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Ed. 1, June 2002 // Ed. 2, Jan. 2003 // Ed. 3, Jan. 2004 // Ed. 4, May 2004 // Ed. 5, Aug. 2004 // Ed. 6, Oct. 2005 // Ed. 7, April 2006 //

"COULD FAMILY PLANNING CURE TERRORISM?" is now a separate document - See Ref. (08S1).

LIST OF TABLES:

* Note 1: In the interests of brevity, the term "international family planning" is replaced by the abbreviation "IFP" or "I.F.P." throughout this document.
+Note 2: A reference citation such as (98C2) signifies the second document cited that was published in 1998 and that has a lead author whose last name begins with "C".

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The growing contentiousness over U.S. support for international family planning (IFP) is traced to the broadening of the issue to include (1) increased educational and economic opportunities for women in developing nations and (2) concerns that demographic issues (over-population and/or population growth) are at the root of the growing social, economic, political, and military instabilities in the developing world. Since these concerns tend to promote increased access to abortion and contraception, support for IFP has grown less bipartisan and more contentious since around the early 1980s. Arguments used by opponents of IFP are analyzed. The economics of IFP are examined and the case is made that just the financial benefits of IFP outweigh the costs by orders of magnitude - for both developed and developing nations. Much of the wretchedness and hope-deprivation found in developing nations can be traced to the largely unmet needs for financial capital (in excess of $1 trillion/ year) due to the demands for capital to fund the infrastructure expansion that population growth entails. The conversion of labor-intensive agriculture to capital-intensive agriculture in developing nations, in combination with a lack of undeveloped arable land in developing nations, adds significantly to population-driven migrations to marginally arable lands and to the urban slums that ring most of the large urban areas of developing nations. A major destabilizing and potentially dangerous result of these trends has been the creation of a rapidly growing "informal" economy throughout much of the developing world. This problem can also be traced to financial capital deficiencies caused by the infrastructure expansion that population growth entails. This problem also adds to the growing social, economic, political and military instabilities of the developing world.

Developed-world support for IFP began in the late 1950s and early 1960s as a largely bipartisan issue motivated by fears of over-population in developing nations. But since around 1980, US support for IFP has become perhaps the most contentious foreign-aid issue considered by Congress. The reason for this change in political environment is the broadening of the issue's scope. Avoiding over-population in the developing world via voluntary family planning has come to be seen as impossible unless desired family sizes can be reduced. This requires increased educational and economic opportunities for women. As a result, opponents of abortion, and artificial contraception have come to see growing public concerns over over-population, and desires for expanded life-shaping opportunities for women, as threats. Both views indirectly promote the rising global tides of abortion legality and usage of artificial contraceptives, even though IFP and modern contraceptives reduces abortion rates in a direct sense.

Direct costs of developed-world support for IFP-related services, and unmet need for such services, are summarized in Chapter 2. The total cost of funding family planning- and reproductive health services in developing countries was estimated by the UNFPA at the 1994 Cairo Population Conference to be US$15.2 billion/ year in 2000 (in addition to money spent by developing world citizens on their own family-planning). The financial shortfall in 2000 from the $15.2 billion/ year cost estimate is about $10.7 billion/ year - $7.3 billion for family planning and $3.4 for reproductive health. The unmet need for family-planning services in the mid-1990s was about 350 million couples (UNFPA estimate). The UNFPA apparently estimated these needs would cost $20/ couple/ year to fill. It would appear that the number of couples with unmet needs has not diminished since the mid-1990s. The estimated median cost of averting a birth through family planning services, US$58, is perhaps a factor of 10 less that via some other strategies. However the cost of averting a birth via family planning services is about a factor of 10 greater than some more recent technologies (Section (2-C) ). A major problem in recent years has been that funds that would otherwise have gone to family planning services have been diverted to HIV/AIDS issues (07S2). (See Table (1-S) below.)

Table (1-S) ~ Time history of the percentage of total population assistance expenditures allocated to 4 major categories of expenditures ~
(from a graph) (Data provided to Prof. Joseph Speidel to "Return of the Population Growth Factor: Its impact on the Millennium Development Goals," Report of the Hearings by the All Party Parliamentary Group on Population, Development and Reproductive Health (January 2007) p. 12)
Col. 2 - Family Planning Services
Col. 3 - Basic reproductive health services
Col. 4 - Sexually transmitted diseases and HIV/AIDS activities
Col. 5 - Basic research, data and population and development policy analysis.

The direct benefits of developed-world support for IFP-related services in developing nations are also summarized. Filling the unmet need for family planning services and basic reproductive health services could reduce the total fertility rate of the developing world from 3.2 down to 2.7 children per woman. The reduction to 2.1 (required for eventual population stabilization) would need to come from reductions in desired family size, i.e. from women having more life-shaping options such as educational and economic opportunities. Only 33% of developing-world population growth comes from unwanted fertility. About 49% comes from momentum caused by the population age structure, and this requires at least two generations to eliminate. About 18% of population growth comes from high desired family size. All this insures a global population several billion larger than today's six billion unless developing world fertilities can be reduced to below replacement levels, i.e. below about 2.1. Some analyses suggest that "replacement level" fertility is somewhat larger in the current environment of the developing world. The world's food/ natural fiber/ freshwater supply systems are unable to support this on a sustainable basis, given the financial capital constraints faced by developing nations (08S2). Even without these financial capital constraints, significant doubts remain as to the ability to meet the basic needs of even the current level of human populations in the developing world.

A key element in the debate over support for IFP is the explanation for the ills of developing nations. If these ills are not related to over-population, then IFP cannot address these ills. Opponents of abortion and artificial contraception see these ills in terms of "bad government". Those concerned about over-population see these ills as effects of over-population. This question is evaluated here. A compelling body of evidence supports the conclusion that the basic ills of developing nations are rooted in over-population (Section (4-A) ). Bad government is just one of many end-results of over-population that degrade the human condition. Most Americans agree with this contention (Appendix B).

