

Political and other considerations

governing the distribution of

U.S. population assistance

In the long run, levels of U.S. population assistance, like other forms of U.S. development

aid, will be determined by an overall assessment

of the importance of population growth to U.S.

interests. The Middle East provides an important example. Because high levels of Security

Supporting Assistance have been appropriated

for Middle Eastern countries, population assistance to Egypt is a major effort, well-justified by

Egyptian national needs but also by U.S. security interests. Population assistance for Egypt

can be expected to increase in recognition of the

crucial role of the “Arc of Crisis” countries of

that region.

The situation in Latin America is quite different. Increasing migration to the United States

from Mexico and the Caribbean is alerting U.S.

citizens to the high rates of population growth

of many Western Hemisphere countries. Even

where the United States does not provide direct

population assistance, the United States has a

strong interest in encouraging multilateral or

NGO assistance and expanded programs. Over

the long run, lower population growth rates in

Latin America and the Caribbean would be expected to reduce pressures for migration and to

ease social and economic conflicts within and

among countries.

The United States is likely to maintain strong

political and humanitarian ties to Asian nations,

three of which—China, India, and Indonesia—

are projected to contribute almost 37 percent of

world population growth to 2000. The government of India, which is expected to experience

the world’s largest population increase in the

next two decades (346 million as compared to

the projected U.S. increase of 38 million) has

given high priority to slowing its population

growth.

Africa poses a special problem with respect to

levels of population assistance. While U.S. in-
Ch. 9—Financial Support for LDC Population Program “ 197

terest and concern over African development

are increasing, the scope for population assist=

ance is partly limited to demographic and census work, and informing African officials of the

consequences of rapid population growth rates.

There is an immediate need for increasing the

number of qualified technical personnel to identify Africa’s population issues and encourage

consideration of these issues by policy makers.

Future funding needs for population programs will depend on both political and demographic factors. The total need is vast, but in deChapter 9 references

1. Agency for International Development, “AID Population Task Force Report to IDCA,” June 1980.

2. “Congressional Presentation for FY 80,”

Washington, D. C., 1980.

3. Table 400—Population Program Assistance

by Major Organizations: Funding Allocations FY

65-80, December 1979.

4. Table 500—Primary Sources of Grant

Funds ‘for International Population Assistance,

1979.

5. Berelson, B., “Prospects and Programs for Fertih

ity Reduction: What? Where?” Population and Development Review, vol. 4, No. 4, December 1978.

6. Corsa, L., and Oakley, D., Population Planning

(Ann Arbor, Mich.: University of Michigan Press,

1979).

7. Hemmer, C., Special Assistant for International

Organizations, Office of Population, AID, Washington, D. C., personal communication, 1981.

8. Heiby, J., Ness, G., Pillsbury, B., “AID’s Role in Indonesian Family Planning: A Case Study With

General Lessons for Foreign Assistance,” December 1979.

9. International Planned Parenthood Federation,

Report to Donors (London: IPPF, 1979).

10. Lubell, I., Director, Association for Voluntary

Sterilization, persona] communication on Association for Voluntary Sterilization expenditures for

calendar year 1979.

11. Mauldin, P., Berelson, B., Sykes, Z., “Conditions of

Fertility Decline in Developing Countries,

1965 -1975,” Studies in Family Planning, vol. 9, No.

5, May 1978.

12. Nortman D., and Hofstatter, E., Population and

termining which components and how much of

this need should be met by the U.S. Government—either directly or indirectly—regional,

programmatic, and economic considerations

weigh heavily. There is a continuing role for

private agencies, for U.S. government-togovernment (bilateral) programs, and for multilateral agencies. This mix of different channels,

which suits the mix of different national and

regional needs and preferences, deserves regular review and evaluation.

Family Planning Programs: A Compendium of Data

Through 1978, 10th edition (New York: Population Council, 1980).

13. O’Connor, M., Chief, Program Planning and

14,

15<

16.

17.

18.

19.

20.

21.

22.

23.

Statistics Branch, UNFPA, personal communication, 1981.

Organization of Economic Cooperation and Development, Development Cooperation: 1980

Review (Paris: OECD, 1980).

Pathfinder Fund, Annual Report (Chestnut Hi]],

Mass,: 1979).

Piotrow, P. T., “World Population Crisis,” Praeger

Special Studies in International Economics and Development (New York: Praeger Publishers, 1973).

“World Population: The Present and Future Crisis,” Headline Series 251 (New York: Foreign Policy Association, October 1980).

Salas, R. M., International Population Assistance:

The First Decade (Oxford: Pergamon Press, 1979).

Siew-Ean Khoo, “Measuring the Thai Family Planning Program’s Impact on Fertility Rates: A Comparison of Computer Models,” Studies in Family

Planning, vol. 10, No. 4, April 1979.

Simmons, G. B., “Family Planning Programs or

Development: How Persuasive is the New Wisdom?” International Family Planning Perspectives,

vol. 5, No. 3, September 1979.

Speidel, J., Deputy Director, Office of Population,

AID, Washington, D. C., ‘(Cost Implications of

Population Stabilization,” draft memorandum,

March 1981.

personal communication, 1981.

United’ Nations, Demographic Yearbooks, 1952,

1957. New York.
198 ● World Population and Fertility Planning Technologies: The Next 20 Years

24. “World Population Trends and Prospects 28

by Country, 1950-2000: Summary Report of the

1978 Assessment,” New York, 1979.

25. U.N. Fund for Population Activities, Fact Sheets 29

(New York: UNFPA, 1980).

26. “Reports on Population Assistance—

1977, 1978, 1979,” Table I—Population Assistance

U.S. Census Bureau, “Illustrative Projections of

World Populations to the 21st Century,” Special

Studies Series P-23, No. 79, January 1979.

Weintraub, D., Director, Family Planning International Assistance, personal communication on

Family Planning International Assistance expenditures for calendar year 1979.

by Major Donors 1971-1979; Table 2—Assistance 30. World Bank, Annual Report (Washington, D. C.:

to Population Programs by Country and Region by World Bank, 1980).

Major Donors; Table 3—Assistance to Population 31. World Development Report (Washington,

Programs by Country and Region and Major Pop- D. C.: world Bank, 1980).

ulation Sector. 32. World

27. “Report of the International Conference years).

of Parliamentarians on Population and Development” (New York: UNFPA, 1979).

Table A-l.—Regional Distribution of All External

Fertility Survey, Country Reports (various

Population Assistance

(In millions of U.S. dollars, not including regional, interregional, or global funding)

Region (country specific) 1977 Percent 1978 Percent 1979 Percent

SOURCE: Office of Technology Assessment.

Table A.2.–Kinds of Population Assistance by Region, 1979

(in millions of U.S. dollars, not including regional, interregional, or global funding)

1979 Percent 1979 Percent

Africa Latin America

Family planning services. . . . . . $22.2 58% Family planning services. . . . . . $55.5 81‘Yo

Data collection. . . . . . . . . . . . . . 7.1 18 Data collection. . . . . . . . . . . . . . 2.3 3

Information, education, Information, education,

and communication. . . . . . . . 2.3 6 and communication. . . . . . . . 2.5 4

Policy development. . . . . . . . . . 1.8 5 Policy development. . . . . . . . . . 3.2 5

Institutions and training/ Institutions and training/

research and evaluation. . . . . 4.9 13 research and evaluation. . . . . 4.9 7

Total. . . . . . . . . . . . . . . . . . . $38.3 100% Total. . . . . . . . . . . . . . . . . . . $68.4 100 ”/0

Asia MiddIe East

Family planning services. . . . . . $152.9 85% Family planning services. . . . . . $17.0 650/o

Data collection. . . . . . . . . . . . . . 4.4 2 Data collection. . . . . . . . . . . . . . 3.3 12

Information, eduction, Information, education,

and communication. . . . . . . . 4.2 2 and communication. . . . . . . . 1.1 4

Policy development, . . . . . . . . . 5.6 4 Policy development. . . . . . . . . . .3 1

Institutions and training/ Institutions and trainingl

research and evaluation. . . . . 12.3 7 research and evaluation. . . . . 4.9 18

Total. . . . . . . . . . . . . . . . . . . $179.4 100”!0 Total. . . . . . . . . . . . . . . . . . . $26.6 100’YO

SOURCE: Office of Technology Assessment.
Ch. 9—Financial Support for LDC Population Program ● 199

Table A-3.—Total International Assistance Flows to

50 Most Populous LDCS, 1977.79, per Capita Dollar,

1979

(in millions of U.S. dollars)

1977 1978 1979 Per capita aid/dollars

China . . . . . . . . 0 o+ $0. 4 $0.00 +

India. . . . . . . . . $19.5 $35.6 36.5 .05

Indonesia. . . . . 42.4 23.8 24.2 .16

Brazil . . . . . . . . 5.0 9.0 9.7 .08

Bangladesh . . . 18.0 20.7 43.8 .49

Pakistan. . . . . . 4.2 2.3 3.1 .04

Nigeria. . . . . . . 1.4 1.4 1.9 .02

Mexico. . . . . . . 5.3 7.6 8.3 .12

Vietnam . . . . . . 1.2 0.7 5.4 .10

Philippines . . . 4.3 19.0 14.5 .28

Thailand. . . . . . 7.3 11.7 18.2 .38

Turkey . . . . . . . 1.2 1.5 2.1 .05

Egypt . . . . . . . . 2.2 7.3 6.6 .16

Iran. . . . . . . . . . 1.1 1.9 0.1 .00 +

South Korea. . 5.4 3.1 8.1 .46

Burma . . . . . . . 0.1 0.1 0.1 .00 +

Ethiopia. . . . . . 0.4 0.4 0.4 .01

South Africa. . — — — —

Zaire. . . . . . . . . 0.7 0.4 1.0 .04

Colombia. . . . . 7.7 7.6 11.2 .43

Argentina. . . . . 0.2 0.4 0.6 .02

Afghanistan . . 1.2 1.6 2.5 .12

Morocco . . . . . 2.5 2.4 2.4 .12

Algeria. . . . . . . 1.6 0.5 0.3 .02

Sudan. . . . . . . . 1.3 0.6 0.3 .02

Tanzania . . . . . 5.8 3.2 2.4 .14

North Korea. . . — — — —

Peru . . . . . . . . . 0.8 1.6 2.0 .12

Kenya. . . . . . . . 7.5 11.9 7.5 .47

Venezuela . . . . 0.1 0.5 0.2 .01

Sri Lanka. . . . . 3.8 2.5 2.7 .18

Nepal . . . . . . . . 5.2 2.2 3.4 .24

Malaysia . . . . . 1.7 2.6 2.9 .22

Uganda . . . . . . 0.5 0.6 0.6 .05

Iraq. . . . . . . . . . 0.1 0.2 0.2 .02

Ghana . . . . . . . 2.4 1.9 2.5 .22

Chile. . . . . . . . . 1.7 1.8 1.6 .15

Mozambique. . 0.3 — 1.1 .11

Cuba. . . . . . . . . 1.3 1.0 1.1 .11

Kampuchea. . . — — — —

Madagascar. . . 0.2 0.4 0.5 .06

Syria. . . . . . . . . 0.6 1.1 0.8 .10

Cameroon . . . . 0.1 0.3 0.4 .05

Saudi Arabia. . 0.0+ – – —

Ecuador. . . . . . 0.8 0.8 1.6 .21

Ivory Coast. . . 0.0+ 0.4 0.5 .06

Zimbabwe . . . . — — 0.0 + —

Guatemala. . . . 1.2 0.8 1.0 .14

Angola. . . . . . . — — — —

Upper Volta. . . 0.1 0.1 0.1 .01

NOTE: Per capita dollars aid reflect 1979 U.N. medium variant population.
200 ● World Population and Fertility Planning Technologies: The Next 20 Years

Table A-4.—Population Dynamics of 50 Most

Popuious LDCS and Seiected MDCS and Regions

Population, in millions Rate of natural Years to double

Country 1981 2000 increase, 1981 population, 1981

China. . . . . . . . . . . . . . . . 0.80/0 59

SOURCES: Population figures from, U.N. 1979-World Population Trends and Prospects by Country,

1950-2000: Summary Report of the 1978 Assessment. Rate of natural increase and doubling

time figures from Population Reference Bureau, 1981 World Population Data Sheet.
Ch. 9—Financial Support for LDC Population Program . 201

Table A-5.–Socioeconomic and Quality of Life Indicators for TOP 50 LDCS and Selected MDCS

1971 GNP 1975 adult 1981 life

per capita literacy rate expectancy 1981 infant

Country (U.S. dollars) (percent) (years) mortal it ya

China. . . . . . . . . . . . . . . . . . . . . . . . . .

India . . . . . . . . . . . . . . . . . . . . . . . . . .

Indonesia . . . . . . . . . . . . . . . . . . . . . .

Brazil. . . . . . . . . . . . . . . . . . . . . . . . . .

Bangladesh . . . . . . . . . . . . . . . . . . . .

Pakistan . . . . . . . . . . . . . . . . . . . . . . .

Nigeria . . . . . . . . . . . . . . . . . . . . . . . .

Mexico . . . . . . . . . . . . . . . . . . . . . . . .

Vietnam . . . . . . . . . . . . . . . . . . . . . . .

Philippines . . . . . . . . . . . . . . . . . . . . .

Thailand . . . . . . . . . . . . . . . . . . . . . . .

Turkey . . . . . . . . . . . . . . . . . . . . . . . . .

Egypt . . . . . . . . . . . . . . . . . . . . . . . . . .

Iran . . . . . . . . . . . . . . . . . . . . . . . . . . .

South Korea . . . . . . . . . . . . . . . . . . . .

Burma . . . . . . . . . . . . . . . . . . . . . . . . .

Ethiopia . . . . . . . . . . . . . . . . . . . . . . .

S. Africa . . . . . . . . . . . . . . . . . . . . . . .

Zaire . . . . . . . . . . . . . . . . . . . . . . . . . .

Colombia . . . . . . . . . . . . . . . . . . . . . .

Argentina . . . . . . . . . . . . . . . . . . . . . .

Afghanistan . . . . . . . . . . . . . . . . . . . .

Morocco . . . . . . . . . . . . . . . . . . . . . . .

Algeria . . . . . . . . . . . . . . . . . . . . . . . .

Sudan . . . . . . . . . . . . . . . . . . . . . . . . .

Tanzania . . . . . . . . . . . . . . . . . . . . . . .

North Korea . . . . . . . . . . . . . . . . . . . .

Peru . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kenya . . . . . . . . . . . . . . . . . . . . . . . . .

Venezuela . . . . . . . . . . . . . . . . . . . . . .

Sri Lanka . . . . . . . . . . . . . . . . . . . . . . .

Nepal . . . . . . . . . . . . . . . . . . . . . . . . . .

Malaysia . . . . . . . . . . . . . . . . . . . . . . .

Uganda . . . . . . . . . . . . . . . . . . . . . . . .

Iraq . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ghana . . . . . . . . . . . . . . . . . . . . . . . . .

Chile . . . . . . . . . . . . . . . . . . . . . . . . . .

Mozambique. . . . . . . . . . . . . . . . . . . .

Cuba . . . . . . . . . . . . . . . . . . . . . . . . . .

Kampuchea . . . . . . . . . . . . . . . . . . . .

Madagascar . . . . . . . . . . . . . . . . . . . .

Syria . . . . . . . . . . . . . . . . . . . . . . . . . .

Cameroon . . . . . . . . . . . . . . . . . . . . . .

Saudi Arabia . . . . . . . . . . . . . . . . . . . .

Ecuador . . . . . . . . . . . . . . . . . . . . . . .

Ivory Coast . . . . . . . . . . . . . . . . . . . . .

Zimbabwe . . . . . . . . . . . . . . . . . . . . . .

Guatemala . . . . . . . . . . . . . . . . . . . . .

Angola . . . . . . . . . . . . . . . . . . . . . . . .

Upper Volta . . . . . . . . . . . . . . . . . . . .

United States . . . . . . . . . . . . . . . . . . .

Japan . . . . . . . . . . . . . . . . . . . . . . . . .

United Kingdom . . . . . . . . . . . . . . . . .

France . . . . . . . . . . . . . . . . . . . . . . . . .

$230

180

360

1,570

90

230

560

1,290

170

510

490

1,210

400

2,160b

1,160

150

120

1,480

210

850

1,910

240

670

1,260

320

230

730

740

330

2,910

190

120

1,090

280

1,860

390

1,410

140

810

NA

250

930

460

7,690

880

840

480

910

300

160

9,590

7,280

5,030

8,260

56

134

91

84

139

142

157

70

115

65

68

125

90

112

37

140

178

97

171

77

41

185

133

127

141

125

70

92

83

45

42

133

44

120

92

115

38

148

19

150

102

81

157

118

70

138

129

69

192

182

13

8

13

10
202 “ World Population and Fertility Planning Technologies: The Next 20 Years

Table A-6.—Population Trends in Selected Countries

Involving U.S. Security Interests

1981 rate Years to

1981 population of natural double

Country (millions) increase population

Bangladesh. . . . . . . . 91.4 2.60/o 27

Bolivia . . . . . . . . . . . . 5.7 2.5 28

Brazil . . . . . . . . . . . . . 130.0 2.4 29

Central America. . . . 95.9 2.7 26

Egypt . . . . . . . . . . . . . 43.1 3.0 23

India. . . . . . . . . . . . . . 709.8 2.1 33

Indonesia . . . . . . . . . 155.4 2.0 35

Kenya. . . . . . . . . . . . . 17.0 3.9 18

South Korea. . . . . . . 38.6 1.7 41

Mexico. . . . . . . . . . . . 72.4 2.5 28

Morocco . . . . . . . . . . 21.0 3.0 23

Nigeria. . . . . . . . . . . . 79.7 3.2 22

Pakistan . . . . . . . . . . 85.1 2.8 24

Philippines . . . . . . . . 52.5 2.4 29

Somalia. . . . . . . . . . . 3.8 2.8 25

Thailand . . . . . . . . . . 49.0 2.0 35

Turkey . . . . . . . . . . . . 46.5 2.2 32

Venezuela . . . . . . . . . 15.4 3.0 23

Zimbabwe . . . . . . . . . 7.7 3.4% 21
Appendixes
Appendix A

Evolution of China's

Birth Planning Policy*

Introduction

The government of the People’s Republic of China

(PRC) announced the adoption of birth planning as a

national policy in the summer of 1956. Following its

formal declaration of antinatalist policy, the government moved to train medical personnel in birth planning procedures, set up family planning clinics, initiate biomedical research on contraceptives, and implement a massive publicity campaign.

