AD 139 71

111THORTIVLE

INSTITTIOspotis AG Y

PUB pro

DOCUE!T :RESUME,

Stokes, Bruce*Pilling the Family Planning Gap.12. '

Worldwatch Inst., Washington, D.C.United Nations Fund for Population0 N.Y.1 May 775p.; Not available in hard copy due'to mWrginal

legibility of the original dpcument.Worldwatch Institute, 1776 Massachusetts Avenue,N.W., Washington, D.C.-20036 ($2.00 pap'erbound,qpantitY discounts available)

MF-$0.83 Plus Postage. BC-Not-Available from EDRS.Adult Education; Birth Rate; Community tple;*Contraception; Developing Nations; 'Family LifeEducation; *Family Planning;,*Global Approach;Government Role; Parent6;-Peer Relation4i0;*Population Trends; *Program Effectiveness; '*WarldProblems

-EDRS PRICE':DESCRIPTORS

ABSTRACTThe author provides a global reView af fa ily

planming techviiques and their impact on natiomal birth rates .terilization,- the pill, and intramterine devices are the most

p pular methods-ok contraception worldwide. Abortion, where it isgal, is also extremely popular. In cauntrie8 such as the.Uni

S ates where population, control is not an urgent concern, ther is atneed to educate young people about contraception, make d vi-readily available, and eliminate the social stigma that bir h controlis an untouchable subject. In developing countries-with criticalpopulation problms, family planning action is required on severalfronts. Decentralized programs have shown greatest success. rhese .

programs combinejncreased supply of devices and motivation in theform of peer reinforcement and educational efforts--When a( varietycontraceptives isolade available, peoplT seem mpre willing tourticipate in family planning because coercion by community OTgovernment seems less rigid. The agthor describes in detailsmccebsful programs in China which are the responsfblity of smalgroups in factories and villages. Tight community bonds areinstyumental in their success. Funding needs and-agencies for gl bbirth control are discussed, as well as changing at.titudes ofnational governments. (AV)

*********************************** *** ****** *********** ***

Documents acquired by ERIC include many informal unpublished 0materials not available from other sources. ERIC makes every effort *to obtain the best copy.available. Nevertheless, items of marginalreproducibility 4re often encountered and this afifects th.. quality,of the microfthhe and hardcopy reproductions 'ERIC makes availablevia the ERICidocument Reproduction Servide (EDRS)-4EDRS is notresponsible, for the-quali y'of the original document. Reproductionssupplied byvEraS are the b t that can 'Ye made from the-original_*************************** *****************************************

-PERMISSIO REPT/904CE THIS',.coPvRIGHTED mATERIAL ETFICHE OLYA EEN

TO CRIC AND ORGANIZATIONS OPERAT

INR UNDER AGREEMENT5 WITH THE NATIO.NAL INsliTure oF eDuciwor,RugTHER RERRODUCTiON OuTSHDE.-THE ERIC SYsTkM REQUIRES RERMISSION OF THE CopyRiGHT 4,NNEIT "

ULDEPARTMENTOFHtJLTH. ."EoucATooN A WAARE

..NTIONAL INSTIT TR OP.AEDUCATiON

THII. DOCUMENT 'HAS SEEN REPR0 -.0t,CED EXACTLY AS RECEIVED FReMTHE PERSON OR ORGANIZATION ORIpiN-MING IT ROINTS OF vIEW OF1OPINIONS4STATED 00 NOT,,NECIssARLY REPRE-ANT OFFICIAL NATIONAL INSTITUTE OF

FOUCATION POSITION OR OOLICV

aper 1277

paper drawi on research supported hy the United.,Na-tions Fund for Population Activities. Sectinons` of this papermay be reproduced in part:in magazine§ and newspaperswith acknowkdgernent to Worldw tch Intitute,

The -views expiessed ay% those f the author and do not ;necessarily represent those of tie Manuscript reviewers;of Worldwatch Institute and its di*ctors , officers;,or staff; orof the United Nations Fund for Po ulation Activities.

WorldwatCh titute

orldwatch Ins itute is anresearch ereafocus attention-on global pLester:R. Brown Worldwatchfou4datiobs-, United 'Nationsgovrnmental agencies. Won,

fora wOrldwide audience of,srholars',..andtbe general pt

,depehdent, non-profited to identify an& taoblerYs. Directed by-

"- funded by, priVateganizations, and

dwatoh papers are;wtitdecision maker-blic.

Copyright Worldwarch Institute:1977Library of Congress Catalog Card Number 77-78349

ISBN" 0-916468-14-9

Printed on rg6rcled Over

ily Planning s Disenfranchised

A Smorgasbord of.ServiceS-

The Growing Commitment . . . . . . . . .

Cominunities Take Reponsibility

lilhng the Gap

Notes

= . '

ore than halr the world'S _couples go to byd eachnight unprotected from unplanned pregnancy.. Formore than 300 -million couples the fundamental deci-sion or Whether or when to have a child is seldom a.

ec::"on_at all. Few of these Men and-women have adequate_ in-formatIon about the health implications of ill-timed childbearing;:few

.receive feedback on the impact of th'eir fertility decisions on theircommunity; and- few have.access to-rnedern-famiry planning methods'.To narrow this family planning gap, many governments have begun

decentralize family- planning programs,_ extending services- andusing peer pressure to-promote the acceptance of contraception anof small families.

More couples are effectively planning their family size than everbefote. In the first half of this decade, the use of oral contraceptives,intrauterine devices (IUD), and both male and female stefilizationthe three most effective ,means of preventing unwanted puegnanciesrose markedly in both rich and voor countries. Yet, despite dramaticprogress, a .majority of couples still do not use these methods. Primi-tive contraceptive practices and old prejudices against contraceptionremain. Archaic laws make contraceptives and safe abortion difficultto obkIn. Family planning's disenfranchised mindritiesthe poor,

, ,the the unmarried and the ruralstill cannot time and spacetheir chil bearing effectively.

=

The exact number of couples in the world.Who need, family plannin-services to avoid an unplanned pregnancy is- difficUlt to' assay witany certainty. At any One time, about a fourth to a third of a country'sfemale population of reproductive- age (ages-15-44) is pregnant, inter-ested in becoming pregnant, or unable to bear children. This portiondiffers somewhat among ,pocieties, -depending on age structures andbirtkrates.

oThe author wishes At) thank, Martin E. Corosh, 'Marshall Green. Michael Henry, K.Kanagaratnam, David Konen. Deborah Oakley. Phyllis Piotrow, J. Joseph Speidel,Jack Sullivan, Michael Teitelbaum. and Robert S. Wickham for revieWittk the manuscript.

,

Thus, somewhere betw,een two-thirds kind Ah'iee-quarters of the fmales sif reproductive agein any nation face the possibility of an il _

6 timed or unwanted pr -nancy. According to Joy Dryfoos of the. AlanCuttmacher Institute t is portion totaled about 30 million women inf ithe Unite States 1975, nearly 70 per_cent of whom were proiected

. by some orm Of contraception. Approximately 500 million women inthe wor d in 1971 the International Planned Parenthood Federation(IPPF) contendkswere fertile, not pregnant, and not interkted in be-coming ',pregnant. Fewei4han one-third of these hall a billion womenwere prbtdcted by conlraarition,.and half of those who were used un-reliable methods. SinCe this IPPF. survey was taken, family planninprograms have expanded considetably, especially in China, ThailanIndonesia, the Philippines, and Coloilbia. While the inimber of womenthreatened by unwanted or unplanned pregnancies may have been re-duced somewhat by these Worts, more Ahan 300 million women, and-thus couplei, still use no family planning methods at all.i.

Certainly, the record of legal and illegal abortions each year testifiesto the fact that too many family planning,decisions are made after thefact. In .one El Salvadorthospital, J. Mayone Stycos of 'Cornell Uni-versity report% one of every five women admitted suffers from corn-.plicatiOns arising from the illegal terrnination of a pregnancy InMoscow, two abortions are reported.for every live birth lArt5rnen under20 bear -a surprisingly large portion of all babies in rich tind poorcountries alike, despite evidence that postponing first iilregnanciespast adolescence reduces maternal and infant mortality and Illness. Art18-county stucry in 1974 in upstate New York showed that 43 per-cent of all birihs were mistimed or unwanted. In disparate ways, thenumber of ill-timed pregnancies and widespread reliance on abortionamong all social classes.and groups signal an unmet need .for contra-ception.2

,

Ecginomic.and spcial conditions' deny many couples access to familyplanning services. Official programs in developing countries haverarely rvched the poorest of the poor. Evqn in countries where con-traceptive use iptwidespread, the poor, are often the last to receive fam-ily' planning setVices. lh West Germany in.1974, only pix family plan-ning clinics serv_ed the 2.3 million low income. foreign workers in. ,

6

"Mojitan 300-million Wemenflu faitily planning methdds at- alt."

the country; yet-, every sixth baby born in Germany had at least oneforeign parent. In th't IJjtited States, racial minorities, among the most.-

_ disadvantaged groups up the society, have the highest rates of un- 7planned pregnancies. T e wives of manual laborers in Britain are,studies show, less likel than the well-to-do to use contraception and,more likely than the ell-off to rely on the-least effective methods.Using putdated contraceptive techniques, principally withdrawal and-the rhythm method, e'ven the most conscientious of ten fail to avoidpregnancy,'

The yoUngboth married and single---face pahiCufaily, difficult bar-riers in their efforts,to obtain information about contraceptives and toprotect themselves from unwanted pregnancy. Thirteen million wom-en around the world who bore children in 1975 -became mothers be-fore they became adult6. In the United States during the same year;about one rnilhon teenagqs became pregnant; they, Aided 600,000persons to the population and collectively lost approximately 6,000

Anfants v4(ho tnights have lived if their mothers had Waited until theyWere 20 years ',old toi bear children. Only 30 percent of the never-'marriect sexually active teenagers who were canvassed by Johns Hop-kins' University researchers in 1976 reported using some method ofairth control regularly. Seventy percent of .the sexually active adoles-

nt women who did not use contraceptives told interviewerS con-ctug a similar stficly that precptions were unnecessary becauseey ought they could not become pregnant. Such ignorance often

, en s in abortion.Women in their teens have.one of everY four abortionsin Great Britain, Sweden, and Australia.'

any couples Marry young and have one or two Children while stillin the setond decade of life. 41Vhile raising the legal age of marriagemight help delay childbearing in i-d-rne societies, custom may defy law.common law marriage and pre-marital childbearing, acCepted prac-ticeS in many societies, contribute to the problem of adolescent preg-nancy. The dissolution of traditional communities and the flight frorrN4the countryside to cities, especially in developing countries, ', have.:;;weakened many moral injunctions against pre-marital sexual relations:

_ and 'hay have increased the number of births to-unmarried teenagers.'

