Unnatural Increase?

Robert Engelman

From at least the Axial Age (800-200 BCE) until the late eighteenth century, most organized efforts to influence the size of populations aimed at boosting it. Women have been extolled, pressured, or coerced into having children early and often, whether or not they would have timed their own childbearing that way if left to their own devices (contraceptive or otherwise). But let's consider for amoment the strategies that have gained the greater attention since the time of Thomas Robert Malthus: the kind designed to slow demographic growth by reducing family size and birthrates.

The first true promoter of actually acting on population issues appears to have been Francis Place, a self-educated son of the English working class.Married at age 19 to a woman two years his junior, Place fathered 15 children and lived in poverty. In latemiddle age he became the world's first birth control theorist and propagandist. In an 1822 book onMalthus's population principle, Place proposed substituting contraception for late marriage to moderate birthrates. Not content to let the book plead his case, the author wandered the streets of London and northern English industrial cities, posting anonymous handbills arguing that large families risked the health of mothers and children, caused economic anxiety and suffering, and led to low wages because large cohorts of workers flooded labor markets. If couples would just use the sponge, Place suggested, they could solve these problems. Place also stressed a value that underlies mainstream population policies up to the present: control of births not by government or other outsiders, but by women and couples themselves, "so that none need to have more [children] than they wish to have."

Not surprisingly, civic groups and civil authorities challenged many nineteenth-century writers on population as purveyors of indecency. The tracts and books were, after all, discussing sexual intercourse. In the late 1870s, procontraception activist Annie Besant and attorney Charles Bradlaugh published Knowlton's Fruits of Philosophy for the British market and were quickly charged with spreading obscenity. Their trial turned into a publicity bonanza for birth control. Prosecutor Hardinge Gifford called Fruits "a dirty, filthy book" and added that "no decently educated British husband would allow even his wife to have it. The object of it is to enable a person to have sexual intercourse, and not to have that which in the order of Providence is the natural result of that sexual intercourse." Besant and Bradlaugh were convicted and sentenced to six months in jail, but the verdict was reversed on appeal. That judgment effectively ended contraception's legal status as obscene in the United Kingdom. Sales of books on contraception soared into the hundreds of thousands throughout Europe and North America. The Besant-Bradlaugh trial helped launch a slowing of demographic growth within England and Wales that continued for decades. Births peaked around the time of the trial at about 35 per 1,000 people per year and then slid down a steady slope to 17 per 1,000 per year by the 1930s.

Not only in England but in several European countries and as far away as Brazil and Cuba, organizations calling themselves Malthusian and Neo-Malthusian Leagues sprang up in the early 1880s to promote wider use of contraception. In Germany, physician Wilhelm Mensinga developed a hollow half hemisphere of rubber with a watch spring threaded around its rimto hold it over the cervix. This device, soon known as the diaphragm, was easier to use and more effective than anything then available. In the Netherlands, the country's first woman physician, Aletta Jacobs, established centers for instructing midwives in how to teach contraceptive methods to women in their homes. The need for such instruction is an ironic indicator of the folk wisdom that midwives must have lost since the Middle Ages-including, perhaps, the memory of their predecessors' persecution in the witch trials. Nonetheless, with Dr. Jacobs's medical supervision as a defining feature, these centers mark the origin of reproductive health education and provision as practiced today.

Variable Winds

Across the Atlantic, the winds of change blew in the opposite direction. In a uniquely American development, a Protestant moral arbiter named Anthony Comstock crusaded for laws to criminalize as obscene the advertising and sale of contraceptives. A receptive U.S. Congress in 1873 rushed through passage of what came to be known as the Comstock Act to accomplish these objectives. For the District of Columbia and federal territories, the act banned even the possession of contraceptives. Comstock himself was deputized as a special agent of the Post Office Department, authorized to inspect suspicious mailings and to make arrests. State laws along the same lines as the federal one soon followed and, in some northeastern states where the Catholic Church wielded political influence, legislatures prohibited physicians from prescribing or even advising on contraception.