These activities were abruptly suspended in August of 1958, when the “People Commune” and

“Great Leap” movements were introduced, but were

resumed in the spring of 1962 in the aftermath of the

Great Leap failure. Although the birth planning policy had not been under attack during the 1966-68 Cultural Revolution, the service delivery system was disrupted by administrative breakdowns. At Chairman

Mao’s insistence, however, a nationwide, three-tiered

system of rural health care was established that laid

one of the foundations for China’s spectacular decline in rural fertility during the 1970’s.

In 1971 the State Council, headed by the late Premier Chou En-lai, issued “Directive No. 51,” which

called for vigorous promotion of birth planning to

reduce fertility levels as quickly as possible. The government then began to diffuse, step by step, the

three reproductive norms that were to serve as

guidelines for birth planning:

Late marriage.—Urban men and women were

urged not to marry until age 28 or 25, respectively;

for rural dweller the respective ages were 25 and 23.

However, the legal age of marriage remained unchanged until September 1980, when the National

People’s Congress raised it from 20 to 22 for men and

from 18 to 20 for women, The new marriage law became effective January 1, 1981.

Longer birth interval.—Although the first

child may be planned right after marriage, a subsequent birth was expected to follow a 4-year or longer

interval.

Fewer births.—Each urban couple was at that

time expected to have only two children, and each

rural couple three children, regardless of the children’s sex. In 1977 the term “fewer births” was redefined as two children per family, whether urban or

rural. In 1979 the term was further redefined to

mean “one is the best; at most two; never the third.”

“The People’s Republic of China has established historic precedent by

rapidly lowering its birth rate while still at a low level of modernization, Understanding the magnitude of China’s fertility decline is essential to assessing LDC population growth prospects to the year 2000. For this reason, and

In China, the three reproductive norms are known

as wan xi shao, which means “later, longer, and

fewer.”

The post-Mao leadership has given top priority to

the four modernizations—agriculture, industry, defense, and sciences—as the PRC attempts to raise its

per capita gross national product (GNP) to $1,000 by

the year 2000. In the official view, the success of this

effort is contingent upon bringing about zero population growth as quickly as possible. In February of

1980, Premier Hua Guo-Feng called for reducing the

country’s population growth rate to 10 per 1,000

within 3 years. At about the same time, the National

People’s Congress approved a revised constitution,

which in article 53 states that “the state advocates

and encourages birth planning.”

Vigorous implementation of China’s birth planning

policy during the 1970’s produced a phenomenal decline in the country’s crude birth rate, which fell

from about 31 per 1,000 in 1971 to 18 per 1,000 in

1979. The official natural increase rate for 1980 was

12 per 1,000, representing a net increase during that

year of 11.6 million persons.

Yet despite this unprecedented achievement, PRC

policymakers remained dissatisfied with the nation’s

population growth rate. An internal population projection showed that if the 1978 estimated total fertility rate of 2.3 were to remain constant, the population would grow from 958 million in 1978 to 1,282

billion by 2000 and to 2,119 billion by 2080 (18), Because of high fertility rates in the 1950’s and 1960’s,

half of the population was under age 20 in 1978; between 1980 and 1995 the number of women reaching the recommended age of marriage (23) annually

will rise to between 12 million and 13.5 million, or an

average increase of 18 percent over that number in

1980 (13). Even if each of these women has only one

child, these births alone would exceed 10 million per

year, a number equal to almost 60 percent of the total births recorded in 1978.

Faced with this awesome prospect, the post-Mao

leadership in 1979 launched a two-stage campaign,

which calls for the reduction of the natural increase

rate to 5 per 1,000 by 1985, and achievement of zero

population growth by 2,000. According to Vice Premier Chen Mu-hua, the government official in charge

because of China’s significance as 29 percent of the total LDC population, a

special report on events in China was prepared for this assessment by Pichao Chen of Wayne State University The following summary of his report

provides detaded data on China’s population policies and programs and on

the results of these efforts, and new information on the rapidly changing

situation in the world's most populous countrv,

205
206 . World Population and Fertility Planning Technologies: The Next 20 Years

of China’s birth planning programs, of the 17.4 million births in 1978, 30 percent, or 5.2 million, were

third and higher parity births, or multiparty births.

If these multiparty births were to be reduced by

half, the crude birth rate could fall from the 1979 figure of 18 per 1,000 to 15 per 1,000, and the natural

increase rate from 12 per 1,000 to 9 per 1,000. If

multiparty births were to be entirely eliminated by

1985, there would then be 5 million fewer births, the

crude birth rate would drop to about 13 per 1,000,

and the natural increase to below 7 per 1,000. Because these changes would still fall short of the target for 1985 by two percentage points, the government is now promoting the one-child family. In view

of the expected increase in numbers of women

reaching reproductive age in the next two decades,

the promotion and spread of the one-child family is

considered imperative if the nation hopes to achieve

zero population growth by the year 2000 (4). Since its

inception 2 years ago, the one-child campaign has exceeded most expectations. By the end of 1980, 10 million couples who were parents of one child had reportedly signed the official “one-child certificate,”

pledging to have no more children in return for a

series of benefits.

Organization and management of

the birth planning programs

The agency in charge of China’s overall birth planning program is the Birth Planning Leadership Group

of the State Council, which was created in 1956 as

the Birth Planning Guidance Committee of the State

Council (9). The agency was revived and reorganized

in 1963, 1973, and again in 1978, when Vice Premier

Chen Mu-hua assumed its direction. Madame Chen

Mu-hua has continued to head the agency since its

elevation, in March 1981, to the State Birth Planning

Commission. The Commission draws its members

from a host of ministries, such mass organizations as

the Women’s Federation and the Young Communist

League, and such related professional associations as

the China Medical Association. Working directly

under it is the Birth Planning Staff Office of the State

Council, which is responsible for day-to-day coordination and supervision of the birth planning programs throughout the country. The office convenes

the annual birth planning work conference, usually

held in December or January, to which provincial

and selected county birth planning staff offices send

delegates. The work conference is one of the mechanisms used to transmit new policy directives to the

lower units, receive briefings and reports from

below, and cite and reward advanced units. Concrete

action plans for the next year are then developed

through vertical consultation.

Below the national level, each province has its own

planned-birth committee (or leading group), which is

presided over by a deputy party secretary of the provincial party committee or a vice chairman of the

provincial government. The provincial committee

draws its members from various provincial government functional departments (health, public security, commerce, education, etc.) and provincial chapters of such mass organizations as the Women’s Federation, the Young Communist League, and the

Trade Union Federation. Under its direction, the provincial birth planning staff office carries out the dayto-day operations of the provincial birth planning

programs with a small full-time staff and a modest

budget. The Guangdong Provincial Birth Planning

Staff Office, for example, has a staff of 32 full-time

members, who are responsible for: 1) setting annual

and intermediate-term plans and targets; 2) supervising lower level units in implementing programs and

realizing targets; 3) providing technical assistance to

lower level units (e.g., organizing training classes in

which physicians and paramedics at lower levels are

trained in surgical planned birth procedures); 4) organizing information, education, and motivation activities, including the printing of posters and utilization of mass media; 5) identifying innovative, successful units within the province and diffusing their

innovations by convening on-the-spot conferences to

exchange experiences; 6) calling annual provincial

planned birth work conferences, in which the targets for the next plan year are set (by consultations

with birth planning offices at other levels), and advanced units and persons in birth planning are cited;

and 7) monitoring the program’s progress and

collecting and tabulating its statistics.

In 1980, for example, the annual budget of Guangdong’s provincial Planned Birth Staff Office was 12.5

million yuan (1 yuan is equal to 60 U.S. cents), divided

as follows:

• procurement of contraceptive supplies and reimbursement for the four planned birth operations (IUD insertion and removal, tubal ligatiord

occlusion, vasectomy, induced abortion) (50 percent);

. information) education, and motivation (1 EM) ac.

tivities including subsidies to lower level birth

units (30 percent); and

● manpower training and research (20 percent).

The budget covers neither the salaries of the 32

full-time staff members nor those of the planned

birth workers at lower levels, whose salaries are

budgeted under the overall personnel payroll of the

level of the government for which they work. Part of

the IEM fund has, however, been allocated to subsidize the salaries of the commune-level full-time

planned birth cadres.
App. A—Evolution of China’s Birth Planning Policy ● 207

County birth planning offices also maintain 10 to

15 member full-time staffs. Their functions are to

work out annual birth quotas; train, supervise, and

supply contraceptives to the lower level units, the

communes and brigades; direct IEM activities at

lower levels; reimburse commune health centers for

expenses generated by the four birth planning operations; and keep records and collect statistics.

Each commune has a birth planning leadership

group, headed by the first Party secretary of the

commune, who is its most powerful member. The

group, which supervises the implementation of the

local birth planning program, contains members

from all rele~ant units within the commune: the

commune Party committee, commune management

committee, public security police station, commune

chapter of the Women’s Federation, Young Communist League, militia, local school system, commune

health center, and so on.

Each brigade within the commune also has its own

brigade birth planning leadership group, which supervises the local barefoot doctors, the part-time maternal and child health (MCH) workers (or trained

birth attendants), and the team-level health aides

who deliver contraceptives to the households and accompany the women or men to the commune health

center to obtain the kind of planned birth operation

they have chosen. The brigade group is also responsible for conducting local IEM activities, which are

community based; community leaders (i.e., the local

cadres) are deployed to educate the local people

about the benefits of birth planning and persuade

them of the importance of births planned in accordance with the new reproductive norms.

Urban organization of planned birth offices is similar to that of rural areas. A planned birth committee

and staff office operate at the municipal level and a

network of committees and offices functions at each

of the various levels into which the city administrative struction is divided: the districts, neighborhoods,

resident committees, and resident small groups (each

of which consists of between 15 and 40 households).

The organization and responsibilities of the districtIevel planned birth committees and staff offices are

patterned after those at the municipal level, though

with fewer staff and, of course, smaller areas of operation. By the early 1970’s, each urban neighborhood, residents’ committee, and residents’ small

group had reportedly set up its own planned birth

committee or group (called a “group” when attached

to a residents’ small group). The neighborhood

planned birth committee is made up of members representing the local party committee, the local administrative office (called a revolutionary committee until 1979), local chapters of the Women’s Federation,

Young Communist League, and Trade Union Federation, and the neighborhood hospital or clinic. Under

its umbrella are several “women’s work” cadres—one

for each residents’ committee under the jurisdiction

of the neighborhood administrative office. They

assist and supervise the “planned birth propagandist” at the lower levels, and supervise the paramedics (the urban counterparts of barefoot doctors)

working at the neighborhood or residents’ cooperative medical station who deliver planned birth services.

At the residents’ small group level, a “woman representative” (who represents the women in the unit

at the neighborhood chapter of the Women’s Federation) is responsible for promoting planned births in

her unit. Assisted and supervised by the women’s

work cadres at the next higher level, these women

representatives carry out planned birth activities in

the residents’ small group—which in recent years

has come to include the formulation of community

birth plans, as discussed in Community planning of

births. Women working either in the state factories

or neighborhood cooperative cottage industries attend mandatory political study sessions at their place

of work. These study groups, which consist of 10 to

15 workers and are headed by “women’s group”

leaders (the factory’s equivalent of the women’s representative from the residents’ small group), are a

variation of the government mechanism used to promulgate the official ideology. These women’s groups

handle the birth planning activities of the women in

the group, including education, provision of contraceptive supplies, arrangement of planned birth operations, organization of the group planning of births,

and record-keeping.

All large state enterprise service units and large

governmental organizations such as universities and

hospitals have also set up their own planned birth

committees, usually headed by a deputy Party secretary or deputy director of the unit. This committee

handles the planned birth program for its employees

and is required to coordinate its activities with the

district-level planned birth staff office, or the neighborhood-level planned birth committee. This pattern

of coordination whereby the planned birth work at

an individual unit must be coordinated with that of a

planned birth staff office responsible for a defined

geographical-administrative area is referred to in

China as the “vertical and horizontal integration” pattern.

Virtuallv all goverment bodies in China operate .

under what is called “multiple leadership, ” which

consists of: vertical leadership, or control by another

government body with a similar function at a higher

level of the administrative structure; and horizontal
208 ● World Population and Fertility Planning Technologies: The Next 20 Years

leadership, or control by first, the supreme local government organization at its level, and second, the local Party organization at that level. Planned birth offices are no exception. Given the enormous power of

the Party organizations, what this means in practice

is that only when Party members on any given level

and in any given locality are active and imaginative

concerning planned birth activities will these activities be well thought out and executed. This is in

marked contrast to family planning programs in

other LDCS, where family planning networks normally operate in isolation either as part of a ministry

of health or family planning, or as a specifically created bureaucracy. Chinese sources have repeatedly

admitted to “uneven progress” in birth planning

work across provinces and regions, and have often

attributed good performance to “strong” Party

leadership and poor performance to “weak” Party

leadership and involvement.

Community planning of births

The underlying philosophy of the birth planning

policy is to combine state guidance (education and

persuasion as opposed to administrative orders) with

the “voluntarism” of the people. The government

does, however, see that its wishes are carried out.

The most effective tactic at its disposal is community

planning of births,

Although many of its elements have changed since

the promulgation of the one-child family norm, the

idea behind the model is simple. Since the mid-1970’s,

the State Council Birth Planning Staff Office has set

yearly targets for natural increase rates (births

minus deaths) in the various provinces, according to

such factors as socioeconomic development, previous performance, and ethnicity. Each province, upon

receiving the target that the central government has

established for it, sets a natural increase rate target

and allocates a birth quota for each of the prefectures under its jurisdiction. This process is repeated

downward until it reaches the production team (or

factory, residential unit, or whatever the birth planning unit happens to be in a particular locale; for this

discussion we will refer to the production team). The

production team must work out its birth plan, taking

into account those couples who plan to marry—for

such couples must report their plans to their employing or residential units months or even a year in advance and receive permission to do so—and assigning

permission to have children to those couples who

have observed the three reproductive norms. Childless couples and couples intending to marry soon

who have observed the late marriage norm have first

priority, followed by couples who have one child

aged three or older. If the eligible number of couples

is larger than the quota allowed, some eligible

couples must wait until the following year. Exceptions to these reproductive norms are allowed in

practice wherever they are deemed justified by the

local people and with the approval of the local birth

planning leading group.

Each production team, having worked out its team

plan, submits it to the brigade, which in turn works

out a brigade plan. The brigades send their plans up

to the commune, and so on. Sometimes adjustments

must take place along the way; a commune committee may add quotas to one brigade and subtract them

from another if it feels this is necessary.

Once a commune birth plan is approved, the members of the commune are expected to implement it.

Couples who have been given permission to have a

child are issued a “planned birth card” and may forego contraception; others are expected to practice

contraception or to undergo abortion in the event of

contraceptive failure. Because things do not always

proceed as planned–eligible couples fail to conceive,

an infant dies, a husband must be absent for a long

time, an ineligible wife becomes pregnant accidentally—periodic adjustments must be made. If a couple

who did not receive a birth quota conceives and then

requests a quota, and another couple with a quota

fails to conceive and agrees to give up their quota for

that year, the request may be granted.

As these reproductive norms have become increasingly well understood, it is no longer necessary to

call time-consuming group meetings to iron out community birth plans. Instead, eligible couples simply

submit their own birth plans, and local birth planning committees work out multiyear plans in accordPhoto credit: Leslie Corsa

The reproductive and contraceptive status of every woman

in a neighborhood near Nanjing, China, is shown on

the local health center’s monitoring board
App. A—Evolution of China’s Birth Planning Policy ● 209

ance with the three norms and notify the couples

concerned. The latter are expected to abide by the

community’s decision (6,7). Because every unplanned

birth in defiance of the community decision means

that an eligible couple must give up a birth permission they deserve and have earned, there is a collective interest in seeing that the community plan of

births is carried out. Chinese birth planning programs thus involve local communities in the planning

and implementation of a policy of vital national importance. In the process, community and/or peer

pressure ensures its successful implementation.

In isolated instances, local authorities, under pressure to improve program performance, have resorted to high-handed methods. These have included

denying full food rations and mobilizing intense community pressure against the defiant. Couples with

three or more children have also been mobilized to

undergo sterilization or abortion in order to fulfill

quotas. The central government has repeatedly condemned and forbidden such practices, and emphasized the importance of patient education and persuasion.

Contraceptive service delivery

PRC population programs have fared as well as

they have largely because of the government’s success in creating a nationwide network of primary

health care systems. Each of the 2,300 counties is organized into a regionalized, integrated, three-tier

health care system that provides community-based

preventive, contraceptive, and primary health care

to virtually every member of the rural population.

At the county level, under the overall supervision

of the county health bureau, are the county hospital,

anti-epidemic station, and maternal and child health

hospital. These facilities supervise and provide technical support (including in-service training) to the

commune health centers within the county in their

respective areas of specialization.

At the commune level, a commune health center

serves a population of 5,000 to 50,000 persons; it has

an average of 15 to 40 beds and 25 to 50 staff members, about one-third of whom are middle-level physicians and traditional herbalists. It is responsible for

preventive, curative, and surgical contraceptive services for the entire commune. The health center also

superises and provides continuous in-service training to the barefoot doctors serving the next lower

level, the brigade level, who offer preventive, contraceptive, and simple curative services. Cases

beyond the competence of the barefoot doctors are

referred to the commune health center, which in

turn refers difficult cases to the county general

hospital.

At the bottom of the three-tier health service system is the cooperative medical station, manned by

two to four barefoot doctors, at least one of whom is

female. They supervise environmental sanitation, administer preventive health measures, treat minor ailments, and provide contraceptive services. This medical care unit is financed cooperatively, through payment of premiums by the members of the production brigade. It also receives subsidies from brigade

and commune welfare funds, receipts from the

growing, processing, and sale of medicinal herbs (in

areas where this is done), and fees from users of the

service. The state subsidizes cooperative medical

services in several ways: 1) prices of some western

drugs are set below cost; 2) vaccines and contraceptives are provided free; and 3) most of the initial and

continuing cost of training barefoot doctors is subsidized. Once established, the cooperative medical

service is expected to practice ‘(self-reliance, ” raising

its revenues from the abovementioned sources.