Yet as taboos' about sex crumble, objections to sex education persist.Few countries teach the young about reproduction Ind sexual respon-sibility, and only in 5weden is sex education dee ly entlenched in thecUrriCulum. Many American school, districts act_ ally prohibit suchinstruction. Indeed, both information and family planning servicesare largely out of reaCth.of the young. By the end of 1975, only 26states and the District of Columbia in the United Stateshad grantedadolescents the legal right to obtain contraceptives. Today's teenagersare ushered into a world of tem ting sexual freedom that all too oftenbecomes a trap because family p alining programs are inadequate a

fhe urban bias of most organized birth control programs is universal,even in an avowedly rural-oriented, egalitarian sotiety like China, In.1974, the Planned Parenthood Federation of America estimates, 2.5million women in hon-metropolitan areas in the United States hadnoaccess to any family planning servicesprivate physicians or organ-ized clinics. A study in 1975 in France by the Mouvernent Francaispour le Plannini -Familial revealed that few Country-dwellers hadaccess to the government:s family planning clinics. While .the portionof the world's population living in rural areas is falling, those in 'thecountryside in most developing nations and in parts of eastern andsouthern Europe still represent the majority and still tend to havelarge families_ "There is never more land, only more children,- aChilean peasant woman told an International Labor Organization ob-server in the early seventies; her words evoke thLharsh rural realitiesof insufficient land and inequitable land distribuTion, problems thattoo many claimants on a family's patrimony only exacerbate. Providing family planning services to those in rural areas may be more difFicult than reaching needy couples in the city, but the rural demand forassistance in planning births is no less pressing than the urban one!,

r,--

CoupleS often face the threat of unplanned pregnancies beca se.,access to modern contraception is limited by law. Prescription requite-ments inhibit ,use.of the pill in India, and the Japanese governmentpermits doctors to prescribt the pill only to regulate menstrual chs-orders. 12aws in many West African countries impede cl'r forbid the saleand distribution of contraceptivesa legacy of F,rench colonialism that

'Today's teenagers are ushered into --a 'world of tempting sexual freedom

that all too often becomes a trapbecause family planning programs are

inadequate,"

has survived France's domeitic about-face on the issue. In Algeriabirth control is available .only to motheri(with four children. Manygovernments view -Sierilization as an exirente form of family planninand deny this option to the young, even to those who have severa

`ldrett, Customs dulies, manufacturing and quality controls, andvertising regulations often so limit the availabilit-y of contraceptives

'that pedplè infer that their governinent opposes family planning,even if it is officiallY neutral on the subject_ industrY's codes of prac-tice disallow advertising-contraceptives on radio or television in theUnited 5 tates.7

For couples bent upon planning and spacing their families and forgoyernrnents eager to slow population growth, reducing--the familyplanning gap is not merely a matter of using-or providing some formof contraceptionIt is also a questiOn of choosing or ptomoting themost reliable and 'safest birth control methods. Where ready 'access tomodern contraceptive techniques is provided, the highest portion ofcouples use contraception. In the United States, Australia, Japan, andEngland and Wales, More than 60 percent of all married women regu-larly use contraceptives. Over the years, the preferences of womenin these Countries have gradually changed; and as more effectivemeans.have become available, they have replaced the rhythm methodand withdrawal. (See Table 1.)B

Taken together, the most effective contraceptive methods are increas-ingly popular in the English-speaking world and account FOE Morethan half of all ciintraceptive use. Concern over health risks associated

. with the pill does not se&n, to have seriously affected oral contracep-tive use in these countries, although U.S. women are more likely thantheir British and AuStralian counterparts te use the pill for a while and_.then to shift to other methods. Sterilization is growing in acceptanceand its use has doubled in the United States in just 10 years. Thesetrends hold for all industrialized nations except Japan; there, -the pillis difficult to obtain, the IUD was illegal until 1974, and sterilizationis not widely accepted. Japan's success in slowing population growthreflect4 the poptilailjty_of the condom, the use of which is effectivelybacked by a liberal abortion law.

- Table I.: ContraEeptive Practice in Selec ed Deve oped CountriesAmong Couples of Reproductive Age Using Contraception

Sterili-Pill U-0 zation Condom OtherCountry

...4

United States (1973)Japan (1975)*Australia (1971)**

. England andWales (1972)***

(percent)36.0 9.6 23.5 13.5 ,17.43.0 8.6 4.7 . 77.8 50.9

38.0 8.0 ' 9.0 45.0

58.0 1.0 25,0 23.0Dash indicates data no,tavailable.

*Two responsed were allowed so total exceeds 100. "Melbourne 5More than .

one response was allowed so total exceeds .100. The survey was kmong. recentlymarried couples..

Source: Charles F. Westoffi Popillation Problems Research Council: Australian National tUniversity; and j. Peel and G. Carr.

Among the larger developing countileS, China has the most %Vide- I

spread use of contraception. While exact data are unavailable, the IPPFestimates that 35 percent of all married Chine e couples practicedcontraception in 1971. Figures for the Shanghai unicipality In 1971given to Pi-chao Chen, one' of America's forem st -observers of Chi-nese family 'planning, indicate that 70 percent of couples- used contra-ception in Shanghai even before ttie government expanded family

'planning srvices in the 'early seventies. All wl- a have observed theShanghai p'rogram agree that it-is decidedly m* advanced than ef-forts in the \Chihese countryside,' where modern\ contraeeptiv7 havebecome availkble only in recent years. While estimates of, rural and ur-ban use differ greatly, reports from several large)cities indicate morethan- half of al '1 urban couples of reproductive age' use contraceplion, alevel of 'Use t at compares favorably with that in Noah America,Europe, and jap ,n,9

., /To fulfill its deSire . to slow population growth rapidly, the Chinesegovernment has niade a full range of contraceptive methods available.According to repot6' pieced together from variods travalers ip China,

,. sterilization may be:\ the most popular method of limiting fa1%ly size.\' ,

Table 2: ContracePtive Usi in Shanghai Among Couples of,Reproductive 4ge Using Contraception, 1971

-Mithod Perceitt

191(;)

Condo-et and diaphragm- Female sterilization 44 ..

Male sterilikation 10

Total, 100

Source; Pi.chao Chen

Among methods whose effects. can be reversed, thpilI has gainedreced-ence oVer the IUD in recent 'years; as the figures indicate. (Seeable 2.) The Chinese were the firsr in the world to experiment with

a low-estrogen pill, whi,ch is ofterhtmpregnated- on edible lice paper;but how extensively the paper pill is used is not known. Abartion is-available on request in Claina, and no stigma seems to be attaehed toits use as a fall:back when contracePtion fails, Over?ll, the govein-ment'appears to be making every effort to expand family planning.lo

Studies of contraceptive use in poor- countries other than China, ate .sketehy at b'est. The data that do exist are for nations with- well-'established family planning, programs. (See Table 3.) Taken alone,these statistics often show rapid growth of contraceptive use andgreat dependence on modern methods. But Since these countries aretao few in number to be truly representatiVe and since all such figueesire mere estimates contfaceptive-use. statistics for these,. countries

-should be viewed cautiously; they serve best as indicators of relatiyetren.ds:

In Hong Kong and ,fingapore, most women get their contraceptivesfrom official programs and many use effective methods. Nearly halfof all couples rely on the pill, the IUD, or sterilization; and, predict-__ably, birth rates have fallen in the last decade, lie portion of married

Contraceptive Use in Selected Developing Countries Among-Couples of Reproductive Age

1969 1970 1971 1972 1973 1974' 1975 1976(p cent)

Hong Kong t 42.0Indih _. 8.0PhilippinesSingapore 37.0South Korea 25.0Thailand . 7.4

50.012.0

' 45.032.07.6

5L0

_8.1

9..6

54.013_2*11.0

.30.018.7

52.013.64:

,_15.0

, 25.7

,0j5-1*

tr-. -

.-60 .130_524.8

57.015.6..

,34.01'26.6

61.0i6,9*21.777.134.232_0

Dash indicate's data not available.*GoVerrinient family planning program only_, -Source; Population Council_

women ages 15-44 using contraception exceeds 5b percent and ap,proaches that in mcilst developed countries. Family Planning_programsin Thailand and in the Philippines have yet to reach a third of thosein need; yet, the portion of married women using 'contraception-mushroomed from 8 to. 32 percent in Thailand .and froth 8 to 22 -per-cent insthe N-Iilippines between 1970 and ,1976, according to estimates -

reported` by Dorothy4Nortman of the Population Council. Preliminarydata for Ccilombia show similarly impressive trends; Jerald Bailey ofthe Population Council estimates half the married wornen in Bogotaused contraception in 1974, almost twice the number of those _.whodid so in 1964. About 30 percent of all Colombian couples, the 1976census suggests, pratticed corttracption similar impressive but pre-liminary figures exist for Indonea. In East Java and Bali, sites ofnew' farnily planning programs-, ,34 'percent of married couples usedcontraception by January 1977. On th'e other hand, ooly one in sixmarried It/omen in India used contraception by 1976, despite theIndian government's lwo decades of irivolvement in family planning.''

The poorly organized, poorly funded family planning programs thatexist in most poor counlries cannot be ekpected to attain overnightcontraceptive use artlie levels preyalent in Hong Kong and Singapore.

12'

Fewer than one in ten couples in Africa, in trie Middle East, and onthe Indian subcontinent used contraception, in 1971, the IPPF esti-mated; indeed, contraceptive use had increased little in these areas by 11976. Some critics charge that this dismal performance indicates thatfamily planning prograrns will never succeed. But the record in Thai-land and in the Philippines demcgstrates that poor countries can getfamily planning programs off the ground.

Overall, the birth rales in countries containipg fully 40 perGent of theworld's population fell significantly between 1970 and 1975. Yet innations with 60 percent of tfi planer s,population, birth rates changedlittle..Why.some birth rates fell while.cithers did not is not real.iily appar-ent; a simple causal relationship .,hetween falling birth ratbs and theavailability of family planning services cannot be established. But itis evident that in.countries where birth rates have fallen, family plan-ping programs are extensive or expanding,- and where birth rates haveremained high, family ,planning programs are often woefully inade-cplate.12

The relationship between birth rates and family planning is readilymeasured using a rule of thumb suggested by Bernard Berelson, Presi-dent Emeritus of the Population Council_ Countries with 30 percentof their pOpulation using contraception, he contends, have a birth rateclose to 30 per thousand; for every two points difference in the per-._centage.using contraception, the biir'th rale usually changes by aboutone point. For example,' South Korea's 34-percent contraceptive userate corresponds roughly to its birth rate of Zs per thousarid."

As uging Berelson's formula suggests, a society and ,its individualfamilies both can begih to experience ,some of t e advantages of-re-duced fertility long before the national majority practice ContraceptioltIn most African, Asian, and Latin' American countries, where birthrates range from 35 tp 50 per thousand; family planning prognimscannot immediately cover all women at risk of unplanned pregnancy_However, reaching a third of those in need could bring- birth ratesdown to about 30 per thousand, improving materhal and infant healthand relieving pressure on the dornesti'c economy, the environmenr,and the social fabric. Filling even that portion of the family planning

13

gap Poses a challenge. Yet, with the success of several -programs onrecord, setting a one-in-three goal for 1985 does not appear unreal-

14 istic for many countrIes.

A Smorgasbord of Servfces

Once a.cajlectiori of folk myths, family planning has become a scieke-...and a business. As interest in controlling fertility has grown; a -Widevariety of techniques and methods has evolved; some are adaptationsof age,old practices ethers products of recent research. The legaliza-tion of aleortion the ping reliance on sterilization, and the slowbut steady increase in lir number of women using oral contraceptivesall argue that many coiiples do want and seek out a choice of familyplanning services.

The first family planning campaigns all too often relied solely on onemethod apd on,one means of distribution; they also often ignoredlocal prejudices, taboos, and concerns. In 1965, the Indian Govern.-ment made the IUD the foundation of its birth control program; butby 1969, efforts to enamor Indians of the IUD collapsed in the wakeof reports of medical complications, a blow the already troubled familyplanning program- could scarcely withstand. Similarly, the CatholicChurch's early prohibition of all- means df birth control except .therhythm method has until recently stalled effective farn6 planning inpre_ommantly Catholic Latin America.

While the idea of providing a smorgasbord of family planning servicesfirst suggested in the early sixties, only in the mid-seventies@did

us approach take hold. Almost obvious, the theory is that the mosteffective distribution schemes are sensitive to various types of de-mand. In the commercial world, several brands of cola are often man-ufactured by the same .company, a practice that both responds toand creates demand. But providing couples with a choice of contra-ception is not merely a matter of good salesmanship. Choice gives theuser a sense of personal control over his or her fertility, and choiceborn of. variety encourages widespread community involvement in

.14

early 1978, nearly t a-thirds of theworld's Women had t e right to legal

abortion."

-family planningthe' corner greengrocer can sell condoms and the.neighborhood paramedic can dispense the pill_ As the means of limit-ing -family size are tailored to individual preferences, contraCeption 1 5can become thore acceptable and accessible to all couples.

Before the modern era, family planning meant withdrawal, primitiveabortions, and various concoctions reputed to prevent pregnancy. Theancient Egyptians used alligator ,dung as a spermicide_ The Englishin Elizabethan times thought that covering the penis.with tar beforelove-making would make conception impossible. Like their maternal,ancestors, women in many Parts of the world still swallow potionsto induce miscarriages or use sllarp instrume ts to abort unwantedfetuses.

While today abortion is no longer primitive or dangerous where it islegal, it is possibly the most commonly used non-permanent methodof averting birth. Estimates of the number of unwinted pregnanciesterminated each year by abortion range from 30-55 million_ Where othermeans of limiting family size are`difficult to obtain, abortion is par-ticularly prevalent. In Brazil, an estimated half of all conceptions endin abortion. hi Egypt, as many as 500 illegal abortions are performedevery day."

Aware that prohibition does not prevent practice, many governmentshave shifted their positions on abortion dnring the seventies. At thebeginning of the decade; 38 percent of the world's people lived incountries where legal abortion was readily available. By early 1976,laws had changed in dozens of countries, and nearly two-thirds of 'theworld's women had the right to legal- abort,ron. Unfortunately, evenwhere abortion is legal, abortion services arc not alwayt available.Although the Unitec. States Supreme Court established in 1973- awoman's right to abortion on request during the first six months ofpregnancy, many U.S. hospitalsparticularly those in non-metropoli-tan areashave no abortion facilities whatsoever. Planned Parent-hood's Alan Guttrnacher Institute estimates that in 1975 as Many as770,000 women who had unplanned pregnancies 'and who rniy. havewanted abortions could not obtain them,"

1 5.

