International Journal of Gynecology & Obstetrics
Volume 106, Issue 2 , Pages 148-150, August 2009

To have or not to have: The critical importance of reproductive rights to the paradox of population policies in the 21st century

  • Gill Greer

      Affiliations

    • Corresponding Author InformationIPPF, 4 Newhams Row, London SE1 3UZ, UK.

International Planned Parenthood Federation, London, UK

published online 19 June 2009.

Article Outline

Abstract 

Reproductive rights continue to be under threat, even some 15 years after the landmark International Conference on Population and Development in Cairo declared the importance of a satisfying and safe sex life, the capability to have children, and the right to decide on the timing, number, and spacing. The right to choose whether and when to have children is at risk both from some who seek to increase birth rates through pronatalist policies and from some who seek a return to “population control” as a response to global climate change, environmental degradation, endemic poverty, global recession, and food shortages. This paper argues the success of the rights-based approach to family planning, reproductive health and health education, and outlines issues and policy responses related to low fertility. This is contrasted with the unmet need for family planning in the poorest countries. It calls for health providers to advocate for reproductive rights, affirming that the freedom of women to control their fertility is the basis for other essential freedoms.

Keywords: Fertility, Policy responses, Sexual and reproductive rights

 

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1. Perspectives on populations 

The right of women to choose the number and spacing of their children is once again an issue of public debate. Media headlines in 2008 spoke of “fertility tourists” [1], a “fertile French bébé boom” [2], and “the population paradox” [3]. While fertility rates remain high in some parts of the world such as Sub-Saharan Africa, with average rates of 5.1, they have declined globally, reaching 1.2 in some countries, well below replacement level. Global population projections of 11.5 billion by 2050 have now been revised to 9.5 billion [3]. Some economists have declared that low fertility—together with ageing and the decline of the family—herald “a demographic winter” [4] and escalating economic crises. Some claim that only a new conservatism and restitution of family values will halt population shrinkage and economic collapse [5]. Others, however, argue that our planet is, “bursting at the seams in human terms, in economic terms, and in ecological terms... one billion people are too poor even to get on the basic ladder of development... what we are already doing on the planet in terms of effects on physical systems is unsustainable” [6]. In saying this, Jeffrey Sachs calls for an interconnected approach and a rapid demographic transition on a voluntary basis, linked to child survival and family planning. Meanwhile the world's population increases by 70–80 million a year, partly because 200 million women cannot access family planning.

While some argue that it is the rate of increase rather than the number of people that is the vital factor, what is often not central to the debate is the right of women to choose the number and spacing of their children, to access good reproductive health services including contraception. The rights-based approach at the heart of the Programme of Action developed at the International Conference on Population and Development (ICPD) has contributed to individual, community, and national development but is now at risk because in some countries fertility levels have not stabilized as expected. When low birth rates are accompanied by increased life expectancy and an ageing population, policy makers often become increasingly concerned about dependency ratios, productivity, and economic prosperity. As a result, a number of governments have reversed their previous policies in order to encourage higher birth rates. Yet even within those countries there often remains unequal access to education, health care, housing, water, sanitation, and employment. Addressing such social injustice needs to be an urgent priority to ensure all people can lead lives of dignity, meaning, and respect.

As women in Singapore, Hong Kong, Korea, Russia, Italy, Japan, and elsewhere are exhorted to have more children, 2 out of 3 women in low-resource countries [7] lack access to modern contraception, and donor funding for contraceptives has stagnated since 2001 although demand is expected to rise by over 25% between 2000 and 2015 [8]. Poor sexual and reproductive health accounts for one-third of the global burden of disease for women aged 15–44 years [7]. Furthermore, many governments still fail to recognize the critical importance of women's empowerment, education, and sexual and reproductive health and rights to poverty elimination and sustainable development.

Traditional and social expectations to have children immediately after marriage have led women in countries such as Korea and Japan to choose to marry later, or not at all, cohabit, or remain childless. Korean fertility rates dropped to below replacement level within 20 years of introducing widespread family planning, combined with increased access to education and employment for women. Subsequently, total fertility rates dropped to 1.3 (2001) then 1.08 (2005). This extreme decline has been attributed to the increased proportion of single women and women's changing attitudes [9]. In the 1960s, posters encouraged Koreans to have 3 children, 3 years apart by age 35; in 2006 they were reminded, “many candles are brighter than one candle” [10].