"Bad-government" theory rests on little more than conjecture. Yet it is condemns billions of people to a downward spiral of ever-increasing wretchedness, wars, and all the other life-is-cheap trappings of over-population. The resultant economic, social, military and political instabilities of the developing world subject the developed world to huge, and growing, economic and military risks and expenses. This is especially tragic when that spiral could be largely reversed by allocating an extra $10.7 billion/ year to IFP-related services for a few decades. There is probably no other misdiagnosis that could have such major long-term consequences in terms of the scale and depth of wretchedness created - and that could have such extreme effects on the future.

A second key element in the IFP debate is whether "market forces" would solve whatever substance there is to population problems. Evidence against this is compiled in Section (4-B) .

A third key element in the IFP debate is whether developed nations should involve themselves in IFP. Opponents of IFP argue that developed nations should avoid supporting IFP in nations where an element of coercion exists regardless of whether IFP funds support this coercion. They also argue that family planning in developing nations is none of the business of developed nations. Several nations have attempted, invariably out of desperation, to impose family planning on its citizens. Donor nation funds have never supported such projects. These projects have largely failed. Clearly, involuntary family planning has no future. Developed nations must understand the motivations behind these attempts. Withdrawing support for IFP from nations that make these attempts is to withdraw support where it is needed most. This holds the potential for creating serious global problems. IFP might logically be considered to be none of the business of developed nations only if the ills of developing nations do not affect developed nations. Facts and arguments here show that the ills of developing nations do have major spill-over effects on developed nations. Some contend that IFP is being "rammed down the throats" of developing nations. This charge is contrary to the views and wished expressed by developing nations themselves at the 1984 Population Conference in Mexico City. Also, since IFP funding is unable to meet the demands for such funds, why forcibly impose IFP funds on developing nations? (Section (4-C) )

An analysis is given here of some of the indirect costs and benefits of developed-world support for IFP-related services (Section (5-A) ). There is increasing global awareness that indirect issues such as:

• Environmental protection,
• Security and stability of economic-, social-, educational-, religious- and political institutions against internal and external forces,
• Security of capital, capital investments,
• Risks associated with loans to developing nations,
• Natural resource costs,
• Costs of making the outputs of key natural life-support systems sustainable,
• Military expenses and
• Quality of life

are strongly impacted by the ills of developing nations. The developing world's ills impose serious economic, political and military risks and costs on both the developed and the developing worlds. Thus developed-world support for IFP-related services is easily justified in terms of economic self-interest - not just in humanitarian terms.

Each 1% growth of population requires a capital investment of 12.5% of a nation's GNP (GDP) in its new citizens (educational-, industrial-, commercial-, and transportation- infrastructure, plus housing, land development, judicial systems, other government facilities, utilities etc.). Thus developing nations now require over $1.0 trillion/ year to accommodate population growth. This magnitude readily explains why developed-world development- and humanitarian aid and loans to developing nations have been ineffective in uplifting developing nations. It also indicates the huge gains to be expected from investing relatively modest sums in IFP-related services.

The economic analysis in Section (5-A) includes rough estimates of the financial benefits of a $15.2 billion/ year investment in IFP-related services in developing nations. Just the following potential reductions offer benefits orders of magnitude greater than costs for both the developed and developing worlds.

• International development and humanitarian aid,
• Risks to private investments,
• International peace-keeping & emergency humanitarian aid,
• Outlays for military operations,
• Risks of default by developing nations on external debt,
• Capital cost of providing for population growth.

The developing world's dire shortage of financial capital is examined in Section (5-B) . This shortage is so severe as to put investments like the following virtually impossible to meet.

• Basic infrastructure needs required by population growth and migration to urban areas;
• Making food/ natural fiber/ freshwater supply systems sustainable;
• Making food/ natural fiber/ freshwater supply systems more productive;
• Developing the human capital needed for eventual achievement of developed-world status

Population growth rates in the developing world are clearly excessive and dangerous. Success of the "Asian Tiger" economies and a number of others in solving their financial capital problems with active family-planning programs could serve as a model for the developing world to follow.

So much is riding on broadening and strengthening public recognition that the ills of developing nations are a direct consequence of over-population (the culprit in natural resource problems) and/or population growth (the culprit in financial capital scarcity problems). Therefore an 800-page document (06S2) has been prepared which reviews the global literature on degradation and loss of the world's soils, forests, grazing lands, irrigated lands, water supplies and fisheries. It covers virtually all of the earth's reasonably biologically productive land and water, and identifies population-related environmental stresses as the primary source of the ills of developing nations. A summary and analysis of these review documents is found in Ref. (08S2). It shows that the outputs of the developing world's food/ natural fiber/ freshwater supply systems are not sustainable as currently managed. The current population growth rates in developing nations make the financial capital needed to achieve sustainability unavailable. The large-scale migrations now going on in the developing world are also analyzed (Section [H] in Ref. (08S3)). These are also shown to be non-sustainable in terms of the options available and the needs for economic, social and political stability. Clearly, the developing world is either over-populated or increasing its population at an excessive rate, and is headed toward conditions worse than today's. Arguments to the contrary, common in the mass media today, largely ignore sustainability issues. Other fallacies behind these arguments are also pointed out.

• Few issues have as strong a bearing on global political- and economic stability, economic progress, peace, and environmental quality as over-population and unaffordable rates of population growth in the developing world.
• These population-related issues underlie virtually all the ills of developing nations.
• These ills create huge costs, and pose major risks, for the developed world.
• Therefore no other issue comes before the US Congress having such a strong bearing on the future as the degree to which international family planning is supported.