, Where abortion has been legalized, its irtiiác t on population growth anamaternal- health shoWs. After Japan made abortions legal in 1948, the

16 Japanese birth rate fbll by a third in five years. Now one abortion isperformed for every live birth, and, abortion is ccintributing to thegradual decline. in Japan's birth rate. In the United States, approxi-mately one in 14 women of reproductive age has had at least one abor-tion. Over a million sdch operations were performed in 1975, makingabortion one of the most commonly performed operations in thecountry and- slowing- U.S. population growth by about a quarter. In1969, when abortion was- illegal in New, York, 6,590 women wereadmitted td municipal hospitals with post-abortion complications.By 197,3, three years after abortion waS legalized, half that numberof medical complications were reported ,16

Means of ending pregnancy have been vastly° simplified in ,recentyears. Some techniques now in use permit the process to, be handledin outpatient clinics Or by trained persons traveling from village to .

village. The vacuum-as`piration procedure, a method widely used forearly termination of pregnancy, requires just the simple use of a hand-held, hand-operated, oversized syringe. Menstrual extraction, a mini-abortion that induces menstruation within a few days of the tims awoman misses her first period,(,may also_ hold great promise since itrequires only 5imple equipment and can+eiDerformed by paratnedicalpersonnelan- important consideration in doctor-short countries.While abbition is one of the Most common means of fertility control,it remains an expensive .and/, where illegal, often clSrigerous form offamily planning. For thi.4 'reason, ever moie couples are turning topreventive family-planning Measures.-

-Attfrripts to

,-estimate the- number of couples using each kind of con-

traception are fraught with dubious assumptions and are highly con-troversial. Little hard' data exists even for the developed countries,,andthose making estimates /sometimes develop figures that tend to sup-port their pet programs. Table 4 is the product of an attempt to helpfill that information gap with admittedly imprecise estimates of theuse of various contraceptives ri 1970 and 1976 . As Sallie Craig Huberwrote in 1973 when IPPF published similar estimates, "This surveyis. a strictly_ peactical rather than academic exercise, -designed to pre-

,

16

Voluntary sterilization is truly hecontraceptive phenomeno of the

nties."

, sent the best picture possible at tbis point in=time. WeehoPe our rms-.

takes wil4 be seen by others as a challenge to.make better guesses, tomake gRod deficiencies by further studY mad, generally, _to correct 17them." 17

-

Table 4: E_stimated Number of Couples Controlling Their Fertilityby Fornh Planning Method

1970 1976

Sterilization 20.4Pill 30Condom 25 30IUD 12 15

Other 60

Total 147 240

Abortion 30-55 30-55

Source: AID and the Population Council.

Voluntary sterilization is truly the contraceptive phenomenon of theseventies. Alt ough it was once regarded'as an e)Ztreme and undesira-ble- form of birth control, the ntimber of couples using sterilizationnow exceeds Ithe number of those using any other single preventivefamily-planning measure. In 1950, no more than four million couplesin the world depended upon sterilization to control their fertility; in1975, four million sterilizations were -performed in Europe alone. InKorea, 13 percent of all married; couples using contraception havechosen sterilization. In the United StateV, ;the figure is nearly 25 pes--cvit; in Puerto Rico, one of three couples ielies on it. Some 75 millioncouples around the world now use sterilization as a family planningmethod."

In Europe and North America teiilization is legal or unregulatedeverywhere except in Italy, Fraptce, Turkey, and some Canadian prov-

Despite the Vatican's absolute ban in late 1976 o sterilizationevent pregnancy, increasing numbers of female sterilizations are

g perf rmed in Latin America, particularly_ih Colombia. In Sririka,- the lalge tea estates have established ihcentive programs to en-urage w _kers to be sterilized Q nc-e they ha.ve built their families.19

er emphasizing various contraceptive techniques with limited suc-cess; the Indian Goyernment in 1976 made sterilization a cornerstoneof their trisl-k program to reduce average family size; by the end of theyear, over -seven million steriliza,tions had been perforated, and suchan unprecedented effort had proved difficult to=adrninister. Attemptso compel individuals to have /he operation led to objections on the

grounds that hdman rights were being violated; and coercive action- tomeet quotas set off several violent political demonstrations. Reported-ly, some locak diSease immunization prOgrams failed because .peoplefeared they might be forcibly sterilized whn they showed up for thei,rshots.

Ultimately, the Indians came up agaihst a variant of Gresham's Law--reliance on a massive, at times compulsory, sterilization pro'gram un-derrriined public support for voluntary family planning efforts. Oppo-sition to thesterilization program helped unseat the -ruling CongressParty in the Spring 1977 national elections, and the new goverrunentpromised to halt all coercion and cash incentive% for sterilizationand to expand condom and pill distribution_ India's inSistence oh,

ushifig only one family (planning method may have once again setack family planning in that cou try.20-

Despite this backlash, the numb'r of sterilizations performed aroundthe world should continuerto grow, largely because the surgical pro-cedure involved has been simplified. In the late sixties and early seven-ties, vasectomy was the most popular form of sterilization, becausefemale sterilization required major abdominal surgery, general anesthe-sia, and several days of hospitalization. At the Indian ,sterilization,camps in the states of Kerala and Gujarat in 1971, where several hun-

-dred thousand operations were performed in short intensive_ can-paigns vasectomies accounted for almost all the sterilizations pet,fo d Without sig 'ficantly curtailing interest in the male operations,

18

new surgical methods such as the' minilaparotomy (an operation donenear the ,bellybutton) have simplified female sterilizations. TheY nowconstitute an = important part of farnily planning programs in thePhilippcges and Thailand and have surpassed vasectomies in popu-larity in the 1,Th ited States.

-Especially developing/countries, where medically trained personnelai a premium,. the advent of simplified procedures means that

sterilization can ,be moved out of the hospitals and into the villages..Some new methods are so simple that in one programtit 'Bangladesh,village women, miny of whom are ilhterate, have been able to learn-the technique and perform tubectomies. Their success has been strik-ing; their patients have a lower infection rate than db the patients oftrained doctors: This project Suggests sterilization rnay Well -becomeeven more common in the_future.2'

The pill.closely trails sterilization as a preferred contraceptive. Acçoding to the Agency for International Development (AID), 55

°couples were controlling their fertility with oral contraceptives- bylate -1976. Among women in western industrialized countries thepill has overwhelming popularity, and its use seems to be on the riseon all continents. In countries just developing family planning pro-

_grams, the pill is often the standard-bearer of the new contraceptiverevolution.

r-

However, in, well established programs in Korea, Taiwan g Kong,5ingapore, and Egypt, the number of women accepting oral contra-ceptives' has leveled off 6.1- declined. Although the pill remains the_main form of contraception in many countries, growing concern overhealth complications with its use has prompted some women to tryother methods. Soviet doctors reportedly advise against the use,of thepilt and many women in the United State§ have began, to rethink theunkhow`n Costs -associated.with th`e pill and to switch to sterilizationor the diaphragm. Only time will tell if this pattern will .be repeated

_

in poorer societies.az,The condom, 'the oldest and simplesL means of contraception, hasrecently gained new respectability, and is now used by an estimated

30 million couples: Long conSidered unreliable, inconvenient, anddemeaning-to a man's virility, condoms ,of every hue and shape are °

20 now a staple of many family planning progr4ms. InIndias,,Sri Lanka,Kenya, and Thailand, effort& to step up the marketing of contracep-tives through commercial outlets chave 'increased 'cdndom saks.mark-edly. Wherever women ore demaridipg that men tak; equal responsi-bility, for birth control, ane condok is 'being welcomed back. In cul-tures, in which the male makes 'rail major family decisions, the avail-ability of a contraCeptive that the man controls often wins acceptancelot a family planning program.

Other means of cbntraception hav'e been less widely adopted. TheIUD, once 'thought to hold great promi'se'far women in the deOklop-ihg woad, has only about 15_mitlidn uSers worldwide. After the deviceinitially proved successful in- the United States and Taiwan, family

lanners touted the IUD a-s- ari effective method free oF the draw-acks of regular çiii or condom use: but the intrauterine device ,has

never lived iip.-to`thesd -expectations. In most countries, well below10 percent of all women of reproductive age use the IUD. For somewomen, IUDs have worked .well. Others have?experienced unsettlingside effectspain, irregular bleeding, uterine dalnage or infection, andexpulsion.

A study of= well-educated women in the United Stalesc,suggeSts thatthe didphragm- is as effective in preventing pregnancy and as accept-

- able to users as.more sophisticated contraceptives. One, yeas after thetest began, only one out of five women given the diaphragm discon-tinued using it, a smaller_ percentage, of dropouts than .for any other,contraceptive method. Moreover, the low frequency with which thosesfudied accidentally became pregnant challenges the wrenched- po-lion that the diaphragm is uhreliable and bodes well for-its wider use_In addition, a- study by Christopher Tietze of thg Population Councilindicates that the diaphragm or the condom, backed up by legal abor-tion, is-the safest means of contraception for women_23

The injectable contraceptive is one new family planning option underexperiment. Already quite Popular in Thailand and tried in the Philip-pines and' Indonesia, injectables are not legal in the United States.

2 0.

-The ideal family planning methodwould be completely safe, effective,

reversible, easy to obtain and use,cheap enough for the poorest personto afford, and culturally acceptable."

,Lon asting but u/timately reversible, the injectable appears attractivebecae it does not require repeated iction,or vigilance by, the c9uple

.involv . Still, its hcalth implications are riot fully understood,- afid itsaceeptability in a wide range of settings, remains unknowik

. .

-_..._

The ideal family planning method w6uld be completely safe, effective,reversible,' easy to obtain and use, cheap enough for the poorestperson to afford, and culturally acceptable. Measured against thesecriteria, all known methods come up short. The most effective meth-odsabortion, sterilization, the pill, and the IUDhave improvedgreatlY over time and are certainly less dangerous than an °unlimitednumber of pregnancies ancOmore effective than withdrawal, rhythm,°Volk medicines. Yet the uncertainty of safety, cost, lart adaptabilityatgues against sole reliance on'any one of these methods. ,

..

'Concern -Over the safety of the pill dominates discussions of thedrawbacks of contraceptive use. Since the public and the -medicalcommunity have lingering doubts about the long-term health effectsassociated with pill use, women under a doctor's regular care Olould

.have a medical examination before taking the pill_ liut in countrieswhere women- go their whole lives without seeing a physician andwhere taking the pill is far safer than having a baby, regulations thatrequire a prescription to obtain . the pill ,may be too stringent. Thethrust of the data on maternal and infant mortality associated with

.childbirth among the poor is incontrovertible; the pill is far safer'than childbirth for women under 40. A family planning prograGn that

e ded ,the pill would sentence many women and infants to theirayes -24

The pill should be among the range of contraceptivis available inevery family planning program. Yet, sole feliance on comparative

-mortality statistics to justify wholesale distribution of oral contracep-tives neglects the human dimension of birth controi. Women, not statis-tics, -take the pill;. and some of these- wOmen experience bleeding,cramps, mood chariges, and skin problems in conjunction with theuse of oral contraceptives. Rumors about such Me.dical complications.

, often g ossly distorted, can travel like wildfire in any community, andexperie ce with the IUD in India and with declining pill use in many

2 1

decreloping countries only underlines the' importance of assessing andantiCipating potential backlash to pill use before a family planning

22 program is built around it.