This insistence on mobilizing local resources while

the state provides inputs not available locally largely

accounts for the PRC’s success in establishing its

nationwide health care network. The three-tiered

health care system, with the cooperative medical

services as the base of the pyramid, provides comprehensive, community-based health and contraceptive services despite low per capita incomes and significant financial constraints.

By 1965, each of China’s 2,300 counties was reported to have a well-equipped and competently

staffed l00-bed general hospital; larger hospitals

averaged 200-300 beds (3). By 1973, virtually all of

China’s 50,000 people’s communes were said to have

clinic/heahh centers, a third of them funded by the

state and the remainder by the communes (8). By

1978, 80 percent of the nation’s brigades, estimated

to number 750,000, had their own cooperative medical service units, staffed by two to four barefoot

doctors, or one barefoot doctor for every 400 rural

residents (2).

over the last few years, the number of barefoot

doctors has declined, from 1.76 million in 1977 to

1.67 million in 1978 (21). Many barefoot doctors,

underpaid or dissatisfied with their relatively low incomes, have abandoned paramedical practice in favor of farming. To counter this attrition, the Ministry

of Health in April 1981 issued a directive, approved

by the State Council, calling on rural communes and

brigades to increase their subsidies to cooperative

medical services and to ensure adequate compensation for barefoot doctors (11).
210 . World Population and Fertility Planning Technologies: The Next 20 Years

PRC birth planning programs have given major emphasis to providing as many contraceptive services

within the community as possible. The goal of the

programs is to make it possible for insertion and removal of IUDs to take place at the brigade medical

station, and for the other operations (tubal ligationlocclusion, vasectomy, induced abortion) to be

performed at the commune health center.

Most female barefoot doctors are trained in contraceptive counseling and some are able to perform

abortions by the vacuum aspiration method. Assisted

by the part-time birth attendant, MCH worker, or

health aide who serves at the team level, the female

barefoot doctor is responsible for providing prenatal

and postpartum counseling; delivering babies; inserting IUDs and providing follow-up care; conducting

contraceptive education; delivering contraceptive

supplies to the homes of couples who need them; referring or accompanying to the commune health

center clients who expect childbirth complications,

need obstetrical or gynecological services, or wish to

have one of the planned birth operations; keeping

records of planned births and vital statistics for the

brigade; and forwarding these statistics to the commune.

Since 1974, PRC birth planning programs have provided contraceptive services free of any charge to

users. The county/municipal birth planning staff office reimburses health units that perform the four

planned birth operations (i.e., tubectomy, vasectomy,

insertion and removal of IUDs, and induced abortion). Women and men who undergo any of the four

operations receive benefits in the form of nutritional

or cash subsidies, paid leave of absence in the urbanindustrial sector, and workpoints in the rural-agricultural sector.

The most popular method of contraception in

China at present is the IUD (table A-l). In the estimate

of the State Council Birth Planning Staff Office, IUDs

account for about 50 percent of all contraceptive use

in China. In Jiangsu province, which ranks as one of

the country’s highest-performance provinces in birth

planning, IUD users account for 52 percent of a]] current contraceptors; in Guangdong, a poor-performance province, the figure is 55 percent.

The second most popular method is sterilization. In

most provinces for which data are available, female

sterilizations far outnumber vasectomies. An exception is Sichuan province, where male sterilizations

reportedly outnumber female sterilizations. Oral

contraceptives are apparently not well accepted in

rural areas, with some notable exceptions. In Gansu

province, an economically backward province in the

northwest, pill users surprisingly account for 23 percent of current contraceptive users. The reason for

this is not clear. In major cities, the number of pill

users as a percent of total current contraceptors

ranges from 17 percent in Shanghai to 26 percent in

Tianjin. Two highly effective methods, the IUD and

sterilization, together account for about 80 percent

of all contraceptive use in China.

Induced abortion was legalized in 1956. Shortly

thereafter the social indications for induced abortion

were liberalized, and the procedure has since been

readily available, free of charge, and granted to

women on request.

Table A-2 summarizes induced abortion statistics

for the whole of China. As the table shows, China’s

abortion rate, or number of abortions per 1,000

women aged 15 to 44, remained more or less constant in the decade of the 1970’s, averaging 26 abortions per 1,000 women of reproductive age. The

abortion ratio, or number of abortions per 1,000 live

births, rose from 128 in 1971 to 318 in 1978. China’s

abortion rate and abortion ratio are very similar to

those of the United States in recent years. The statistics substantiate the official Chinese position that

Table A“I.—Contraceptive Users by Method and as Percent of Total Current

Users in China and Selected Provinces, 1978 and 1980

Sterilization

Year Female Male Both Steroids IUDs Barriers Others
App. A—Evolution of China’s Birth Planning Policy ● 211

Table A-2.—Number of Abortions, Abortions

per 1,000 Women of Reproductive Age, Abortions

per 1,000 Live Births, China, 1971078

abortion is not to be used as a method of contraception, but resorted to only as a last recourse in the

event of contraceptive failure.

In certain major cities for which data are available,

the abortion ratio is two or three times higher than

the national average. For example, in 1977 the abortion ratio was 1,231 in Xian (the capital of Shaanxi

province), 818 in Changsha (the capital of Hunan

province) and 1,200 in Chengtu (the capital of

Sichuan province). By comparison, the abortion ratio in Guangdong province was 318 in 1977 and 439

in 1980, and in Gangsu province the figure was 303

in 1979 and 249 in 1980. The extremely high abortion ratio in some of China’s major cities (which may

be attributable to rural women who come to urban

centers for abortion services), has led some outside

observers to wrongly conclude that China has relied

principally on abortion to control fertility—an assertion not supported by the available national and provincial abortion statistics.

Program performance

In the 1970’s, the Chinese birth planning program

evolved and diffused a system of program performance evaluation. First innovated in the major cities on

the Yangtze delta, the system is designed to measure

the extent to which eligible couples in a given geographic-administrative unit conform to the government-promoted reproductive norms. The system’s

three measures are the late marriage rate, the birth

limitation rate, and the planned birth rate, which are

defined as follows:

Number of men married at

25 years or age or older in

Late marriage rate = one calendar year

x 100

(male) Total number of men

married in one calendar year

Number of women married

at 23 or older in one

Late marriage rate = calendar year

(female) Total number of women

married in one calendar year

Number of men married at 25

years or older plus number

of women married at 23 or

Late marriage rate = older in one calendar year

(couple) Total number of men and women

married in one calendar year

Number of fecund married women

of reproducing age practicing

Birth limitation rate = contraception

Total number of married women of

reproductive age

Number of first live births to

mothers conforming to the late

marriage norm plus number of

second live births to couples

conforming to the longerPlanned birth rate = spacing norm

Total number of births

x 100

x 100

x 100

x 100

Table A-3 summarizes the available data about the

performance of birth planning programs in several

provinces. Figures for the late marriage rate for the

various provinces are not strictly comparable for the

following reasons. First, until very recently in some

proivinces (e.g., Guangdong) it was possible for young

couples to marry, but to wait until they reached the

right ages to register the marriage, provided the

team and brigade cadres cooperated (14). Second,

recommended optimal ages at marriage differ not

only between cities and rural counties, but also

among prefectures and sometimes counties within

the same province. Moreover, the demographic

Table A-3.—The Late Marriage Rate, Birth

Limitation Rate, Planned Birth Rate, and

Crude Birth Rate, Selected Provinces, 1977.80

Province Year LM R BLR P B R C B R

Guangdong . . . . . . . . ......1978

1980

Jiangsu . ................1977

Hebei . ..................1977

Shaanxi . ................1980

Gansu . .................1979

1980

Shanghai:

City proper . ...........1978

Periurban counties. .. ...1978

Tianjin:

City proper . . . . . . ......1978

Periurban counties. .. ...1978

90 85 85 7.4

80 80 75 15.3

95.2 a 86.8 92 15.4a

73 65

84-587 0 - 82 - 15
212 “ World Population and Fertility Planning Technologies: The Next 20 Years

meaning of such statistics is difficult to interpret except that a relatively high late marriage rate implies a

relatively high average age at marriage. However,

within a province, it does measure the relative conformity to the late marriage norms among various

subunits and in the same subunit over time, provided

that the same definition was observed and that the

degree of underregistration of marriages is of the

same magnitude. To this extent, it is a useful index of

program performance. Because of local variations in

interpretations of planned birth norms, the figures

for planned birth rates for the various provinces are

not comparable. This rate is, however, a useful indicator of relative program performance.

The birth limitation rate used in Chinese programs

differs from the contraceptive prevalence rate commonly used in international comparisons. The principal difference is that the denominator excludes

naturally sterile women, who become a large proportion in the older age groups. Another difference is

that the numerator is derived from program statistics that usually credit partial use of contraception

during the year with full use. Thus, a Chinese birth

limitation rate of 70 is comparable to a contraceptive

prevalence rate of 60, as commonly used internationally.

There is little doubt that China’s programs have

succeeded in raising average age at first marriage

substantially. In Shanghai county, a periurban county under the jurisdiction of Shanghai, the average female age at first marriage rose from 20.9 in 1955-59

to 24.96 in 1975-79 (26). These figures may be compared with an average age at first marriage for females of 17.7 in north China in 1929-31 as obtained

from John Buck’s land utilization survey (2). There is

also little doubt that the Chinese programs have succeeded in persuading an overwhelming majority of

women of reproductive age to regularly practice

contraception. A birth limitation rate of 70 percent

and above is very different from the situation in the

1930’s, when it may reasonably be assumed that the

deliberate practice of contraception was virtually

nonexistent in China.

A rapid, substantial increase in women’s age at first

marriage has an immediate, substantial depressant

effect on the crude birth rate, provided there are no

or few premarital births. By vigorously promoting

late marriage, rapidly increasing the use of effective

contraception, and terminating about one-fourth of

pregnancies, the Chinese programs were able to

sharply reduce China’s crude birth rate from 31 per

1,000 in 1971 to 18 per 1,000 in 1979. However, the

benefit derived from the rapid substantial rise in age

at marriage is by its nature a one-time occurrence.

Although the majority of young women have been

restrained by the programs from marrying before

reaching the required age and thus delayed their

first birth, once they reach that age they can marry

and are then entitled to receive permission to have

their first child. This, together with the much larger

cohorts of young women who were born in the highfertility period of the 1960’s and are now nearing

marriage age, will result in a vast increase in the

number of women entering the approved childbearing ages, beginning in 1983. The process has already

begun in a number of cities and provinces. This dramatic surge in numbers of women eligible to bear

children is a major reason for the initiation of the

one-child campaign. The campaign’s success would

prevent a new surge in the crude birth rate during

the 1980’s and enhance China’s likelihood of achieving population stabilization by the end of the century.

The historic one-child campaign

In the August 1979 article in which she made public the government’s intention to encourage one child

per family, Vice Premier Chen Mu-hua indicated that

a “planned birth law" designed to encourage the

spread of the one-child family would soon be promulgated. Several drafts of the proposed planned

birth law have been circulated at the grassroots level

for comments and feedback. By August 1980, the

eighth draft of the law was in circulation. However,

the only legislation that has so far been enacted is the

upward revision of the minimum legal age at marriage, passed by the National People’s Congress in

September 1980. Three reasons are believed to account for this lack of formal legislation on the onechild family. First, PRC policymakers have apparently not been able to reach a consensus on an experiment of this nature. Second, the law involves both

monetary and nonmonetary rewards for couples

who pledge to have only one child, raising the ques-
App, A—Evolution of China’s Birth Planning Policy ● 213

Photo credit: J. Chao and Population Information Program,

Johns Hopkins University

One child family in Shanghai, shown with grandmother

tion of financing such rewards. Third, there are

questions about the enforceability of the law in cases

where couples defy the government admonition not

to have a second birth, and of how the law would apply to national minorities, who so far have been affected by the birth planning policy selectively and

less profoundly than the Han Chinese.

What has happened instead is that in September

1980 the Chinese Communist Party issued an open

letter to all members of the Party and of the Young

Communist League, which numbers 86 million, to

take the lead by practicing the one-child-per-family

norm (16). Using the draft planned birth law as a

model, most provinces took the initiative in drawing

up and promulgating their own provincial planned

birth regulations on a trial basis.

The specific incentives offered by these provincial

trial measures vary among provinces. All, however,

contain generous economic and noneconomic incentives to one-child couples who pledge to maintain this

status. Upon obtaining a one-child certificate, couples in urban areas are entitled to such benefits as: a

monthly stipend ranging from 5 to 8 percent of the

mean monthly wage for workers in urban-industrialized sectors, to continue until the child reaches 14

years of age; living space equal to that of two-child

families, and preferential treatment when applying

for housing; supplementary retirement pensions

over and above those provided for under the current

~abor protection law; and priority consideration in

job assignment and in admission to desired schools

for the only child. Couples who have no children, but

intend to stop at one child, are not eligible to apply

for the certificate until their first child has been

born.

In rural villages, couples who sign the one-child

pledge are to be rewarded with as much as an extra

month’s work points for each of the child’s first 14

years. The child can receive an adult’s grain ration

and count as 1.5 persons in the allocation of private

farming plots. When the couple is unable to work because of old age, the official goal is to provide a standard of living equal to or higher than the local average.

In both cities and villages, should the only child of a

one-child couple die, the parents may have another

child and continue to enjoy the same benefits. If,

however, they break their pledge by having a second

child, they would have to return all stipends or

workpoints received and would be fined.

Virtually all Chinese provinces are now believed to

have promulgated their own trial regulations. In August 1981, Shanghai, the pace setter in birth planning

in urban areas, promulgated a set of revised planned

birth regulations. The new regulations retain previous measures aimed at spreading the one-child

norm, and add new provisions designed to encourage late marriage, late births, and to “strictly control

the second birth.” Young men and women who marry after they reach 27 and 25 years of age are entitled to one extra week of wedding leave. Women

who give birth to their first child after they reach 25

years of age (23 in periurban counties) are entitled to

15 extra days of maternity leave. Second parity

births are to be strictly controlled by denying birth

permissions to current one-child couples except for

special circumstances (e.g., the one child has congenital, nonhereditary disease and will not grow to become a regular laborer; remarried couples who have

only one child; couples certified by hospitals to be

sterile who consequently adopted a child only to

have their own child later) (23).

These provincial trial measures in effect reverse

former welfare policy. Prior to 1977, official rules

and regulations used in allocating housing, living

space, welfare subsidies in urban areas, and in allocating basic grain and private farming plots in rural

areas favored large families, and therefore had a pronatalist effect. 8

In the 2 years since the government’s formal announcement of its one-child campaign, Chinese birth

planning programs have placed major emphasis on

raising the one-child certificate rate and the ratio of

first births per 100 total births. Table A-4 summarizes data on the first-birth ratio for several provinces. Sichuan, the pace setter in birth planning for

rural China, appears to have set the pace once again.

In 1979, first births accounted for 72 percent of total

births among this province’s 100 million population.
214 ● World Population and Fertility Planning Technologies: The Next 20 Years

Table A-4.—First Parity Births as Percent of Total

Births, 1979-80

First parity births

as percent of

Total Births

Area 1979 1980

China . . . . . . . . . . . . . . . . . . . . —

Beijing:

Western District . . . . . . . . . 77.7

Shanghai . . . . . . . . . . . . . . . . . 52

Shanghai county . . . . . . . . 74

City proper . . . . . . . . . . . . . . —

Periurban counties . . . . . . . —

Gansu . . . . . . . . . . . . . . . . . . . NA

Shaanxi . . . . . . . . . . . . . . . . . . NA

Guangdong . . . . . . . . . . . . . . . NA

Sichuan . . . . . . . . . . . . . . . . . . 72

51

—

One-child

Number of one-child certificate

Area Date certificate hoiders rate.

China . . . . . . . .

Beijing ..,....

Jiangsu . . . . . .

Zhejiang . . . . . .

Shandong . . . .

Gansu. . . . . . . .

Shaanxi . . . . . .

Guangdong . . .

Liaoning. ....~

Sichuan . . . . . .

December 1979

December 1960

June 1981

June 1980

February 1980

December 1979

March 1980

December1960

December1960

December1980

December1979

December1979

December1980

5,000,000

10,OOO,OOO

11,000,000

220,000

930,000

120,000

1,170,000 ——

—

NA

400,000

1,700,000

29—

57

78.6

88

NA

77

25.6

79.6

21.9

86—

NA

The record in Shanghai, urban China’s pace setter in

birth planning, is no less impressive; the first-birth

ratio was 95 percent in the city proper and 75 percent in periurban counties in the first half of 1980. In

Gansu and Shaanxi, two economically backward

provinces to the northwest, first birth ratios were 57

and 53 percent, respectively, in 1980. Even in Guangdong province, where the birth rate in 1980 was the

highest of all provinces (excluding the autonomous

regions), the first-birth ratio was 43 percent. According to Madame Li Xiu-zheng, deputy chairman of the

State Planning Commission and director of the State

Council of Birth Planning Staff Offices, first births accounted for 51 percent of all births in China in 1980

(1 1).

To measure the one-child campaign’s relative progress, the Chinese programs have coined a “one-child

certificate rate,” defined as the percent of one-child

couples who have obtained one-child certificates

(thereby pledging not to have a second child). Table

A-5 summarizes available statistics about the progress of the one-child campaign in several provinces.

By the end of 1979, 29 percent of one-child couples

had signed one-child certificates. By the end of 1980,

more than 10 million one-child couples had signed

up. By June 1981, according to Madame Li, 11 million

one-child couples had signed up for the certificates,

accounting for 57 percent of the nation’s estimated

total of 20 million one-child couples (about 10 percent of married women of reproductive age) (13).