SECTION (1-A) ~ FRAMING THE ISSUE ~ [1A1]~Earlier Views ~ [1A2]~ Recent Views ~ [1A3]~ Backlash Examples ~ [1A4]~ Why Bipartisanship Died ~ [1A5]~ Mistakes in every direction ~ [1A6]~ Historical Trends ~ [1A7]~ IFP and Maternal Health - Means not Ends ~ [1A8]~ Overpopulation Complexities~

US policy has supported IFP since 1965 (01N1). But since around 1980 the issue has changed from being quiet and bipartisan to highly visible and politically charged. Since 1996, IFP- related issues have been among the most contentious foreign-aid matter considered by Congress (01N1). Many believe this divisiveness should not exist. Making IFP-related services widely available to all who want them is one of the surest ways to foster self-sufficiency, promote preventive health care and basic education, nurture strong and healthy families, stabilize economically-, politically-, and militarily unstable regions and enhance the quality of life for all. In many ways, IFP reflects the core values that most social conservatives - and most Americans - hold dear.

Partisan wrangling over this issue can be traced largely to the abortion issue - even though financing abortions with IFP funds has been illegal since 1973. Many see irrationality and irony here. Why would abortion opponents oppose aid for IFP when that aid reduces developing-world abortion rates (currently about one abortion for every female) (99G1) (96G1)? Data on the inverse relation between abortion frequency and access to family planning and contraceptives are given later in this document. Regions of the world where abortion is illegal tend also to be regions with a lack of access to family planning and contraceptives. Perhaps this is why regions with high abortion rates are also where abortion is illegal (e.g. Latin America). Similarly, regions of the world with low abortion rates are also where abortion is legal (e.g. the Netherlands). One cannot help but suspect that the activities of anti-abortionists, globally, have been responsible for vastly more abortions than the activities of pro-abortionists. Adding to all this irony, a RAND poll (00A1) found that attitudes towards abortion exert only "minor influence" on American attitudes towards IFP. Also, 80% of those polled supported US funding for voluntary IFP programs in other countries. Few other issues can boast this degree of public unanimity. (See other poll results in Appendix B.) But looking deeper into the issue reveals less irrationality and irony, but greater breadth and complexity. This growth in breadth and complexity is examined below. Thus far, the role of opposition to artificial contraception in the controversy over IFP has been ignored. This issue is examined at the bottom of this section.

Part [1-A-1] ~ Earlier Views ~
In the late 1950s and early 1960s International Planned Parenthood Federation and other private foundations began financing IFP aid. The driving motivation for reducing the high population growth rates was the so-called "demographic" rationale (02S1) - concerns over national-level consequences of rapid population growth on economic productivity, savings and investment, natural resources and other environmental values. This motivation still drove policy in 1966 when the UN joined in, followed by the US, other developed countries, and some international organizations such as the World Bank. Global population growth rates were approaching what would turn out to be all-time highs.

During the 1980s a shift toward the "health" rationale occurred (02S1), driven by concerns over the effects of high fertility on maternal-, infant-, and child-mortality. This shift was perhaps driven by a desire to broaden the base of popular support for IFP aid in the face of growing political and ideological influences. As a result, arguments on behalf of US support for IFP were framed in more family-oriented terms, such as:

• Helping the poor in developing nations obtain the information and supplies needed to limit their family size to that which is compatible with their income, values and outlooks;
• Promoting maternal health - helping poor women in developing-nation reduce their relatively high risk of death, disability, paralysis or serious injury associated with pregnancy, narrowly spaced pregnancies, pregnancy at too young an age, too many pregnancies, and unsafe abortions.

The "demographic" rationale did not diminish in the 1980s, and is still a growing, powerful motivation for governments, NGOs and private citizens to provide financial support for IFP. The "health" rational was essentially piled on top of it, in part due to the need to defend IFP and to broaden its appeal in the global political arena (02S1).

Part [1-A-2] ~ Recent Views ~
In the 1990s, the "human rights" rationale for IFP was added to the "demographic" and "health" rationales (02S1). It focused on women's rights, principally reproductive rights and the reproductive health of women and men. According to feminists, governments have a "responsibility" to ensure reproductive rights, and to provide family planning services (02S1). Many might not see how this rationale might add significantly to the existing motivations for governments, NGOs and citizens to support IFP financially; they might even see some counter-productivity. The "human rights" rationale probably had its origins in the realization of the difficulties of stabilizing developing world populations purely with traditional IFP/ maternal health approaches. Technology and IFP funding can only go so far. The lower limit to fertility and population growth rate is determined by desired family size. This size was, and is, well above "replacement level" fertility (2.1** children per woman) in the developing world. But it was found that expanding the educational- and economic options available to women reduces desired family sizes. This broadened the range of motivations for supporting IFP-related services to using smaller family sizes, achievable with IFP, along with other measures, to expand the educational- and economic options available to women in order to reduce desired family sizes and hence fertility.

[** While it is commonly asserted that a total fertility rate of 2.1 is the "replacement" rate, this is true only in low-mortality countries such as the US, Europe and Japan. In developing counties with higher levels of mortality, replacement level fertility may be as high as 3.5 or more ("Replacement is Not Always 2.1", 10/15/03 issue of "Population Reports" available from Johns Hopkins INFO Project, www.populationreports.org) ("The Surprising Global Variation in Replacement Fertility" Office of Population Research, Princeton University, 4/12/04).]

Throughout all this, the original "demographic" motives for supporting IFP were strengthening. Globalization, the growing mobility of information, technology, natural resources, goods, people, labor content and capital was making the ills of developing world increasingly real (07S1), if not also frightening, to Americans (08S1). Population-related problems are becoming increasingly less of a problem associated with distant lands, and more of a global problem. African nations that viewed the "demographic" rationale with dark suspicions in the 1970s (e.g. at the 1974 Bucharest Population Conference) have gradually turned around (e.g. at the 1984 Mexico City Population Conference) and now embrace it completely, or nearly so (UNFPA press release of 2002).

At the same time all this was going on, abortions were becoming more common - and more legal - first in developed nations and then in developing nations. Also, contraceptive technology and use are expanding rapidly - even into regions where fundamentalist clerics are quite powerful, e.g. see Ref. (08S4). A backlash resulted because opponents of abortion and artificial contraception saw two threats to their cause:

• Increased availability of IFP-related services broadens the educational- and, economic options available to women, thereby promoting the legality and frequency of abortion and the usage of artificial contraceptives.
• Growing public concerns about population problems also promotes the legality and frequency of abortion, and the usage of artificial contraceptives.