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2. Diverse policy approaches 

European countries with the highest birth rates in the 1970s such as Italy, Portugal, Spain, and Greece now have the lowest. In 2006, President Putin contended that population decline was Russia's most acute problem [11]. Yet recently, the French are described as “crowing over” the “best” birth rate in 3 decades, as the envy of Europe despite their lagging economy. The increase of 300000 to 63.3 million in 2006 is attributed to supportive policies [2]. Conversely, a Korean newspaper discussed the lack of qualified nannies and other support Korean women believed to be essential [12].

If governments wish to increase the likelihood of women choosing to have more children they need to implement comprehensive, rights-based policies, and recognize that women who have achieved education, employment, and professional success often wish to continue their careers and are more likely to choose to combine this with motherhood if they are not disadvantaged as a result. Conversely, fear of unemployment, particularly in inequitable environments with fewer opportunities for women, together with rising costs for childrearing, increased urbanization, insufficient and expensive housing, costs of healthcare and education, and lifestyle aspirations encourage couples to have fewer children.

Some policy responses, based on free and informed choice, are supportive of women's equity, equality, and advancement; others can effect varying degrees of pressure and coercion, in design or implementation, and can also risk discrimination against disadvantaged minority groups. It is primarily women who bear the cost of contraception, which very few low-resource countries provide without charge, even to the poorest. In some high-income countries consultation for Viagra (Pfizer, New York, USA) is covered by insurance while consultation for contraception is not, and the desire to reverse low birth rates has resulted in significant reductions of subsidized family planning. In Europe, support fell from 62% in 1976 to 38% in 2005 [13]. In either scenario only those who can afford contraception are able to exercise choice. This negates commitments made at the ICPD by 179 countries and the right of all to the highest attainable standard of health.

Lower fertility rates have also increased opposition to abortion, even in countries where legislation is less restrictive, with antichoice proponents arguing reduced access to abortion would contribute to population increase. This approach takes no account of women's reproductive rights, their rights to health and bodily integrity, or the right of every child to be a wanted child. The aggressive pronatalist history of Romania between 1966 and 1989 is a stark reminder of how extreme policies prohibiting access to contraception and abortion deny women their basic rights, resulting in tragic and extraordinary levels of maternal mortality and morbidity.

While some “blame” women's education for low birth rates and debate about the effectiveness of pronatalist policies continues, it is clear that those countries that provide practical rights-based options to support choice, in an environment of gender equity, are more successful. Policy options include subsidized childcare or early childhood education; workplace-based childcare facilities; generous maternal/parental leave; subsidized after-school programs; the right to return to employment without discrimination; state funded training and regulation for early childhood teachers and childcare workers; tax incentives; housing loans; and baby bonuses—a more controversial measure. Short- and long-term policies need to be rights-based, comprehensive, and holistic to encourage a work–life balance and family-friendly workplaces, while also being financially sustainable. They need to be integrated in a coherent, intersectoral policy approach, linking education, health, housing, migration, retirement, pensions, and care for the aged.

While some governments publicly encourage women to have more children, they are nevertheless reluctant to implement policies that support women to combine career and family, or broader approaches like later retirement or more open migration, although it is true increased migration cannot be a stand alone policy or panacea. For the European Union, 79.4 million migrants or 1.6 million a year would be needed just to maintain the working age population [14]. Furthermore, migration is increasingly contentious in some countries, with specific issues related to culture, health, and integration.

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3. A comprehensive rights-based approach to sexual and reproductive health 

In some countries involuntary infertility is increasing. Age, lifestyle, and environmental factors including obesity, smoking, environmental toxins, synthetic chemicals, reproductive tract infections, and sexually transmitted infections (STIs) such as Chlamydia impact on the fertility of both men and women, while other health conditions also take their toll. Yet relatively few governments wishing to drive policies to either increase or reduce fertility rates have invested in comprehensive sexual and reproductive health strategies, including comprehensive sexuality education for young people, health promotion, or condom promotion for protection against STIs and HIV. Such initiatives would reduce the risks of STIs and unplanned pregnancy, and contribute to fertility awareness and preservation. They would also increase individual and community well-being and contribute to reducing the preventable pandemic of maternal mortality that continues to kill 500 000 women a year.