As a World.Bank- ktudy of family p nning Kojects noted in 1976,-however, few experiments on the liealth implications of distributingunpres?ribed pills -in developing countries have been conducted:cWithout substantial testing, the impact of prolonged pill use by womenin poor areas simply cannot be determined. Even in the developedworld, the pill's lifetiMe effects have not been fully studied, since oralcontraceptives.have been used fcil- less than one generation. Applyinto frequently undernourished and genetically different women indeveloping cnuntries what is known about the reactions of Americanand European women to the pill could create problems.25

Only 120 million was spent worldwide in 1974 on the study of thehumarr reproductive system, on tests of the safety of current familyplanning methods, and on the 'development of new -contraceptives,such as a male pill and a pregnancy vaccine. That only three Malefamily planning techniques' exist, two of which are ancient and oneof =which cannot be reversed, suggests that male contraceptive re-search is a virgin field_ Yet male fertility, is biologically much morecomplex than female fertility, and no new male contraceptive is likely .

to emerge soon. Similarly, no research breakthroughs ,on female.eon-Araception are imminent. The lack of medical understanding about thelong-term effects of the pill on the human body argues forcefully forgr eater r esearch.z6

Those who develop family planning programs must also address theissue of contraceptive supply. The U.S. government is fast becorninga major supHier of contraceptives, providing 70 pereent of the con-doms and seven of every eight monthly pill cycles dispensed by inter-national agencies to more than 60 countries in the liev_eloping world ,-in 1975. These figures mask the fact that many indus,kial natiOnsprovide contraceptwes through bilateral assistance. Nevertheless,many obserlters- question the wisclom of a supply_ system that couldbe crippled by the political whimsy of the U.S. Congress, undoingyears of public education and field work in the best programs.g7

22

mily planriin .methods equi re an ever-expanding supply ofntraceptivesa stea y drain,on foreign reserves in poor countries.costs are to be internalized, the source of supply stabilized, and the .23

impact of imports on _domestic economies minimized, contracep- '

five Foroduatiqn must increasiRgly be shifted to the developing world.Condom-manufacturing operations have already sprung up in mostAsian'Countries, and Indonesia has met all of its own IUD demandsince-1974; Mexico, India, and Cuba all have the raw materials and

the pharmaceutical industqes capable of meeting a growing por-tion of their oral contraceptive -demand. Unfortunately, developmentagencies and private pharmaceUtical industries have been slow to en-courage self-sufficiency A gradual shift of AID supply contracts toThird World producers, which would require Congressionarconsent:would be a shot in the arm to an infarct industry; moreover, with theproper incentives, international pharmaceutical houses could lendtheir manufacturing and marketing expertise to their emerging coun-

' terparts in I-atin America, Africa, and Asia.28

Where family planning programs become self-sufficient, they can better'supply each segment of society with- the contraceptive it prefers_ TheChines have experimented with the paper pill, develdped their ownIUD, and invented vacuum-aspiration abortion, all unique responsesto their own needc In Western Europe and the United States, afflu-ence has enabled 4ociety to create multiple services that have con-tributed vitally to increasing contraceptive -use, Whether a familyplanning program is aimed at the majority or at those by-etassed bythe contraceptive revolution, important elements in its success are

- the breadth of the choice of; birth:control methods and the ease of

accessibility to those methods_

The Growing Commitment

(-In 1960 President John F. Kennedy expressed doubt ihat any U.S.President would ever be asked to sign a bill providing foreign aid,forfamily planning. Within a decade, Washington was footing most ofthe bill for the international family planning effort. This turnabout in

23

sentiment did no confine itself in recent .yeais to Washington. The.-governments of many developing nations voiced strident oppositiOni,to family planning at the World Population Conference in Bucharestin 1974. Yet, by 1976 a commitment to limit family size and 'to im--prove the_ human sopdition linked in common purpOse most of -the -countries represented at the United-Nations.29

Family planning at the international level has onl-) recentty receiVedconcerted support. In the early post World War Il years, few-globalorganizations, national governments, or foundations wanted to. in- .1volve themselves in the extremely controversial And highly national-istic -debate over family planning. Not until the mid-siXties, whenthe economic health of developing nations worsened and food short-ages struck in India, did the reluctance of many to give money tofamily planning begin to dissolve.

By the mid-seventies, most international organizations and manynational governments and local communities no longer debated -therole population growat plays in economic developmentthe urgencyof slowing population' growth while pushing through economic re-forms had become self-evident. With unexpected vigor, countries putthemselves to the task. The international community substantiallyincreased multilateral financial assistance, National --leadersLuisEcheverria in Mexico, Suharto in Indonesia, and Ferdinand Marcosin the Philippines, among othersworked to reverse longstanding .domestic pronatalist policies and set the tone for -a revolution ih na-tional attitudes. At the community level, the stagnation of job markets,th4- frustration'of personal ambitions by unexpected children, and- therecurrence of food 4hortages all caused many who had been passedover by earlier family planning progr:ams to begin to take childbearingout of the hands of providence.

During the siventies, family planning's budget grew substantiallywhile new :aid patterns emerged_ (See Table 5.) Bilateral assistancegradually shrank over the years to less than a third of all aid. Mostdonors now channel their funds through, the major internationalpopulation organizationsthe United NationS Fund for PopulationActivit(UNFPA) and the IPPF..1°

2 4

=

Table 5i Primary Source of Bilateral and Multilateral Population'Aaistance

Country GTInstitution 1990 f#371 1972 1993 1974 1975 1976

(millions of doll;rs)Cinada LO 3.9 4.7 6:2 4.7 12.5 13.6Dem-nark -1.4 1.9 2.0 4.0 2_4 4.0 5.0Ford Fdn. 15.1 15.2 13.7 12.0 '14.0 10.7 10.8Japan 1.5 2.1 2.2 _2.8 5.4 7.9 12.9Netherlands , 1.4 1.5 3.0 5.7 6.0 7.2 8.7Norway 1.0 3.9 5.5 12.5 12.7 13_6 25.7Rockefeller Fdn. 15,1 2.8 6.6 5.9 6.1 6.2 6.5Sweden 6.5 9.2 12.7 13.7 18.3 27_4 30.6United Kingdom - 1.0 2_5

'9'5_96.7 4.2 3.0 , 6.0 - 8.4

United States 74,5 123.3 125 6 112_4., 110.0, 135.2West Germany 1.5 1-7 2.4 4.3 5_9 7-.5 7.0World Bank 2.0 7.8 ,34,4 26.5 37.0 25.0 61.8

Total 122.0 148_4 217_2 223.4 227.9 238.0 271.2

Source; AID and World Bank.

Although Washington long provided more than half of all.the bilateraland multilateral resources given to Third World programs, U.S. 6,v-ernrnent contributions to population projects decreased in the mid-seventies -and failed even to keep pace with inflation. fibru 19r3 to1975. In 1976 Congress showed new interest in population programsand funding rose accordingly. The major Arnerican foundations earlysupporters of the population movement, have begun slowly to scaledown thei,r donations_

Fluctpations in the U.S. commitment have been offset in part by morethan $10 million that 18 Arab League states have provided ,over atwo-year period for population projects in the Middle fast and NorthAfrica. In addition, other western nations and Japan substantially ici,-okeased their aid between 1970 ,and 1976. To date, nine ofevery ten

2

2.6

dollars disbursed by UNF A have come frorn non-communist_ coun-tries. The Soviet Uniop and the Eastern European nations have longbeen opposed to givink, and only Hungary and Yugoslavia have evercontributed to UNFPA.

The, demand for funding rings loud and clear from all parts of theworld. In 1976, the UNFPA budget met only two-thirds of the re-quests for assistance it received. The amounts for which Latin Ameri-can countries have asked, originally small, have increased about seven-fold in five years and_reflect growing national concern over the needto integrate population planning and development activities_ Asian andLatin American countries receive the lion's share of available resources

,-arid spend well over half of this money on contraceptive-distributionprograms.West Africa may be the only area of the world where popula-

,tion planning has not made important strides \in the seventies. Un-interested and even hostile, government leaders there have done littleor nothing to encourage the use of modern contraception in the faceof high population growth rates. -the traditional pronatalist equationlinking rapid population growth with economic growth lingers on inmany countries.31

Direct bilateral population assistance has been focused on a few coun-tries_ In 1974, the largest beneficiary of direct aid was the Philippines,with $34 million; Bangladesh and India followed with $21 million

"and $14 million, respectively. In many countries, outside assistanceoften provides a substantial ['cation of the family planning budget.But in some countries, including Indonesia, Korea, and the Philip-pines, more than 60 percent of the program is domestically financed:32

No one knows with any certainty how .much international organiza-tions, governments, private groups, and individuals spend annuallyon family planning. The Alan Cuttrnacher Institute estimates that inthe United Sta,tes in 1975 the federal, state, and local governments,along with prniate groups such as Planned Parenthood, spent $275million on medical family planning services. In additioo, private indi-viduals spent approximately $1.1 billion dollars on doctors visitsand contraceptive-supplies. There have been no attempts to estimatetotal expenses on a global basis since John Robbins of the IPPF did

2 6

. "President Suharto sits down everythree months,With his provisional

governOrs to review their progress inexpaiading contraceptive services."

so in .1971. At that time Robbins reckoned that the amount spent oneverything from condoms to -sterilizations was in the neighborhoodof,$:3-billion, nearly half of which was spent on abortions. While Rob-bins estimate is imprecise and outdated, it is instructive to note thatthe $271 million spent on international population assistance in 1976is less than 10 percent of all the money spent on family planningaround the world.33

Governmental .interest in family planning at the national level hasflowered in-the forms of new laws and adrninistrativ4actions aimed atlowering fertility. In T975, Asian and Pacific coudOies as a group,adopted for the first time specific target goals and dates for reducingtheir birth_rates; they hope to reduce average family size to two chil-dren within two decades_ In 1974, Mexico and Thailand added to theirConstitutions provisions that promise federal support for familyplanning, while the Brazilian government reversed its position andendorsed its citizens' right to have access to family planning. Duringthe early.seventies, Singapore initiated a wide-ranging program of economic incentives (such as giving sterilized couples priority in the-allocation _of housing) and disincentives (such as limiting maternitybenefits). In 1976, Phil:ippine social security benefits were extendedo-rovy9tcrilization.34

In Indonesia, where populati'ort growth is rapidly crowding people offthe archipelago's r ain islands, President Suharto has taken a personalinterest in family nning. tle sits down every three months with hisprovisional governqr to review their progress in expanding contra-ceptive services and has made the governors personally "responsiblefor the program's success. To back up Suharto's initiative, the gov-, .ernment has committed 40 percent of its total annual health budgetto family planning.35

Governments have begun to dismantle the barriers that make birthplanning difficult or impossible. Canada, the United States, aria Ger-many now provide family planning services to low-income womenat no cost. In Great Britain, all °contraceptives are available gratis fromthe' National Health Service. In- 1975, France made these items free argovernment clinics. In the same year, Singapore legalized sterilization

27"

7

2

for conSenting married persons over 21 years of age. In 1976, Swedenremoved all obStacles to sterilfkation for thbs`e 25 years of age andolder. The Philippines, Pakistan, Sri, Lanka, Bangladesh, South Korea,Iran, and Iraq have all removed prescription requirements for the pill.In the mid-seventieS, France and 'Italy made Advertising and distribut-ing contraceptives legal. In early 1977, U.S. courts were reviewingthe constitutionality of state laws lirniting the advertising and sale ofnon-prescription contraceptives.36

Yet, the passing of a law legalizing abortion scarcely helps a pregnant16-yearold who knows nothing of the services available to her andfears the chastisement of parents and society. To provide birth plan-ning services to the poor, the young,'the unmarfied, and those in ruralareas, family planning strategists have had to tailor programs to smaller groups . -In the Unite&States, BritainGermany, the Netherlands,and Sweden, special projects have been deSigned to reach out to adoles-

- cents, most of whom have long been denied family planning serviceshave been neglected by organized programs. To help mitigate the

special problems that poor working women often have obtainingcontraception, the United States has experimented with family plan-ning clinics at industrial sites, England has init Stec! speeial program

-_macle_a strong P ffurtto rekh farm women_

In developing countries, fa,rnily planning programs once tended totop at the city limits of the capital. Rural projects often failed be-ause they wyre run by urbanites or 'by international bureaucrats,any of whom did not speak the .local language and did not under-and village life.. Learning from these past failures, some governmentsve put local groups in charge of family planning programs.

'

As awarenes of the economic, social, and environmental costs of highfertility grows, so does the recognition that couples can effectively

- plan their families. A unique combination of factorsthe overlap of /s9n5l and.cornmunity interests in decisions about childbearing, the

icitous.marriage of family planning programs to self-help develop-ment projects, and the development of .innovative ways to reach themajority with modern contraceptivesexplains some of the new inter-

28

est in family planning. In turn, this interest itself suggests that theonce seemingly inevitable doubling or tripling of village populationsis not inevitable_at all.

