APPG Report by HC120911132124


									                             APPG Report

   The effect that population growth is having on the
   achievement of the Millennium Development Goals


The International Planned Parenthood Federation (IPPF) is a non-governmental
organization that provides services and advocacy for sexual and reproductive
health and rights. We respect the rights of individual men and women to choose
when, or whether, to have children or not, and to enjoy good sexual and
reproductive health. In this report we will only be discussing the Millennium
Development Goals (MDGs) in the context of sexual and reproductive health and
rights, a cross-cutting theme that we believe affects all of the MDGs.

There is still an enormous unmet need for sexual and reproductive health
education, information and services in many countries. An estimated 201 million
women in developing countries would like to stop childbearing or space their
next birth, yet they are not using a modern contraceptive method. Meeting their
wishes would avert 52 million unintended pregnancies annually, which would
prevent 142,000 pregnancy-related deaths (many of which are related to unsafe
abortion) and 1.4 million infant deaths (1).

Lack of access to sexual and reproductive health services goes hand in hand with
rapid increases in population growth. HIV/AIDS, which is predominantly sexually
transmitted, threatens to become the greatest drain on the economies of some
of the poorest countries in the world, and in some cases the size of their
populations may be an even greater burden. This has been detailed in a recent
article for the Lancet by John Cleland and IPPF’s Director-General, Dr Steven
Sinding, which is referenced in this report. Without the provision of access to
sexual and reproductive health services for all who desire them, the MDGs, with
their over-arching aim of reducing global poverty, will miss their targets.

Reproductive health has now been recognized as central to the attainment of the
MDGs, and it was mentioned specifically twice in the outcome document at the
recent World Summit, in relation to efforts to combat HIV/AIDS and to promote
gender equality and the empowerment of women.

If the MDGs aim to promote development and reduce poverty by half, efforts to
attain these goals must pay more than lip service towards the conclusions of
other international agreements (such as the 1995 Fourth World Conference on
Women and the 1994 International Conference on Population and Development)
to be successful. Strong, unwavering commitment is needed.

Current and predicted levels of population growth

Population growth in the last half-century is unparalleled in the history of our
planet. While overall annual growth rates have fallen from their all-time high of
two per cent in the late 1960s, human numbers are still increasing. World
population could reach between 7.7 billion and 10.6 billion by the mid-21st
century, depending mostly on future birth rates.

Even if the world’s average family size fell immediately to just more than two
children, population would still gain several billion before stabilizing, due to the
built-in momentum generated by the unprecedented number of young people
entering their reproductive years. This is linked with high rates of urban
population growth and shortages of cropland, affecting the environment (2).
Young people aged under 25 are also the group most likely to be affected by
sexually transmitted infections (STIs) and HIV, thus, the provision of
comprehensive youth-friendly sexual and reproductive health (SRH) education
and services is particularly important.

Regional statistics and projections
In Asia (south Asia, southeast Asia, and east Asia) and Latin America, and to a
lesser extent in the Arab states, international promotion of family planning has
been successful in reducing birth rates, and hence, population growth (3). About
a third of the rising prosperity in east Asia is thought to be attributable to short-
term and long-term effects of falling birth rates (4).

In Africa, birth rates remain high and population trends have been most affected
by the HIV/AIDS pandemic. Since 1960, the population of sub-Saharan Africa
has grown from 225 million to 751 million people. With use of the United
Nations' medium projection variant, population size in this region is expected to
more than double in the next 45 years, although conditions vary between
countries (3). For example, in Botswana, Lesotho, South Africa, Swaziland, and
Zimbabwe, populations are expected to remain static or even fall, because of the
combination of declines in birth rates and the high number of AIDS-related

The expectations of the United Nations about the future of fertility in Africa are
grounded in an assumption that sub-Saharan Africa is destined to follow the
demographic pathway of the other poorer regions of the world and see a
pervasive decline in birth rates. Although this assumption might prove to be
correct, there are three main reasons for serious doubts to remain (5).
First, desired family sizes in Africa, although decreasing slowly over past decades,
remain high. In seven of the 15 countries of western and middle Africa that have
done nationally representative surveys since 1995, women's average desired
family sizes were in excess of six children. Corresponding estimates for Asia and
Latin America 40 years ago were much lower, typically three or four children (6).