Part [1-A-3] ~ Backlash Examples ~
One anti-abortion group said that women should work outside the home only if there is a financial crisis in the family, and they should consider such employment as "bondage" (89R1). The late economist Julian Simon, whose influential 1981 book "The Ultimate Resource" (81S1) challenged the very concept of over-population, was apparently linked to the Catholic organization Opus Dei, an organization with an agenda opposing artificial contraception, women's rights, abortion etc. (86M1). In December 1983, the Vatican's Congregation for Catholic Education issued a document to all governments which stated "It is the task of the state to safeguard its citizens against injustice and moral disorders such as the . . . improper use of demographic information" (Ref. American Democracy p.184). In other words, it is the responsibility of the government to censor demographic information that suggests the existence of an over-population problem (86M1). The Vatican killed the NSSM 2000 Initiative and the Rockefeller Commission Initiative during the Nixon administration (96M1). These documents compiled the data and analyses for the contention that problems associated with global over-population threatened the national security.

Part [1-A-4] ~ Why Bipartisanship Died ~
Thus a once simple, largely bipartisan issue has been broadening, starting in the 1980s, into an increasingly tangled web of alliances among philosophies of government, theories about global peace and prosperity, and convictions about the proper role of women in society. Bipartisanship grows increasingly unlikely is such a changing and complex environment. The apparent irrationality and irony alluded to above are simply consequences of failures to recognize the expansion and strengthening of the motivations for favoring and opposing US support for IFP.

Part [1-A-5] ~ Mistakes in Every Direction ~
Part of the problem is that this changing landscape is not fully recognized. Instead of substantive debates over the "demographic" rationale, opponents of IFP engage in shallow analyses that ignore key issues like sustainability and the serious degradation processes that are affecting food/ natural fiber/ freshwater supply systems throughout the developing world. Supporters of IFP, on the other hand, stay focused on now-peripheral arguments on unmet needs, etc. Their "demographic" rationale arguments rarely rise to the level of vague allusions. This is in spite of the fact that public opinion polls show that a strong majority of Americans are concerned about over-population in developing nations and its harmful effects on, and risks to, all mankind.

Instead of substantive debates over the proper role of women in society, opponents of abortion, and artificial contraception use code words like "family values" and vague allusions to bygone eras. These imply that expanding life-shaping options for women is not in the best interests of anyone - as if women lack the intelligence to make sound choices. Supporters of IFP sometimes address the same issue in belligerent and polarizing terms rather than in terms of well-reasoned analyses. Feminist arguments on the "human rights" rationale ignore the sound logical basis of the demographic rationale and talk more about God-given rights to a share of national budgets - arguments that are weak and/or counter-productive and unlikely to inspire increases in IFP funding.

Mankind surely deserves better than this on an issue that will largely shape the future.

Part [1-A-6] ~ Historical Trends ~
Human numbers first started increasing rapidly during the 1800s, due to advances in medicine and sanitation. Contraception was outlawed in the US in 1873 (00P1). In 1952, India established the first family planning program (02S1). In the late 1950s and early 1960s population assistance became a global issue after International Planned Parenthood Federation and other private foundations began providing money to developing countries to reduce population growth rates. In 1966 the UN joined in, followed by the US, other developed countries, and some international organizations such as the World Bank. But even with these efforts, the population of the developing world nearly tripled in the past 50 years, adding 3.2 billion people (97W1). Around 1965 the last anti-contraception law was found unconstitutional by the US Supreme Court - around the time developing world population growth peaked at 2.4%/ year. Abortion was illegal in almost every nation until the second half of the 20th century. But by the mid-1980s (1973 in the US), most developed countries and several developing countries had lifted their prohibitions against abortion (99D1).

By 1976, 94 nations gave direct support for family planning; another 17 gave indirect support, while 15 restricted support/ information (00U3). In the early 1980s the dominant rationale for family planning programs shifted from the "demographic" rationale (concern with national-level consequences of rapid population growth on economic issues, natural resources and the environment) toward a health rationale (concerns about the consequences of high fertility on maternal, infant and child mortality) probably due to its greater appeal to policy makers (02S1). By 1984, developing nations had become convinced of the urgent need to reduce their population growth (a reversal of their position at the 1974 Bucharest Population Conference). In the 1990s, the dominant rationale for family planning programs shifted again - to a human rights rationale with a focus on women's rights, principally reproductive rights, and the reproductive health of women and men (02S1). By 1998 145 nations gave direct support for family planning, another 34 gave indirect support, while one restricted support/ information (00U3). In 1998 family planning programs existed, or were directly or indirectly supported, in 192 countries, which cumulatively contained 99% of the world's population (00U3). By the late 1990s, contraceptive prevalence in developing countries had risen to well over 50% (02S1). By 1999, 55% of women in developing nations, and 86% of women in developed nations, lived where abortion is permitted on broad grounds (99D1). Between 1985 and 2002, the number of countries restricting access to medical sterilization procedures has declined from 28 to 8 (02E1). (Keep in mind however that roughly half of the women in the developing world lack access to medical [surgical] sterilization. This is why inexpensive, non-surgical sterilizations such as quinacrine sterilization are so important (07S3).)

Part [1-A-7] ~ IFP and Maternal Health -Means, not Ends ~
The above long-term trends seem unlikely to reflect, primarily, growing concerns over maternal health and helping the world's poor to have the number of children they want or can afford. Nor were these trends likely to reflect primarily growing feelings that family planning services fell into the category of basic "human rights". Instead, these trends and the motivation for financially supporting IFP probably reflect ever-increasing components of:

• Public concerns about global risks and consequences of over-population and population growth.
• Women's desires for more life-shaping options.