Like each couple, each-soun ry has attempted to reach'the goal ofsmaller families in it-Sr' own way. Some contend that within broaddemOgraphic guidelines and with the 'financial support of the centralgovernment,: state officials will be best -able to lower birth 'i:ates. In::Indonesia, this approach seems effective; in India, it hasn't worked.In,1976, the Philippine Government issued a Presidential Decree call-ing for the creation of an Office of Family ?tannin& in every city andmunicipality to do premarital counseling on responsible parenthood.lite Thai GoVernment's vigoious program uses schoolteachers toprescribe pills, and traveling medical paraprofessionals and storekeep,ers of all-sorts to-distribute them,37

But -the most successful faMily planning programs in both rich andpoor countries share common characteristics. In all, there is a nationalcommitment to provide family planning services either through pri-vate medical, and commercial channels .or through government pro-grams. In all, abortion, sterilization, the pill, and the IUD are uni--- ly-bearing reflect the influence of their peers arid their corriniunity a;well as their self-interest_

Communities Take Responsibility

Traditional approaches to fillin the family planning g p have notcome close to 'meeting the need. Public familY planning-services werefirst offered in clinics. Some-programs were sensitively ru'ri; but inmany, persons could obtain contraceptives only by enduring considerable inconvenience and humiliation. Moreover, in Africa, Asia, andLatin America, clinics-often reached only those who lived within a fewmiles of a facility_ The difficulty the Indian subcontinent has, experi-enced in slowing its population growth rate significantly after yearsof effort stands as a mute reminder of many' failed attempts, tocontrol fertility. _ a

2 9

29

tLy 1.h_e community has replaced the clinic as the foCal point_ al innovative farnili planning progr,ams;. and efforts to slowpulation growth have been 'linked to attempts to raise the legalage Of -marriage, to the eicpansion of women's roles,, and to otherreforms. In several countries, contraceptives are now providedthiough comMunity-based distribution systems, in which a villagerwho is known'ind trusted by his or her neighbors supplies them withlow-cost contraceptiVqs. In some nations, contraceptives are now sold'ixt the village market, where even' the poorest congregate. In addition,pasaprofessional health workers now dispense pills and peTformabortions. All these grassroots techniques have increased family plan-ning's sphere beyond that of the woefully inadequate medical systemsof many poor countries to encompass the everyday life of averagecouples.

The type of family planning work now being done at the communitylevel and the amount orcitizen participation in these programs variesby country. Creating new projeets _and supplying contraceptives,the government controls the program in most nations; but govern-ments have begun to transfer to the local level some of the responsi-bility for distribution and User -motivation. In many government-runUTMl nuig.prograrns ,, new-ef for ts-terpersonalize -s-ervic-ess-nd toeach e disadvantaged are under way. In China, Indonesia, andrea, groups of couples who collectively plan their childbearinghave begun to play a ndw catalytic role.

)

Fittingly enough, the world's most cm:ganized arid decentralized familyplanning program is in the world's most populous country, China.,The Chinese family planning credo itself is concise: each couOleis entitled to, but should have no more than, two or three childrenirrespective of personal preference, social litatus, or incone. Familyplanning in ,China is legitimized by the oft-quoted phrases of MaoTse-tung that pepper the' discussions of the Chinese family plannersjpnd- by the support of tli Planned Birth Office within t e Stareouncil, the country's hig est administrative.body. Chinese familylanners push Jate marriag while marrying at 18 is legal, waitinguntil the combined ages the bride ant+ groom equal at least 50years is rapidly becoming ãç rigueur. It is almost national .dogma

in China that women can- be men'i equals only if they are freed froindless shildbearing, so child spacing and small families are encouraged. -A -pension system in the urban areas and guarantees of basicnecessities For chilaile-ss couples in the countryside have helped lessendependence on children for old-age security.38 ,

.Family planning in- China is the -responsibility of numerous smallgroups in factories, neighborhoods, and villages. Meeting once or.tvvice a year in assemblies of 10 or ?.o, couples plan among themselvesthe number of births for their group f r that year. Schooled by theneed to plan locally for production, inc rne distribution, investments,-and social welfare, these groups,fully un erstand the cost to the corn-

- munity.of exces'sive childbearing and coo ate ibeir birth plans withthe targets set by community, regional, and national ag'encies. Onceihe humber df births for a factory or neighborhood group has beenset, the members allocate the births among themsdves. Pi-chao Chenreports that couples are given priority in the following order: firstare the newly married who are free to have- their first child withoutdelay; second ,are couples with only one or two children; and thirdare couples whose youngest child is nearest to five years of age. It .isnot known if this method of group Planning, which was appasentlyfirst developed in Shanghai in the early seventies, has been fullyadopted in rural areas; but travelers in China report its 'partial use ineven the most remote provinces_30

The main unanswered question about family planning in China., ishow birth planning groups get people to agree and to cooperate.Reports of the loss of- ration, cards and of employment, housing, anddducational sanctions against thase who defy the birth planninggroup occasionally filter out of the country_ Yet, Chinese, familyplanning officials in countless interviews over the last five years have .insisted that patient persuasion by peers, and not coercion, is the key.Indeed, tight community bonds typify Chinese society, and these havebeen strengthened by A mutual self-interest born of the remarkableimprovement in the standard of living over the last generatiOn_ Sochshared sentiments suggest that ifidividual desires may be more easilysubordinated to the will of the community iyi China than in mostother societies. Since few countries have such cohesive forces, tile

..

3'1

techniques that Chinese family plinneys use to motivate and educate-people may -not work well, in otfter cultures. Surely,- Chirias successin family planning .is "tied to profound social and political changes -.

"that may be difficult to repeat in other developing nations.

The ease with which the 'Chinese provide couples with tontraceptiveservices,:-influences their tuccess in lowernig- their birth rate. Everygovernmental bpdy-o5 unit of industry has one person in charge ofcarrying on family planning' education. broth men and women canobEain pills and condoms-at their wOrkplace or at home. In addition,someone in each of the courtyards- around which houses are clusteredin the older parts -of the citiis administers basic first aid and both

,gives out and reminds coupks to use contraceptives. The nationalhealth service aid for by the central government ahd the local corn.-munity provi es alt.-contraceptive servicesincluding sterilizationand abortion on demandat no charge. 40

The Chinese faraily planning system was designed to distrthute inex-pen4ive contraeeptives on a massive scale within a country with rnea-er incomes arid too few trained personnel. Most observers agree thate program has Veen uniquely successful: it provides a full range of

contraceptive services nationwide; responsibility for the success ofthe effort rests with tho`se moo affected by population growth; andthose .at risk of unwanted 1..,,,.b.piancy haVe contraceptives delivered totheir doors. In some form all these methods have been attemptedpiecemeal with mixed success in other countries. Only recently havethose directing family planning programs recognized, as the Chineseapparently did, the benefits to be derived from pursuing these ap-proaches simultaneously. .

In Indonesia iri the early seventies, a bew sense or the urgency ofslowing population growth emerged. From the office of the Presidenton down, an awareness grew -that family planning could not be left.solely within .the purview of the Minister of Health. Population pres-sure came to be viewed as a problem affecting general communitydeveloprnent; and thoughtful Indonesians recognized that strength-ening family planning meant_making--- birth control efforts a commun-ity rather than a central-government undertaking.

3 2

-The Natioha amity' PlanningCoordinating Board refit its programs .

to the social structures and decision-making patterns-of Indonesian village

life. '

Originally, the Indonesian government tried to establish a clinic-basedfamily planning program. When the program failed to increase contra-- ceptive use significantly,- the National Family Planning CoordinatinBoard (BKKBN) refit its programs to reflect the social structures andecisionLmaking patterns of Indonesian village life. Since Indonesianstend to view themselves as members of a village community first and.-as independent individuals second, the approval of their families, their

- neighbors, and their friends counts for much. For centuries in Bali,family heads have met monthly to make decisions affecting the wholevillage. In Java, the elected or .traditional headman of each hamlet-commands the respect and obedience that a father in a family does.Thus, the BKKBN turned to these headmen arid to these decision-making bodies for help in Tecruiting contraceptive users and in sellingvillagers on the idea of small families.Ai

In response to village women's complaints about traveling long dis-tances to obtain contraceptive supplies, the Indonesian government;established some 27,000 village pill and condom depots in Java and'Bali, often in private homes. In many villages, women needing sup-plies siinply come to the pill distributor's home periodically. In others,;women assemble monthly at meetings of the local mothers club, orApsari, to buy their contraceptive supplies at nominal fees and to dis-cuss their health problems. Often a nurse-midwife attached to the'regional BKKBN attends to discuss these problems and to examinenew pill users xtensive charts and lists are kept and displayed sothat every villager knows'who uses each method of contraception.

That the role of the central government has helped determine thesuccess of the Indonesian program is apparent. In most cases theApsuri began at the initiative of the family planning field workers,and many grew out of existing women's clubs for older women. Inmost villages, the government has rallied the headmen in support ofthe program and the Apsari meet jn the headmen's homes under theirwatchful eyes. Yet, reports' indicate, woinen attend more out of a senseof participation than out of obligation, and they bring their friends.When a woman drops out of the group or stops using contraception,the village headman is likely to call her in for a talk, and members ofthe Apsari may visit her to discuss the matter. The success of this

3 3

effort seems rooted in the shitne Indonesian, Villagers tend to feel if'they are abtraCized by their community.

The Apsari meetings have grown beyond mere exercises in familyplanning. Speakers and discussions expose women to alternative andsupPlementary roles to motherhood. Numerous studies indicate thatthe wornervfnVolVed have_cleveloped a new sense of village participa-tion and take .pride in community development_ Several groups havestarted cooperative rice-savings banks, developing a food reserve for

,the.village. Others have developed small savings and loan operations,,.tlending money to start community gardens, stores, or to support

special projects like the rerpair of irrigation works. Overall, the ,activi-ties of the Apsari are closely coordinated with other cooperative devel-opment actiVitiel encouraged by the Indonesian government.

Indonesia's 'familir, planning program is neither a populist under-,taking in the midwestern American tradition, nor solely the handi-work of the authoritarian military regime in Jakarta. It seems to be aunique blend of gbv rnent initiative and local custom. The programhas yet to,reach a ijority of Indonesian villagers and its impact onfertility, and ultim y on development, has yet to be adequately

,measured.

Many criticize th program and some suggest that contraceptive usemar level off after, he most easily motivated have been Teached. Tobe sure, the ultirrAte success of family planning in Indonesia willdep-end on the_ goyernment's ability to cope with the country's manyeconomic and ecoltigical problems. Yet there is some reason for op-timism. Prehmina ',results horn the Indonesian World Fertility Surveysuggest birth ..rat itave dropped faster in Java and Bali in recentyears than._in.,ey other developing country save China. Instead ofestablishing complicated bureaucratic systems flat registering births,marriages, and the distribution of contraceptives, a whole range offertility-related activities,is carried out at-the community level. Somevillages have acted on their own to raise the local legal age of marriage.As Haryono Suyono of- the BKKBN points out, -the long term suc-cess of- family planning in Indonesia hinges on the ability a thegovernment to transfer to the individual and the community the same

3 4

sense of urgency'that now exists at higher levels of government ra herthan simply imposing .a family planning program on an otherwise'Uncommitted public. ''42

Less anthitious than Indonesian family planning effeirts, the Mothers'Clubs of South ICorea form one of the oldest and largest systems ofcommunity-bdged contraceptive distribution..Originally, the Koreanfamily, planning program depended on field workers Who werevidually responsible for reaching over 2,000 couples each in as manyas 610..villagesa caseToad that would make a saint flinch.,To rectifythis sitpation, the Planned Parenthood Federation of Korea reorgan-

tiz4d-and expanded its family planning serVices through the cieation..of the Mother's Clubs.43

--Today many women meet in the homes of their elected club leadersto receive their monthly supply- of pills or condoms and to discuss

f the value of small families and child spacing. Though some bureau-crats in Korea's family planning progr4rn would, reportedly, like tosee the Mothers' Clubs focus almost exclusively on birth control, theClubs emphasize village economic development. According to a studyconducted in 1973, three-quarters of the more than= 20,000 MothersClubs had established credit unions. Others had initiated'reforestation'projects, diveloped new rice lands, bought livestock herds, and open-ed,grocery storeS. While family planning programs in most develop-ing countries are today much more effective in urban than -in ruralareas, the Korean program is almost equally effective in bothAnd theMothers'.Clubs deserve much of the credit.

Not all decentralization projects have worked. In the mid-seventiesthe Pakistani government launched a bold contraceptive inundationprogram in which contraceptives were to be distributed throtlh35,000 shop -outlets and 750 clinics, and by over 5,000 fieldworkgrswho were supposed to visit,and advise all the married couples in theirassigned area three to four times a year. The theory behind this pro-gram was that flooding the countryside with affordable birth controlpills and condoms would satisfy a latent, previously unfulfilled de-

. mand for contraception and actually' increase that demand. Yet, a,

study conducted in February 1077 by -the U.S. Senate Committee on

3 5

Foreign Relations coJided, the availability of contraceptives inPakistan has not significantly increased contraceptive use.45

Proponents of -the Pakistani program argue that the gOverrirnent.wassimply unable to establish an effective distribution system, so suppliesremained in thewarehouses. Critics charge that the government is ri0t,,fully committed to the program. Furthermore, many observefs question whether supply creates its own demarid;~- they argue that inun-dating the market with contraceptives will not significantly increasethe number of couples using modern methods of contraception untilcouples :are motivated to change their views on the number of chil-dren tfiey wish to have.