Second, uptake of modern contraceptive methods by married women, the main
factor to affect birth rates in other regions, has changed little in past decades
and is still very low in western and middle Africa, exceeding 10 per cent in only
two countries with recent surveys.

Third, family-planning programmes in Asia and Latin America undoubtedly
benefited from abundant international funding and the high priority attached in
earlier decades to the reduction of rapid population growth. Although most
African governments have policies to reduce birth rates, international
commitment to support their implementation has undoubtedly weakened and
funding has decreased (7).

With this in mind, sub-Saharan Africa may prove to be the region where the
targets of the MDGs are most threatened by population growth.

How population growth interlinks with specific MDGs

Lack of access to SRH services, including family planning, has contributed to
rapid population increases and many health problems in some developing
countries. This undermines all of the MDGs, both overtly and subtly.

MDG 1: Eradicate Poverty and Hunger
Lack of access to voluntary family planning programmes and other SRH services
leads to increased birth rates, and increased levels of sexual and reproductive
illnesses and unintended pregnancies. Sexual and reproductive health conditions
account for approximately one-fifth of the global burden of all disease, and for
one-third of the health burden of women of reproductive age (8). In sub-
Saharan Africa, which contains many of the world’s poorest nations, poor
reproductive health accounts for nearly two-thirds of disability-adjusted life years
lost among reproductive-aged women. In many developing countries women
earn 40 to 60 per cent of household incomes, so maternal death, or chronic
sexual or reproductive ill health, makes a huge difference to individual families,
both socially and financially (9).

Smaller family size contributes to economic opportunities; families and
governments can invest more in each child, and eventually they can also save
more, invest more productively, and stimulate economic growth. This has been
seen in several countries in East Asia where access to desired reproductive
health services have been instrumental in increasing the ‘dependency ratio’ of
workers to dependent children. Before this, as recently as the 1950s, statistics
for health, literacy, fertility and economics in East Asia were similar to present
day sub-Saharan Africa (9).

MDG2: Achieve Universal Primary Education
An expanding population and inability of individuals to protect their sexual and
reproductive health impacts negatively on education. Capital deepening is
prevented, as governmental per capita spending becomes stretched to provide
for more individuals. Where education is not available free of cost, parents with
large families will struggle to send all their children to school, often resulting in
gender bias where boys are more likely to be educated than girls. Young women
and girls who become pregnant may drop out of school or be excluded.

MDG3: Promote Gender Equality & Empower Women
Where there is rapid population growth and a lack of access to sexual and
reproductive health services, women are likely to be younger when they have
their first child, and less able to space or limit subsequent births. This lack of
access to SRH services, including contraception, denies women a basic human
right – the right to be able to plan a family and enjoy good sexual and
reproductive health. It prevents them from completing their education, disrupts
their ability to take on paid work, and hampers their ability to fully participate in
other aspects of society.

In societies where women have little status, it is difficult for them to negotiate
safer sexual encounters with their partners, such as the use of condoms. Lack of
status also puts women and girls at increased risk of economic and educational
inequalities, trafficking and sexual exploitation, and also of gender based

MDG4: Reduce Child Mortality
Where fertility remains high, it has been suggested that increased child spacing
alone could reduce infant mortality by up to one-third (2). Research also shows
that where parents in developing countries have fewer children, they tend to
invest more resources in each child, improving levels of overall health and also
education (an additional positive contribution towards MDG 2: Achieve Universal
Primary Education).

MDG5: Improve Maternal Health
If populations become larger, and the lack of access to SRH services remains or
worsens, we will see an even larger disease burden and greater number of
maternal deaths.