IFP and maternal health-related assistance were probably never seen as ends of a magnitude comparable to the end of stabilizing human populations. Instead they were probably seen, to a significant degree, as means to a greater end. In the late 1950s through the 1970s IFP-related aid was motivated almost entirely by concerns over-population growth (the "demographic" rationale). In the 1980s and 1990s, a realization developed that only reduced desired family sizes could stabilize the developing world's population. This required not only increased educational and economic opportunities for women, but also reduced risks and hobbling effects related to maternity, i.e. increased maternal health care. Thus those motivated by the demographic rationale found allies in people seeking to broaden basic female outlooks and options.

Whether broadening basic female outlooks and options is seen as an end, or as a means to an end, is also argued here to be immaterial. Over-population entails ever-increasing desperateness in the struggle for basic resources (See Chapter 4). Women - and their status, options and outlooks - have always been victims of this struggle. Thus over-population should be seen as the crux of the matter, regardless of one's priorities. Nothing here should be taken as insinuating that expanded options for women, improvements in maternal health etc. are not legitimate and worthwhile ends in themselves. What is being said here is that these ends are certain to remain unmet unless human populations can be bought within the Earth's capacity to support such populations on a sustainable basis.

Part [1-A-8] ~ "Over-Population" Complexities ~
Over-population is taken in this document to mean

• Populations and standards of living beyond the carrying capacity of food/ natural fiber/ freshwater supply systems;
• Population growth rates outside the limits imposed by the capital generation rates needed to maintain social, economic and political stability (Chapter 5).

But the issue is significantly more complex. Adding to the complexity:

• Carrying capacities of food/ natural fiber/ freshwater systems increase over time due to technological advances, and diminish due to degradation phenomena that tend to be, for all intents and purposes, irreversible.
• Degradation phenomena in food/ natural fiber/ freshwater systems are growing in scale to rates that would be hard to match by sub-replacement-level fertilities.
• The major food/ natural fiber/ freshwater productivity-enhancing technological advances of the past four or more decades are approaching, if not exceeding, fundamental limits (08S2).
• Conversions from labor-intensive- to capital-intensive agriculture in developing nations (plus several other important processes) are causing large-scale human migrations that add to population-growth-driven migrations (08S3). Accommodating these migrations requires financial capital well beyond what is available, risking social, economic and political instabilities.

To avoid getting distracted by these complexities, Ref. (08S2) and Ref. (08S3) review these issues. This enables this main document to stay focused on IFP, maternal health care, options for women in developing nations, root causes of developing world ills, the potential for "market mechanisms" to eliminate these ills, and the basic economics of IFP.

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SECTION (1-B) ~ THE ROLE OF OPPOSITION TO ARTIFICIAL MEANS OF CONTRACEPTION IN THE IFP CONTROVERSY ~ [1B1]~Catholic Laity in the Developed World ~ [1B2]~ Developing World Artificial Contraception Politics ~ [1B3]~ Winds of Change in the Vatican ~ [1B4]~ Power Politics in the WHO ~
One might at first think that opponents of abortion would be in favor of IFP, because numerous studies have found that increasing the availability of contraceptives decreases the rate of abortion. But abortion opponents tend to be the primary opponents to IFP. One might also think that outlawing abortion would decrease abortion rates. But the regions where abortion tends to be illegal are also where abortion rates are the highest (e.g. Latin America) and regions where abortion tends to be legal are also where abortion rates are the lowest (e.g. Europe). One might explain these two puzzling observations by postulating that opponents of abortion tend to also be opponents of contraception. Thus regions where abortion is illegal would also be the regions where contraceptives are difficult to obtain, and regions where abortion is legal would also be the regions where contraceptives are readily available. This postulate has difficulties however. Opposition to contraception is far less common than opposition to abortion. In fact, 80% of Americans who are anti-abortion support women's access to contraception (based on a 2005 poll by National Family Planning and Reproductive Health Association (06J1)). This means that only 20% of Americans who are anti-abortion are also anti-contraception.

To explain the difficulty in winning support for IFP we need one additional postulate - that Americans who are both anti-abortion and anti-contraception are far more dedicated and aggressive in pressing their views in arenas of public policy. They are the ones who make contraceptives difficult to obtain in Latin America, and they are the ones who influence legislators to vote against US support for IFP. They make up for the fact that they are an extremely small minority of Americans by their extreme dedication and activism. They can overcome their disadvantage of being an extremely small minority probably because (1) Americans feel generally secure in their own access to artificial means of contraception, and (2) Americans don't fully comprehend the magnitude of the potential benefits of IFP in addressing the ills of the developing world - and/or they hear that fertilities are plummeting throughout the developing world and assume that the problems IFP are intended to address are well on their way to being solved. They have not yet come to an understanding of the effects of the additional three billion people that are expected in the developing world within the next 4-5 decades on the economic, social, political, and military stability of that region.

Opposition to artificial means of contraception is diminishing virtually worldwide. Even in the Muslim world it is in rapid retreat (08S4). But that does not mean that the US population of those opposed to both abortion and contraception is shrinking or growing less dedicated. The leadership of this hard core is the Vatican and it has sufficient resources to sustain this core. This is true even though these resources are largely provided in the US by Catholics whose views on abortion, contraception and sexual issues generally are completely at odds with those of the Vatican. Consider the following.

Part [1-B-1] ~ Catholic Laity in the Developed World ~
At the laity level of the Catholic Church in the developed world there is virtually no opposition to artificial means of contraception. Some of the lowest Total Fertility Rates in the world are in predominantly Catholic countries (e.g. 1.3 in Italy (97% Catholic); 1.4 in Poland (95% Catholic); 1.2 in Spain (94% Catholic) (data of around 2002)). This would be impossible without widespread use of artificial means of contraception (given that "natural" family planning methods have a failure rate of over 25%). In the US:

• About 88% of both Catholic and non-Catholic U.S. women exposed to the risk of unintended pregnancy use contraception (84B1).
• The incidence of US Catholic use of "natural family planning" is no more than 5% (according to the 2002 National Survey of Family Growth (06J1)). (The low incidence is probably a result of that method's high failure rate (06J1))
• Catholic Americans use the same contraceptive methods as non-Catholic Americans (84B1).
• Catholic Americans have the same attitudes toward abortion as non-Catholic Americans (84S1).
• In 2000-2001 in the US, 40% of women who had an abortion identified themselves as either Catholic or evangelical - about the same as the percentage of Catholics and evangelicals in the US population (06J1).
• Catholic Americans have the same desired family sizes as non-Catholic Americans (78W1).
• Most American Catholics disagree with the Vatican's position on the need for population growth advocacy (86M1).

