Financial Times reports that family planning may be coming back in style.

For more than 15 years family planning has not been on the international aid agenda.  Reproductive health, women's education, reduction of infant mortality were all seen has having priority over providing women with birth control to enable them to have the number of children they wanted.  Growing concern over aging in the developed world ( due mainly to low fertility) and the increasing  contentious battle over abortion in the United States all conspired to remove birth control from the agenda.  A recent article in the Financial Times suggest that concern over the environment and the failure of Africa to complete the demographic transition may bring family planning back into the international development discussion. 

Financial Times FT.com

In the family way

By Andrew Jack

Published: December 10 2009 02:00 | Last updated: December 10 2009 02:00

Five years ago, Boniface K'Oyugi began to receive troubling news. After 30 years during which family planning programmes had halved the number of births per woman in Kenya to fewer than five, the trend went into reverse.

"When you have a high birthrate people have difficulties with clothing, educating and feeding their children," says Mr K'Oyugi, who heads his country's National Co-ordinating Agency for Population and Development. "We are unable to create sufficient jobs when they enter the workforce - and unemployed people living on marginal land can create conflict."

His concerns reflect a growing worry that some developing countries have failed to follow the broader "demographic transition" to lower fertility levels that has occurred in past decades in the western world and more recently across Latin America and much of Asia. Experts and policymakers are calling increasingly for a renewed and more nuanced approach to family planning, focused on countries in sub-Saharan Africa as well as others such as Yemen and Pakistan that trail the trend.

The issue is coming back on to the international agenda after a long absence. Many policymakers argue that without fresh efforts, economic growth will be severely impeded, sparking political instability and environmental degradation.

Rwanda, where pressure on land helped trigger genocide in the past, is among countries taking the lead. With Africa's population symbolically now reaching 1bn people, and the current debate on climate change provoking new concern about the effect of further births, there is a broader effort to shake off the complacency of recent years.

"If you look at countries like Mali, where the population is doubling, agricultural production has not kept up and land is being lost to desertification, you are really in for a Malthusian disaster," says John Cleland from the London School of Hygiene and Tropical Medicine.

The solutions, he argues, are cheap and well understood: the provision of contraceptives to the 200m women who are estimated to want them but are unable to gain access. They need enhanced family planning services, subsidies and promotional programmes, with support from doctors, teachers and political leaders. "All the lessons were learnt 20 years ago," says Prof Cleland.

To some, such arguments underplay human ingenuity in overcoming difficulties and confuse cause and effect. In most of the world, birth rates have fallen consistently as countries develop economically, slowing global population growth towards a projected equilibrium currently forecast at 9bn people in 2050 compared with 6.8bn today.

Bill Gates, whose philanthropic foundation is a large funder of the fight against childhood disease, says: "Fairly quickly, parents will have less kids knowing that their chance of having a couple survive to take care of them will be much higher if the health situation improves."

Even in countries with a currently high proportion of young people such as China and India - let alone more developed ones including Italy, Russia and Japan that are already feeling the impact of a predominantly older population - discussion is turning to the burdens of supporting the elderly.

A long-standing view holds that poverty reduction comes before family planning; that the birth rate falls only once the costs of having more children exceed the benefits. Conception remains high as long as parents have children who die in large numbers, want extra hands to work their land or see few sources of support in retirement other than their own offspring.

Y et this pattern - with family size falling simply as the consequence of development - is not universal. Active family planning in Nepal and Bangladesh in the late 20th century significantly reduced fertility rates in countries that were still poor, for example.

"It is not so much a question of which comes first as of getting a virtuous circle of reinforcing changes going," says Stan Bernstein at the United Nations Population Fund, pointing to all the women who want but do not have contraception. "The challenge is not to make something happen that isn't in progress but to see that the benefits and opportunities are available to all."

Historically, childhood deaths and adult infections have fallen largely as a result of improved nutrition and sanitation spurred by economic growth. But in recent years, medical advances and increased funding rapidly extended vaccinations and treatments for many infectious diseases across the developing world.

John May, a specialist in African demography at the World Bank, says: "Economic and social development is of course the best contraceptive, but contraceptives are also good for development." When fertility is high and population growth rapid, he adds, instead of a virtuous circle there emerges a vicious one.

