Draft
Population Growth – Impact on The Millennium Development Goals
Written Evidence Submitted by Marie Stopes International
to the
All Party Parliamentary Group on
Population, Development and Reproductive Health
The Marie Stopes International Global Partnership (MSI) is a non government, not for profit organisation, which was established in 1976. The organisationis committed to upholding the fundamental right of individuals and couples to decide freely and without coercion the number and spacing of their children and their right to obtain both the information and the means to do so. MSI believes that family planning is a key factor in population growth, economic growth, health of women and their children and human rights.
Introduction
It is more than five years since governments gathered at the Millennium Summit in 2000 and agreed a set of eight quantified targets aimed at reducing poverty by 2015. Already, the slow rate of progress, particularly in Sub Saharan Africa, is causing concern and the realisation that many countries may not achieve the targets is being voiced. Yet, despite the recognised relationship between population growth and poverty, there is little debate on the impact of population growth on progress towards achieving the Millennium Development Goals (MDG). This evidence focuses on MDG 5 – improve maternal health, but as all the MDGs and population growth are intrinsically linked, also touches on others. We will make the case that population dynamics, specifically population growth, structure and movementare factors contributing to the slow progress on achieving the MDGs, by meeting demand for sexual and reproductive health services progress towards meeting the MDGs will be made and the rate of population growth slowed. The evidence presented is illustrated with examples of how Marie Stopes International Global Partnership is addressing these issues.
Addressing Population Growth, Addressing Reproductive Rights
The rate of population growth has declined following a peak in the 1960s. At that time, population growth had slowed in industrialised countries and an association was made between population growth and economic development. In many developing countries, population control programmes were introduced in response both to the rapid rate of population growth and to the visual realisation of the finite resources of the planet following transmission of the first images from space. The rate has further slowed in recent years due to deaths from AIDS. Population projections suggest that actual population figures are likely to fall far short of the estimates calculated in the 1960s due to the effect of AIDS[1]. Despite this slowing in growth rate, overall population growth is occurring in many developing countries due to the momentum created by a predominantly young population.
The paradigm shift from population control to reproductive rights was confirmed in the International Conference on Population and Development Programme of Action in 1994. Whilst this confirmed the rights of couples and individuals to decide freely and responsibly the number of spacing of their children, it also stressed the importance of the ability to make informed choices and access services to enable them to control their fertility. However, as vertical support for family planning programmes based in the population control paradigm was removed, resources for reproductive health services to ensure that couples and individuals were able to achieve their rights were not forthcoming.
At a recent workshop in Paris organised by the Agence Française de Développement (AFD) and the UK Department for International Development (DFID) on Demography, Reproductive Health & Sustainable Economic Growth in Africa, the relationship between population growth and gender equality, reproductive health and the MDGs was discussed. It was agreed that demography and population growth should be priorities in aid provided to African countries.
However, it is important to note that achieving demographic goals through population based targets is unlikely to be successful. Human based approaches, through creating demand for smaller families and accessible and affordable reproductive health services are likely to slow population growth rates. This was recognised at the workshop, which noted that demography is about people and their right to choose.
An example of where top down, supply side population programmes were replaced with programmes aimed at creating and meeting demand occurred in Bangladesh, where innovative and intensive family planning programmes led to massive increases in contraceptive use and associated decreases in the total fertility rate. The contraceptive prevalence rate rose from 7% to 58.1% between 1975 and 2004,while the total fertility rate fell from 6.3 to 3.0 over the same period[2]. In 1990 the maternal mortality ratio was estimated to be 850 per one hundred thousand live births and 600 in 1995. Data from the 2001 Bangladesh Maternal Mortality Survey, using household survey data shows a further drop to 382 pregnancy related deaths per one hundred thousand live births2. Marie Stopes Clinic Society has been providing reproductive health services since 1998 through a combination of clinic and outreach based services. In addition to the successful model of community based distributors, to which the success of the family programme has been largely credited, MCSC also provides services to young women in factories and to the poorest of the poor through mini centres based in slums.
