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PIP: The consensus achieved at the 1994 International Conference on Population and Development (ICPD) signaled a move away from discussing population issues in the context of demographic targets, toward global recognition that the problems associated with rapidly growing human populations are part of a broader human development agenda. Devoid of demographic targets, the ICPD program of action instead challenges countries to change their approach to population programs, family planning, and reproductive health. World Fertility Survey and Demographic and Health Survey data indicate a high level of unwanted fertility in almost all countries covered. The lack of availability or inaccessibility of family planning services is but one reason why there is so much unmet need. There would be greater uptake of family planning if services were planned with community involvement and oriented toward clients, offering them real choices and paying more attention to them as individuals and their overall circumstances. That expansion in concept and of services is at the core of the Cairo agenda. A number of countries around the world have started taking steps to broaden existing family planning and related programs to include other reproductive health information and services. Mexico and India are examples of two developing countries which are making program and structural changes in order to implement the ICPD recommendations, while most African countries have welcomed the approach and are looking for technical and resource help for implementation.^ieng

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In 1972 the World Health Organization initiated the Special Programme of Research, Development and Research Training in Human Reproduction. Now cosponsored by the United Nations Development Programme, the United Nations Population Fund, the World Bank and WHO, the Programme has become the main instrument of research in reproductive health in the United Nations system. The progress that has been made, and the prospects for the future, are reviewed below.

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International, national and local level politics influence the uptake of contraception through consensuses, laws, financial and moral support or the creation of an enabling atmosphere. Opposition to contraception generally comes from some churches and groups opposed to particular technologies. Socio-economic factors, particularly education, the health care system and the perceived or actual cost of fertility regulation as compared to benefits expected from children also powerfully influence contraceptive use. For many poor women in developing countries their powerlessness in relation to their male partners is an important obstacle.

PIP: Recent estimates put the overall contraceptive prevalence rate (CPR) in less developed countries (LDCs) at over 50%, a 6-fold increase from a 1960 average of 9%. Thailand's rate of 10% in 1971 rose to 50% in 1979 and to 75% in 1992. China, Colombia, Mexico, and Mauritius also have had significant changes in their contraceptive profiles. The contraceptive revolution has been fostered by international agencies through various conferences: the 1965 UN Debate on the population problem, the 1968 Teheran Conference on Human rights, the 1974 and 1984 population conferences, and the 1975 and 1985 conferences on the International Decade of Women. Ardent feminists oppose the distribution of the injectables Depo-Provera and Norplant, while the US Food and Drug Administration requirements take more than 10 years for the development and testing of a contraceptive. The US's so-called Mexico City Policy stated that the US would not fund any organization that promoted abortion, and, thereby, it influenced the availability of contraceptives. The US managed to bring down its total fertility rate from 6.0 to 3.5 between 1842 and 1900. Indonesia achieved the same fertility decline between 1961 and 1984. Colombia, with much stronger programs and higher CPR, achieved it in 15 years, while Thailand, with a very comprehensive program, and China, with an even stronger one and an aggressive political leadership, achieved a similar rate of decline in 7 years. Higher gross national product is correlated to lower total fertility rate except for China, Sri Lanka, and Kerala in India. In communities where children contribute to the family economy, birth control tends to be regarded negatively; while in societies where the family contribution to the child's education is high, contraceptive use is also high. The cost of contraception includes the actual cost of the product, the cost of delivery, and travel costs and waiting time to the consumer.

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PIP: Developing countries, nongovernmental organizations, and the international development community support the Safe Motherhood Initiative. These partners know why they need to take action to assure safe motherhood, but do not agree on how to make motherhood safe. The dominant view is that the 1st priority is to provide and/or improve needed obstetric care at the 1st referral level and manage complications once they occur. It is based on the fact that the medical community cannot yet identify most women with pregnancy complications in time to prevent their occurrence. 2 safe motherhood advocates challenge this view. They point out that it only centers on reducing maternal mortality. 2nd they believe that prenatal care and health education do play a strategic role in making motherhood safe because they can inform, motivate, and empower women to use formal emergency care services. 3rd health workers should not dismiss prenatal care since some interventions are indeed effective, e.g., prevention, detection, and investigation of anemia and hypertensive disease of pregnancy and prevention and treatment of sexually transmitted diseases. Finally some areas in developing countries do not have the resources to establish or upgrade referral level health facilities so they must maximize existing resources to intervene and treat complications such as training midwives, nurses, and traditional birth attendants. The advocates propose 3 tired strategies to bring about safe motherhood. The provision of prenatal care, trained attendance at delivery, accessible emergency services, and family planning and abortion services comprise the 1st tier. The 2nd tier of activities targets youth. These activities include sexual and reproductive health programs, education, female employment opportunities, and legislation on age of marriage. The 3rd tier embraces all factors that influence women's health and status: sexual and reproductive health, education, income, social and cultural practices, and laws that govern women and their social position.^ieng