The one-child campaign has fared still better in several provinces. In Sichuan province, one-child certificate holders rose from 400,000 in 1979 to 1,700,000

in 1980. By the end of 1980, Shangdong and Shaanxi

had achieved one-child certificate rates of 77 and 80

percent, respectively. Even in “backward” Guangdong, 22 percent of one-child couples had signed

one-child certificates by the end of 1980.

Because of the way in which the one-child rate is

defined, it will fluctuate substantially from year to

year, since both the numerator and the denominator

will change drastically from one year to another,

Moreover, with numbers of women reaching the age

of reproduction expected to average more than 10

million each year, the one-child campaign will do

well to raise the one-child rate to 50 percent and

maintain it at that level for any extended period.

The son-preference found among the overwhelming majority of rural peasants is a product of Confucian heritage reinforced by a rational calculation of

old-age security needs. Although there is an adequate

old-age pension system for a large proportion of

those employed in the state-owned, urban-industrial

sector, these employees number no more than 10

percent of the total population. In rural areas, agricultural collectives provide some security assistance,

and are setting up the “five-guarantee household”

system (whereby childless old people are guaranteed

food, shelter, medical care, clothing, and burial by

the collective), and institutionalized old-age care. But

because it will be decades before the agricultural col-
App. A—Evolution of China’s Birth Planning Policy . 215

lective units can afford these expenses, in today’s

China, as in the past, the average personmust look to

his or her son(s) for support in the declining years.

And time-honored tradition calls for the son(s) and

not the daughter(s) to support aged parents. Under

such circumstances, the average peasant couple may

not be ready for the one-child family if their first

child is a female. The Chinese programs have promoted and arranged matrilocal marriage in recent

years in cases where the bride’s parents have no

male child. This helps reduce multiparty births, but

is likely to have little impact on the one-child campaign. If two families each have one child–one male

and the other female—the questions of whose home

they will live in upon marriage and whose parents

they will support in old age become crucial. If they

try to support both, the strain on their resources

would be twice that of couples who support one set

of parents. From the parents’ point of view, two

children, whatever their sex, are clearly better oldage insurance than one. Given the sex ratio at birth,

believed to be 106 males to 100 females for the Chinese population, a 50-percent one-child certificate

rate is probably the maximum feasible rate the onechild campaign can hope to sustain over a long period of time.

Population growth prospects to 2000

and beyond

The Chinese Birth Planning Commission appears to

be in agreement with the assessment that the maximum feasible one-child certificate rate is 50 percent.

Wang Shou-dao, a member of the Commission and

the President of the China Birth Planning Association, reportedly told a visiting Japanese delegation

that “our current program is aimed at reducing the

average number of children per married couple to

1.5 on a step-by-step basis” (10). A total fertility rate

of 1.5 implies, among other things, total elimination

of third and higher parity births and a 50 percent

one-child rate.

When she formally announced the launching of

the one-child campaign in 1979, Vice Premier Chen

Mu-hua indicated the campaign’s target was the realization of zero population growth by the year 2000.

What will China’s population size be in 2000 if the

one-child rate can indeed be sustained at 50 percent

over the next few years? And when will China

achieve the coveted goal of zero population growth?

According to Chen’s computer simulation of the

future growth of China’s population (using the scattered demographic data available to the outside

world), if China can raise its one-child rate to 50 percent by 1983 and maintain it at that level thereafter,

China’s population would reach 1.189 billion in 2000,

an increase of only 18 percent over the 1978 total.

Thereafter, the momentum of population growth

would so weaken that the annual net increase would

amount to about 2 million. By the end of the first

decade of the 21st century, China would achieve

zero population growth.

A computer simulation undertaken by a group of

Chinese population scientists in 1981 arrived at a

figure more or less similar to Chen’s: 1.14 billion in

2000 if the total fertility rate were to be brought

down to 1.5 in the next two decades.

If the Chinese government should decide to continue its one-child campaign after its population

reaches zero population growth, China’s population

would decrease in absolute size, and the proportion

of population aged 65 and above would steadily increase. If this policy were to continue in force, it

would pose formidable social problems in the third

and fourth decades of the 21st century. Obviously,

Chinese policy makers have by now been informed

by China’s population scientists of the long-term consequences of indefinite pursuit of the one-child campaign.

In implementing the one-child campaign, the

Chinese government hopes to persuade 50 percent

of couples born in the 1960’s and 1970’s to forego the

privilege of having two children, thereby avoiding

otherwise inevitably high population growth rates in

the next two decades, and bringing China’s population to zero growth in 20 to 30 years. After realizing

zero population growth, the government would presumably allow the fertility rate to rise to replacement

level, or 2.16, but no higher, and stabilize it at this

level for several decades.

In view of the lack of necessary information and

the magnitude of a decision of this nature, it is difficult to imagine that the Chinese government has formulated its long-term population policy beyond the

next three decades. A group of Chinese population

scientists, however, recently advocated two scenarios (fig. A-l). The first scenario calls for reducing total fertility to 1 by 1985, and allowing it to rise to 2.16

after 2000, which would stabilize China’s population

at 700 million in 2070. The second scenario calls for

reducing the total fertility rate to 1.5 by 1990) and allowing it to rise to 2.14 after 2025. If this scenario

were to be followed, China’s population would stabilize at 700 million by the end of the 21st century. Although the scientists suggested that the governrnenc

strive to realize the first scenario, they conceded that

it was not feasible. They did, however, strongly advocate striving to realize the second scenario, maintaining the total fertility rate at 1.5 in the next several
216 ● World Population and Fertility Planning Technologies: The Next 20 Years

Figure A-1.-The “Ideal” and “Realistic” Population Growth Pattern, China, 1978=2100

9

9 “-- — ,, —., —, , “Ideal”

decades so that China’s population would not exceed

1.2 billion when it reaches its peak size (19).

The greatest problem of the one-child campaign to

date appears to be the financing of its economic rewards. Thus far, the government has taken the easy

step of mandating all employing units in urban areas

and collective units (i.e., the commune, the production brigade, or the production team) in rural areas

to pay for both cash and noncash benefits. In the urban industrial sector, all workers or government officials work for employing units “owned” either by the

collective or by the state, which ultimately shoulders

the burden of financing benefits to one-child families. In rural areas, mandating the collective unit to

pay for such benefits in effect means that those couples who pledge to have only one child benefit at the

expense of those families who are either ineligible or

unwilling to make such a commitment. Since the income and living standard of the urban industrial population is already much higher and less subject to cy -

clical fluctuation, it is difficult to justify a policy that

calls upon rural collective units to bear this burden

without subsidy.

The provincial trial measures call for payment of

48 to 60 yuan (about 29 to 36 U.S. dollars) or more

per year to the one-child family for 14 years. In 1980,

this amounted to about $0.34 (U. S.) per capita. In addition, commune and brigade costs for planned birth

staff salaries rose to about $0.25 (U. S.) per capita, and

subsidies to couples having a planned birth operation

were about $0.15 (U. S.) per capita. A slight increase

in the state contribution for county and higher level

staff salaries, contraceptives, planned birth operations, training, and publicity, to about $0.24 (U. S.)

per capita, raised the overall 1980 governmental

costs for China’s planned birth program to a world

high of about $0.98 (U. S.) per capita, or a total approaching $1 billion in U.S. dollars. As the number of

one-child certificate holders increases, this will

become a sizable financial burden for an economy
App. A—Evolution of China’s Birth Planning Policy . 217

whose per capita GNP is only 256 U.S. dollars.

Whether the government is prepared to take on this

financial burden by centralizing the financing of the

one-child payment remains to be seen.

Conclusion

The PRC accomplishment in birth planning in the

last decade is unprecedented in the annals of organized fertility reduction. Despite its youthful age

structure, China’s crude birth rate declined from 34

per 1)000 in 1970 to 18 in 1979 (fig, A-2). This is a remarkable feat for a country where most of the population lives in rural areas, the labor force is largely

agricultural, and the per capita income is very low.

However, the PRC government has made tremendous strides in education, the emancipation of women, and health. By 1978 China had achieved virtual

universal education for its vast numbers of young

people; more than 96 percent of elementary schoolage children were attending school. Although the

lives of contemporary Chinese women remain very

different from those of their sisters in western Europe and North America, their legal and social status

has improved tremendously since 1949. This improvement is particularly marked when the status of

Chinese women is compared with that of women in

nearly all other LDCS. China’s accomplishments in

public health and medical care are best measured by

the life expectancy of its population: a recent estimate by western demographers yields a life expectancy at birth of 63 to 64 years for 1975 (l).

PRC government efforts to provide minimum but

equitable living standards, universal primary education, equality for women, and basic health care for

its vast population have greatly strengthened the

Figure A-2.–The Vital Trends of China, 1950-80

45

40

35

5

0

1950 52 54 58 58 60 62 64 66 68 70 72 74 76 78 80

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

government’s appeal to the populace to accept the

new reproductive norms. But the central factors in

the PRC's success in birth planning have been the

government’s commitment of enormous resources,

its capability to organize and implement a vigorous,

highly organized birth planning program, and the apparently widespread grassroots support for these efforts. No government has ever committed greater

human and financial resources to limiting its population growth, nor has any other government been

able to rally the degree of community-level commitment and support seen in the PRC.

The task the PRC government has set for itself for

the next two to three decades is even more prodigious. Enormous resources have been committed to

its accomplishment. PRC leaders have repeatedly indicated that the success of China’s four modernization programs is contingent upon realizing the demographic target they have set for the country in the

next 20 to 30 years. China’s experience in socioeconomic development has borne them out on this

point. The population increases of the last three decades have offset their efforts to improve living standards in many areas. Although the total grain output

has almost doubled in the last 30 years, there has

been virtually no improvement in per capita grain

output, which increased from 234 kilograms in 1952

to 260 kilograms in 1980. Population growth combined with the conversion of cropland to industrial

and residential use has reduced cropland over the

last three decades to the point that in 1979 arable

land per farmer in China was a mere 0.12 hectares—lower than the amounts of land per farmer in

Bangladesh—0.15 hectares—and South Korea—O.14

hectares. Even densely populated India has an

amount of arable land per farmer of 0.45 hectare.

Over the long run, the ability of the PRC government

to improve the nutrition, living standards, health,

and education of its population will depend on its

success in limiting population growth. Its ability to

create jobs for its burgeoning labor force and to

Appendix A references

1 . Banister, J., and Preston, S., “Mortality in China,”

2.

3.

4.

Population and Development Review, 7(9):98-110, 1981.

Buck, J. L., Land Utilization in China (Nanking: University of Nanking Press, 1937).

Chang, T., “The Development of Hospital Services in

China,” Chinese Medical Journal, 84: June 1965.

Chen, M., “To Realize the Four Modernizations, It Is

Necessary to Control Population Increase in a Planned

Way,” Renmin Ribao (People’s Daily), August 1979,

translated by Pi-chao Chen, September 1979, with title

bring about acceptable rates of economic growth are

all contingent on successful population limitation efforts.

PRC population programs have succeeded virtually

without external assistance. The PRC government

did not become the recipient of external assistance in

population activities until June 1980, when the

United Nations Fund for Population Activities approved a 4-year, $50 million population assistance

program for China. Most of these funds will go toward the import of hardware such as computers and

materials for contraceptive manufacturing plants,

leaving little for technical assistance and personnel

training. The World Health Organization and the

Rockefeller Foundation have also provided small

grants to China to support small-scale biomedical and

contraceptive research.

To successfully implement its ambitious population

programs, China needs more information and scientific knowledge than it now possesses. In the near future China will require extensive scientific expertise

to allow policymakers to plan and implement population programs, to continuously monitor and evaluate

their progress, to anticipate their consequences, and

to develop appropriate policy options.

Because China constitutes one-fifth of the world’s

total population, its population programs are a matter of worldwide concern. China’s success in achieving population stabilization in the next 20 to 30 years

will have global significance, as the Chinese population accounts for almost 30 percent of the LDC

population total.

Neighboring Japan, which has become a major donor of international population assistance, will shortly initiate a program of population assistance to

China at the request of the PRC government. Political

stability and economic prosperity in China, which

will depend to a great degree on its success in planning its population growth, will also be of strategic

importance to the United States.

5.

6.

changed to “Birth Planning in China,” International Family Planning Perspectives, 5(3):93-101.

Chen, P., “Birth Planning,” in Rural Health in the People’s

Republic of China, Washington, D. C., National Institute

of Health Publication No. 81-2124:105-127, 1980.

Population and Health Policy in the People’s Republic ;f China, Washington, D. C., Smithsonian Institution, Interdisciplinary Communications Program, Occasional Monograph Series No. 3, 1976.
App. A—Evolution of China’s Birth Planning Policy . 219

7. Ch’iu-Lyle, K., “Planned Birth in Tianjin,” China Quarterly, 83:551-67, 1980.

8. FINS (Foreign Broadcasting Information Service), 1:123B

p. 1, 1973.

9. Huang, Y., Birth Control in China, (Hong Kong: Union

Research Institute, 1967).

10. JOICFP (Japanese Organization for International Cooperation in Family Planning, Inc.), The Report of the F’amily Planning observation Mission to China, June 27th-July

Ioth, 1980, Tokyo: JOICFP.

11. JKB (Jian Kang Bao, Health Journal), “Continue To

Advocate One Child Per Couple,” June 7.1, 1981.

12. , “A State Council Approved Report Issued by

the Ministry of Health: It Is Hoped That the Various

Localities Solve the Problem of Reasonable Compensation to the Barefoot Doctors,” March 8: 1; “An Important

Measure to Stabilize the Development of the Troop of

the Barefoot Doctors,” 8:1, March 1981.

13. , June 7, 1981, p. 1, “Continue To Promote One

Child Per Couple” and Madame Chen Mu-hua, “Answer

the Xin Xua Correspondence Questions Regarding China’s Population,” Guangmun Ribao, Oct. 27, 1981, p. 1,

14. Liu, Z., “March Toward Zero Growth of Population,”

Sichuan Dazue Xuebao (Sichuan University Journal), Philosophy and Social Science Edition, 3:10-17, 1980.

15. Parrish, W. L., and Whyte, M. K., Village and Family in

Contemporary China (Chicago: University of Chicago

Press, 1978).

16. PIACT (Program for the Introduction and Adaption of

Contraceptive Technology, “Contraceptive Use in

China,” product News, 2(1):1-8, 1980.

17. RMRB (Renmin Ribao, People’s Daily), “The (Community) Party Center Calls Upon the Members of the Party

and the (Young Communist) League To Take the Lead

in Having Only One Child,” September, 26:1, 1980.

18. Ri, X., “On the Situation and Tasks of Current Birth

Planning Work,” Renkou Yanjiu (Population Research),

1:3-5, 47, 1980.

19. Song, J., et al., “On the Target of the Population Development of Our Country,” Renmin Ribao (People’s Daily),

7:5, March 1980.

20. “A Report of a Study of the Ideal Population

Size of ‘Our Country,” (manuscript), Apr. 27, 1981, the

content of this report is summarized in Renmin Ribao,

Feb. 24, 1981,

21. State Statistical Bureau, “Communique on the Results of

Implementing the 1978 National Economic Plan,” Renmin Ribao (People’s Daily), June 27, 1979.

22. “The Principal Statistical Figures Regarding the

National Economy,” May 1980.

23. “Communique)” in Survey of World Broadcast,

F~671~/C/l-9, Apr. 30, 1981.

24. IWHB (Wen Hui Bao, a Shanghai daily), “Regulations

Concerning the Promotion of Planned Birth in Shanghai

Municipality,” 10.2, August 1981.

25. Xibeirenkou (Northwest Population), 2:48, 1980.

26. Zhang, L., “Birth control, Late Marriage, and Decline in

the Natural Increase of Population, ” Renkou yu J@ji

(Population and the Economy), 1:35-39, 1980.

27. Zheng, W., and Gu, X., “Family Planning in Shanghai

County” (unpublished manuscript), 1981.
Appendix B

Indonesia Looks Toward

Continued Fertility Decline*

Rapid population growth on the island of Java was

recognized as a problem as early as 1800 by Indonesia’s Dutch colonial rulers. Pressures were particularly acute in the crowded city of Jakarta. Java’s carrying capacity had become seriously threatened by

1900, when a policy of redistribution or “transmigration” was begun, in which individuals and families

were moved from this densely populated region to

the sparsely inhabited outer islands of the archipelago nation.

Yet official recognition of Indonesia’s high growth

and birth rates as constraints to national well-being

was slow in coming. In 1964, measures to reduce

birth rates were not considered to be in keeping with

Muslim customs and morals, and the administration

of then-President Soekarno felt that the nation’s population pressures could be adequately eased by

transmigration, which could also provide the means

to develop an economic and agricultural base on the

outer islands.

The first advocates of family planning in Indonesia

were private groups that provided services and information in the early 1950’s to an educated and

highly motivated urban middle class. These small

groups later merged to form the voluntary Indonesian Planned Parenthood Association, which set the

stage for eventual governmental initiatives, The first

official government action took place in 1968 when

Soeharto assumed the presidency and was one of 20

heads of state to sign a U.N. declaration on population which stated that “the number and spacing of

children is a basic human right.” An ad hoc advisory

committee then recommended the establishment of a

national family plaming program for Java and Bali,

which was initiated in 1969. REPELITA I (1969-73)

was the first National Development Plan to include a

family planning component and set a target (3 million) for new contraceptive users. In 1969-70 the National Family Planning Board was established, and

“Family planning program efforts have had a remarkable impact on the island nation of Indonesia, where fertility rates have

fallen significantly in recent years. In Kenya, by contrast, high

birth rates persist despite substantial population assistance efforts. The following brief overviews by David Cantor of activities

in these two countries indicate the wide range of sociocultural influences to be considered in the development of family planning

programs in LDCs and the importance of country-specific approaches to the provision of fertility planning services.

Photo credit: Agency for International Development

Indonesian mother and baby participating in Indonesian

maternal and child health care program

the groundwork laid for what was to become one of

the world’s most successful family planning programs.

REPELITA II (1974-78) cited rapid population

growth as the country’s most important problem and

family planning as the major focus of its population

policy. This plan called for 8 million to 12 million new

users in Java and Bali and 1 million new users in the

outer islands within the 5-year period. These goals

were supported by strong statements urging the

adoption of a small family norm through intensive information, education, communication/motivation activities, and innovative approaches toward the

delivery of family planning services.