Maternal Health: Reducing maternal mortality
In many countries, efforts to achieve Millennium Development Goal 5, to improve maternal health, do not appear to be making an impact. It has been recognised that since most life threatening complications cannot be predicted and require medical intervention, women must have access to essential obstetric care packages if maternal mortality is to be averted. Sierra Leone has some of the poorest indicators in the world. For example the maternal mortality ratio is estimated to be 2,000 per hundred thousand live births and the infant mortality to rate of 162 per thousand live births. Despite such high levels of mortality, the fertility rate is high (TFR 6.5) so the population growth rate is high at 4.3%. Marie Stopes Society Sierra Leone is providing essential obstetric care at its centre in Freetown. In addition to providing EOC to increasing number of clients, it also serves as a training centre: to date more than 40 doctors and 50 midwives-in-training have been completed part of their training at the centre, supervised by the MSSSL medical and midwifery team.
The World Health Organisation states that the lack of trained health workers providing services is directly threatening efforts to achieve the MDGs[3]. While the population in many developing countries is rising, the numbers of trained health providers is stagnating or falling in actual numbers, leading to an increasingly smaller proportion of health workers per head of population. There are a number of reasons for the decline in numbers of health providers, including the impact of HIV/AIDS, particularly in Sub Saharan Africa. As well as providers becoming ill and unable to work, recruitment is becoming difficult as people are afraid of infection and the futility of caring for people who will not recover. This is just one example of how the MDG interlink and are interrelated.
Population movement
When population growth is coupled with migration of trained health providers to developed countries, the effect of health systems is catastrophic. Marie Stopes recognises that remuneration is only one factor on which employees make a decision as to whether to stay or to move elsewhere and therefore place great emphasis on providing training and personal development opportunities to team members. In addition, Marie Stopes is working with governments to train providers in a wide range of skills, including tubal ligation, vasectomy, obstetric care and quality of care of family planning services.
Population growth is only one part of population dynamics which affects economic and social development. As shown above, population movement also impacts on health status. When populations move in particular when such movement is forced or involuntary, the effect on health status, including maternal health is often negative. One country in which Marie Stopes International is working where this can be clearly seen is Sri Lanka. Whilst the overall country indicators show that health status, in particular maternal health, is better than other countries in the region, there are wide disparities when comparing the conflict affected north and eastern regions to the southern part of the country. Maternal mortality is 1,100 per 100,000 births as opposed to 240 per 100,000 births nationally. Infant mortality is 19.94 per 1,000 births against the national average of 16.3 per 1,000births. The World Health Organisation has highlighteda significant lack of trained SRH staff, facilities and information within the North and Eastof the country as hindering disease control and prevention, as well as contributing to poor maternal and child health. Whilst the government has made many commitments to SRHR and better gender equity for internally displaced people, there are also restrictions not present in the rest of the country. For example, in the northern and eastern parts of the country, a woman must have five children and be over the age of thirty to be allowed to undergo sterilisation, yet no such restrictions exist among women in other parts of the country. The contraception prevalence rate is 51.3% compared to 84.7% for all of Sri Lanka.
Rapid Population Growth – A Young Population
Rapid population growth has led to an unprecedented proportion of the world’s population being under the age of fifteen. Almost thirty percent of the world’ population are aged under fifteen[4], whilst in some developing countries, for example Malawi, the proportion of those under 15 years isas high as 45%[5]. In many developing countries, women begin child bearing before the age of twenty, one of the “four toos” recognised as a risk factor for maternal mortality: too early, too many, too close and too late.
Banja La Mtsologo (BLM), MSI’s partner in Malawi is working in collaboration with both government and non governmental organisations to provide information and services to young people in school, in the community and in young offenders’ institutions. Information and services are provided at service delivery centres, youth centres, young offenders’ institutions and in the community. Services are provided and managed by young people creating a non threatening atmosphere in which young people feel comfortable and provides a sense of ownership. In 2003, 420,000 young people were reached through BLM and by 2005 this figure had risen to over one million. This demonstrates the demand for information and services among young people.
Provision of reproductive and sexual health services is also essential if MDG 2 - achieving universal education is to be met. Despite nominally free primary education, in many countries fees are charged and additional items such as uniforms and books must be paid for. Many parents give lack of money as a reason for not educating their children. Conversely, many state that the reason they want only a small number of children is so that they can afford to educate them.
Population growth contributes to the difficulties faced by governments in achieving MDG 2. Assuming class sizes of 40, an extra 2 million school teachers per year are required just to stand still. As the demand for education increases with growing numbers of young people, the number of teachers is declining through AIDS mortality. It is estimated that up to a million children lost a teacher through AIDS in 2001[6], putting greater pressure on already overstretched education systems. Teachers appear to have been disproportionately affected by HIV, possibly due to higher social status and mobility leading to a greater number of sexual partners. In particular, children in rural areas are affected as HIV positive teachers become less willing to work in rural areas, away from health care.[7] The head of the World Bank stated in 2000 that in some countries more teachers are dying each year from AIDS than can be trained.