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A reproductive health approach recognizes that the foundations of women's health are laid in childhood and adolescence, and are influenced by factors such as nutrition, education, sexual roles and social status, cultural practices, and the socioeconomic environment. Reproductive health care strategies to meet women's multiple needs include education for responsible and healthy sexuality, safe and appropriate contraception, and services for sexually transmitted diseases, pregnancy, delivery, and abortion.

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PIP: By expanding use of family planning Sub-Saharan Africa, countries can limit the expected growth in population to below 1.8 billion by 2050: evidence for unmet needs, as well as feasible means of improving use of family planning are discussed. Government generally support family planning, but actually provide limited services, usually restricted to maternal-child health clinics. They need to expand services to adolescents, young married women and men, to offer more choices including sterilization, and to utilize other means of distribution. Evidence for unmet need for family planning, that is numbers of women who do not currently use, but who express desire for no more children, is suggested by the rising abortion rates. Educated women especially are increasingly resorting to clandestine abortions. A few areas and pilot studies indicate high contraceptive rates, when services are provided effectively. People fear contraceptives because they think they cause infertility. People fear contraceptives because they think they cause infertility, while unprotected women actually are at higher risk of infertility because of illegal abortions and problem pregnancies. Governments need to supply more choices of contraceptives, and especially female sterilization. Vasectomy is virtually unused. Community-based and non-governmental distribution are untapped resources. Clinics are known to be less effective in motivating people to come for preventive care. In contrast, community women can provide services at lower financial and psychological cost, while improving the community's sense of control over health.^ieng

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PIP: An official call for action was issued at the end of the conference on Safe Motherhood held in Nairobi, Kenya, in February 1987. The conference was organized to draw attention to the half million maternal deaths that occur each year. Women in developing countries run 50-100 times the risk of dying in pregnancy or childbirth than their counterparts in developed countries. There are only 2.9 maternal deaths/100,000 live births in developing countries compared to 300-1000 maternal deaths/100,000 live births in developing countries. Illegal abortion from unwanted pregnancies accounts for 25-50% of these deaths. The causes of maternal mortality are rooted in the adverse social, cultural, economic, and political environment women face in the Third World. These causes must be addressed if women's health and status are to be improved in the long term. On the other hand, there is an immediate need for low-cost, effective interventions that can have a major impact on reducing mortality and morbidity from obstructed labor, hemorrhage, toxemia, infection, and complications of abortion. A political commitment must be generated to reallocate resources so that maternal mortality can be reduced by 50% in 1 decade. Needed is an integrated approach to maternal health care that makes it a priority within the context of primary health care services and overall development policy. Women need to be involved in planning and implementing programs and policies to ensure that their needs and preferences are taken in account. In addition, family planning and family life education programs need to be expanded and made socially, culturally, financially, and geographically accessible. These activities need to involve both governments and take advantage of the flexibility, responsiveness, and creativity of nongovernmental organizations.^ieng