The current population policy of REPELITA III calls

for further expansion of family planning efforts to all

regions of the country, stresses the need for developing the outer regions through planned and voluntary

transmigration, and recommends a national demographic policy aimed at slowed population growth,

reduced infant mortality, and more even distribution

of the population.

International population assistance to Indonesia

began in 1968, when the government initiated official support of family planning. At that time the

220
App. B—Indonesia Looks Toward Continued Fertility Decline ● 221

country provided a very small amount (4 percent—

see table B-1) of the total dollars spent on its population activities. AID was the major foreign donor and

has continued to be a major source of assistance over

the 12-year period. During the period 1968-78 AID

contributed $43.2 million in grants and $14.3 million

in loans. Total funds provided to the Indonesia family

planning program through 1978 totaled $208 million;

of this amount, 50 percent was provided by the Indonesian government, 28 percent by AID (which includes AID intermediaries as well as donations to

multilateral), and 22 percent by other foreign donors. The trends outlined in table B-1 reveal the government’s growing willingness to provide support

for its own program (61 percent in 1978). At the

same time the kinds of assistance provided by major

donors have shifted. AID, for example, had historically delivered its assistance in the form of contraceptive commodities and funds for developing and supporting family planning service activities. In keeping

with an overall government policy shift to promote

self-sufficiency, AID is now—along with UNFPA—

providing raw materials for the local production of

contraceptives. The government’s goal is self-reliance in the production of oral contraceptives by the

years 1985-90. The main focus of assistance for AID

and most international donors, however, continues

to be the provision of commodities to and support

for Indonesia’s village family planning program.

The National Family Planning Coordinating Board,

the semiautonomous government agency responsible for family planning, began a clinic-based operation in 1969. This became a broad-based community

distribution system known as the Village Family Planning Program in 1974 and has within the last 2 years

begun to reach beyond the Java-Bali region to the

outer islands.

The initial clinic approach to family planning was

well received because government leaders viewed

the issue as primarily one of health care. Numbers of

new contraceptive users grew through this approach by some 50,000 each year. Their numbers

were increasing by more than 1.6 million per year by

197’4; condoms and pills were the main methods of

choice. The government felt that although the clinic

program was successful, achieving the kind of fertility decline outlined in REPELITA II—a 50 percent

drop in fertility by the year 2000–called for an intensive outreach effort to bring family planning services

to the people.

An important aspect of the present Village Family

Planning Program is the way in which the distribution network is organized. Like the Indonesian political structure, the services delivery network has a hierarchically organized, top-to-bottom organizational

approach (see table B-2). The Ministry of Health clinics provide basic services and supplies to subdistricts

and to village outpost points or contraceptive supply

depots. These depots in turn service several village

user or family planning groups which are the basic

units of the distribution system. The contraceptive

supply depots are staffed by volunteer village leaders

who are responsible for registering eligible couples

and maintaining contraceptive records.

These influential village leaders include such figures as chiefs, religious leaders, and school teachers,

who are recruited and trained to both establish and

monitor the contraceptive supply depots at the village level. They in turn form village subgroups that

consist of current contraceptive users among whom

individuals are chosen to recruit new contraceptive

users. These village subgroups also serve as forums

for promoting such other activities as nutrition education and overall family welfare.

Table B-l.—Indonesian Population and Family Planning Program Financial Resources,

Government of Indonesia (GOI), and Foreign Donor, 1968.78

Total per capita. . . . . . . . . . . $0.028 $0.021 $0.060 $0.076 $0.120 $0.177 $0.263 $0.297 $0.272 $0.324 $0.395 –

SOURCE: AID estimates from various sources.
222 . World Population and Fertility Planning Technologies: The Next 20 Years

The Village Family Planning Program has been operating in Java-Bali since 1975, and in parts of the

outer islands since 1977.

In 10 years (1968-78) the programs of the National

Family Planning Board have recruited 13 million new

contraceptive users. In March of 1979 current contraceptive users totaled 5.5 million (see table B-3). In

Java and Bali this represents 30 percent of all married (or cohabiting) fecund couples.

A different perspective of this program success is

provided by a summary of the impacts of these interventions since their inceptions. In 1970 the rate of

population growth in Indonesia was about 2.5; today

it is estimated to be between 1.9 and 2.0. In Java and

Bali, where the impact can best be measured, a 15

percent drop in fertility occurred during the 10 -year

period from 1969 to 1979. The crude birth rate during this period fell from 45 per 1,000 to 33 per

1,000—a drop of more than 25 percent.

Effects of family planning program

How much has Indonesia’s comprehensive program contributed to reducing the country’s fertility

rate? How much population growth would have occurred had there been no family planning program?

How much and to what extent have such natural

phenomena as later age at marriage or economic

growth contributed to this reduction?

A demographic analysis designed to quantify the

change in fertility rates in Java and Bali due to family

planning interventions was carried out by the Community and Family Study Center, University of Chicago, using 1971-76 data (see table B-4). The first column measures the fertility rate changes that would

have occurred naturally due to various social and

economic phenomena. The second column is based

on very optimistic assumptions of contraceptive use;

the third column uses a more conservative projection. Actual rates are reliably considered to fall between the second and third columns.

Substantial fertility declines due to family planning

program efforts are particularly noticeable on East

Java and Bali. By lowering crude birth rates to more

closely correspond to previous reductions in death

rates, Java and Bali are undergoing their own demographic transition as growth rates, based on either

high or low program estimates, fall substantially. According to these figures, family planning measures

are largely responsible for slowing the population

growth rate between 1971 and 1976.

Influence of political, cultural,

religious factors

What has brought about the apparently overwhelming success of family planning interventions in

Indonesia (particularly Java and Bali) in lowering

birth rates? The general consensus points to a fortuitous combination of circumstances, events, timing,

and dedicated people. The replication of these conditions in other LDC cultures is considered highly unlikely.

Table B-3.–Contraceptive Use Rates by Method, 1978

IUD Percent Pill Percent Other Percent Total

Java-Bali . . . . . . . . . . . . . . . . . . . 1,413 28 3,197 64 392 8 5,002

Outer Islands. . . . . . . . . . . . . . . 81 15 373 69 85 16 540

Indonesia total. . . . . . . . . . . . . . 1,494 27 3,569 64 478 9 5,542

NOTE: Figures may not add due to rounding
App. B—Indonesia Looks Toward Continued Fertility Decline “ 223

Table B-4.—Annual Growth Rates Under Various Assumptions for Java-Bali

Annual growth rate Annual growth rate

No family High Low No family High Low

Province planning program program Province planning program program

Jakarta: Yogyakarta;

1971 . . . . . . . . . . . . 2.9 2.9 2.9 1971 . . . . . . . . . . . . 1.5 1.5 1.5

1972 . . . . . . . . . . . . 2.9 2.8 2.8 1972 . . . . . . . . . . . . 1.5 1.4 1.5

1973 . . . . . . . . . . . . 2.9 2.7 2.7 1973 . . . . . . . . . . . . 1.5 1.3 1.3

1974 . . . . . . . . . . . . 2.9 2.6 2.7 1974 . . . . . . . . . . . . 1.5 1.1 1.1

1975 . . . . . . . . . . . . 3.0 2.5 2.6 1975 ......, . . . . . 1.5 1.0 1,0

1976 . . . . . . . . . . . . 3.0 2.4 2.6 1976 ..., . . . . . . . . 1.5 0.9 1.0

West Java: East Java:

1971 . . . . . . . . . . . . 2.8 2.8 2.8 1971 . . . . . . . . . . . . 2.0 2.0 2.0

1972 . . . . . . . . . . . . 2.7 2.7 2.7 1972 . . . . . . . . . . . . 2.0 1.9 1.9

1973 . . . . . . . . . . . . 2.7 2.5 2.5 1973 . . . . . . . . . . . . 1.9 1.6 1.7

1974 . . . . . . . . . . . . 2.6 2.3 2.3 1974 . . . . . . . . . . . . 1.9 1.3 1.4

1975 . . . . . . . . . . . . 2.5 2.1 2.2 1975 . . . . . . . . . . . . 1.8 1.0 1.2

1976 . . . . . . . . . . . . 2.5 1.9 2.0 1976 . . . . . . . . . . . . 1.8 0.9 1.1

Central Java: Bali:

1971 . . . . . . . . . . . . 2.1 2.1 2.1 1971 . . . . . . . . . . . . 2.4 2.4 2.4

1972 . . . . . . . . . . . . 2.1 2.0 2.0 1972 . . . . . . . . . . . . 2.4 2.2 2.3

1973 . . . . . . . . . . . . 2.1 1.9 2.0 1973 . . . . . . . . . . . . 2.4 1.9 2.0

1974 . . . . . . . . . . . . 2.1 1.8 1.9 1974 . . . . . . . . . . . . 2.4 1.5 1.7

1975 . . . . . . . . . . . . 2.1 1.6 1.8 1975 . . . . . . . . . . . . 2.4 1.2 1.5

1976 . . . . . . . . . . . . 2.1 1.5 1.6 1976 . . . . . . . . . . . . 2.3 1.0 1.5

President Soeharto. is widely respected and

revered by large portions of the population, and his

emphatic messages are taken to heart. Soeharto

stresses family planning as an integral part of the Indonesian ’’Code of Ethics” which states that belief in

God, Nationalism, Humanity, Democracy, and Social

Justice are the five pillars on which people should

base their lives. The government’s commitment is

also reflected in its flexible programming and

widespread acceptance and use of international

population assistance.

Commitment by government leaders and availability of international assistance alone cannot effect the

desired change, however. In Indonesia, cultural and

religious beliefs have had a positive effect on contraceptive use at the community level. Traditional Islamic religious law or “Adat” is a strong behavioral influence on Muslim people. When the government instituted its national family planning program there

were fears that contraception would conflict with

the law of Adat for Javanese Muslims, But the Koran

states that “all of God’s children must be cared for,”

thus providing an underlying admonition to have

only wanted births. Islamic leaders and “K1ian” members (village elders) have publicly endorsed contraception as a means of preventing unwanted births

which thereby enables families to better provide for

children already living. Traditional Islamic values

constrain the use of certain methods because of their

modes of administration. According to the Koran,

any public display of the genital area renders one

“malu” or “shamefully embarrassed” which poses

problems with IUD insertion. The fear of malu is especially strong among rural Muslims on the outer islands where peer influence is most important. Since

most doctors in Indonesia are male, a woman using

an IUD would almost certainly be considered malu.

Interestingly, this fear is unknown in Bali, where

Hindu tradition imposes no such threat. The pill has

consequently been the favored modern method in

Java while the IUD has gained widest acceptance on

Bali.

Bali is a unique example of an area where the family planning program has been woven into the

island’s cultural fabric through the use of strongly

structured existing institutions to promote contraceptive behavior. For centuries on Bali there have

been organizational divisions within villages, called

“ban jars.” The banjars, which have been trusted

foundations of local government for hundreds of

years, are also effective mechanisms for social

change. Since 1974, as part of the village family planning program, these units have been responsible for

encouraging and monitoring family planning services and use. Each village has from 5 to 10 ban jars;

each ban jar contains up to several hundred nuclear
224 Ž World Population and Fertility Planning Technologies: The Next 20 Years

families. A good deal of agricultural work is performed collectively by banjar members for the

benefit of the entire community, which defuses

much of the argument that a family needs many

children in order to increase its labor force.

No one factor can be cited as the key to the successes experienced in Indonesia. Socioeconomic development and higher age at marriage undoubtedly

played important roles. The islands of Java and Bali

may also have been ripe to embrace the notion of

limiting their numbers by the visible evidence of population pressures present in a crowded city like

Djakarta or within the confines of a small island like

Bali, Generally speaking, family planning measures

were made available, found acceptable and desirable.

and their use was not disruptive of people’s day-today lives.

Based on its swift national success, the government

of Indonesia has shortened the time span during

which it hopes to reach its 1970 goal of a so percent

reduction in fertility: the deadline date is now 1990

instead of 2000. Since 1979 the government has also

professed a “beyond family planning” philosophy,

which includes incorporating family planning efforts

with nutrition and other development services

through integrated programs at both administrative

and field levels, Vigorous efforts to recruit new contraceptive users and maintain current usage levels

are continuing.

Although the elements of Indonesia’s family planning success cannot be neatly diagramed for replication in other settings, the high priority given by the

government to providing Indonesians with both the

motivation and the means to limit their fertility has

clearly been a powerful influence.

Appendix B references

1 . Alan Guttmacher Institute, International Family Planning 5. U.S. Agency for International Development, Program

Perspective, vol. 5, no. 2, June 1979. Evaluation Report No. 2; “AID’s Role in Indonesian Family

2. MacAndrews, C., Tansmigration in Indonesia: Prospects Planning: Case Study With General Lessons for Foreign

and problems, Asian Surveys, vol. 18, May 1978. Assistance,” December 1979.

3. Population Reference Bureau, Population Bulletin, “In- 6. United Nations, World Population Trends and Prospects

donesia’s Family Planning Story: Success and Challenge,” by Country, 1950-2000, summary report of the 1978 asvol. 32, no. 6, November 1977. sessment.

4. United Nations Fund for Population Activities, Population

Profiles, No. 14, Indonesia.
Appendix C

Record Population Growth

Persists in Kenya

In 1966 Kenya became the first country in subSaharan Africa to officially recognize the effects of

rapid population growth on social and economic development. Although various private organizations

had been providing family planning services without

official consent for more than a decade, it was not

until the 1966-70 5-year development plan that the

government called for a reduction in the rate of population growth and the increased availability of family planning services at its hospital and health centers. Forty such clinics had become operational a

year later.

Because the official aim was to reduce infant mortality and provide voluntary family planning services, no growth or birth rate targets were set, but ensuing 5-year development plans (1970-74 and

1974-78) increasingly emphasized the role of population growth in meeting long-term development goals.

The most recent plan called for a reduction in the

growth rate to 3.3 percent by 1980. Yet Kenya’s current growth rate of close to 4 percent is now the

world’s highest. Its continuation would result in a

doubling of the country’s population within 18 years.

A 5-year $40 million integrated Maternal and Child

Health/Family Planning Program was a major focus

of the 1974-78 development plan. It was designed to

promote maternal and child health and strengthen

the entire health delivery system in support of the

government’s position on the relationships between

reductions in child mortality and morbidity and reduced fertility (4). The current 1979-83 development

plan, which continues to recognize population

growth as a major development constraint, for the

first time incorporates recently gathered population

data in efforts to deal with such problems as urban

to rural migration, unemployment, and economic

growth.

Kenya’s President Daniel Arap Moi, unusually outspoken on the subject of his country’s rapid population growth, has set a target of 4.7 children per Kenyan family by 2000. Although the country’s leaders

have cautiously proclaimed their support, a wide

range of cultural factors stand in the way of a rapid

deceleration in Kenya’s population growth rate.

National and international assistance

Large dollar amounts ($9.8 million in 1978) from a

multiplicity of external sources have been spent for

population assistance to Kenya in recent years.

Twenty-four separate donors designated funds for a

variety of family planning activities between 1967

and 1977; the major donors and areas of assistance

are shown in table C-1. The Government of Kenya

has also contributed substantial sums of its own—approximately $2.5 million in 1978–to family planning

efforts. The 1974-78 development plan, as table C-2

demonstrates, was the watershed period for coordinating national and external population assistance in

Table C. I.—External Assistance to Kenya;

Functional Support by Agency, 1967-77

Purpose

Research Training IEC FP services

Multilateral

225
226 ● World Population and Fertility Planning Technologies: The Next 20 Years

Table C-2.–Development Plan, 1974-78

SOURCE: Office of Technology Assessment.

initiating Kenyan population and development efforts.

AID has contributed substantial amounts to

Kenya’s program through bilateral funds and nongovernment intermediaries. Family Planning International Assistance (FPIA) has worked with Kenya’s

Ministry of Education in developing family planning

educational materials, and the Association for Voluntary Sterilization (AVS) has provided surgical sterilization equipment for women, to cite two examples.

The largest private donor has been the International

Planned Parenthood Federation, (IPPF) which in

1979 contributed $994)

000.

International population assistance to Kenya in recent years has resulted in substantial per capita totals. During calendar year 1977 Kenya received 47

cents per person from international donors, an

amount which rose to 61 cents per person in

1978—one of the highest per capita amounts ever

given to an LDC (see table C-3).

The data in table C-4 illustrate the extent to which

external assistance has focused on family planning

services during the last few years. These services

have included contraceptive supplies, delivery systems, and, in some cases, funding for health clinics

and salaries for personnel.

Despite a continuing large flow of dollars into the

country and a high level of cooperation and coordination among donors, little progress in reducing

birth rates has been made during the 13-year span of

official government efforts. The attention of both external donors and the Kenyan government has now

begun to focus on the disparity between the actions

thus far taken to curb the country’s population

growth and the results obtained.

Effect of family planning program

By the end of the 1974-78 Development Plan, there

were 505 integrated maternal and child health/family

Table C-3.—External Dollar Flows for Population to

Kenya by Agency, 1977-78 (in thousands)

Table C.4.—Sectoral Breakdown of Population

Assistance to Kenya, 1977.78 (in thousands)

Family Training

planning IEC and Population

services activities research policy Data Total

1977 . . . . $7,121 $174 $67 $0 $80 $7,508

1978, . . . $9,389 $63 $139 $19 $188 $9,788

SOURCE: Office of Technology Assessment.

planning clinics in operation. Although the cofinanced, integrated program had expanded the number of clinics, because of Kenya’s infrastructure and

development planning problems they were unevenly

distributed throughout the country and women

were often required to travel great distances to obtain contraceptive supplies. The Government’s original targets for establishing contraceptive use had not

been met and had to be readjusted. The dropout rate

was very high: only 18 percent of women who began

using oral contraceptives in 1967 were still using

them 1 year later. The reasons most often cited for

Kenya’s program failures were the inadequacy and

unavailability of services, and a lack of demand for

supplies and services.

Clearly, national and international interventions to

reduce birth rates have not yet been effective. In

1965 the birth rate was 50.2; by 1980 it had dropped

only to 49.o. The contraceptive prevalence rate of 9

percent is unusually low for a country with an

established population policy, a longstanding family

planning program, and a substantial inflow of

population assistance funds.