Timing of births and total number of children both impact upon the health of the
mother. Lack of means to space births leads to a severely detrimental effect
upon maternal health, and with each additional birth a woman has an increased
risk of suffering obstetric complications. High birth rates in developing countries
could further strain the resources of health care systems, where there are
already too few trained birth attendants and little access to emergency obstetric

Currently, more than 500,000 women die every year from pregnancy-related
causes, and more than 99 per cent of these deaths take place in the developing
world. This represents a lethal combination of: lack of access to contraception;
pregnancies that occur too early in life, too late and too often; and lack of skilled
care in pregnancy and childbirth. Fatal obstetric complications contribute to
approximately 80 per cent of maternal deaths globally, and even with the best
primary care, 15 per cent of women will experience potentially fatal
complications during the pre-natal period or childbirth, and require emergency
obstetric care (9).

Unintended and unwanted pregnancies in developing countries also contribute
directly to maternal mortality in another way. This year alone, an estimated 19
million women and girls will face the deadly consequences of unsafe abortion.
Around 70,000 of them will die, making up 13 per cent of the total annual global
maternal deaths (and perhaps as much as 50 per cent in some countries in
Africa and South East Asia), and hundreds of thousands will be left with
debilitating and frequently lifelong injuries. Extensive independent research
shows that restricting access to safe, legal abortion does not make it go away; it
only makes it clandestine and unsafe. In addition to making contraception and
other SRH services more accessible, there is an urgent need for health
authorities and government leaders in more countries to re-examine abortion
policy (10).

MDG6: Combat HIV/AIDS, Malaria & Other Diseases
Although HIV/AIDS is often classified alongside diseases such as malaria, it is
without a doubt a sexual and reproductive health issue, and should be regarded
as such if prevention and treatment are to be successful worldwide. Lack of
access to comprehensive SRH services is likely to result in increased birth rates,
and makes it harder for people to protect themselves from STIs, including HIV.
In addition, HIV and AIDS have affected population demographics in some
countries, and remain a threat to development.

More than 40 million people around the world are living with HIV or AIDS. Almost
half of them are women, and this proportion is increasing. One-third of them are
aged between 15 and 24. HIV/AIDS-related death and morbidity are damaging
social and economic prospects in some of the hardest-hit countries, for example,
in Zambia in 2001, one in sixteen teachers died from these causes, severely
affecting the education system (9).

In some countries, separate funding of HIV services has led to diversion of funds
away from SRH programmes, even though the majority of new HIV infections are
sexually transmitted. In the absence of a vaccine, efforts must concentrate upon
prevention of transmission, and on treatment and care for people who are HIV
positive. SRH services are ideally placed to promote prevention efforts, and to
provide non-stigmatizing testing and treatment.

Prevention can be successful if a broad approach is employed, including: delayed
sexual debut, learning the skills to negotiate safe behaviour, use of condoms and
so on. It has been shown that heavily promoting abstinence-only programmes
and denigrating the effectiveness of condoms, as seen in recent efforts by the
United States and the Vatican amongst others, is not effective in preventing the
spread of HIV. Programmes must be evidence-based, not founded upon ideology.
The male or female condom is the only effective technology available to prevent
HIV transmission during sexual intercourse, and must be used consistently and
correctly. Unfortunately, the need for promotion and supply of condoms is still
far greater than the resources that have been committed.

Mother-to-child transmission of HIV accounts for 10 per cent of HIV infections
annually (9). Integrated HIV and sexual and reproductive health services are key
in preventing new infections among women, in offering voluntary counselling and
testing to women who are pregnant or thinking about becoming pregnant, and in
preventing transmission from mother to child.

Reducing population growth in most-affected areas

If placing a high priority on the reduction of birth rates is central to the long-
term reduction of poverty, a three-pronged policy approach is suggested — one
that combines a focus on increased availability of family planning programmes
with an intensified effort to prevent the spread of HIV. This approach recognizes
that the two programmes share an essential aim, namely to break the link
between sexual intercourse and negative consequences: unintended pregnancy
and infection.