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PIP: There were marked differences between the views expressed at the 1974 Bucharest World Population Conference and those expressed at the 1984 Mexico City World Population Conference. At the 1974 conference there was considerable disagreement between delegates who emphasized the need to control population growth directly through the development of effective family planning policies and programs and other delegates who argued that a decline in fertility would occur automatically in response to vigorous development programs. By 1984 most participants had acquired a deeper understanding of the complex relationship between development and population growth, and most recognized the need to develop comprehensive family planning programs and policies. Ironically, the US, which in 1974 had taken a strong family planning stance, reversed its position, and in 1984 adovacated the less popular developmental approach. The 1974 participants did affirm that all couples and individuals had the right to freely limit and space their children, but the 1984 participants adopted specific recommendations to promote and strengthen family planning initiatives. They recommended that governments make all appropriate and medically approved family planning methods available to all couples and individuals, and especially to the most vulnerable and most difficult to reach segments of their populations, that governemnts ensure that all children have the opportunity to grow up in healthy and supportive environments, and that public and private organizations use their resources to help governments meet these goals. They further recommended that governments 1) improve the quality, effectiveness and safety of their family planning programs 2) utilize all appropriate and available channels to promote the delivery of family planning services, 3) provide family life, sex education, and appropriate family planning services for both male and female adolescents; 4) ensure that all couples and individuals have the right to freely and responsibly limit and space their children, and 5) refrain from using any family planning strategies which are coercive or discriminatory. The delegates also called on governments to translate family planning goals into specific policies and operational activities and to develop policies to help parents meet their child rearing responsibilities, to improve child welfare and child care services, to promote the establishment of adequate maternity and paternity leaves, and to help parents acquire suitable housing. Delegates also recognized the need to formulate development policies which supported each country's population policies, advocated upgrading the status of women, and dealt with the problem of maternal mortality. After considerable discussion, the participants recommended that abortion should not be promoted as a family planning method, but that women who have abortions should be treated humanely and provided with counseling. Many delegates from the developing countries criticized the conference for failing to deal adequately with the issue of funding. Many countries lack the resources needed to implement the conference's recommendations.^ieng

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Despite several decades of international effort, the development problems of sub-Saharan Africa remain acute. By many of the quality of life indexes, the majority of African countries are standing still or moving backward. A rapidly growing population with an adverse dependency ratio places demands on services that present development strategies cannot satisfy. A reorientation of development is necessary to establish realistic population policies and to implement comprehensive family planning programs.

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PIP: Although family planning has been practiced throughout the world since earliest times, the population and family planning field is still confronted by difficult ethical issues. More contraceptive research is needed within developing countries so that the resulting technology will reflect local conditions. The politicization of contraceptive development and testing impedes consideration of the ethical issues. High ethical standards must be maintained, with attention to such aspects as the choice of human subjects to avoid double standards or discriminatory practices. The World Health Organization is helping to resolve ethical problems of contraceptive testing through its network of test centers in both developed and developing countries. Those who argue that it is unethical to offer contraceptives without providing health coverage as well overlook the contribution of birth spacing to health. Access to full and accurate information and services for family planning has been accepted as a basic human right. The consent of the individual choosing a contraceptive method must remain inviolate. There should be no preselection of method by program or service personnel, and no information on the contraceptive should be withheld. The issues of spousal and parental consent and withholding services from unmarried persons must be faced in diverse social and cultural contexts. In the debate over abortion, the ethics of withholding a technique known to be less hazardous than carrying a pregnancy to term should be considered, as should the morality of denying to the poor a service available to wealthier women regardless of its legality. Governments or programs which manipulate the availability of family planning information or services for demographic or other reasons are acting unethically.^ieng

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PIP: The food situation in Africa is discussed in light of the demographic realities of the region. The unique demographic situation of Africa, the continuing dependence of the region on grain imports, the low nutritional quality of food consumed over the greater part of the region, and the poor health conditions of most African children and mothers are underlined. The importance of the food situation to political stability is noted and the concern is expressed over the increasing time lag between the realization of the problem and action. The low priority given to Family Planning Programs is discussed. The urgency of increasing quality and quantity of food production in Africa and in particular the need for additional measures to decelerate the rate of population growth are underlined.^ieng

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PIP: Genocide implies an effort by the white races to reduce the number of or eliminate the colored races. In Africa the belief that family planning is a way of advocating genocide combines with the problem of lack of real experts in the field of family planning and of disproportionate allocation of funds to this area without regard to the goals of overall development. Additionally, some methods of fertility control are recommended by foreign "experts" which may be culturally unacceptable. In spite of these problems population programs are advancing in Africa. In order to be more readily acceptable, however, they will have to be considered within the global context of overall development, and they will have to be carried out largely by national personnel with international aid and international personnel remaining in the background.^ieng

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