Whilst the majority of young people could be expected to have completed primary education before they become sexually active, many children, particularly girls in developing countries have numerous interruptions to their education and are in their teens before finishing primary school. This is being exacerbated by HIV/AIDS as children are now being required to look after sick parents rather than attend school.
The association between education and risk of HIV infection has been shown repeatedly in many countries. Whilst HIV/AIDS is one of the major challenges to achieving MDG 2, improvements in education are required if MDG 6 – combat HIV/AIDS, malaria and other diseases is to be reached.
The provision of integrated HIV/AIDS services into improved sexual and reproductive health services is essential if the development goals are to be met. There is evidence that linking SRH and HIV/AIDS services is essential if all target groups are to be met, in particular adolescents, who do not attend centres where only maternal and child health services are,or are perceived only to be available.
Reducing the number of unplanned pregnancies
In many developing countries there is a gap between desired family size and actual family size as women do not have access to an appropriate choice of methods of family planning. This not only leads to increased risk for maternal mortality, due to unsafe abortion, too close together and too many births, but contributes to population growth. In his recent “Practical Plan to Achieve the Millennium Goals” Sachs cites expanding access to SRH information and services, including ensuring consistent supply, as one of the quick wins - those interventions which, if implemented immediately, would see results within three years[8]. Worldwide, there are at least 350 million women who want, but do not have access to, modern methods of contraception. This number will continue to increase as the world's population increases in size and the numbers of young people becoming sexually active increases. It is essential that an appropriate method mix, including long term and permanent methods of contraception is provided.
In many quarters, there is still a reluctance to discuss the benefits of surgical, permanent contraception. As a result of abuses of reproductive rights by over zealot governments, surgical contraception became associated with the population control programmes of the 1970s. There is no doubt that forced and coercive sterilisations took place, most notoriously in India and Indonesia. However, tubal ligation and vasectomy are methods of contraception suitable for those who do want to limit their family size. In many developing countries, women have reached or exceeded their desired family size by the time they reach the age of thirty. Providing permanent methods of contraception to these women and their partners prevents two of the “four toos” risk factors for maternal death – too many and too late.
Madagascar is one country in which demand for MSI voluntary surgical contraception services (VSC) is increasing. The population growth rate of Madagascar (3.13%)is one of the highest in the world and a maternal mortality ratio of 550 per hundred thousand live births. The total unmet need is estimated to be 23.6%, of which 12.3% is for limiting[9]. In 2004 Marie Stopes International Madagascar expanded it voluntary surgical contraception services through outreach to districts distant to the capital. This resulted in a three fold increase in number of VSC clients by the end of 2005, representing over 56,000 couple years of protection.
Conclusion
The relationships between poverty and population growth are complex as both are a cause and consequence of the other. The MDGs are targets to reduce both causes and consequences of poverty. Regarding maternal mortality, direct relationships between population growth and maternal health can be seen at the micro level in large family size and at the macro level in increased pressure on health systems. Addressing the micro level, through improved access to reproductive health services is essential. As noted by the Millennium Project, sexual and reproductive rights, including laws and practices related to abortion, are essential to meeting all MDGs, particularly Goal 4 and 5[10]. MSI is working to ensure a supportive and enabling environment for SRHR at international and national levels. As we have illustrated, we are also reaching out to provide services to those who most need them.
The highest rates of population growth are seen in countries which have high fertility and mortality rates. These are seen in the poorest countries and among the poorest people in these countries. While demographers talk of fertility and mortality, individuals and families experience birth and death. Through the realisation of reproductive rightsfor all, smaller, healthy families can be achieved, contributing to slower rates of population growth and moving towards achieving the Millennium Development Goals.
1
[1]UNFPAState of the World Population, 2004
[2] National Institute of Population Research and Training (NIPORT), ORC Macro, JohnsHopkinsUniversity and ICDDR,B. 2003. Bangladesh Maternal Health Services and Maternal Mortality Survey2001. Dhaka, Bangladesh and Calverton, Maryland (USA): NIPORT, ORC Macro, JohnsHopkinsUniversity, and ICDDR,B.