Comstock was virtually a caricature of the malemoralist, righteously determining that women should bear all the children whom God and their husbands sent their way. But his nemesis appeared within a few decades. Margaret Sanger was driven just as powerfully by the opposite idea: that women should determine for themselves if and when to have children, based not on abstinence but on birth control. Earlier and more energetically than any other single individual, she honed and promoted the idea that women freely choosing when to become pregnant would improve not only their own lives, but humanity itself. That conviction led her to the conclusion that the spread of birth control would slow or end world population growth-and also that it could improve the genetic quality of the human species. In this complex and ambiguous legacy, she represents to some extent the equally complex and ambiguous history of modern population policy itself.

Trained as a nurse, Sanger worked with immigrant women on New York's Lower East Side and witnessed the impacts of unplanned childbearing and unsafe abortion. Thus began Sanger's lifelong commitment to make birth control-two words she was the first to link together, in hermonthly newspaper The Woman Rebel-available to any woman who wanted to use it. By 1916, after visiting clinics in the Netherlands, the descendants of Aletta Jacobs's training centers, Sanger had set up the first birth control clinic in the United States in the Brownsville neighborhood of Brooklyn. Though she spent a month in a jail cell the next year, her prosecution for promoting birth control yielded a legal victory in the state and a political one nationally. The court case led to an exemption under the NewYork state Comstock laws by which physicians could provide contraception for medical reasons. That exemption led to the spread of legal birth control clinics under the supervision of doctors, first inNew York and then elsewhere.

Sanger founded the American Birth Control League in 1921 and opened the doctor-operated Birth Control Clinical Research Bureau under league auspices. In 1939 the bureau and league merged, and three years later the new organization was renamed the Planned Parenthood Federation of America. In 1948 Sanger helped to found the International Committee on Planned Parenthood, which became the International Planned Parenthood Federation four years later.

Sangermade important contributions to the field of demography as well. In the two decades or so after WorldWar I, demography was not yet a well-established scientific discipline, and the topic of conception control still carried the whiff of smuttiness among the era's mostly upper-class scholars. Fromher own backers Sanger raised private funding and, through that, gained scientific support for a first ever conference on world population. The meeting, held in 1927 in Geneva, Switzerland, led eventually to the establishment of the International Union for the Scientific Study of Population, a still-thriving association of demographers.

On the Radar

To the surprise of demographers and campaigners for birth control, the decades that followed World War II saw the most dramatic increases in population the world had ever known. In industrialized countries, the combination of returning soldiers and the prosperity of postwar reconstruction yielded baby booms no demographer had foreseen. U.S. fertility rates approached four children per woman by the mid-1950s, having bottomed out at little more than two during the Depression.

The larger influence on global demographic trends, however, was the growth seen outside of North America and Europe. Public health initiatives introduced in the remaining and former European colonies were reducing death rates dramatically-by 30 to 50 percent in some countries. Vaccinations, improved water supplies, sanitation, roads and railroads to move crops to markets, food and fertilizer aid, hygiene education, and more than a few applications of the pesticide DDT-each of these steps, large and small, slashed away at the high rates of infant and child death that for centuries had clamped down population growth in Asia, Latin America, and Africa. Birthrates, too, were rising modestly in some places, making their own small contributions to growth. Improved health and nutrition are the most commonly cited reasons for this, but a loss of traditional contraceptive methods may have played a role as well. Within a decade of WorldWar II's end, populations were growing by more than 3 percent a year in many of Europe's colonies and in newly independent nations. The world's growth rate exceeded 1.8 percent.

Without intending to, industrialized countries themselves had helped bring about this rapid demographic expansion. Public health measures introduced from Europe and North America to keep infants and children alive had the side effect of boosting family size and hence population growth rates in the rest of the world. Less-developed countries were struggling to adjust to numbers and densities of people they had never experienced and for which they were scarcely prepared. But reversing this process without giving up the effort to boost child survival was a problem. How could people in wealthy countries promote the use of birth control in poor ones? The topic was always awkward, and often taboo. The influential Roman Catholic Church forcefully opposed "artificial" contraception, which effectively eliminated modern methods. Religious leaders in Islamic countries reacted more diversely but often with just as much hostility. So it could not be the West (or, as it came to be called later,"the North") that pushed for the world's first policies aimed to pull down soaring population trajectories. Instead, it was national governments in Asia and North Africa.