Data from the World Fertility Survey (WFS) reveal

that today’s generation of women of reproductive

age are having as many children as their mothers

did. The total fertility rate in 1969 was 7.6 births per

woman. In 1980 this rate among married women of

reproductive age in Kenya had risen to 8.1, a current

world record. An unusual aspect of this high fertility

was revealed by the 1977-78 Kenya Fertility Survey,

which found that 90 percent of these births were desired by the mothers. Only 17 percent of female respondents said they wanted no more children; the

comparable average from WFS countries is 50 percent.
App. C—Record Population Growth Persists in Kenya . 227

—---- 4 -

- f -

Photo credit: World Bank

Family planning instruction is part of the regular routine

at Machakos Hospital, Kenya

The country’s high birth rate has also persisted

despite a reduction in infant mortality. This decline

in infant deaths has increased Kenya’s dependency

burden; half of the population is now younger than

15 years of age. If the present birth rate continues,

the number of dependent primary-school age

children (6 to 13), which in 1975 was 2.6 million,

would reach 8.5 million by 2000. The rapid rise in

numbers of Kenyan children is shown in figure C-1.

Development activities have historically been weak

in Kenya, but the political and cultural pressures that

motivate people to have children appear to play a

central role in Kenya’s persistently high growth rate.

Figure C-l.– Kenya’s Population Age Structure

Influence of cultural and political

factors

The cautious tone that pervaded official Kenyan

response to early offers of foreign population assistance stems from the country’s closely connected culture and politics, and the omnipresent strength of

tribal loyalties. The Kikuyu and Luo tribes, which

dominate the political scene and set national policy,

have often been accused of promoting family planning to reduce the numbers of rival tribes while

maintaining an “undeclared” pronatalist policy for

their own people. While disclaimers abound, a tribal

“pecking order”—a kind of caste system—in which

overall strength is judged by sheer numbers of people, appears to prevail. The Kikuyu and Luo have two

of the highest overall growth rates of Kenya’s major

tribes.

It is generally agreed that people in LDCS, as elsewhere, despite government proclamations and pressures at the community (or tribal) level—whether

pronatalist or antinatalist–tend to try to do what is

best for themselves. In Kenya it still appears to be in

the best interest of the individual to desire, and produce, a large family.

Eighty percent of the people still depend on agriculture for their livelihood, and women are faced

with most of the field work and all of the household

chores. The rural women’s workload has traditionMALE

in 1969 and as Estimated for 1979

FEMALE

1969 1979

60+

50-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0 - 4

1
228 ● World Population and Fertility Planning Technologies: The Next 20 Years

ally risen when husbands and older sons migrated to

follow crop seasons or to find grazing lands for

herds. Now economic development and increasingly

scarce agricultural land are also drawing rural Kenyans to urban and cash crop areas in search of jobs,

Men continue their almost total domination of Kenyan political and social life, and some one-third of all

marriages are still polygamous unions. Because few

Kenyan women have access to paying jobs outside

the home, status for women can generally be obtained only through the political, occupational, or

family status of their husbands, or through their children. Thus large numbers of children not only give a

woman more helping hands but increase her status

in the eyes of her husband. Having a large family can

both ease a woman’s overall workload and (in the

case of smaller tribes) increase the probability of offspring marrying into a tribe with greater political

and economic strength. When her husband precedes

her in death (Kenyan women on average live longer

than men), she must depend on sons for support

because land is nearly always passed through the

male line. To be sure that her children are old

enough to support her when she becomes a widow,

it is to her advantage to marry and begin childbearing at an early age. The average age at marriage of

rural women surveyed in the Kenya Fertility Survey

was between 17 and 18.

A recent bill that would have given wives in polygamous unions equal property and inheritance rights

was soundly defeated in the Kenyan Parliament,

where it was denounced as un-African and culturally

unacceptable. In short, from the individual perspective, there appears to be little reason for a rural Kenyan woman to want to limit her family size, given her

need to labor in both field and household, her hope

for security in old age, and her desire for social

status.

This picture may be changing for particular groups

of women, however, as lower fertility rates have reAppendix C references

1. Mott, F. L. and S. H., “Kenya’s Record Population

Growth: A Dilemma of Development,” Population Bulletin,

vol. 35, No. 3, Population Reference Bureau, October

1980.

2. UNFPA Fact Sheet, Report on Population Assistance,

1971-78.

3. UNFPA, Inventory of Population Projects in Developing

Countries Around the World, 1978/79.

cently been noted among more educated women and

those residing in the urban areas of Nairobi and

Mombasa, where there are fewer barriers to acquiring contraceptive information and services. But

women who live in cities or who have secondary

educations are a very small proportion of the total

population; only about 12 percent of the women covered in the Kenya Fertility Survey had gone beyond 8

years of school. Although girls have gained significantly in recent rises in primary school enrollment,

they remain far less likely to attain the secondary

school level, where educational gains translate into

significant fertility declines. Their involvement in

modern employment is also negligible, and the pace

of their entry into nontraditional jobs is expected to

be slow, as opportunities will fall far short of the

large numbers of young women entering adulthood.

The demographic objectives of the current 1979-83

National Development Plan again stress the government’s intention to reduce Kenya’s rate of population

growth, and to work toward bringing the age structure into balance by 2000. Encouragement of child

spacing and reduction of infant mortality are family

planning program priorities. The government has

also concluded that information, education, and communication activities must be expanded beyond the

realm of the Ministry of Health. Kenya’s leaders are

now voicing the belief that future population assistance and family planning programs will have to take

greater account of fertility-related attitudes and the

role of women in the family planning decisionmaking

process.

Yet the extent to which these factors can realistically be addressed in Kenya is a controversial topic.

The importance of recognizing individual needs in

the structuring of Kenya’s development programs is

clear, but the momentum of today’s record-breaking

growth rates is likely to substantially delay the

achievement of the country’s development goals.

4.

5.

6.

UNFPA, Kenya, Report of Mission on Needs Assessment

for Population Assistance Report No. 15, June 1979.

U. N., Department of International Economic and Social

Affairs, Population Division, 1979, World Population

Trends and Prospects by Country, 1050-2000, Summary

Report of the 1978 Assessment (New York: U.N.).

World Bank, Population and Development in Kenya,

report No. 2775-KE, March 1980.
Appendix D

Production and Distribution

Capabilities for New Fertility

Planning Technologies Over

the Next Two Decades*

Introduction and conclusions

This section reviews the interrelationships between changes in the manufacture and distribution* * of current and new fertility planning technologies and their availability in less developed countries (LDCs), and looks at the ways in which production and distribution will influence the development

of new technologies.

These impacts ultimately influence the cost, formulation, design, and ease of supply and resupply of

the contraceptive technologies to be distributed by

government programs in LDCs. Many agencies and

organizations in addition to the government agencies

directly responsible for distributing the relevant

technologies significantly affect and are affected by

manufacturing and distribution decisions. These include ministries of trade, labor, industry, and

finance in LDC governments, as well as international

donor agencies, technical assistance agencies, and

manufacturers. Other agencies are peripherally involved; these include those responsible for setting

manufacturing and quality control standards, for

regulating drugs and devices, and for supplying

manufacturing equipment.

The following pages provide a qualitative consideration of the likely courses of events over the

next 20 years in the production and distribution of

fertility planning technologies. More extensive research would be necessary to accumulate quantitative information.

“This summary is drawn from a report prepared for OTA by Richard T.

klahoney of the Program for the Introduction and Adaptation of Contraceptive Technology. The development of new fertility planning technologies

and increased demand for contraceptives will require extensive changes in

systems of manufacturing and distribution. The effects of these changes will

be significant in both LDCS, where governments will need to examine their

capability to provide commodities in the context of moving toward selfsufficiency in their family planning programs, and MOCS, whose roles in

providing future population assistance are likely to be substantially altered.

“ “Distribution here refers to the processes and routes whereby contraceptives arrive in the hands of users from their initial point of manufacture

While this includes distribution from receiving points for supplies at the

commodities headquarters of LDC family planning programs to clients of

such programs, the major focus of this paper IS on distributing mechanisms

and channels that precede this point in the sLIpply chain.

Several conclusions have been reached about the

evolution of family planning programs and the

development of new technologies over the next two

decades:

1. Many of the prospective fertility planning

technologies (silastic implants that release

steroid hormones, biodegradable implants, injections that utilize hormone-carrying polymers,

silastic vaginal rings) will require the creation of

new manufacturing capacities for their widespread distribution. No similar technologies,

either for fertility planning or for other purposes, are currently being marketed in large

scale. This requirement for new manufacturing

technologies may:

2.

3.

a) increase the time required for new products

to become widely available;

b) increase the dependency of the public sector on the private commercial sector (located mainly in more developed countries

(MDCS)) for establishing the capability to

manufacture the new technologies;

c) make it increasingly difficult for most LDCS

to establish local production of new technologies; and

d) enlarge the role of international donor agencies and MDC manufacturing companies in

determining the kinds of technologies that

will be available to LDCs.

Other constraints to the introduction of products may be of more importance for the availability of new or improved methods than possible limitations in manufacturing. Because introduction of a new product into a family planning program is expensive, time consuming, and

can lead to disruptions in the program, program

managers need substantial justification for its introduction. The most important justification is

that the new product will result in a significant

new increase in contraceptive use.

There is a trend in a number of the most populous LDCs toward government sponsorship of local production of fertility planning technologies.

The impetus for this trend often comes from

229
230 ● World Population and Fertility Planning Technologies: The Next 20 Years

4.

5.

6.

7.

high government levels—the president, prime

minister, or cabinet—rather than from donors

or officials of the family planning program itself.

Those LDCS that do establish local production

may be limiting their access to future improved

versions of the technology. This is true not only

because of the difficulties in “retooling” a manufacturing facility (to switch from an “older” to a

“newer” version of an IUD, for example) but also

because access to the new technology may be

constrained by patents and licenses. An LDC

may find it prohibitively expensive to acquire

the production know-how and licensing necessary to manufacture the improved technology,

and thus opt to stay with the “older” version of

the method.

As a corollary to conclusion 4, LDCS that do not

establish local production of a particular method

may be enhancing their future access to modifications and improvements of that method. Further, the levels of product use they can achieve

will permit them to request, for very little additional cost to the donor or themselves (depending on whether the commodities are donations

or purchases), ‘(customized” products* to fit

their particular needs. These LDCS will, however, continue either to be dependent on donors

for their commodity supplies or will have to use

hard currency to purchase products on the international market. These considerations, and

others, could lead some countries to the conclusion that local production is the more desirable

course to pursue.

The eight large multinational firms that manufacture most of the world’s contraceptives will

continue to play an important role through the

year 2000. These firms will probably be responsible for manufacturing products for use by

nearly one-half of the population of the developing world, Local production in the LDCS with the

largest populations (such as India, China, and Indonesia) may meet the needs of the other half.

For economic reasons, if family planning programs are to have adequate supplies of commodities, the large bilateral and multilateral

donors (the U.S. Agency for International

Development (AID) and the United Nations Fund

for Population Activities (UNFPA)) will need to

remain active in commodity procurement

through 2000. However, they will be likely to

diversify the commodities they provide in

response to re~llests from LDCS for products

● Products utilizing special packaging or presentations to meet local needs.

8.

9,

more suited to their individual social and

cultural needs.

The two major international aid agencies have

taken similar policy stances on procurement of

commodities and local production although

UNFPA has given slightly greater emphasis to

the latter. UNFPA has been directed by its Governing Council to provide logistic support, including contraceptive commodities, if required

and to encourage, where appropriate, the local

production of contraceptives. AID’s program is

under continual review but currently gives preference to the supply of commodities. AID takes

the view that the development of local production facilities must be considered in the context

of the total aid commitment to the particular

country and to the needs of the country. If the

total aid package and the need for local production are compatible, AID will support local production.

It seems unlikely that manv LDCs will Procure

products produced by government-ov&ed or

private locally-owned factories in other LDCs.

Manufacturing constraints to the

development and supply of future

technologies

Because few radically new* * fertility planning

technologies are expected to be made available in the

next 20 years, most manufacturing and distribution

efforts will focus on existing technologies and the

modifications of these technologies likely to be introduced within the next decade (see ch. 5).

Radically new technologies are likely to reach only

the stage of prototype manufacture and large-scale

field testing by 2000. If the major clinical and laboratory studies of these contraceptive technologies now

under way demonstrate their safety, efficacy, and acceptability, they would be ready for introduction to

national family planning programs. Preparations for

the introduction of subdermal silastic implants are

already being launched by the Population Council

and the Rockefeller Foundation in several LDCS.

But before any of these methods can be introduced

on a large scale, mass production facilities to provide

adequate supplies must be established. Because each

of these technologies, as a technology per se, is rela-

“ ● “Radically new” is used here to designate those contraceptives under

development or that will be discovered that would represent a fundamem

tally different biological means of contraception than those technologies

currently available. For instance, a hormonal injectable contraceptive for

men would be radically new, whereas a new hormonal injectable for

women would not.
App. D—Production and Distribution Capabilities for New Fertility Planning Technologies Over the Next Two Decades ● 2 3 1

tively novel, the startup time for its large-scale manufacture would be considerably longer than that required for a new pill, for example.

Thus, the early large-scale manufacture of these

contraceptives is likely to be carried out by large

multinational pharmaceutical firms in MDCs, which

have the expertise, facilities, and resources to launch

the production of a new product in a comparatively

short period.

Public sector family planning programs already

rely heavily on large contraceptive manufacturers in

MDCS) and the advent of improved methods appears

likely to continue this dependence. This analysis examines some of the consequences of this dependence, but an in-depth evaluation of its costs and

benefits would clearly be useful.

Richard Buckles (2) contends that the public sector

has paid insufficient attention to the production component of making new contraceptive technologies

available. He believes that research and development

organizations should work out full-scale plans for

how, where, at what cost, and with what personnel

new technologies are to be produced. Public sector

development assistance agencies are generally not

prepared to undertake such production, he points

out, and are doing little to become more effective

partners with industry in making new methods

available to national programs.

Distribution system constraints to

the availability of new technologies

The introduction of a new technology can have

great impact on a government family planning program. Although it is possible for a national program

to introduce and distribute new technologies in a

fairly short period, experience indicates that to do so

is likely to lead to severe damage to the program, and

there is growing recognition of the need for careful

planning prior to the introduction of a new technology.

The sheer inertia of large bureaucracies can

lengthen the interval needed for introduction of a

new technology. For example, even though the Copper T IUD was developed in the mid-1970's, very few

family planning programs have yet introduced it for

widespread use.

The introduction of a new “improved” technology,

such as an oral contraceptive or IUD, into a national

program can take from 2 to 5 years. In most cases,

the introduction process can be expected to take

even longer.

The systematic introduction of a new technology

involves a number of major steps:

1.

2.

3.

4.

5.

6.

7.

8.

9.

Obtaining the approval of the body responsible

for distribution, such as the ministry of health.

Obtaining the approval of the local drug regulatory agency.

Identifying a donor agency willing to provide

continuous supplies, or establishing local manufacturing capabilities.

Conducting and analyzing studies on product acceptability among the target populations.

Determining the qualifications of personnel approved to distribute the product and implementing training programs,

Developing training materials for service providers.

Designing and implementing motivational and

promotional campaigns.

Establishing physical distribution, storage, and

warehousing procedures.

Designing and implementing monitoring programs to evaluate product performance.

In order to carry out these steps, numerous institutional, financial, and individual resources need to be

marshaled. They include those of the relevant offices

in the ministry of health, the local drug regulatory

body, donor agencies, university or private research

groups skilled in market research, the medical community, university or private groups skilled in the development of information, education, and communication materials, and university or private

research groups skilled in program evaluation. Completion of these steps is obviously time consuming

and can inhibit the introduction of new technologies.

Program managers in LDCs are likely to want substantial justification for the addition of a new technology or the replacement of an old technology. The

likelihood that an IUD will reduce bleeding among

users may be insufficient reason for its introduction

if it offers no other advantages or has concomitant

disadvantages such as short lifetime or high price. Although a new sterilization procedure may be faster

and easier to perform, it may not be introduced if it

requires retraining of the entire medical staff providing the program’s sterilization services.

An oft-stated reason for introducing a new technology is that it will provide an alternative for users of

currently available methods. This argument is based

on the net increase in contraceptive use commonly

observed when a program introduces a new method,

The incremental increases in contraceptive use experienced by a typical family planning program can be

seen in figure D-1.

Program managers realize that the introduction of

a new or modified method with clinical advantages

over currently used methods can result in increased

contraceptive use, but express concern about wheth84-587 9 - 92 - 17
232 ● World Population and Fertility Planning Technologies: The Next 20 Years

Figure D-1 .—Prevalence of Contraceptive Use

SOURCE: G. Perkin and L. Saunders, “Extending Contraceptive Use,” PIACT

Paper, no. 5, 1980.

er the new method can attract sufficient additional

users to justify the costs, in both financial and institutional terms, of adding the product to the distribution program.

An example is the use of the injectable contraceptive Depo-Provera in Thailand, the country most

often associated with program use of this method.

The government has not moved aggressively to expand distribution of Depo-Provera, which has never

been used by more than a few percent of all users,

for several reasons, including the international controversy that surrounds this product because of the

Food and Drug Adminstration’s (FDA) lack of approval for its use as a contraceptive by women in the

United States. A major factor is the relatively more

complicated and expensive logistical cost of DepoProvera distribution compared with that of pills and

condoms. Depo-Provera is roughly equal in purchase

price to the pill in terms of duration of protection but

requires either that mobile teams of doctors, nurses,

or midwives visit users on a regular basis, or that the

user herself return to the distribution center for a

new injection. Oral contraceptives have their own

logistical problems, but the additional problems of

Depo-Provera have inhibited its broader distribution

in a country where its safety and acceptability are

widely recognized.

The development of new or improved fertility

planning technologies is clearly a matter of high priority. It should be recognized, however, that the development of a method that has statistically better efficacy rates than presently used products will not

naturally lead to the introduction of that product to

family planning programs. The new or modified

product could well remain a little-used product.