Some countries are more generous than others in their provision of in vitro fertilization (IVF) and other assisted reproductive technologies (ARTs). Often access is limited to those who can afford it and while the cost-effectiveness, risks, and success rates of ARTs continue to be debated, they are part of a rights-based approach to reproductive health. In the Nordic countries, some 4% of births result from IVF [15]; in Israel, ART is proactively encouraged, contributing to almost 5% of births, and citizens regardless of religion, marital status or sexual orientation are entitled to unlimited publicly funded ART treatments until they have achieved two live births, although some may suggest this is more related to nationalist goals than health outcomes [16].

In countries with low birth rates, campaigns to strengthen the “family” and celebrate the fecundity of women have included Korea's Pregnant Women's Day, Russia's Motherhood Medals and Day of Conception, and Singapore's Love Boats. Traditionally in many societies men's and women's status and value continue to depend on their number of children. In polygamous societies, in war or in response to threats to a country's stability or that of a political regime, reproduction becomes a patriotic duty. Ugandan women have been urged to “have more Ugandans,” Pacific children remain “The gift of God,” media laud celebrities' public pride in their pregnancy, while a peasant woman can be beatified for having 12 children. Women can experience social and psychological pressure to conform to such expectations, resulting in stress and diminished well-being. Women are subjected to violence for becoming pregnant or failing to become pregnant. At its worst, rape becomes a weapon of war and genocide, the ultimate denial of human rights, and yet women are often still denied a legal abortion in such circumstances.

Policies related to fertility must not only be comprehensive and rights-based, but specific to communities and countries. Sometimes it is the least educated, most disadvantaged young women, those for whom motherhood is the only way to adulthood, who have the highest fertility rates, so reinforcing a cycle of poverty. Sometimes, they are targeted and encouraged to have fewer children while those in more advantageous circumstances are encouraged to abstain from sex, marry early, and build a family. Such approaches can be rights-based, or coercive and discriminatory. There are 22.5 million African people living with HIV, yet discrimination, stigma, and lack of knowledge too often prevent them from exercising their reproductive rights and accessing the full range of options to prevent mother-to-child transmission.

“The advancement of women's rights, and particularly sexual and reproductive rights has been strongly contested… one of the sharpest critiques has been that it is a Western notion, ignoring the cultural tradition of other societies. The argument of cultural diversity has been effectively used as a screen to justify and perpetuate even the grossest violations of women's humanity” [17]. Female genital mutilation and child marriage not only deny human rights, but contribute to poor reproductive health. There are higher rates of unmet need for contraception among married adolescents than older women [7], as well as of fistula and uterine prolapse, while pregnancy-related factors are the major cause of death for 15–19 year-old girls in low-income countries.

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4. Meeting the unmet need 

While some policy makers and religious leaders focus on increasing fertility in a context of declining births, the graying of the population, and religious ideology, one-third of all pregnancies worldwide are unintended, and 80% of those women are not using modern contraception [7]. A predicted 99% of population growth over the next 50 years is expected to take place in low-resource countries, 90% in the poorest countries. Uganda's population will double to 56 million by 2025, while 11 countries in Africa have a growth rate of 2.6% and the population of Niger and Burkina Faso could treble in the coming decades [18]. Yet there are clear examples where the birth rate has fallen significantly, based on voluntary family planning, and contributing to sustainable economic growth and development. However, the world's investment in family planning is only 10% of that projected at the ICPD. Increased investment could reduce maternal mortality from 15% to 31% and child deaths by 10% [19].

Some who oppose women's rights continue to link family planning only to a past history of coercive “population control” and “targets.” The link of rights-based family planning to population and sustainable development is not just a matter for the media and policy makers. Indeed, the extent to which public policy should determine private choice is debatable. However, there is a role for health providers as practitioners and advocates to ensure that all people are able to exercise their right of informed choice. To implement this most basic human freedom, individuals must have access to quality services, evidence-based information, and the widest possible contraceptive options, including emergency contraception. Young people, men and women, need to be given an understanding of positive sexuality and factors affecting a safe and satisfying sex life. With the largest generation of young people ever, accessible, youth-friendly, nonjudgmental services including outreach, workplace, and community and school-based initiatives are imperative, together with comprehensive sexuality education and health promotion through a range of media, as part of youth development strategies, so contributing to reducing gender stereotypes and sexual violence. Health providers need to be powerful public advocates for private choice and reproductive rights, including the rights of young people in line with their “evolving capacity” [20]. They need to be vocal advocates against gender-based violence—which impacts on STIs including HIV, unplanned pregnancy, and abortion—and for increased funding and contraceptives and responsive health systems.