US Catholics are frequently chided for being "Cafeteria Catholics." The above data would suggest that the overwhelming bulk of US Catholics are "Cafeteria Catholics". While they tend to be generous of their time and money with the Church, apparently donating the reasoning portions of one's minds to the Church is felt to be going too far.

Part [1-B-2] ~ Developing World Artificial Contraception Politics ~
Tragically, opposition to artificial means of contraception is alive and well in a few of the African nations where HIV/AIDS is running rampant. The clergy there have been known to buy up all the condoms in the local markets and burn them. Some Church officials there say that don't want their nation turning into a "Sodom and Gomorra", despite all the evidence that there is no correlation between contraception scarcity and sexual abstinence or between contraception availability and promiscuity. In the Philippines the Catholic Church warned candidates for public office that they face problems in the 2004 elections if they spoke in favor of non-Church-approved family planning (IPPF News, 8/22/02). Note that the Muslim clergy in the Philippines have recently spoken in favor of family planning and contraception.

Part [1-B-3] ~ Winds of Change in the Vatican ~
Even within the Vatican, change appears to be in the winds in recent decades regarding artificial means of contraception. Thomas Burch, one of the 64 lay members of the Papal Commission on Population and Birth Control (1966) revealed in the National Catholic Reporter that the tacit purpose of the Commission was to find a way for the Church to approve artificial means of contraception without undermining Church authority (A. Jones, Vatican, "International Agencies Hone Family, Population Positions." National Catholic reporter (reprinted in Conscience, May/June 1984, p.7)) The Papal Commission was asked by "the high authority" to consider two propositions:

• Suppose the Vatican changed its mind on contraception. What can we do to present this in such a way that the church will not lose its moral influence over people?
• Suppose the Vatican does not change its mind on these issues. How can we preserve our (the church's) influence over the martial behavior of individuals?

The Papal Commission voted 64-4 that changes in the Church's stand on artificial birth control were both possible and advisable. The report was submitted in mid-1966 to a commission of 20 cardinals and bishops. Eight voted in favor of recommending the report; six voted against it (including Pope John Paul II, then a Cardinal). The remaining six abstained. Cardinal Alfredo (second most powerful person in the church) lobbied against the decision of the commission of cardinals during 1967 and 1968. As a result, the pope ignored the commission and published "Humanae Vitae on 7/25/68 retaining the ban on "artificial contraception" (p.23-24 of Ref. (86M1)). Both the people who prevented the change in the Vatican view on artificial means of contraception are dead.

David Yallop's best-selling book "In God's Name: An Investigation into the Murder of Pope John Paul I" (Bantam Books, 1984) submitted substantial evidence that Pope John Paul I was killed by threatened insiders just as he prepared to alter the birth control position and financial organization of the Church (86M1).

Part [1-B-4] ~ Power Politics in the WHO ~
The political powers of the Vatican should not be underestimated however. Professor Milton P. Siegel detailed how the Vatican seized control of World Health Organization (WHO) population policy making from the beginning (Ref. 304 of Ref. (96M1)). Siegel was Assistant Director General of WHO for its first 24 years and is considered among the world's foremost authorities on the development of WHO policy. During the third World Health Assembly (1950), the Vatican threatened to kill WHO and start their own organization if the director general did not stand up before the Assembly and specifically state that WHO would not get involved with family planning. He did. WHO did not get involved at all for more than a decade. In its 45-year history, WHO has had a deplorable record in family planning. Its commitment has been minuscule. Even today, family planning accounts for only a tiny fraction of the WHO budget. The Vatican continues to have considerable influence at WHO. For example, in the mid-1990s it succeeded in having appointed as director of WHO's Human Reproduction Program a professor from a Catholic University in Rome, Dr. Giuseppe Benagiano, the son of Pope John Paul II's dentist. Benagiano promptly set out to kill any further clinical studies of the quinacrine pellet method of non-surgical female sterilization (Ref. 305 of Ref. (96M1)).

SECTION (1-C) ~ GOALS AND OPTIONS ~
Arguments developed in Section (4-A) support the contention that eliminating over-population is a goal worthy of efforts on a global scale. This goal can be broken down into three intermediate goals.

Goal (1): Universal Access to I.F.P.-Related Services
In operational terms, universal access to IFP-related services means making sure all couples in developing nations have ready access to family-planning knowledge and services, including access to modern, effective means of contraception, free of coercion to either accept or reject such services. (Involuntary IFP has been found to work poorly, or to be counter-productive (Section (4-C).) Motivations for developed nations to support Goal (1) extend beyond the charitable (Section (5-A)). An analysis by Bongaarts (95B1) concluded that 43% of the fertility decline that occurred in the developing world between the 1960-65 period and the 1985-90 period could be attributed to family planning programs. Another analysis found that as much as 40% of the reduction in developing nations' fertility, (from around 6 in the mid-1960s to the present 3.2), is attributed to IFP programs (98B1). Were Goal (1) to be achieved, developing-nation fertilities could be further reduced to an estimated 2.7 children/ woman - about halfway down to "replacement level" (2.1) (90B1) (94B1) (00S1). However, it is easier to reduce fertilities from 6 to 3.2 than from 3.2 to 2.7 when desired family size is 2.7.