In 1948, Japan's diet (parliament) legalized contraceptive sterilization and abortion. News stories depicting the horrors of botched illegal abortions in the wake of Japan's defeat had mobilized public and political support for making both options legally available. The country's total fertility rate began what must have been the most precipitous fall the world had ever seen, from roughly four to two children per woman in less than a decade. Within a few years of this postwar reproductive revolution, the country became a manufacturing and trade powerhouse that drove the phrase "made in Japan" into every corner of the industrialized world. Much later, in the 1990s, economists would recognize that such rapid fertility decline could produce a "demographic dividend" by reducing the proportion of dependent children and allowing more of the wages of working parents and the revenue of governments to flow toward long-term investments rather than short-term consumption.

By 1955, India, Taiwan, Ceylon (now Sri Lanka), and Egypt had taken tentative steps to slow the growth of their populations by establishing programs through which married couples could secure methods to prevent unwanted pregnancy. The strategies followed in the steps of the neo-Malthusians and Margaret Sanger: Offer all married adults family planning information and contraceptives. Couples will use them. Fertility and population growth rates will fall. Sanger's prewar visits to Japan and India and the colonial exposure of India and Egypt to British thinking may have played some role. So, no doubt, did the visits of Western experts sponsored by U.S. foundations.

But it would take much more than this to bring the governments of industrialized nations into direct action on world population. In the United States, President Dwight D. Eisenhower in 1958 openly disavowed a government role, despite the recommendations of a presidential commission: "I cannot imagine anything more emphatically a subject that is not a proper political or governmental activity or function or responsibility," he told a press conference when a reporter asked about the commission's recommendation. "The problem of birth control [is] not our business."

The president's stance did not prevail, however. Rapid world population growth had become a palpable worry tomany typical newspaper readers, including typical newspaper-reading bureaucrats and politicians. Even the Catholic Church couldn't stop the gathering momentum of U.S. concerns about population growth. John F. Kennedy, the former Massachusetts senator and first Catholic president, gave a green light to federal government action on world population. Like the national programs of India and Egypt, the U.S. program of international family planning assistance started out small and tentative. But within a decade the U.S. Agency for International Development (USAID) was supervising a US $125 million program (worth over $585 million in 2007 dollars) to distribute U.S.-made contraceptives to countries around the world.

Beyond U.S. shores, the 1968 United Nations Tehran conference on human rights established for the first time a basis in rights for the provision of family planning to all. In the same year, Paul Ehrlich's book The Population Bomb was published, helping tomark an enduring divide between those who celebrated individual childbearing decisions as the basis of sustainable population and those who despaired about the demographic future no matter what options were available to childbearers.

In 1970, the U.S. Congress voted to offer family planning services to Americans with low incomes. Some supportive congressmen included the growth of U.S. population among the arguments for passage. The new law (Title X of the Public Health Service Act) brought within view and in her own country Margaret Sanger's dream of universal access to birth control. Federal largesse for family planning services, however, came nowhere near eliminating unintended pregnancy in the United States. Then, as now, nearly half of all pregnancies were wanted later or not at all by the women involved. But the new program undoubtedly contributed to the fall of U.S. total fertility rates from 2.5 children per woman in 1970 to fewer than 2 by 1980. Later Congresses were less enthusiastic about the program, however, which helps explain why U.S. fertility later rebounded, reaching 2.1 children per woman today.

The United Nations, USAID, and many of the world's governments operated on the assumption that women able to decide at any given time whether to become pregnant would end up on average having two children. Even as early as the late 1960s, when Ehrlich and others were writing pessimistically about population growth, evidence was accumulating that this assumption was valid. Nearly 40 years later, the close correlation between access to effective contraception and average family sizes of two children or less still holds true.