But similar projects, often called househcld distribution schemes, arebeing _experimented with in a number of countries, seemingly 'Withmore success. In Colombia, part-time family planning workers sella variety of contraceptives to their neighbors at low cost, makMg asmall profit on,each sale. In a project in Honduras a small group ofsatisfied contraceptive users are paid a monthly salary to supply other

.women in their community with contraceptives.4a

-These programs differ significantly from the community mobiljzationtaking place in China and in the Mothers'Clubs iA parts of Indonesiaand Korea, though both 'styles rely -on 'peer pressure and neighbor-hood structures:, Household distribution schemes are designed pri-marily 'to improve the deliyery of contracePtive supplies and do notattempt to motivate increased contraceptive use by linking familyplanning to other development activities. Similar efforts to decen-tralize family planning in other ways have also, focused on attemptsto increase access to services_

For years; family planning clinics resembled the olit-patient facilitiesof hospitals. Those who used contraception had to seek out servicesas if the users 'were patients with illnesses_ The clinic was a passiveforce in the communify. While clinics remain the major focus offamily planning activity in most countries, ,many governments havebegun to use clinics to back up more comprehensive effort., In 19b6,several countries launched an intelnational postpartum family plan-

3 6

-

"Outgrowing the confines of theclinic, new family planning strategiesreach people where they shop, work,

worship, and live."

ng program. Their aim was to reach women who had just givenirth or who hadjust had an abortion iri a hospital or clinic. By-1974,cite thin 1,700 institutions in 21 countries (including 926 in the 37

United States) were using the postpartum approach. Encouragingatients to be sterilized, to have an IUD inserted, or to use the pillas proved sucEessful with about one in three Nomen in these pro-

grams.47

Some governmeht health planners now consider family planning asan integral part of maternal and child health care. Studies have shownthat children born to youris mothers, the youngest children in largefamilies, and children born within a year or so of their siblings Oftensuffer horn malnourishment, are susceptible to illness, and have deathrates much higher than the children of Women in their twenties Whohave spaced their _childbearing. Struck by these correlations, theCuban and Tanzanian governments have established village-levelmaternal and child health-care prbgrams that include distribution dcontraceptives.45

In those many nations in which-most babies are born outside the \reach of the formal medical 'establishment, governments are harcUpressed to build hospitalS fast enough or to revamp their healthstrategies soon enough to meet imenediate family planning needs. Thedemand at health clinics for curative services usually swamps doctors'best efforts to -integrate family planning into full health services,especially where fully trained medical personnel are scarce. To over-come these problems, many countries are looking toindigenous mid-wives and to teams of health workers schooled in preentive medicine.The portion of women accepting family planning who chose the pillover less effective methods rose from 10 percent to 72 percent duringthe first two years that auxiliary midwives in Thailand were permittedto prescribe the pill. In addition, possibly because pill dispensershad pefsonal ties to pill users, those recruited by the midwives tended -

to stay on the pill longer than those who received oral -contraceptivesfrom doctors in clinks.49

Outgrowing the confines of the clinic, new family planning strategiesreach people where they shop, work, worship, and live. Although a

3 7

\

day's walk separates some communities from the nearest- hospital or_ family planning clinic, most potential contracePtive users have dailycontact with grocers and itinerant, folk-medicine inert, By linking Alpwith an established commercial distribution network, family plannershope to reach a large portion of the populatipn -at a -low cost. Urifortunatelyimarketing se.herires, -like hourseh-old distribution strategies,

-- already involve little loriglasting mdtivaticin and can only serve thosealready interested in using contraception. Moreover, stories abound,

_ of condoms beiitg sold as'balloons and of shopkeepers downplayingthe promotion oftbirth con.trpl devices. Just what contribution adver-

=tising and the cOrnmercial distribution of _contraceptives can make toward filling the family plan ing gap remains to be seen. -

..

One of the fir* majorlation Servieef. _rnatior%04The pragyarn12.. n in 1"Preethi" happiness in blanguages in. ' Lavarious comm.hand with thkfinger, has Becthe island's tea

isold each monname of

ting proms was that started by PopuLanka and nov+.', cun by IPPE. '

ort to- Market a condom called--alese 'a mil, the two principal.

o a UitIibutes condoms throughrid the ''Preethi- s'c,mbol, a stylized

held betweenthe thumb and fore-as the bunches of bananas that grace

id-1976, over" 450,000 condoms wereere distributed nationwide u 'der, the

ich means -the woman's friend.', .claims that saletf figures- icate that growing numbers of per-

, sOns are practicing contraceptioti and that more are also siva hing toeffective Means of planning lam s '. Howevet, the reethicampaign is aimed at those With a verage incomes; pric s wereset to encaurage the idea that con aye, intrinsic, value and toenable the program to becctme sel Mg eventually. A thoughthe poor, who would have to pay mi e rr -,a day's wages f r three-Preethi- condoms, are by-Passed in t ktn4 bf marketing effort,such programs do meet the contracept ds -I certain s gmentsof society.

SiMilar projects have sprung up in a nThailand opened what is possibly 'the

e 1 developing countries .

rst contrace tive su--.,

permarket in a Bangkok bus terminal in 1975; various contraceptivesand educational materials are sold in the store, and a midwife,coun-selor doubles as a salesclerk. In Colombia social customs hindered,if not blocked altogether, access to .contraceptives for years. Now pills,condoms, and contraceptive foam are familiar; counter-top items inurban pharmacies and country stores. It is estimated that from 1970to 1976, nearly half of all users of modern contraceptive methods inColombia obtained them from commercial outlets.51

In tilt industrialized world, the- commercial salcof contraceptives isrestrieted primarily to no-n-prescription methoels. Door-to-door con-

- dom saleswomen in Japan generate a sizable portion- of the sales ofJapan's falrorite contraceptive, in many cases selling directly to otherwomen.One-third of the condom sales in England take place in barbershops, while-department stores carry condoms in Sweden. In Bologna,Italy, condoms are available from vending machines on the street. Inthe Urtited States, however, contraceptives are marketed less exten-sively. A national survey conducted in 1975 levealed that more thanfour of ten pharmacists refused to exhibit condoms openly, a legacyof the under-the-counter image that inhibited condom sales a genera-tion ago.52

orking- with "youth is the focus of one decentralization effortGrape-vine, Britain's Lcommunity sex -education project for adolescents.

-Grapevine trains young volunteers to work with people their own agein coffee bars, in pubs, and on the streets. This program, whichstarted in London, has expanded to other British towns and wasrecently imitated in West Germany. Because of a shOckingly high vene-

a'eal disease rate among students, rap sessions on adolescentS sexual ,problems led by volunteer peer counselors have been organized dur-ing school hours by 11 New York City high Schools. Since 1974,Woodson High School in Washington, D.C. has had the only satool-

, based contraceptive clinic in the United States; peer Counseling goeson during cl5ss hours, and students can have phjrsical examinations,and obtain contraceptives from the clink in the school at the close of

; the school day. So, too, mariSr American colleges and universities haveloosened- their restrictions on dispensing contraceptives in studenthealth centers.53

Bent upon.reaching tile young mare effectively, many, national familyassociations .are also re-examining-their internal structures. Too often;

recent study of the 12 European members of IPPF showed, poliCyis forffinlated and-carried out primarily-by per4one over 35 years of

,age. Sirnilarly, the boards of these organiz,atiops seldom hawe mem,hers under age 23 although adolescents are otie of the main Igrpupsserved by some family planning.prograrns.

Even though all workers need contraceptives and though the number,.=,.of _women workers grows steadily, few eMployers and trade unions inthe industrial wbrld offer family planning serviceS to their-employees.Where health serviCes do exist, family planning services usually re-main outSide the scope of the Care provideii Job-site family planning_centers are still few and far between.54

.

In the developing world, hOwe'ver, some employees now provide cont _traceptives and incentives to keep'-fainilies small; tsugge5tte5tu c1s ha-1 tmaking such .,services , aVailable increases worker .pfoduetiviry -andattendance. Possibly the most innovative program involves 'womenworkers on tea estates in South India: each month during whfch a

..lernale employee does not bear a child, a small sum of money is put in-to a retirement fund for her.-Therprogram trieS to get parents to space,children at intervals of- three or more years and to limit family size totiree children A worrian forfeits part of her retirement fund if she haschildren in rapid succespion or opts for a lar'ge family.55

Often the largest single employer in a developing economy, goverp-ment too can sponsor work-telated family planning._The Indian staterailroad provicres fainily planning se'rvices, including sterilization, forall its employees. In the Philippines, employers with more than 200workers are required, to provide fkile family--,planning services. TheCoffee Growers Committee, a natiorwide maelcetin,g Cooperative, sup-plies approxiMately half the funds for Colombia's -rural family plan-ning program and lends legitimacy to'efforts to expand contrac'eptiveuse,56

,

That organizations of all sorts can help their memberg plan their-families is.brought home,by the story of the Iglesia ni Crigto, an eVan-

4 0

-Sund4y sermons often contain aword onchild spacing, and

contraceptives are distributed as thecollection plate is passed."

gelical Christian denomination in the Philippines with about fourmillion members. Since 1973, this church has preached the social And

rsonal responsibility of its members to limit family size, and it has_ecome the major private agency ,involved with Philippine familyplanning, running the largest male sterilization program in the coun-try. Church-owned radio stations beam family planning messagesdaily_ Sunday sermons often contain a word on child spacing, andcontraceptives are distributed as the collection plate is passed. Churchprograms are also developing in other areas: in Mauritius', the Catho-lic Church backs programs to teach women the proper use of therhythm method; in South Korea, the National Council of Churcheshas organized door-to-door contraceptive distribution arid set upfamily planning clinics in parish halls in Seoul, Pusan, and Taejón.57

Decentralized family planning programs run the gamut from highlyarticulated;political programs to modest efforts to improve the dis-tribution ca- contraceptives. Where contraceptive use has been linked toindividuaL social standing in the community and to personal economicimprovement, preliminary studies suggest that family planning ac-tivitY has risen sharply. Programs that are more stipply-orientecl andhat involve less effort to motivate couples to practice birth control

are more controvftsial, with successes and failures dotting the map_It may be some time before the best decentralization strategies areidentified.

Filling the Cap

James Boswell, biographer of Samuel Johnson, once observed thathumanity often deludes itself with -the triumph of hope over experi-ence.- In the last generation, many who were fervently committed toslowing population growth were mesmerized by their wishes andenthusiasm; struck by the urgency of what seemed to be the inescapa-ble logic of demographic extrapolations, they often grasped for simplesolutions to the complex question of why parents have large families.In the process, governments and foundations have firec_ salvos ofmoney and expertise at th-e population problem with, until recently,relatively little success. While the rich have generally established con-

.

4 1

41

trot over their fertility, the poor, the young, the unmarried, and therural continue to have difficulty planning their families.5$

The several hundred million couples in the world who, without thebenefit of a safe and reliable contraceptive, face 'the risk of an un-planned or unwanted pregnancy bear wisness that there is no simpleway to provide family planning services. In Asia, Africa,. and LatinAmerica, family planning still ranks with basic health care as a Humanservice that large segments of the population do without. A couple'sdecision on childbearing is often taken in isolation, with little oppor-tunity to relate it to the overall welfare of the couple involved or tothe well-being of the community, Family planning remains for manya fumbling exercise of odtdated, freqUently futile, and often danger-ous methods.

Yet two-thirds of the married women in most industralized nationsuse contraception. Few social service programs have progressed asrapidly as the family planning programs in rich countries, and newevidence suggests that this success is being replicated in several devel-oping nations. While memories of dashed expectations are sobering,some tentative and hopeful conclusions can be drawn- from recentfamily planning experience, pointing tlie way towards what can bedone to close the family planning gap.