Maternal Health Care: At the 1994 Cairo Population Conference the importance of maternal health care to population concerns was given much greater recognition than before. Recognized was the need for women in developing nations to reduce their relatively high risk of death, disability, paralysis or serious injury associated with pregnancy, narrowly spaced pregnancies, pregnancy at too young an age, too many pregnancies, and other maternity-based problems (Section (2-B) ). Aside from humanitarian considerations, the purpose of this is to render women less hobbled by maternity-based problems, making it possible for them to take greater advantage of educational and economic opportunities (Goal (2)). This decreases desired family sizes and hence fertilities. This component of Goal (1) also seems motivated by the compassion Americans feel for the low social status and resultant wretched conditions endured by many women in developing nations. In the 1990s it became a human-rights issue (02S1) (Section (2-B)).

A close symbiotic relationship exists between family-planning services and maternal health-care. Family-planning clinics have the same customer base as clinics devoted to maternity-based problems. Also, offering maternity-based services draws women to the clinics, permitting family-planning issues to be discussed. Also, it makes family-planning clinics more socially acceptable.

Goal (2): Expanded Educational and Economic Opportunities for Women
Educational and economic opportunities have been found to significantly reduce desired family sizes - and hence fertilities. The range of options available to women in developed nations appears to be capable of reducing desired family sizes and fertility to, or below, replacement-level. The question of whether this same result might also be expected in developing nations is examined in Chapter 3. Goal (1) makes it more possible for women, having fewer children, to broaden their range of educational and economic options. So achieving Goal (1) can contribute to achieving Goal (2).

Goal (3): Stabilized Agriculture, Forests, Fisheries and Water Supplies
Achieving Goals (1) and (2) implies achieving total fertility rates of 2.1 (replacement level) and, after population-growth-momentum effects die off, population stabilization. Achieving this within the smallest possible time - a few generations after Goals (1) and (2) are met - imply a maximum global population of about 9 billion (01U2) (99U4). Yet all basic systems related to supplying food, natural fiber and freshwater are degrading, even under the population pressures of 6 billion. Also, the engines that have driven productivity-growth over the past four decades are at, or approaching, their limits, or have become counter-productive (08S2). The combination of these two factors force the conclusion that productivity levels are growing increasingly non-sustainable. Also, many of the food/ natural fiber/ freshwater-supply systems of developing nations are being converted to low-labor-input-high-capital-input systems producing food and natural fiber for export to markets with median incomes far greater than $2/capita/day median income in developing nations. This conversion is adding significantly to the population-growth-motivated migration to urban areas. There, due to capital constraints, there are nowhere near enough options for the new arrivals (08S3).

These changes are occurring under the stresses of a current global population of 6 billion. The world's population is projected to reach 8 billion by 2025, and 9 billion by 2050 (01U2) (99U4). So system degradation rates, being proportional to excess population, should be expected to be far greater than these population growth rates during the next five decades. Something beyond Goals (1) and (2) is required. The two options are:
(A) A significant period of below-replacement fertilities and
(B) Actions to stabilize food/ natural fiber/ freshwater supplies.

Ref (08S2), based on a large compilation (06S2) of data on degradation of food/ natural fiber/ freshwater-based life-support systems makes a case that both Options (A) and (B) would be essential. But neither option could ever be achieved without a clear, global understanding of the need for these options. Achieving this requires compelling arguments to rebut arguments by IFP opponents that Options (A) and (B) and Goals (1), (2) and (3) have no relevance to developing-world ills. Chapter 4 makes a case against these arguments.

Go to Table of Contents ~ Go to List of References ~ Go to Home Page of this website ~ 

IFP opponents argue against increasing life-shaping options for women, and argue that the earth's key natural life-support systems are so vast and expandable as to make over-population and large-scale degradation of these natural systems little more than remote possibilities (81S1) (01L1). In order to explain the observed degradation of life in developing nations without admitting any role for over-population, abortion opponents have resorted to arguing that the ills of developing nations are:

• Due to "bad government" and/or;
• Best solved by "market mechanisms".

This places these ills conveniently beyond the ability of developed nations to address them. So in recent years, opposition to support for IFP-related services is supported by arguments aimed at:

• Diminishing women's role in society,
• Belittling concerns about over-population, and
• Blaming developing world ills on factors conveniently out of reach of the developed world.

The remainder of this document is devoted to:

• Analyzing Goals (1) and (2) in Chapters 2 and 3,
• Addressing the full range of arguments posed by abortion opponents aimed, directly or indirectly, at reducing developed-nation support for IFP-related services in Chapter 4, and
• Examining the role of unmet needs for financial capital formation in limiting population growth rates in the developing world (Chapter 5).

Note: Ref. (02D1) breaks the developing world data above down into 4 regions of the Earth, and breaks the developed world into 3 regions of the Earth. Then it breaks those data further down into all nations. It does this for each of the 6 years 1995 through 2000. Note that unintended pregnancies and births do not include mistimed pregnancies and births. Note that the ratio of unintended pregnancies to total pregnancies suggests that the average woman gets pregnant about one time more than she intended. The average woman on this planet gets one abortion during her lifetime. Comparing abortion rates to unintended pregnancies suggests that about 75% of unintended pregnancies are aborted. Note the huge difference between the various death rates in developing nations as compared to those in the developed world. Only a small fraction of these differences can be explained by population differences. Much of the remaining difference is probably explained by the larger fraction of abortions that are illegal in the developing world. Some of the remaining difference is probably explainable by the lower quality of health care generally.

Magnitude: Some estimates of unmet needs are given below. For perspective, the number of women of reproductive age (15-49) in developing nations is 1.2 billion (99M1) (00S1). A more recent figure is 1.32 billion (04S1). About 236 million of these women have had a tubal ligation or have a partner who has had a vasectomy (04S1).