A recent study by his agency argued that demographic factors predicted two-thirds of the shortfall in subSaharan Africa's economic growth compared with other developing regions. The burden of parents looking after their children and the instability of rapidly rising youth unemployment were the main constraints.

Such views helped trigger funding for family planning programmes in the second half of the last century, providing contraceptives, counselling and abortions to supplement traditional methods led by abstinence and prolonged breast-feeding to stagger births further apart.

They were supported by non-profit groups such as the International Planned Parenthood Federation and large donors led by the US, notably beginning with President Richard Nixon. They culminated in the UN international conference on population and development in Cairo in 1994, which called for comprehensive sexual and reproductive health provision.

But funding and political commitment never matched the rhetoric. There was a shift to broader and less well focused "reproductive rights", at a time of suspicion of birth control as coercive or smacking of neo-colonialism. China's one-child family policy had required strong social pressure; forced sterilisation had taken place during Indira Gandhi's state of emergency in India.

Equally, fertility rates were already on the wane in much of the world. "Family planning was killed by its own success," says Mr Bernstein. "A growing number of countries reached a plateau, and people took the attitude that the problem was solved. They forgot that new generations needed to be re-educated."

Third, donors became inspired by new fashions, notably a focus on tackling diseases. None became a greater drain than HIV/Aids, especially in Africa, which bore the greatest brunt of the virus as millions died and many tens of thousands of children were orphaned. "Vertical" programmes improved treatment for individual diseases but undermined other parts of poorly funded healthcare systems, drawing doctors and nurses away from jobs including family planning.

Finally, there was a hardening attitude from religious groups including the Catholic Church and evangelical Protestants, who remain highly influential in Africa, as well as "family" groups influencing US policy. Ronald Reagan's so-called "global gag rule" in 1984 banned federal funding to non-governmental organisations that performed or promoted abortion. It was reinstituted by George W. Bush after his inauguration in 2001. "It put poison in the atmosphere and had a widespread chilling effect," says Adrienne Germain, head of the International Women's Health Coalition, who says support faded for emergency contraception, intra-uterine devices and other approaches. "When the US sneezes, everyone gets sick. The years of the Bush administration had a profound effect."

Defenders of Mr Bush argue that he helped save millions of lives in Africa through a substantial expansion in programmes to treat those with HIV. But these also focused on treatment and on prevention programmes that encouraged abstinence and fidelity at the expense of condom distribution.

The result was that funding, estimated at about $340m (€231m, £210m) a year today, stagnated. The UN abandoned plans for a 10-year anniversary of the Cairo conference in 2004, for fear that the US would upset a fragile international consensus. Even events to take stock this year have been hastily arranged, reflecting a reluctance to plan ahead of the 2008 US presidential elections.

But in recent months, the mood has begun to change again. One of Barack Obama's first decisions as president this year was to scrap the global gag rule. He has since announced an overhaul of global health funding, with fresh emphasis on broader programmes including family planning rather than focusing on a handful of high-priority diseases.

His actions have been mirrored by other large donors. "Integration" is the new buzzword. "Family planning is a necessary part of health services," says Ms Germain. "It has to be offered in maternity clinics and alongside treatment for HIV and sexually transmitted diseases."

The UK's Department for International Development and Australia's Ausaid have placed fresh emphasis on such approaches. The World Bank, criticised in an internal review for letting family planning fall to just 2 per cent of its health, nutrition and population programme budgets in the decade to 2006, is preparing a new strategy for Africa. Along with the Global Fund to Fight Aids, TB and Malaria, and the Global Alliance for Vaccines and Immunisation, it is providing funding to support health systems. Mr Gates' foundation provided significant support to a family planning conference in Kampala last month that attracted 1,500 participants.

The Copenhagen summit now under way has added a fresh impetus to debates about the need to stabilise the world's population - although many family planning advocates are wary of over-emphasising the link, given that people in rich countries generate much larger carbon footprints.

That still leaves considerable debate over why African countries have struggled so much to make the demographic transition to lower fertility and consequent economic development. The answers will help determine whether even with enhanced family planning, fertility will fall sustainably. Prof Cleland suggests that not only do African cultural values place emphasis on larger families but communal childcare within clans puts less responsibility on individual parents to limit the number of children.

Greater emphasis on family planning may not be a sufficient condition to accelerate a region's demographic and economic transition - but it seems at least to be a necessary one.

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