Those committed to the reproductive health and rights approach of ICPD and the Fourth World Congress on Women (Beijing, 1995) must also acknowledge the impact of rapid population growth on basic social and natural resources including sanitation, housing, health and education, water, food, and fuel, so increasing potential for instability, conflict and displacement, compounding gender, social, environmental, and economic injustice and inequity. However, those who cite the “population factor” as the main cause of global warming need to recognize fully the importance of human rights and women's reproductive rights, as well as the consumption levels of high-income counties, including those seeking to increase their population. Those who contribute least to climate change are the first to feel its devastation. A rights-based approach is vital in addressing the complex interactions between growth, development, climate change, and sustainability.

In 2007 the General Assembly of the United Nations agreed that the ICPD goal “universal access to reproductive health by 2015” should finally be included as a target for Millennium Development Goal 5: improving maternal health. The challenge is to ensure that this universal right becomes a universal reality, and is not eroded in the face of an increasingly paradoxical debate about population numbers in which there is frequently too little focus on a woman's right to choose. This risks women being seen, yet again, in terms of numbers and not as individuals; as puppets of public policy rather than as active protagonists with control over their own lives, so recognising, that women's “rights to choose whether and when to choose to have children… is the freedom from which other freedoms flow” [21].

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References 

  1. Prasad R. The Fertility Tourist. The Guardian. July 30, 2008.
  2. Campbell, M. Fertile French Crow Over Bébé Boom. The Sunday Times. July 7, 2008.
  3. Vallely, P. Population Paradox: Europe's Time Bomb. The Independent. July 14 2008.
  4. Joyce, K. Missing: The “Right” Babies. The Nation. February 14, 2008.
  5. Kurtz S. Hoover Institution Policy Review. Demographics and the Culture War. Available at: https://www.hoover.org/publications/policyreview/3431156.html. Accessed June 4, 2008.
  6. Sachs J. BBC Reith Lectures 2007. Lecture 1: Bursting at the Seams. April 11 2007;
  7. Camp S. Presentation on “The Reproductive Health Landscape.” Guttmacher Institute Report. September 2008;
  8. UNFPA. Donor support for contraceptives stagnates despite rising global demand. Press release. October 2, 2008. Available at: http://www.unfpa.org/news/news.cfm?ID=1194. Accessed January 17, 2009.
  9. Eun ES. Lowest-low fertility in the Republic of Korea: causes, consequences and policy responses. Asia-Pacific Population Journal. 2007;22(2):51–72
  10. Planned Parenthood Federation of Korea Poster. Produced in 2006.
  11. Gauthier J. Human rights considerations in addressing low fertility. Entre Nous. 2006;63:8–9
  12. Eun-joo, Parents' Worries About Child Care. JoongAng Daily. July 1, 2008.
  13. Bloom DE, Canning D. Europe's looming population bust. Entre Nous. 2006;63:14–15
  14. Lutz W, Scherbov S. Can immigration compensate for Europe's low fertility?. Vienna: Vienna Institute of Demography of the Austrian Academy of Sciences; 2003;Available at: http://www.oeaw.ac.at/vid/download/edrp_no1.pdf. Accessed January 17, 2009
  15. Nygren KG, Lasdane G. Current trends of fertility – and infertility – in Europe. Entre Nous. 2006;63:10–11
  16. Chavkin W. The old meets the new: Religion and assisted reproductive technologies. Development. 2006;49(4):78–83
  17. Presser HB, Sen G. In: Women's Empowerment and Demographic Processes: Moving Beyond Cairo. New York: Oxford University Press; 2000;p. 167
  18. Population and Sustainability Network. Population Matters. 2007;5:2–4
  19. UNFPA, UNICEF and WHO. Improving health outcomes for women: What is holding us back? Joint paper, 8-9 May 2008.
  20. United Nations, Convention on the Rights of the Child. General Assembly Resolution 44/25. November 20, 1989. Available at: http://www.unhchr.ch/html/menu3/b/k2crc.htm. Accessed January 17, 2009.
  21. Sadik N. In: Huston P. The Right to Choose. London: Earthscan Publications Ltd in association with IPPF; 1992.

PII: S0020-7292(09)00149-0

doi:10.1016/j.ijgo.2009.03.028

International Journal of Gynecology & Obstetrics
Volume 106, Issue 2 , Pages 148-150, August 2009

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