Attitudes about family size are critical to the accptance of family plan-- ning. Throughout history, when couples have __ecided small family

was in their own interest, they have limited the number of their chil-dren deSpite all obstaclesalbeit imperfectly and at considerable risk.The view espoused- by some, that the'poor bear children irresponsibly,bespeaks prejudice and misunderstanding. Large families are less theproduct of unrestrained fertility than of perceived par,ental self-interest, birth control failures, or the view that family size is beyonda ccniple's control_59

Today attitudes toward family size are in flux.- Recent surveys con-ducted in Japan, Europe, and.the United States all show that womenhope to have fewer children than their mothers 'or even their oldersisters did. Similar surveys in developing countries are inconclu-

4 2

sive, but desired family size generally remains large. The precise man-ner in which changing attitudes toward family size come about andhow they translate into fertility decline is not fully understood. Theold demographic transition theory, which- suggested:that birth ratesfall after development has occurred, is now in question. Recent studies,suggest that the connection is less direct, that fertility may fall with-out significant- economic development, and, that improvement inliving standards smay even encourage, the formation of larger. fami-lies. While this debate waxes and wanes, it would ap'pear that organizedfamily planning programs work best in countries where averagincome is highesti where the distribution of social services is relativelyequitable, and where economic and social reforms have given the poornew opportunities.60

If any lesson can be learnekfrom past experience,lt is that inadequatehealth care, educption, housing, nutrition, employment, and familyplanning are all aspects of the same afflictionwhose symptoms can-not be treated in isolation. China'S rapidly declining birth 'rate, forexample, reflects a combination of radical social changes made forthe overall benefit of the majority of the people. Despite administra-tive difficulties, the most suCcessful development efforts and familyplanning programs have been those that addressed a whole range ofproblems comprehensively and simultaneou4ly.

Family planning action is required on several fronts Since 1970,ternational financial resources available for family planning havemore than doubled. But even these dramatically expanded resourceshave not been able to keep up with the demand from national gov-ernments for funds_ While some of this aemand no doubt represents awillingness to take advantage of any available international develop-ment assistance, the actions of many governments suggest that theircommitment to family planning has deepened. Throwing money atthe population problem will not solve it, but censuses and familyplanning programs conducted as part of overall health care and devel-opment strategies do cost more than many poo'r governments 'canafford. The major international donors may well need to double thesums they now give; indeett at least 400 million dollars a year for thenext ten years could be put to efficient and effective use, according

4 3

to UNFPA and AID. These levels of as istance could, of course, de-cline as countries begin developing se f-sufficient family planningprograms, producing their own coniraceptives and funding their owndistribution programs..1

Developing effective programs_ and creating a legal and social atruos-Phere in which family planning has a cli.ance, to work requires stronggovernment support. Between 1974 and 1976, more than 40 govern-ments took steps either to update existing family planning laws andpolicies or to introduce new ones_ At the same time nations began tochange laws and social customs, such as the age of marriage and therole of women in Society, that affect fertility. Fewer governments,however, have backed innovative development strategies that en-courage fertility decline or have committed the resources necessaryto launch a broad-based effort to fully educate the public about theconsequences of rapid population growtb..2

To date the most successful family planning programs have been themost decentralized ones_ They have shown that they can win overmore people to contraceptive use, achieve higher contraceptive con-tinuation rates, and cost less than conventional efforts_ Most of theseprograms have focused on improving supply lines. Supporters of im-praed distribution efforts assert that the first task of both interna-tional and national programs is to pro%;ide c'ontraceptives to thosewho want them. Yet many observers believe that complementaryefforts to increase the number of people who 'desire the services areeven more necessary. But these two approaches need not clash. Newsupply outlets include many organizationschurches and industriesthat should-be viewed as little communities; and new motivationalstrategies can often exploit peer pressure in these groups to changeattitudes about family size.

Such peer reinforcement is commonly found where birth rates are fall-ing_ In both the. birth planning committee meeting in the Chinesevillage and the rap sesion in the American college dormitory, the

-opinions of peers prompt both men and women to examine seriouslytheir expectations about family size.

4 1

" eer reinforcement is commonlyfound where birth rates are falling."

Success in such efforts depends on working with well-organized com-.rnunities., Wherever possible, family planning programs should Workwith `groups that possess an internal administrative structure or an in- qaformal means of social control over their members and with groupswhose constituents have shared interests_ Where this has happened, thegroups involved have been strengthened, developing new adminis-trative and organizational skills that they put to good use. For ex-ample, in Indonesia many. Apsari have already begun to pressure the

overnment to expand its other development projects. Self-help fami-y planiiing programs can be linked to self-help housing, health care,food production, and education efforts to encourage individuals and

.-communities to master their personal and collective destinies.63

Where strong community organizational structures do not exis gov-ernment 'policies should help foster them. Most specifically, gov-ernments might extend to whole communities that cooperate in familyplanning ventures economic benefits similar to those now offered inmany countries to couples_ Such group incentivesa villagc well, anew schoolior a better_roadcan often capitalize on peer pressure toencourage communities'to work together to reach specific populationgrowth targets.

Yet peer pressure can only go so far, especially in large communitiesthat are rint socially and politically csyhesive, In many villages, racialand ethnic splits may stymie efforts to utilize broad-based peer pres-sure, The social disruption brought about by recent massive rnigra-tion to urban centers in developing countries has compounded thedifficulty of effectively organizing slum dwellers, In India, the divi-sions of caste and _clan -make such 'appeals in development effortsdifficult_ Clearly, Chinese-style or Indonesian-style peer pressurewill not always work,

Political reforrn, international and national commitment, and in-volvement must ,undergird- successful family -planning stra,ties Butall this will come to naught unless legal abortion and a wi e range ofcontraceptive methods Care made available__ Among devel ping na-tions, only China, Singapore, and South Korea .now perLiit unen-cumbered access to abortion, sterilization, the pill, and the IUD, Even

4

46in rich countries, several million women each, year have unplannedpregnancies because modern means of contraception are not easilyobtainable. Providing couples with the wherewithal to plan theirfamilies safely and effectively is certainly an important element inchanging fertility patterns.

Just as there is no one best contraceptive, there is no single way tofill the family planning gap_ Each country Mu5t find itg own path,designing programs that -are sensitive to the cultural, political, andeconomic realities it faces. In some societies, this may mean improvingthe supply and choice of contraceptives; in others, it may entail work-ing with local groups and using peer pressure to help 'change attitudesabout family size. But the most successful programs will be those thatlink supply and motivation.

The reason for hope that the initiatives outlined here win succeed_springs out of the fresh political climate surrounding family planning.At the World Population Conference in Bucharest in 1974, many gov-ernments vented pent-up frustrations born of development programsthat had failed to reacl ihe poorest of the poor and of populationprograms that slightecVeconomic and social change. The debate thatensued, cleared the air_ In many societies, ',for the first time, familyplanning and development are no longer an tither/or proposition.The rhetoric has begun to turn to action 'as couples in both rich andpoor countries relate their personal childbearing decisions to theirnation's, theit community's, and their family's well-being_

4 6

1. Joy G. Dryfoos, "Women Who Need and Receive Family Planning Services:Estimates at Mid-Decade.- Family Planning Perspectives, July/August 1975;Sallie Craig Huber, "World Survey of Family Planning Services and Prac-tices," in International Planned Parenthood Federation, Unmet Needs inFamily. Plapning (London: Planning for the Future, International Confer-

.

awe, October 22-27, 1973); IPPF is currently updating the "World Survey,'"and the results will be available in November 1977; J. Joseph Speidel,Planning: A "Failur' of Strategy or Resources,- unpublished paper, undated.

2. J. Mayone Stycos- and Cornell Capa, Margin of Life (New York: GrossmanPublishers, 1974); -Marriage and Divorce, Russian StyleStrange Blend ofMarx and Freud," LIS_ News and World Report, August 30, 1976; WilliamBurr Hunt II, -Adolescent FertilityRisks and Consequences,- PopulationReports, July 1976; Erik Eckholm and Kathleen Newland, Health: The Family.Planning Factor (Washington, D.C.: Worldwatch 'Institute, January 1977);John E. Anderson, Leo Morris, and Melita Gesche, -Planned and UnplannedFertility -in Upstate New York," Family Planning Perspectives, January/February 1977.

3. Anna Luise Prager, "One Baby in Six a Foreigner,- International PlannedParenthood Federation Europe Regional Information Bulletin, April 1975;Margaret Bone, Family Planning Services in England and Wales (London: HerMajesty's Stationery Office, 1973).

4. Alan Guttmacher Institute, -11 Million Teenagers,- New York, 1976:John F. Kantner and Melvin Zelnik, -Sexual and Contraceptive Experienceof Young, Unmarried Women in the United States, 1976 and 1971,- FamilyPlanning Perspectives, March/April 1977; Cynthia P. Green and Susan J.Lowe, -Teenage Pregnancy: A Major Problem for Minors," Zero PopulationGrowth, Washington, D.C., 1976; Hunt, "Adolescent FertilityRisks and Con-sequences."

5. Hunt, -Adolescent Fertility=-Ri ks and Consequences-, Alan GuttmacherInstitute, "li Million Teenagers."'

6. Toni Heisler Firpo arid Deborah A. Lewis, -Family Planning Neads andServices in Metropolitan Areas,- Family Planning Perspectives, September/October 1976; -Women's Needs Unmet,- International Planned ParenthoodFederation Europe Region Information Bulletin, April 1976.

4 7

7. Law 'and Population Programme, Fletcher School of Law and Diplomacy,Tufts Umversity, Legal Handbook on Contraception, Voluntary Sterilizationand Abortion (Washington, D.C.: Agency for international Development1976); Japan cl_ration for International Cooperation in Family Planning,Basic Readings on Population and Family Planning in Japan, Tokyo, Septem-ber 1976; "Survey Reveals Rapid Changes," People (London), Vol. 2, No, 4,1975.

8. Charles F. Wescott, -Trends in Contraceptive Practice," Family PlanningPerspectives, March/April 1976; John C. Caldwell, et al., Au5tralia: Knowl-edge, Attitudes4 and Practice of Family Planning in Melbourne,. 1971," Studiesin Family Planning, March 1973; J. Fed and C. Carr, Contraception andFamily Design; A Study of Birth Planning in Contemporary Society (NewYork: Churchill Livingstone, 1975); Population Problems Research Council,Summary of Thirteenth National Survey on Family Planning (Tokyo: Main-ichi Newspapers, August 1975).

9. Huber, -World Survey of Family Planning Services and Practices"; pi-chao Chen, -China's Population Program at the Grass-Roots Level," StudieSin Family Planning, August 1973: Pi-chao Chen, Population and HealthPolicy in the People's Republic of China (Washington, D.C.: SmithsonianInstitution, 1976).

10. "China Rethinking Traditions in Light of Overpopulation,- intercom,Population Reference Bureau, November 1975; Carl Djerassi, -Some Obser-vations on Current Fertility Control in China," The China Quarterly, Janu-ary/March 1974.

11. Dorothy Nortman and Ellen Hofstatter, -Population and Family Plan-ning: A Factbook," Reports on Population/Family Nanning, December4969,July 1970, June 1971, September 1972, September 1973, December 1974,October 1975, and October 1976: Jerald Bailey, Carol Measham, and MariaUmana, -Fertility and Contraceptive Practice: Bogota, 1964-74,- Studies inFamily Planning, September 1976; Working Committie for .the Study of theImpact of Family Planning Programs on the Demographic, Economic, andSocial Structure of Colombia, -An Estimate of the Direct Impact on FamilyPlanning Program in the Birth Rate of Colombia," unpublished eaper, June1976; National Family Planning Coordinating Board, -Monthly StatisticalSummary," Bureau of Reporting and Recording, Jakarta, Indonesia, January

- 1977_

4 8

Lester R. ylrown, World Population Trends: Signs of Hope, Signs ofStress (Washington, D.C.: Worldwatch Institute, October 1976):

13. Bernard Berelson, "World Population: Status Report 1974," RepoPopulation/Family Planning, January 197+.

14. Christopher Tietze and Majorie Cooper Mustein, -Induced Abortion:1975 Factbook," Reports on Population/Family planning, December 1975;.Leste0R. Brown and Kathleen Newland, "Abortion Liberalization: A World-wide Trend," Worldwatch Institute, Washington, D.C., February 1976.

15. Brown -and Newland, -Abortidn Liberalization"; Edward Weinstock et al.,"Abortion Need and Services in the United States, 1974-1975," Family Plan-ning Perspectives, March/April 1976.

16. Japan Organization for International Cooperation in Family Planning,Basic Readings; Weinstock, "'Abortion Need and Services": Tietze and Mus-tein, -Induced Abortion."

17. J. Joseph Speidel, Agency for international Development private coinunication, February 25, 1977; Tietze and Mustein Induced Abortion ;Huber, -World Survey of Family Planning,Services and Practifes.-

1B. R. T. Ravenholt, "World Epidemiology and Potential Fertility Impact ofVoluntary Sterilization,- presented to the Third International Conferenceon Voluntary Sterilization, Tunis, February 2, 1976; Malcolm Potts, -De-mand Grows for Sterilization,' People (London), Vol. 3, No. 2, 1976; West-off, -Trends in Contraceptive Practice", J.. Joseph Speidel and Margaret F.McCann, "Mini-LaparotomyA Fertility Control Technology of IncreasingImportance," presented to Association of Planned Parenthood Phygicians,14th Annual Meeting, Miami Beach, Florida, November 11-12, 1976.