Means and Ends

In 1969, the United Nations launched a Fund for Population Activities to consolidate monies from donor governments and distribute them to family planning programs in poor countries. For a decade or more, there wasn't much data to prove this was a canny strategy. Organizing, promoting, and providing family planning services is detail work, and the U.S. government paid for reams of technical reports to work out the minutiae.

The 1960s had seen the invention of the oral contraceptive pill and the IUD, revolutionary contraceptives that for the first time in human history assured reversible prevention of pregnancy without actually interfering with sex itself. But there were side effects to be considered, and training sufficient personnel to counsel users was a significant challenge. More and more women (and some men) showed up at clinics around the world, and many took home the contraceptives and started to use them. Still, throughout the late 1960s and early 1970s fertility and population growth rates in all but a few countries weren't changing enough to measure.

Ethical standards fromthe beginning stressed voluntarism in family planning programs, but in practice some promoters of family planning stretched the meaning of the word. Early on, a concept known as information, education, and communication, or IEC, evolved to help guide the promotion of contraceptive services. But the line in IEC campaigns that separated the benefits of contraception for clients from aggressive marketing and sometimes heavy-handed propaganda on the benefits of small families was never easy to draw. Pressured to show results, some programs and staff in parts of India and Bangladesh offered incentives to couples considering contraception. Most such incentives were fairly innocuous and arguably reasonable. Without a few rupees for bus fare, for example,many women found it impossible to visit a health clinic that might evaluate problems in pregnancy as well as help them prevent one.

Any money moving from family planning clinics to clients, however, risked the appearance of payments to prevent pregnancy. There's no convincing documentation that such incentives ever amounted to much more than small change. Some critics have nonetheless argued that potential clients in certain Asian programs outside of China,where examples of coercion are well documented even in recent years, felt browbeaten or even bribed into using contraception.

In India in 1976, family planning authorities, operating under a federal state of emergency, rounded up at least some men-it has never been clear how many-in low-income, high-fertility rural areas and forcibly vasectomized them. When the Indian government later offered compensation to men and women who could document having been forcibly sterilized during this period, few men and no women stepped forward, though fear of stigmamay have discouraged potential claimants. But the incidents were enough to make the newspapers, alerting readers to the family planning movement's excesses. India's national family planning programhas never quite recovered, and the stigma contributed to the defeat of Mrs. Gandhi and her party at the polls the next year.

In Bangladesh and Indonesia, women who sought to have IUDs removed from their uteruses, or Norplant rods from their upper arms, sometimes found to their dismay that physicians had received insufficient training or lacked experience in taking out the devices. In Peru, Mexico, and Brazil, physicians sometimes made their own decisions about what their patients needed-and surreptitiously tied the fallopian tubes of women just after childbirth.

In the context of large family planning programs in dozens of countries, such tactics were the exception. Much more common were clinics in which women's preferred contraceptive methods suddenly became unavailable, forcing them to choose a less desirable or inappropriate alternative or to give up on contraception altogether. Or poorly paid workers in poorly staffed clinics failed to give clients the personal attention they deserved and the contraceptives their circumstances warranted. These limitations are anything but history. When I traveled in Kenya in late 2006, I heard the stories of poorly supplied and staffed reproductive health clinics that were little different from those I had heard in other countries 15 years earlier. If anything, in the wake of the shift in health spending toward HIV treatment and prevention in Kenya, family planning services in the country have deteriorated- a story matched, increasingly, elsewhere in Africa and other parts of the developing world.