First, family-planning information and services must be made more widely
available. Countries such as Botswana, Kenya, South Africa, and Zimbabwe,
where family-planning services are widely available, have seen reductions in
birth rates. Greater contraceptive use, through the reduction of the number of
unwanted pregnancies in women infected with HIV, might also be a more cost-
effective way than drug therapy to prevent mother-to-child transmission of the
virus (11).
Second, because desired family sizes are still large, attention needs to be given
to communications efforts that legitimate smaller families and contraceptive use.
The example of Kenya shows how such advocacy can dramatically change
reproductive norms: the steep fall in desired family sizes in the 1980s coincided
with, and was probably partly attributable to, the activities of Kenya's political
leadership in that decade. Leaders expanded family planning services and
repeatedly spoke in public of the need to reduce the rapid rate of population
increase. Key shapers of public opinion such as national political leaders, village
headmen, and women's groups are usually the most effective advocates and
they must be won over.

Third, family-planning and HIV-prevention programmes should be more closely
integrated. In the absence of a vaccine, behaviour change—especially delayed
sexual debut, reduction in the number of sexual partners, and condom use—is
the only way to prevent HIV transmission. No public-health specialty has more
experience in the promotion of behaviour change in less developed countries
than do family-planning programmes (12). This expertise should be harnessed to
encourage people to avail themselves of voluntary HIV counselling and testing
services, to avoid risky behaviours, and to practise dual protection against both
unwanted pregnancies and HIV. Integration of programmes for HIV prevention
and family planning could produce better outcomes than either endeavour could
yield alone, thus, providing a promising solution to the problems of HIV/AIDS,
high birth rates, and poverty that have affected so many developing countries.


When individuals are empowered to exercise their right to access quality,
comprehensive sexual and reproductive health information, education and
services, health is improved and lives are saved. In addition, family sizes tend to
decrease, and development and economic growth are enhanced. This is fully
compatible with the over-arching aims of the Millennium Development Goals,
indeed, it is crucial if the targets of the MDGs are to be attained.


1. Alan Guttmacher Institute and UNFPA (2004) Adding it up: the benefits of
investing in sexual and reproductive health care. AGI and UNFPA: New York.

2. Population Action International (2005) Toward 7 billion: why world population
is still growing, Factsheet 7. PAI: Washington DC.
3. United Nations, Department of Economic and Social Affairs, Population
Division (2005) World Population Prospects: the 2004 Revision. United
Nations: New York. (accessed Sept 30, 2005).

4. Bloom D, Williamson JG (1998) Demographic transitions and economic
miracles in emerging Asia. World Bank Econ Rev, 12 pp. 419-455.

5. Cleland, J and Sinding, S (2005) What would Malthus say about AIDS in
Africa? Lancet, 366, pp. 1899-1901.

6. Mauldin WP (1965) Fertility surveys: knowledge, attitude, and
practice. Studies in Family Planning, 1 pp. 1-10.

7. United Nations Population Fund (2004) Financial resource flows for population
activities in 2002. United Nations: New York.

8. World Health Organization (2004) Reproductive Health Strategy, adopted by
the 57th World Assembly, May 2004. WHO: Geneva.

9. Population Action International (2005) How access to sexual and reproductive
health services is key to the MDGs, Factsheet 31. PAI: Washington DC.

10. International Planned Parenthood Federation (2006) Death and denial:
unsafe abortion and poverty. IPPF: London.

11. Reynolds HW, Janowitz B, Homan R, Johnson L (2004) Cost effectiveness of
two interventions to prevent HIV positive births. XV International AIDS
Conference: Bangkok.

12. Piotrow PT, Kincaid DL, Rimon JG, Rhinehart W (1997) Health
communication: lessons from family planning and reproductive health. Praeger:


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