Thus, in setting priorities for fertility planning technology research, giving priority to those that promise to reach significant new groups of potential users-

—such as men—is extremely cost effective as such

products are likely to have the greatest comparative

appeal to program managers.

To produce locally or not to

produce locally

There is a definite trend toward the establishment

of government-sponsored fertility planning technology production facilities in LDCS. Among the countries that have developed major capacities to meet

their own needs in the past 10 years are Indonesia

(pills), India (condoms, IUDS, and pills), Egypt (pills

and IUDs), and the People’s Republic of China (condoms, pills, IUDS, injectable, barrier methods, and

abortion and sterilization methods).

When an LDC government takes an active role in

facilitating the establishment of local production of

fertility planning technologies, policymakers at the

highest levels, often the president or prime minister,

are apt to be involved in the decision. In several

Asian countries, the push for local production has

come not from the relevant program bureaucracies,

but from top government officials. The Office of the

President in Indonesia and the Office of the Minister

of Economic Planning in the Philippines were highly

influential in the decision to consider establishing

local production of contraceptive technologies in

those countries.

Unlike many other new developments in family

planning programs, this trend toward establishing

local production has been instigated by decisionmakers within the country, often in the face of lack

of support or opposition from donor agencies. The

reasons for this trend toward local production are as

yet unclear, but several observations can be made.

First, the decade of the seventies saw the formalization and implementation of government commitments to family planning, and most governments are

now committed to either directly providing or permitting others to provide contraceptive technologies

to their people. As these programs grew, it became

apparent that the potential market for contraceptive

products is very large compared to the markets for

almost all other health products for whose distribution the government takes primary responsibility.

Contraceptives are provided to healthy couples during a potential three decades of their lives. In most

LDCS) healthy, fecund couples constitute some 15

percent of the total population. In a moderate-sized

LDC of 50 million, the number of eligible couples

would thus be about 7.5 million. If family planning

programs were to reach their goal of up to 70 percent use of contraceptive products, the likely totals
App. D—Production and Distribution Capabilities for New Fertility Planning Technologies Over the Next Two Decades “ 233

avoidance, wherever possible, of paying commercial

prices for products. Even though public sector prices

can be obtained by relying on commodities assistance from international agencies, LDC decisionmakers would not like to find themselves in a permanent position of having a program of major importance to their country’s well-being totally dependent

on foreign donors for supplies of the commodities

necessary for continued program operation.

Donor agencies have carried out similar calculations. Recognizing the valuable role they play by procuring contraceptives at low public sector prices to

LDCS, AID, the International Planned Parenthood

Federation (IPPF), UNFPA (via UNICEF), and other

donors make commodity procurement and supply

important components of their assistance programs.

In order to obtain the lowest possible prices, some

donor agencies procure uniformly packaged products with little product variation (dosage, design,

etc.). Another factor favoring low prices is that manufacturers need incur no marketing costs, or costs of

negotiations with regulatory agencies in the recipient countries, which are handled by the donor.

Private manufacturers have also examined these

market trends and have concluded that confessional

supply of contraceptives to public agencies is an economically attractive alternative to direct privatesector marketing for the huge low-income, littledeveloped markets of potential users in LDCS. They

have determined that if they subtract all costs related

to product merchandising and concentrate solely on

manufacturing costs, they can sell products to public

programs at low prices and still make a reasonable

profit. They have thus been willing to become full

participants in the current three-party arrangement

for supply of contraceptives to public programs that

prevails in most LDCS.

This three-way partnership is not, however, fully

stable because of the differing views and needs of

different participants. For example, the two public

sector donor agencies most involved in commodities

procurement, UNFPA and AID, have somewhat dissimilar views on meeting the need for public sector

support of commodities. Aid, through Joseph J.

Speidel (4), Acting Director, Office of Population, has

stated:

. . . Since AID’s ability to provide support for contraceptive commodities is dependent on annual appropriations for this purpose, a long-range policy must be

subject to continuous review. However, AID does not

at this time intend to alter previous policy regarding

contraceptive supply and our planning includes provisions for the continuation of these efforts.

At present, AID provides grant-funded orals and condoms to all bilateral and grant programs except 1ndo-
234 ‘ World Population and Fertility Planning Technologies: The Next 20 Years

nesia, the Philippines, and Thailand. The Office of Population has discouraged use of loan funds for family

planning commodity programs, but there is no firm

AID policy on this issue. Because a part of population

funds must now be used for loans, there is a tendency

for some AID missions to urge a switch to loan funding

for contraceptive purchases. However, most countries

resist this change and it is anticipated that the current

practice of grant funding will be continued in most

countries.

The following amounts were spent by the Office of

Population for contraceptive commodities during the

years 1975-81 (4).

Amount (rounded)

Year in millions of dollars

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $24

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1978 . . . . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

1979 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

1981 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

These amounts average approximately 20 percent of

the total budget of the Office of Population.

AID appears, in the absence of new policy determinations to the contrary or a lack of funds, to intend to continue the provision of commodities to

family planning programs into the foreseeable future. However, along with other donors, it will continue to review its policy in order to ensure adequate

supplies of contraceptive commodities to LDC programs.

The UNFPA governing council at its meeting on

June 23, 1981 (6) confirmed that support of family

planning will be its first priority. Family planning efforts oriented towards the individual and the family

will include programs integrated with maternal and

child health services in the primary health care context

and

●

●

●

●

●

●

and in other programs as appropriate to social

cultural conditions as well as:

delivery of services at the community level, including improvements in the logistical systems

through which such services can be provided;

training of personnel;

strengthening of management;

logistics support including provision of contraceptives, if required;

encouragement, where appropriate, of local production of contraceptives; and

research into traditional and new contraceptive

methods and development of improved means

including natural family planning methods.

UNFPA will thus support both commodity procurement and local production of contraceptives where

appropriate.

In commenting on local production, Speidel noted

that:

While AID has no “policy” so far as local production

is concerned, such efforts must be undertaken with

caution since the Agency’s experience with such ventures is not encouraging. The rate of population

growth is important to development. As an agency, it is

our policy to assist in the reduction of the rate of

population growth by providing cooperating governments with contraceptive supplies. Local production of

contraceptive commodities puts one into another area

of economic development, and that is the development

of local industry, the provision of jobs, and the

transfer of technology. These elements of economic

development should be reviewed in the context of

other possibilities for the expansion of industry, as

well as in the context of family planning programs.

In order to make high quality contraceptive products available in developing countries at little or no

cost to the user, AID’s purchases of large quantities

of these products have made a significant contribution. In the case of some products, however, most

notably oral contraceptives, the price obtained by

the AID program makes the economics of local production of this product questionable at best without

consideration of other factors. The price paid by AID

has increased approximately $0.04 per cycle since

1974 and is currently less than $0.18. When one considers the retail price in the United States has risen

from around $3 to $8 per cycle during this same

period of time these savings to program costs are

even more striking. The lack of profitability this

price differential provides for local production will

tend to discourage these developments at this time.

In addition, local production of oral contraceptives is

only possible for packaging and tableting. Synthesis

of raw materials is not practical. Dependence on

local production is likely to create problems relating

to locked-in technology, protectionist import policies,

low quality, and uncertainty of supplies.

In this context, it should be noted that AID has

assisted the Government of Indonesia in establishing

local production of oral contraceptives by supplying

raw materials and providing technical assistance.

However, Indonesia represents a very large market

and was the first country to accept, in principle,

commodities on a loan basis.

Very little rigorous research has been conducted to

assess the economic feasibility of local contraceptive

technology production in LDCS. Although it is widely

believed that it costs substantially more to produce

contraceptive products in LDCS than in such MDC

factories as those of Akwell and Syntex, two major

AID suppliers, a recent Program for the Introduction

and Adaptation of Contraceptive Technology (PIACT)

study tends to cast doubt on this assumption (6). Car-
App. D—Production and Distribution Capabilities for New Fertility Planning Technologies Over the Next Two Decades ● 235

ried out at the request of the Government of the

Philippines, the study extensively detailed the

economic feasibility of condom production in the

Philippines. It gathered information from equipment

suppliers in Japan, the United Kingdom, and the

Netherlands, and calculated the costs of latex,

packaging materials, chemicals, miscellaneous supplies, electricity, space, labor, taxes, import duties,

etc. The study made a thorough analysis of the potential demand in appropriate relationship to both

the government family planning program and the

private sector market.

A summary of the study provides a useful comparison of the cost to the U.S. Treasury of placing

one condom in the hands of a Filipino man through

1) a grant by AID; and 2) through AID supporting all

the costs of building and running a condom factory

in the Philippines. Using 1980 costs, these two figures are $0.039 and $0.036, respectively, or a savings

of $0.003 per condom following the local production

route using accepted practices of amortization of

capital costs. The local production cost includes the

value of the customs duties and/or taxes that the Philippine Government would normally levy on machinery and materials for condom production. If the Philippine Government were to waive these duties and

taxes, the net cost per condom would be reduced to

$0.027 or a reduction of 33 percent over grantprovided commodities.

PIACT has also carried out a preliminary assessment of the feasibility of local production of oral contraceptives in the Philippines, which is to be followed

by an in-depth evaluation comparable to that carried

out for condoms. The preliminary study provides approximate figures from which conclusions can be

drawn about the feasibility of local production. Using

the comparison analogy of the previous paragraph,

the AID procurement route would cost $0.188 per

cycle of oral contraceptives including freight and insurance in 1981, and the local production route

would cost approximately $0.20.

The economic feasibility of local production of oral

contraceptives has been recognized by many of the

larger LDCS and by multinational pharmaceutical

firms. As is detailed later, most larger LDCS have

local production of oral contraceptives either in government plants or factories of multinational pharmaceutical firms.

The PIACT calculations for condom and oral contraceptive production were designed to be readily

adapted to the situation in other LDCS; it would appear that in countries similar in population size to

the Philippines the costs would be comparable.

The question of UNFPA and AID support for the establishment of local production is really one of allocation of scarce resources for population assistance to

LDCS. In order for family planning programs to operate, they must have access to contraceptive technologies that couples can use. These technologies can be

provided by donors in two ways: through donations

or through support of local production. It seems

logical that if outlays of financial resources for these

two options are comparable, local production

deserves serious consideration and, in some situations, implementation, particularly in consideration

of the adage that it is better to teach a man to fish

now than to give him free fish forever.

Although the major donors may intend to continue

indefinitely to provide commodities where needed,

LDCS cannot consider these intentions a guarantee.

In some LDCS, local production may fill the need for

the reliable, continuing sources of commodities necessary for a successful national program.

Local production may never be economically feasible in some LDCS. These countries, especially the

smaller ones, will either have to rely on external

assistance or will have to identify other means to

procure the commodities they need.

At the present time, virtually all contraceptives

used in national family planning programs, with a

few exceptions (China, India, Egypt), are manufactured by MDC-based multinational drug firms in factories located in both MDCS and LDCS. Virtually all of

these contraceptive products are supplied by AID,

UNFPA, or, on a smaller scale, the Swedish International Development Authority (SIDA) and IPPF at the

request of LDC governments. The major manufacturers providing these products at confessional

prices to these agencies are:

Pills. . . . . . . . . . . . . . . . Syntex, Schering, Organon

Condoms. . . . . . . . . . . . Akwell, Dong Kuk, Sagami

IUDS. . . . . . . . . . . . . . . . . . . Ortho Pharmaceutical,

Finishing Enterprises

These eight manufacturers account for almost all of

the products used by public programs in countries

that do not now manufacture their own supplies.

Thus both donors and these major manufacturers

have important stakes in the evolution of contraceptive production in LDCS.

The manufacturers are concerned about local production because several of them have developed

local private-sector markets in LDCS. Prominent

among these are Schering, Organon, and Dong Kuk,

Moreover, Syntex and Schering provide raw materials to plants in Indonesia and Egypt, respectively, as

two examples, for the production of oral contraceptives. Local production in LDCS would cut into the

quantities that donors procure for those same countries, but local production might also stimulate the

private sector by enhancing government efforts to
236 ● World Population and Fertility Planning Technologies: The Next 20 Years

encourage the adoption of family planning. On the

other hand, production by local governments might

cut into private-sector production because the

government-produced contraceptives would be

cheaper than those produced for the private sector.

Finally, not all manufacturers supplying LDCS also

have developed private-sector markets in those same

countries, and vice versa. For example, Wyeth does

not supply the public sector but sells to the private

sector in several LDCS; Syntex sells to the public sector but has almost no private-sector sales in LDCS.

In summary, the influence of the private-sector

market in decisionmaking with regard to publicsector production and distribution of fertility planning technologies is difficult to evaluate and varies

from country to country. The factor that will most

heavily affect the private sector is the strength and

nature of the government family program.

The role of the private-sector

market in LDCS

Public information about the size and rates of

growth of private-sector markets for contraceptives

in LDCS is sparse. Studies several years ago showed

that most contraceptive use in LDCS was the result of

purchase through the private sector (l). Although

the relative proportion of contraceptive users supplied through the private sector may have decreased

as the reach of family planning programs has extended, their absolute number has probably grown.

Many would argue that the growth of family planning programs has been a major contributor to the

growth of private-sector sales in LDCS by introducing added numbers of individuals to the use and

practice of contraception. As contraception becomes

a normal part of their lives, some will move from free

or subsidized supplies from government outlets to

purchased supplies from the private sector. Others

would argue, and quite convincingly, that when family planning programs become significant in coverage, they can cut deeply into the expansion of private-sector markets.

The international manufacturers that have been

supplying fertility planning technologies to LDCS

thus find themselves facing a complex series of calculations.

The role of locally owned private

sector manufacturers in LDCS

Although the production of fertility planning technologies is largely the province of governments and

international manufacturers, privately owned factories in LDCS, whose owners are businessmen in

these countries, also play a significant role. In Thailand, a locally owned rubber products company

manufactures condoms, in the Philippines a locally

owned pharmaceutical corporation has been tableting and packaging pills for the local market for several years, a locally owned company in Mexico manufactures IUDS, and a Korean company also manufactures condoms. These companies have, almost without exception, been established to sell products to

the private sector, but sometimes supply products to

the public sector in their own countries.

It would appear that more serious consideration

needs to be given to the role of these companies. In

many countries these local resources have not been

used because Congress requires AID to purchase

U.S.-made products with its funds for commodities.

Thus U.S.-made oral contraceptives are imported for

use in the Philippines even though a private, locally

owned firm manufactures tablets of similar composition.

Current status of local production

and implications for donors

The following table lists the 20 most populous

LDCS and indicates which of these countries had production capacities (G = government controlled, P =

private ownership, (L) = local, (M) = multinational)

for oral contraceptives, IUDS, or condoms as of 1980,

and which are examining plans (pi) for establishing

production of these technologies.

Country

China . . . . . . . . . . . . . . .

India. . . . . . . . . . . . . . . .

Indonesia. . . . . . . . . . . .

Brazil . . . . . . . . . . . . . . .

Bangladesh . . . . . . . . . .

Pakistan . . . . . . . . . . . . .

Nigeria . . . . . . . . . . . . . .

Mexico . . . . . . . . . . . . . .

Vietnam. . . . . . . . . . . . .

Philippines. . . . . . . . . . .

Thailand. . . . . . . . . . . . .

Turkey. . . . . . . . . . . . . .

Egypt . . . . . . . . . . . . . . .

Iran . . . . . . . . . . . . . . . .

Republic of Korea.

Ethiopia . . . . . . . . . . . . .

Burma . . . . . . . . . . . . . .

Zaire. . . . . . . . . . . . . . . .

Argentina. . . . . . . . . . . .

Colombia . . . . . . . . . . . .

Method

Ocs IUDS Condoms

G G G

G, P(M) G G, P(M)

G, P(M) pl p]

P(M) — —

P(M) — —

P(M) G pl

— — —

P(M) P(L) P(L)

— — pl

P(L) — pl

P(M) — —

P(M) — —

G G —

P(M) — —

P(M) — P(L)

— — —

— — —

— — —

P(M) — —

P(M) — —

The local companies are owned by business people

in the LDC; some minor amounts of foreign capital

may be involved. The multinational companies either
App. D—Production and Distribution Capabilities for New Fertility Planning Technologies Over the Next Two Decades ● 2 3 7

export their products to LDC factories for local packaging, or carry out partial or complete manufacture

in LDCs using, in both instances, subsidiary or joint

venture companies.

The table demonstrates that multinational private

pharmaceutical firms have found it economically feasible to establish oral contraceptive tableting and

packaging facilities in these countries. (In many of

these LDCs the companies have established local production because of national restrictions on the import of finished pharmaceutical products. These

firms nevertheless concluded that they could produce locally and profitably–that in fact the local production of oral contraceptives in an LDC can be economically justified.) In four countries—China, India,

Indonesia, and Egypt-the government has established an oral contraceptive facility of its own. If international donors were to terminate the supply of

oral contraceptives to the largest LDCs, these countries would be able to turn to local production facilities to meet their needs, but product selection would

be limited.

The situation is somewhat different for IUDs and

condoms. Here, the governments or local industries

have been more active than multinational firms in establishing production, but only in a few countries. By

and large, the world’s largest LDCs depend on foreign supply of condoms and IUDs. Plans to establish

IUD production in Indonesia are well under way and

locally made IUDs should be ready for use in the national program by mid-1981. Several countries—lndonesia, Pakistan, Philippines, and Vietnam—are exploring the possibility of condom production. It is not

yet clear whether these countries will actually

establish a facility in the immediate future, but

strong government interest will most likely result in

the establishment of production facilities within the

next two decades. Because reliance on outside

donors is greater for these products than for oral

contraceptives, if international donors were to cease

supplying condoms and IUDS to the largest LDCs,

these countries would not be able to meet their requirements from facilities within their borders. The

situation is better for condoms than for IUDs.

Very few of the less populous LDCs have production facilities for contraceptive technologies. None

appear to have facilities for IUDa or condoms,

although condoms are made in a Japanese-owned

factory in Malaysia. Several multinational pharmaceutical firms have set up production facilities for

oral contraceptives in smaller LDCS) but these facilities are primarily to supply regional markets and

provide only small quantities to the local private sector.

In summary, the situation is approximately as

follows:

●

●

●

Oral Contraceptives: The largest LDCs could rely

on domestic sources of supply. The smaller

countries have to rely on sources of supply from

outside their borders.