Despite the half loaf of imperfect programs, however, the neo-Malthusianmodel of "population control" actually began to work. Population was not really controlled, of course. It never is. But gradually, and then at accelerating speeds in several countries, use of contraceptives went up, average family size went down, and population growth rates slowed. The mostly Roman Catholic island nation of Malta followed Japan's track to replacement fertility in the 1960s. Thailand, Taiwan, Singapore, Hong Kong, South Korea, Tunisia, Sri Lanka, and Colombia experienced comparable fertility falls in the 1970s and 1980s. From the late 1980s to 2005, Iran's fertility plummeted from nearly six children per woman to two, after the country's Shia Muslim government ordered contraceptive counseling and provision for all newlyweds. And if Mexico once was characterized by large families, it is no longer: average fertility hovered in 2007 around 2.2 children per woman, leading some Mexican leaders to worry about population aging and even future decline. Stories of family-size decline are similar in Morocco, Indonesia, andmany other countries still considered part of the developing world.

Defying the expectations of economists, countries didn't even need to get wealthier to become less fertile. Cuba, its economy in tatters throughout the 1960s and 1970s, ended the latter decade with a fertility rate of two children per woman, half the rate at the time of the 1959 revolution. Per-capita incomes barely budged in Bangladesh as fertility fell from five to three children per woman from the 1980s to today. The story was similar in Sri Lanka, Tunisia, and Kenya,where government commitment to family planning proved a far more important force for fertility decline than rising per capita income. Pioneers setting up new family planning clinics often were surprised to find crowds of women waiting in line, anxious to begin using contraception as soon as possible.

By the 1980s it was obvious that women and many of their partners wanted later pregnancies and fewer of them. Where governments introduced family planning programs, contraceptive use rose almost immediately, followed not long after by falling fertility and population growth rates. The correlation among the three-government commitment to family planning programs, contraceptive prevalence, and completed family size-is more consistent than the commonly cited one between girls' average years of completed education and how many children they end up having.

The use of contraception expanded by 75 to 80 percent on average every decade beginning with the 1960s. Today more than three-fifths of reproductive-age women or their partners use contraception, a proportion made more impressive by the fact that another fifth of such women at any given time are either trying to get pregnant, are already pregnant, or are not engaging in heterosexual intercourse. One result of all this planning of families is that their size has shrunk in every part of the planet. The average woman gave birth to five children in 1965. Today the average is just over half of that.

One Hand Clapping

Organized family planning is now in many ways a victim of its own success. Its adversaries remain the hierarchy of the Roman Catholic Church, joined by some evangelical Christian and Muslim leaders, and male political elites that see women's control of their own sexuality and childbearing as threats to dreams of national power.

"They plan…to block our growth," wrote the editor of El Salvador's Diario de Hoy of U.S. family planning advocates back in 1963,"slashing the wombs of Latinmothers, castrating Latin males, before we have grown sufficiently or taken possession of the vast empty lands of the continent." Four and a half decades later, family planning services remain rare and underfunded in El Salvador, abortion is punitively criminalized, and the country's population hasmore than doubled since the editorial was written, from 3 million to 7 million people. Archaeological excavations suggest that people living 14 centuries ago in what is now El Salvador atemore diverse diets and occupied sturdier andmore comfortable housing than domost of those in the country today. An additional 2 million or so Salvadorans now live in the United States, where they have taken possession not of vast empty lands, but of apartments that are often crowded and jobs that are often poorly paid.

The U.S. Supreme Court's 1973 decision legalizing abortion severed the population and family planning field from its early hopes of public acceptability. The Catholic hierarchy effectively directed its political influence against modern contraception and the contention that human population could ever grow too large-scientific views to the contrary. After Ronald Reagan tapped George H.W. Bush to be his running mate in the 1980 presidential election, Bush told a friend there would be nomore talk about population and family planning. Reagan built much of his political base among Americans embittered by legalized abortion, and Bush exploited the same base for his own ends when he succeeded Reagan as president- as did his son, the later President George W. Bush. Much of that base refuses to accept the logic that widespread use of birth control prevents abortions, preferring to believe that contraception just encourages sex, which ends up causing more abortions when contraception fails.