19. "Vasectomy in Sri Lanka,- People (London), Vol. 2, NO. 3. 1975.

20. Government of India, Department of Family Planning . private rommuni-cation, December 10, 1976; William Borders, -India Will Moderate Birth CurbProgram," New York Times, April 3, 1977.

21. Nafis Sadik, "Barriers to Sterilization May be Smaller Than They Look,"Populi, Vol. 3, No. 1, 1978.

4 9

22. Nortman and Hofstatter, -Population and Fa ily,PI fining: A FactbOctober 1976 editiorv,

23. Jane E. Brody, -Birth Curb Study, Backs Diaphragm,'" New York Times,May 11, 1976; Christopher Tietze; John Bongaarts, and Bruce Shearer, "Mor-tality Associated with the Control of Fertility,- Family PlanMng Perspectives,'January/February 1976.

24. Eckholrn and Newland, Health: The Family Planning Factor.

25, Robert Cuca and Catherine S. Pierce, Experimentation in Family PlanningDelivery Systerris (Washington, D.C.: World Bank, April 1976).

26. Roy 0. Greep, Marjorie A. Koblinsky, and Frederick S. Jaffe, Reproduc-tion and Heiman Welfare: A Challenge to Research (Cambridge, Mass.: MITPress, 1977).

27. -U.S. Congress Keeps "em Guessing,- People (London), Vol. 2, No. 4,.'1975.

28. Interim Report of International Contraceptive Study Project, United Na-tions Development Program, New York, April 14, 1975; Documents for theFinal Report arid Recommendations Meeting of the international Contra-ceptive Study Project, United Nations Development 'Program, Geneva, Sep-tember 22 and 23, 1975.

29. For an insightful view of the evolution of the American government'sattitude towards family planning, see Phyllis Tilson Piotrow, World PopulationCrisis (New York: Praeger, 1973).

30 t. S Department of State, The United States and the Third World (Wash-ington, D.C.: August 1976); Lloyd Emerson, Agency for International Devel-opment, private communicatwn, April J. 1977; United Nations Fund forPopulation Activities, 1975 Report (New York: 1976); K. Kanagaratnam,World Bank, private communication, April 18, 19T7.

31. Rafael M. Salas, -Statement,- presented to the 19th Session of the UnitedNations Development Program-Governing Council, New York, January 1975_

32. -How the Poorest Lose Out,- People (London), Vol. 4, No. 1, 1977,1F-fartof a spcial issue on community-based.distribution; Nortrnan and Hoistatter,-Population and Family Planning: A Factbook,- October 1976 edition.

5 0

Brigida Doring-Bradley, Alan Guttmacher Institute, privatetion April 20, 1977; Robin Elliott, Planned Parenthood Federation of Ameri-

-ea, private communication, April 20, 1977; John Robbins, "Estimated TotalCost of Fertility Control,"- in International Planned Parenthood Federation,Unmet Needs .in Family Planning (London: Planning for the Future, Inter=national Conference, October 22-27, 1973),

34. U.S. Departmerit of State, The United States and tlze Third World; Bren-da J. Vumbaco, -Law and Policy,- Population Reports, March 1976; -Marcos:APproves Funds for Sterilization,- New York Times, November 30, 1976,

35. Thomas H. Reese III, -Agency for International Development, privatecommunication, September 24, 1976_

36. Pills Easier to Obtain as Nations Start to Relax Rules," PopulationDynamics Quarterly, Winter 1975; Vumbaco, -Law and Policy."

37. Population Division, United Nations Economic and Social Commissionfor Asia and the Pacific, Asian Population Program News, Vol, 5, Nos. 3 an&4,1976.

38. Chen, Populbtion and Health Policy in the People's Republic of China;Djer.assi, "Some Observations on Current Fertility Control in China-; PennyKane, "Family Planning in China,- World Medicine, April 1976,

39. Pi-chao Chen, -On the Chinese Model of Group Planning of Birth,"presented at the Conference on IEC Strategies: Their Role in Promoting Be-havior Change in Family and Population Planning Programs, Honolulu,December 1-5, 1975,

40. Pi-chao Cheri with Ann Elizabeth Miller, -Lesso-ns from the ChineseExperience: China's Planned Birth Program and its Transferability,- Studiesin Family Planning, October 1975.

-41. Selo Soernardian, "Some Cultural Aspects of the Indonesian People,"speech given to American Embassy, Jakarta, Indonesia, December 4, 1969;Haryono Suyono, et al., -Village Family Planning: the Indonesian Model,-Village and Household Availability of Contraceptives: Southeast Asia, Battelle,1976; Laura Slobey, -The Village Family Planning Post -Program," Univer-sity-of Hawaii, July 1976. Much of the material in this section is based on theauthor's observation of the BRKBN's program in. Gendeng, Central Java,March 1977.

5 1

. 42 ,klaryunu_Suyunu, -The Indonesian Family Planning Program, presentedn-iernationaJ Population Conference of the World Population Socie-

asHington, DC. December (3,1976.

Cawfence Kincaid et aL, Mothers' Clubs and Family Planning in RuralThe ease of Oryu Li (Honolulu, University of Hawaii, undaIed).

44, Fran*Korten, Harvard University, private communication. April 8. 1977;\trot -M.. Rogers et al., "Mothers Clubs in the Diffusion of Family Planning

as ini-Korean Villages: An Illustration of Network Analysisr presented toAinerican Association for the Advancement of Science, New York, January

1975:

Settate, Committee on Foreign Relations, United States Develop-:lance Programs in P,akistan, the Philippines, and brdonesia, Com-

Print, February 1977; Milton Viorst, -Population Control! Pakistanajor New Experiment,- Science, January 9, 1976.

,46. Stephen L. Isaacs, -Nonphysician Dioribution of Contraception in LatinAmerica and the Caribbean,- Family Planning Perspectives, July/August 1975_

47. -Fa ily Planning in Hospitals,- People (London), Vol.3, No_ Z, 1976,

48. Eckholm and Newland, Health: The Family Planning Factor,

49. Chat -Hernachildha and Allan G. Rosenfield, -Natival Health Servicesand Family Planning,- American journal of Public Health, August 1975.

50, Market Research Division of Reckitt 'and Coleman of Ceylon Limited,-Estimated Purchases of Preethi Condoms,- February/March 1976,

51. -Thai Doing Well With First Contraceptives Supermarket:: Intercom,Population Reference Bureau, December 1975 ; Joseph E. Potter, MyiiamOrdonez G., and Anthony R: Measharn, -The Rapid Decline of Colombian

PopulatIon and Development Review, September and December1976.

52. M. H, Redford, G. W. Duncan, and D, J, Praser, eds_ The Condom: In-,

creasing Utilization in the United States (San Francisco: San Francisco'Press,1974); -Open Display of Condoms Results in Increased Sales,- Family Plan-ning Perspectives, May/June 1976,

5 2

53. Janet Evanson, Grapevine (London:" Family Planning Associatipn, Decem-ber 31, 1974); 'Youth and Planned Parenthood,- InternationalPlannedParenthood Fediration Europe Regional Information Bulletin, October 1976;Charles and Bonnie Remsberg, -Do Teens Make Good Sex Counselors?'"reprint by Planned Parenthood Federation of America of an article originallypublished in- 1975 in Seventeerr; Lyn Marmet, Planned Parenthood/Metro-pohtan Washington, private communication, February 18, 1977.

54. Martin A, Silver and Mary Singletary, -Offering Family Planning at theWork Site," Family Planningyerspectives, July/August 1975.

55. V. I. :Chacko, "FaMily Planners- Earn 'Retirement Bonus on Plantationsin India." Population Dynamics Quarterly, Summer 1975.

56. -Family Planning in Industry," International Planned Parenthood Fed-eration, London, July 1974; -Asians Bring Family Planning to Factories,"Intercom, Population Reference Bureau, November 1975; "Colombia .Showsthe Flag,- People (London), Vol. 2, Nov. 4, 1975.

Farnily Planning International Assistance Regional Office for East A ia,private communication, September:23, 1976.-

55. This section and much of the_ philosophical underpinning of this paperdraw on the Works of David C. K.orten, including -Management issues inthe Organization and Delivery of Family Planning Services: internationalPerspective,'" presented to the 104th Annual Meeting of the American PublicHealth Association, Miami Beach, Florida, October 20, 1976;" "Managementfor Social Development: Experience from the Field.of Population,- preSentedto the Conference on Public Management Education and Training, Bellagio,Italy, August 11-15, 1976; "Integrated Approaches to Family: Planning SerV-ices Delivery," Development Discussion Paper No_ 10 (Cambridge, Mass.:Harvard Institute for International Development, December 1975); -Popula-tion Programs in the .Post BuclY-akest Erajoward A Third Way,- DevelopmentDiscussion -Paper No. 9 (Cambeidge, Mass.: .Harvard Institute for Interna-tional Development, December 1975); -Populatton Programs 1985: A Grow-ing Management Challenge," Studies in Family PlanningJuly 1975.

59. For traditional attitudes towards family size see Gunnar Myrdal: 1Asi8a)n;Drama: An Inquiry into the Poverty of Nations (New York: PantheoThomas Paffenberger, et al., Fertility ancl Family Life in an Indian Village(Ann Arbor: University of Michigan Center for South and Southeast AsiaStudies, 1976); Yves Blayo, -Vers Une Moderation de la, Croissance Demo-graphique Mondiale?" Le Monde, November 30, 1976.

5

60. Intercom, Population' Referehce Bureau, June 1976; Population ProblemsResearch .Council, Summary of 'Thirteenth National Survey vrz Family Plan-ning; United Nations Fund for Population Activities, -One Child FamilyGaining PoPularitY,- Population (newsletter), September 1976. For generaldiscussion of the social, economic, and political aspects of family planning seeJames E. Kocher, Rural Development; Income'Distribation and Fertility De-cline (New Yorkf' The Population Council, Occasional Paper, 1973); Mah-mood Marndani, The Myth of .Population Control (New York: Monthly Re--,view Press, 1972); William RiCh,. SMaller Families-Through Social and Eco-nomic Progress (Washington, P.C.. Overseas Development Council, Januarcr1973)_ For 'a discussion of how- income differences affect contraceptIve usein China and tan excellent summary of all -available family planning materialOn China see Judith Banister, -;Implementing Fertility and Mortality Declinein. the- People's Republic of ChinaRecent Official Data.- from The CurrentVital Rates-and- Popidation Size of the People's Republic of China and Its -;Provinces, Ph.D. dissertation, Food Research Institute, Stanford University,1977. For A discussion of aspects`.pf the demographic transition theory, seeMichael Teitelbaum, -Relevance of Demographic Transition Theory forDeveloping tituntries," Seience..May 2, 1975.

61. %United Nations Fund for Population Activities, private- communication,February 25, 1977; Agency for International Development, private com-munication, February 25, 1977.

62. Vurnbaco,-"Law and Policy,'

6.3. Geoffrey McNicoll, :'Community-Level Population Policy: An t xplora-tion,- Population and Development. Review, September 1975; HaryonoSuyono, private communication. March 18, 1977

5 4

'THE,WORLDWATCH PAPER SERIES

The dther Energy Crisis: Firewood by Erik Eckholm.The Politica and Responsibility of the North American-Breadbasket by Lester R. Browns4omen in Politics:' A Global Review by KathleenNewland.Energy:it._ The Case far Conservation by Denis Hayes.'TwentylTwo Dimensions of the Population Problem byLester R. Brown, Patricia L. McGrath, and Bruce Stokes.

6.. Nuclear Power: ,The Fifth Horseman by Denis Hayes.7. The Unfinished Assignment Equal Education for Women

by Patricia L. McGrath.8. World Population Trends: Signs of Hope, Signs of Stres

by Lester R. Brown.'9. The-Two-Faces of Malnutrition by Erik EEkholm and Frank

Record.10. Health: The Family Planning Factor by Erik,Eckholm and

Kaalleen Newland. -

II. Energy: mhe Solar Prospect by Denis Hayes.12. Filling the Family Planning Gap by Bruce Stokes.

Worldwatch publications are available on a Subscription basifor $25,00 a year. Subscribers receive--1111 Worldwatch paperand books published during the calendar year for a,aingleannual Subscription,. Single,copies of Worldwatch Papers,inclUding:back copies, can be purchased,for $2.00. Bulkcopies are available at the following prices: 2-10 copies,$150 per copy; 1.1-50 copies, $1.25 per Copy; and 51 or morecopi4s, $1.00 per copy.

BRUCE STOKES is a Researcher with Worldwatch institute. Hissearch has dealt with family planning and the effects of populationgrowth.

5 5