IUDs: A few larger LDCs could rely on domestic

sources of supply. The smaller countries have to

rely on external sources.

Condoms: Several larger LDCS) if current plans

come to fruition, will have domestic production

facilities. Almost all other larger, and all small

LDCs have to rely on external sources.

Almost all LDCs will be dependent upon external

sources of supply for the technologies used in their

national family planning programs during the next

20 years. How they meet these needs will be determined by an interactive process of review and discussion among the countries, manufacturers, and

donors.

Should donors decide not to provide commodities

support to countries in need, the decision on how to

procure those commodities would clearly rest with

the governments of the LDCs themselves, who would

be free to procure either from multinational manufacturers primarily located in MDCa, or from manufacturing facilities located in other LDCs. If donors

continue commodities assistance to LDCs, decisions

on how and what to procure will have to be reached

jointly between country and donor.

Most bilateral donors will require that commodity

assistance be in the form of products manufactured

within their own countries, as is the case with most

current commodities assistance, which is provided

directly in the form of finished products rather than

as financial resources that can be used to purchase

such products. Only multilateral and nongovernmental donors will be free to procure from any available

MDC or LDC manufacturer.

From the LDC point of view there is something to

be said for obtaining commodities support from multilateral or nongovernmental organizations, as this

process allows a much wider selection of products to

be obtained. But because bilateral donors–the funders of multilateral and (either directly or indirectly

through multilateral donors) nongovernmental organizations—most often work under strong political

pressure to procure from companies in their own

countries, it is to be expected that most bilateral

donors will remain directly involved in commodities

procurement.

There are fewer pressures operating on multilateral donors to remain involved in procurement. One

that does exist is from those bilateral donors funding
238 ● World Population and Fertility Planning Technologies: The Next 20 Years

the multilateral organizations who want to spread

the financial burden of procurement and to have

commodities appear as a small proportion of the bilateral’s overail budget. Some bilateral donors, however, do not have contraceptive manufacturers in

their own countries and are therefore more willing

to have the multilateral assume the substantial logistical tasks of commodities supply to many LDCS.

The continued involvement of large bilateral and

multilateral donors in commodities procurement is

supported, however, by the economies to be realized

by large-scale procurement of identical products, not

only in purchase price, but also in distribution and

storage systems. Yet it seems likely that more and

more LDCS, even some of the smaller ones, will be

willing to forego marginal economies of these kinds

in order to have contraceptive technologies more appropriate to the particular needs of the country. The

marginal economies referred to here are those

gained by obtaining uniform bulk quantities of commodities rather than nonuniform commodities, an element that permits the confessional prices offered to

public agencies by companies.

Commodity trade between LDCS

If LDCS exercise control over the procurement of

commodities, one of the options available to them is

to procure from manufacturers located in other

LDCS; this option is receiving increasing attention. A

recent review of population-planning activities carried out by the Association of South East Asian Nations (ASEAN) concluded that a high-priority future

activity was the coordination of contraceptive production among ASEAN countries. In Mexico, an IUD

manufacturer has recently granted the public-sector

rights for sale of his product to other LDCS to the private, nonprofit PIACT de Mexico.

It appears that no LDC has directly purchased contraceptives manufactured in another LDC. UNFPA

has procured condoms manufactured in Korea and

shipped these to other LDCS, and there are probably

other instances of multilateral or bilateral aid agencies procuring contraceptives manufactured in one

LDC and shipping them to another. But LDCS do not

generally procure fertility planning technologies

manufactured in other LDCS. One reason for this is

that program managers believe it is in the interest of

the program to provide a product to users that is

considered to be of international first quality. LDC

consumers, as do MDC consumers, tend to believe—

rightly or wrongly—that products manufactured in

LDCS are unlikely to be of the same quality as products manufactured in MDCS.

A distinction needs to be made here. In several

LDCS) MDC-based, multinational contraceptive manufacturers have established production facilities. If

LDCS do begin to procure their own commodities, it

is likely that they will purchase from these multinational companies, who in turn will manufacture the

product in one of their LDC factories. In such situations it is conceivable that the product label will not

show the country of manufacture or will show only

the country in which the manufacturer is headquartered.

There is little indication at present that LDCS are

prepared to purchase contraceptives from production facilities located in and controlled by either the

government or local private businessmen in other

LDCS) but a thorough survey of this matter is

needed.

Additional conclusions

Multinational contraceptive manufacturers in

MDCS will continue to be, to 2000, the predominant

suppliers to most LDCS. They will not, however, supply most of the LDC population because the world’s

two most populous countries—China and India—will

meet virtually all of their needs through local manufacture in government-controlled factories. But mu]-

tinationals will have access to huge markets totaling

several billion individuals and more than 100 million

users of contraceptive methods. For the most part,

these companies will supply their products to the

public-sector portions of their markets (nonprofit

family planning programs) under special low-cost

confessional terms negotiated with public agencies

and local governments. Supplies are likely to be made

available to the private-sector portions of these markets under normal commercial terms at prices similar to those prevailing in MDCS.

A problem may arise in the interaction between

the development of new contraceptive technologies

and their production in LDCS. It is possible that LDCS

that directly negotiate confessional purchases from

the multinational manufacturers will have more

ready access to new technologies than those LDCS

relying on manufacture in government-controlled

plants or in local factories controlled by local private

individuals, or by multinational manufacturers. The

specialized manufacturing know-how needed to produce the technologies likely to be developed and the

complexities of patent regulations are likely to make

access to these new technologies virtually impossible

for LDCS that rely on local manufacturing operations. LDCS that establish domestic production capacity may thus be substantially limiting access to both
App. D—Production and Distribution Capabilities for New Fertility Planning Technologies Over the Next Two Decades ● 239

new technologies and to future modifications of the

technologies currently in production.

LDCS that procure from the international market

will need to have capacities that permit them to effectively exercise their relative flexibility. They will

need systems to help them identify new technologies, to decide whether a new technology will be

useful to them, and to determine what options they

have in its design, packaging, labeling, etc. These

LDCS will also need the capacity to secure and transAppendix D references

1. Belsky, R. L., and Sollins, A. D., “Commercial Production

and Distribution of Contraceptives, ” Reports on Population/Fami/y Planning, No. 4, June 1970; Westinghouse

Population Center, Contraceptive Distribution in the Commercial Sector of Selected Developing Countries: Summary

Report, Columbia, Md., Westinghouse Population Center,

1974; Westinghouse Population Center, Survey of Global

Patterns of Contraceptive Distribution in the Private Sector

in Se/ectecf Developing Countries: Summary Report, Part

One, Columbia, Md., Westinghouse Population Center,

1972.

2. Buckles, R., “Contraceptive Product Development in

Public Sector Programs, ” PIACT Paper Three, Program

for the Introduction and Adaptation of Contraceptive

Technology, February 1979, Seattle, Wash.

for production know-how. Thus, LDCS that import a

substantial portion of their commodities will not be

able to fully rely upon the procurement mechanisms

and logistics and supply systems set up by commercial manufacturers or donor agencies in obtaining

the best products for their needs in a timely fashion.

They will need to set up experienced, capable staff

units within their national family planning programs

to carry out these functions.

3. “Intravaginal Contraception: United Nations Fund for

Population Activities, “ in Vaginal Contraception, New Developments, G. I. Zatuchni, A. J. Sobrero, J. J. Speidel,

and J. J. Sciarra (eds.), Harper and Row, Hagerstown,

1979.

4. Speidel, J. J., Acting Director, AID Office of Population,

Washington, D. C., personal communication, 1981.

5. UNFPA, draft report of the governing council on its 28th

session, DP/L.344/Add. 3, June 23, 1981.

6. Ylanan, M., “Production of Condoms in the Philippines,”

1980, Program for the Introduction and Adaptation of

Contraceptive Technology, Seattle, Wash.
Appendix E

Workshop Participants, Contributors,

and Acknowledgments

Planning Workshop

Participants *

Linda Atkinson

Ford Foundation

Lester Brown

Worldwatch Institute

Philip Corfman

National Institutes of Health

Irvin Cushner

Department of Health and Human

Services

Jose Donayre

United Nations Fund for Population

Activities

Oscar Harkavy

Ford Foundation

Mary Kritz

Rockefeller Foundation

Luke Lee

Office of Population Affairs

Department of State

Parker Mauldin

The Population Council

Stephen L. Salyer

The Population Council

S. Bruce Schearer

The Population Council

Julian Simon

University of Illinois

Joseph J. Speidel

Office of Population

Agency for International Development

Michael Teitelbaum

Select Committee on Population

U.S. House of Representatives

Contributors

Karen B. Allen

The Futures Group

Linda Atkinson

Ford Foundation

Norman Balmer

Office of Technology Assessment

Gabriel Bialy

National Institutes of Health

Pamela Cain

Hunter College

Sharon Camp

Population Crisis Committee

Pi-chao Chen

Wayne State University

Philander P. Claxton, Jr.

The Futures Group

Rebecca Cook

Washington, D.C.

Philip A. Corfman

National Institutes of Health

Gordon Duncan

The Upjohn Co.

Thomas J. Goliber

The Futures Group

Oscar Harkavy

Ford Foundation

Michael Harper

University of Texas

Carl Hemmer

Agency for International Development

Paula Hollerbach

The Population Council

Robert Lapham

National Academy of Sciences

Richard Lincoln

Alan Guttmacher Institute

Richard Mahoney

Program for the Introduction and

Adaptation of Contraceptive Technology

Margaret McEvoy

The Population Council

Michael Mertaugh

The Population Council

Caroline C. Nielson

The Futures Group

Dorothy L. Nortman

The Population Council

Marion O’Connor

United Nations Fund for Population

Activities

Lisa Olsen

Population Reference Bureau

Marvin Ott

Office of Technology Assessment

Phyllis Piotrow

Population Information Program

Michael Riddiough

Pharmaceutical Manufacturers’

Association

Ronald Ridker

Resources for the Future

S. Bruce Schearer

Population Resource Center

Rahim Shamash

The Futures Group

Joseph J. Speidel

Agency for International Development

Joseph H. Wex

The Futures Group

Steven Wiggins

Texas A&M University

Susumu Yamishita

The Futures Group

Acknowledgments

John S. Aird

Bureau of the Census

Hirofumo Ando

United Nations Fund for Population

Activities

Robert M. Avedon

Rockville, Md.

Judith Banister

Bureau of the Census

Wayne C. Bardin

Rockefeller University

Samuel Baum

Bureau of the Census

Richard E. Benedick

Department of State

Jon Bongaarts

The Population Council

Maura Brackett

Agency for International Development

Sarah Brandel

Overseas Development Council

S. Brogger

World Health Organization

George Brown

The Population Council

Lester Brown

Worldwatch Institute

Edward Burger

Washington, D.C.

Betty Case

Agency for International Development

Willard Cates

Center for Disease Control

Nazli Choucri

Massachusetts Institute of Technology

Ann Harrison Clark

Population Resource Center

William Colby

Reid and Priest

Henry Cole

The Futures Group

Elizabeth B. Connell

Biomedical Research and Development

International

Pierre Crabb6

University of Missouri

Irvin Cushner

University of California at Los Angeles

Paul E. Demeny

The Population Council

Sergio Diaz-Briquets

Population Reference Bureau

Carl Djerassi

Stanford University

“Affiliations as of October 1978.

240
App. E—Workshop Participants, Contributors, and Acknowledgments ● 241

JOS6 Donayre

(.Jnited Nations Fund for Population

Activities

Richard Edgren

Syntex Laboratorie s

Anne Ehrlich

Stanford University

John Evans

World Bank

Thomas Frejka

The Population Council

John Gill

International Development Research

Centre

Halvor Gille

United Nations Fund for Population

Activities

Duff Gillespie

Agency for International Development

Leo Goodman

Center for Disease Control

Howard G[ay

Pathfinder Fund

Cynthia P. Green

Population Crisis Committee

Marshali Gree n

Washington, D.C.

Hans Groot

Family Planning International Assistance

Davidson Gwatkin

Overseas Development Council

Carl Haub

Population Reference Bureau

Louis M Hellman

Washington, D.C.

Llichael Jorda n

Agency for International Development

Kandiah Kanagaratnam

World Bank

Lawrence J. Kane

Human Life and Natural Family Planning

Foundation

Lenni Kangas

Agency for International Development

Omer Kelley

Office of Technolo&v Assessmen t

Alexander Kessler

World Health Organization

Marjorie A. Koblinsky

Wilmer Institut e

Ann Larson

Population Reference Bureau

Gary Lewis

Westinghouse Health Systems

Ira Lubell

Association for t’oluntary Sterilization

Parker Mauldin

The Rockefeller Foundation

Geoffrey McNichol

The Population Council

P, Sankar Meno n

United Nations

Donald Minkler

Berkeley, California

Carmen A. Miro

Panama

Gayl Nes s

University of Michigan

Alfred K. Neumann

Llniversity of California at Los Angeles

Erhard Nutting

G. D. Searle and Co.

Frank Oram

World Population Society

Hal Pederson

Agency for International Development

Gordon Perkin

Program for the Introduction and

Adaptation of Contraceptive Technology

Angela Petros-Barvazian

W’orld Health Organization

Bruce Pharriss

Collagen, Inc.

Catherine Pierce

United Nations Fund for Population

Activities

Dennis Pirages

Rockville, Md .

Stephen J. Plank

Department of Health and Human

Services

Malcolm Potts

International Fertility Research Program

Denis J. Prager

President’s Office of Science and

Technology Policy

Reimert Ravenholt

Center for Disease Control

Bruno Remich e

International Union for the Scientific

Study of Population

Ward Rinehart

Population Information Program

Leonard Robinson

Battelle Memorial Institute

AlIan Rosenfield

Columbia University

Bruce Ross-Sheriff

Office of Technolo&v Assessmen t

Susan Scrimsha w

University of California at Los Angeles

Sheldon J. Segal

The Rockefeller Foundation

Pramilla Senanayak e

International Planned Parenthood

Federation

James Shelton

Agency for International Development

Solomon Sobel

Food and Drug Administration

Sanford Steelman

Merck Institute for Therapeutic Research

Jacob Stucki

The Upjohn Co.

Leon Tabah

United Nations

Conrad Taeuber

Georgetown University

Carl E. Taylor

Johns Hopkins University

Maxwell Taylor

Washington, D.C.

Michael Teitelbaum

The Ford Foundation

Christopher Tietze

The Population Council

William Trayfors

Agency for International Development

Amy Ong Tsui

University of Chicago

Carl W. Tyler

Center for Disease Control

Roxann VanDusen

Agency for International Development

William Vodra

Arnold and Porter

Carl Wahren

International Planned Parenthood

Federation

Walter Watson

Columbia University

Daniel Weintraub

Family Planning International Assistance

Nancy Williamson

University of North Carolina

Margaret Wolfson

Organization for Economic Cooperation

and Development

Nicholas Wright

Rutgers Medical School

Manuel Ylanan

Program for the Introduction and

Adaptation of Contraceptive Technology

Gerald Zatuchni

Program for Applied Fertility Research

George Zeidenstein

The Population Council

The following persons were asked to assess

their countries’ contracepti~re R&D prioritie s

for this report:

Datin Nor Laily Azi z

Kuala Lumpur, Malaysia

Sook Bang

Bangkok, Thailand

Hugo Behm

San Jose, Costa Rica

Elza Berquo

Sao Paulo, Brazil

Rene Cabrere

Santiago, Chile

M. Candau

Switzerland

Liu Cheng

Beijing, People’s Republic of China

Sun Ching-Chi

Beijing, People’s Republic of China

Zafrulla Choudry

Savar, Bangladesh

Ramon Gonzalez Cerutti

Caracas, Venezuela

Grace Delano

Ibadan, Nigeri a

Guillermo Lopez Escobar

Bogota, Colombia

Juan M. F]avier

Silang, Phili~~ines
242 “ World Population and Fertility Planning Technologies: The Next 20 Years
Appendix F

Commissioned Papers

1. Linda Atkinson, S. Bruce Schearer, Oscar Harkavy, and Richard Lincoln, “Prospects for Improved Contraception.”

2. *Pamela Cain, “Future Prospects for the Development of Birth Planning Technology: What the Experts Think.”

3. Pi-chao Chen, “The Evolution of China’s Birth

Planning Policy.”

4. *Michael J. K. Harper, “Prospects for New or Improved Birth Control Technologies by the Year

2000 A.D.

5. *Paula E, Hollerbach, “Factors That Determine

the Appropriateness of New Technologies to Consumer Needs.”

6. Margaret McEvoy, “Factors That Determine the

Availability of New Technology to Consumers.”

7. Richard T. Mahoney, “Production and Distribution Capabilities for New Planned Birth Technologies Over the Next Two Decades. ”

● A\ailahle through the National ‘rechnical Information Senrice as “W’orld

Population and Fertilit} Planning Technologies: The Next 20 Years, \’olume

11—}t’orking papers.

8. *Michael T, Mertaugh, “Factors Influencing the

Demand for Children and Their Relationship to

Contraceptive Use.”

9. Dorothy L. Nortman, “Factors Influencing Government Provision of Family Planning Services in

Developing Nations.”

10. S. Bruce Schearer, “Contraceptive Development

by Public Organizations: An Assessment of Progress and Problems.”

11. S. Bruce Schearer, “Future Birth Planning Technologies.”

12. S. Bruce Schearer, “How the Government Can Facilitate the Development of Improved New Birth

Planning Methods.”

13. S. Bruce Schearer, “The Role of Governments in

the Uptake and Use of Future Birth Planning

Methods.

14. *John G. Stover and Jonathan T. Bye, “The Impacts of Population Growth on Less Developed

Countries.”

15. Steven N. Wiggins, “Economic Factors Affecting

Private-Sector Innovation in New Planned Birth

Technologies.”

An abbreviated copy of the summary of this report (ch. 1) is available free of

charge from the Office of Technology Assessment, U.S. Congress, ATTN: Publishing

Office, Washington, D.C. 20510. The working papers that provided the basis for this

assessment are also available as a separate volume from the National Technical Information Service,

243

U s . GOVERNMENT PRINTING OFFICE : 1982 0 - 84-587