Hostility to family planning among U.S. leaders spreads like an infection among governments, sapping energy and funding from programs that could lead to both healthy reproduction and demographic stability. But poor leadership isn't the only problem. Few people are aware that easy access everywhere to good family planning services is most of what's needed to achieve a sustainable world population. As growth has slowed, news media worldwide-once influential in bringing the "population explosion" to public attention-have turned their attention to the seemingly fresher story of population aging and decline. Fully 45 percent of the world's population lives in countries in which total fertility rates are below their population-specific replacement fertility rates, according to Population Action International. Unless fertility rebounds or immigration surges, these populations are poised to stop growing once today's child bearers grow old. Some countries are already losing population. If the story is population decline, for popular media that find nuance and internal contradiction challenging to convey, it can't also be population growth.

If they think about population growth at all, most policymakers tend to see it as a twentieth-century worry that never matched its crisis billing and is no longer an issue. The topic couldn't fade fast enough formany advocates of women's interests. Family planning suffers from its long association with "population control," a concept some see as an embarrassing relic of patriarchal attitudes long ago discarded. Rather than consider a strategic alliance with environmentalists and others who still express concern about human numbers, most advocates today prefer to leave population out of the picture altogether, discussing contraception as simply one aspect of women's reproductive health. Such views work their way into governments and related bodies and carry weight in international discussions and negotiations.

To some extent, the world's governments consciously chose to think of family planning removed from population growth. In 1994, the International Conference on Population and Development convened in Cairo to consider world population. The conference adopted the view that women, rather than population per se, should be the focus of "population policies," and representatives of almost all the world's governments agreed tomake family planning universally available by 2015 and to significantly expand assisted birth, improve maternal and child health, and prevent HIV and other sexually transmitted diseases. The agreement foresaw global spending of about $11.5 billion a year in 1994 dollars (nearly $16 billion in 2007 dollars) tomake family planning fully available in developing countries.

Spending has never approached even half that level, however, and the goals expressed by the Cairo conferees not only haven't been accomplished, they aren't even agreed on any more. Once most opinion leaders concluded by the mid- to late 1990s that population growth was no longer a pressing issue for the world, concern for women's health failed tomotivate much more than paltry increases in funding for reproductive health-until the global HIV/AIDS pandemic was recognized and addressed. In 2000, when the United Nations governments crafted a set ofMillenniumDevelopment Goals (MDGs) to take a big dent out of global poverty by 2015, most negotiators were weary and wary of the arguments on abortion that grafted themselves onto all discussions of population and reproductive health. The religious right argued that the very phrase reproductive health was code for abortion rights and amounted to a wink and a nod to promiscuity among teenagers. The entire concept was excluded from the MDGs, only to be squeezed into supporting language later by advocates who realized almost too late how badly they had been blindsided.

By abandoning the argument that slower population growth is one benefit of reproductive health services, these advocates let slip a line of reasoning that at least captures the attention of distracted public and policy audiences. In 2006, President George W. Bush proposed cutting U.S. international family planning assistance from $436 million in the subsequent fiscal year to $357 million. An assistant administrator at USAID cited increases in spending to combat HIV and malaria, along with a program to reduce sexual violence in Africa, as evidence that the president had offered "a much better budget than we've had in the past for women's health." On that turf, his argument was plausible, and no reproductive health advocates challenged him. But family planning is about not just women's health, but about all the options that women, their partners, and their children can enjoy in life. And it's about sex, and about a vision of human numbers steered by wanted rather than unwanted pregnancies. These broader connections have largely faded from the discussion, and the case for reproductive health is weaker as a result.

In some of the places where population growth chugs on most rapidly, demographic debates are more alive than ever. But to the extent that policymakers in wealthy countries are thinking about population at all today, the talk is mostly of subsidizing childbearing domestically or attracting the best and brightest immigrants from developing countries. Unless governments focus on creating the conditions by which births result from the conscious decisions of women and their partners to parent a child, there's no reason to be confident that global family size will fall to a two-child average. Even if it does, the grand, one-time-only experiment-how many of us can the Earth and we ourselves sustain?-will continue, for a few decades at least, in the only available laboratory, the only available home.