This is a joint post with Amanda Glassman.
Family planning is back with a bang, thanks to this week’s London Summit. The event, several months in the making, was the brainchild of the UK government and the Bill & Melinda Gates Foundation, in partnership with the UNFPA. According to early reports, the Summit was a resounding success, raising $4.6 billion in commitments from government donors, NGOs, and international foundations. With these funds, donors have pledged to provide access to contraceptives for an additional 120 million women and girls, which they believe could prevent 200,000 maternal deaths, and stop 3 million infants from dying in their first year of life.
Access to contraception is undoubtedly a good thing; as a matter of human rights, women should be empowered to exercise control of their bodies and lives, including the timing and number of their pregnancies. I applaud the summit organizers, and Melinda Gates in particular, for their “no controversy” stance on women’s access. That said, I worry that the summit’s relatively narrow goal – more women using modern family planning – might oversimplify the underlying causes of high fertility and low contraceptive uptake. Women’s lives and choices are complex and varied – religion, norms, personal preferences, education, wealth, and family dynamics all play a role in their demand for children and contraception alike. In contrast, the common rhetorical arithmetic is too neat: family planning = contraception; contraception = fewer children; more donor money = greater access.
To be fair, the simple rhetoric is targeted toward advocacy and promotional purposes, and may not fully represent the attitudes of summit organizers. Still, questions remain. Can donor money counter strong religious convictions about contraceptive use, or cultural norms that encourage large families? Money can bridge financial barriers to contraception, but is that really what’s impeding access? For example, a recent paper suggests showed that contraceptive access alone did not reduce unwanted births unless policies or technologies were also introduced that shifted control of fertility from men to women. And while the concept of “unmet need” is central to family planning advocacy, some public health experts and economists continue to debate whether estimates of “unmet need” are greatly inflated, or whether the definition of “unmet need” is even a useful construct given the many complexities of individual fertility demand.
At CGD, we’ve had a longstanding interest in population and development, and we’ve thought carefully about some of these issues. Earlier this year, we released a working paper with Kate McQueston on the causes and consequences of adolescent fertility in the developing world. After conducting a systematic review of existing empirical literature and analyzing the results, our findings challenged the conventional wisdom about fertility behavior. Contraceptive access programs sometimes increased on contraceptive use, but results varied from study to study; even the strongest results, while statistically significant, showed a relationship of relatively limited magnitude, and a highly questionable connection to actual fertility rates. What’s more, we found that adolescent fertility was more the consequence than cause of negative socioeconomic outcomes, particularly school dropout. Surprised? This finding holds equally true in rich countries: teen moms are not poor “because they have babies. They have babies because [they are] poor.” While we should be careful to overgeneralize, or to conflate adolescents with women more generally, this does suggest that the proximate causes of fertility – sexual activity and contraceptive use – may mask the deeper forces driving fertility behavior, at least among girls.
What does this mean for donors as they make good on their pledges of support to family planning? There are a couple of takeaways. First, have limited expectations. Increasing contraceptive access and uptake may not, on its own, be sufficient to change fertility trends. Nor will it, on its own, be sufficient to empower women who are otherwise oppressed, disenfranchised, or abused; indeed, it is unlikely to reach them at all. Second, think about the big picture. What are the barriers to family planning in the first place? Lack of financial resources? Geographic remoteness? Few opportunities for women outside the home, such that having more children is the most rewarding option? Of these barriers, which are donors prepared to address, and with which strategies? A greater supply of contraception may help, but empirical studies show that conditional cash transfers or scholarships to encourage school continuation or return may be even more effective, both at lowering fertility rates and increasing women’s empowerment.
In this era of shrinking global health budgets, I urge donors to remember that while contraceptive access is necessary for women’s rights, health and empowerment, it is not, on its own, sufficient to achieve any of those goals.