• 100-200 million women in developing countries wish to limit their childbearing, but lack access to adequate information and services to do so (Refs. 9, 51 of Ref. (00S1)).
• 201 million women in developing countries have an unmet need for effective contraceptives (04S1). (This figure includes women who are using traditional methods that have high failure rates and high likelihood of discontinuation.) Meeting these unmet needs would avert an additional 52 million pregnancies per year at a cost of $3.9 billion (in 2003 dollars) (04S1).
• Nearly 230 million women world-wide - roughly 17% of women of reproductive age - still need modern contraceptive methods to postpone, or avoid, future child-bearing (96G1).
• Worldwide, over 350 million couples lack access to a full range of modern family-planning information and services (UNFPA estimate) (95U1).
• Survey research indicates that unmet needs for contraception affect an estimated 10-40% of married women of reproductive age in developing countries (98B1).
• The proportion of married women of reproductive age in the developing world with an unmet need is 17%, lower than the previously estimated 19%. For unmarried women, the proportion is 3% (02R1). #1
• For all developing countries, the total number of women with unmet needs for (modern) contraception is estimated at 150 million (98B1) (98U2). #2
• In the developing world, an estimated 105.2 million married women have an unmet need. Unmarried women add 8.4 million, and the former Soviet republics add 9.1 million (of all marital statuses) for a total of 122.7 million (02R1). (Women using traditional family planning methods are not included in these figures.) #2
• Half of the world's 175 million pregnancies a year are unwanted or mistimed (95P1) (99U5).
• Women in developing countries have an estimated 76 million unplanned pregnancies every year (04S1).
• In developing countries, excluding China, about 25% of all births are unwanted (99B1) (So births plus abortions must be significantly larger.)

#1 - According to UN estimates, in the developing world outside of China, the number of women aged 15-49 grew by 13% between 1995-2000, but the proportion in need fell from 19 to 17% (02R1).
#2 - The figure from Ref. (02R1) is lower than Ref. (98U2) in part because the latter also counts women who use traditional family planning methods. These methods usually have high failure rates, resulting in numerous unwanted pregnancies, abortions, maternal deaths and births (02R1).

In Section (2-C) the financial costs of meeting these unmet needs, and the magnitude of the efforts to meet them, are analyzed. It appears that the cost of providing family planning services is about $20/ couple/ year. So an unmet need of the UNFPA estimate of over 350 million couples would cost over $7 billion/year to fill. The total cost of filling the unmet needs for basic reproductive health services (Section (2-B)) is about half of that. Meeting these unmet needs would lower the total fertility rate (TFR) of the developing world from the current 3.2 about halfway to 2.1 children per woman (the TFR needed for population stabilization after the "momentum effect" has run its course) (Refs. 9 and 51 of Ref. (00S1)) (90B1).

Effects of Universal Access on Population: In 1994, Bongaarts disaggregated the sources of future population growth in developing countries into three categories:

• 49% will come from momentum caused by the population's young age structure (the results of previous high fertility);
• 33% will come from unwanted fertility (births to those who wish to stop child-bearing but who are not using contraception),
• 18% will come from high desired family size (over 2.1 children) (94B1) (00S1).

This suggests that universal access to family-planning services could reduce the population growth rate of developing nations from the current average of 1.4%/ year (02U1) by 33% to 0.94%/ year over the short term. It also suggests a (49+33) = 82% reduction to 0.25%/ year over the long term (50 years) as momentum effects die off. The final 0.25%/ year growth rate (12.5 million/ year in developing nations) would need to be eliminated by increased life-shaping options for women. This is out of a developing-world birth rate of roughly 108 million/ year (computed assuming a global birth rate of 130 million/ year (99M1) (00S1) and a developing world population of 5.0 billion (02U1)).

• Fertilities have fallen to, or below, replacement level in 61 of 184 countries (13 are developing nations) (99U2).
• About 44% of the world's people now live in low-fertility countries (20% in developed countries, 20% in China, 4% in developing countries) (00S1).
• 43% of the fertility decline that occurred in the developing world between the 1960-65 period and the 1985-90 period could be attributed to family planning programs (95B1).
• Over 24 developing nations still have fertility rates of 6.0 or higher, while another 24 have fertility rates of 5.0-5.9 (97W1) (98B1).
• Africa's population growth dropped from 3% to 2.45%/ year during the past decade, but it is still the world's (second-) highest population growth rate, outstripping growth in gross domestic product and food production (UNFPA press release of 9/24/02). (The population in the Arab world still grows by 3.5%/ year.)

Maternal Mortality: In considering the effects of IFP funding on maternal mortality, one must go through a chain of causes and effects, and then judge the magnitude of each such linkage. IFP reduces rates of illegal and low-grade abortions. This reduces maternal mortality in developing nations. US support for the abortion component of IFP services ended in 1973, so no logical direct connection should be made between support for IFP and abortion. The remaining components of IFP services reduce abortion rates. In fact, one of the best ways to prevent abortions is by providing quality voluntary IFP services (01N1). Evidence supports this:

• UN data showed that in Hungary, for example, abortion rates were increasing in the late 1960s - reaching a peak of 80/1000 women/ year - while contraceptive use was around 20%. Then a dramatic increase in contraceptive use, to over 50% of couples in 1978, was accompanied by a sharp drop in abortion rates, to just over 30/1000 women in 1986 (97R1). Studies in South Korea, Russia and Kazakhstan show similar results (98B1), as did studies in three Central Asian republics (98W1) (02S1).
• A study on nearly 150,000 pregnancy outcomes in Bangladesh indicated that women who had access to better family planning services were more likely to use contraception and less likely to have unintended pregnancies and therefore had fewer abortions (01R1) (02S1).
• US data show that women using a method of contraception are only 15% as likely as women using no method to have an abortion (99G1).

Some perspective on the potential for support for IFP services to reduce abortion rates can be gained from the following:

• 36 million (78%) of the world's 46 million abortions/ year occur in those developing countries that receive nearly all IFP services funded by developed-nation donors (99G1).
• Of the 182 million pregnancies/year in developing countries, 66 million (36%) are unplanned, and 36 million (20%) end in abortion (99G1).

Some perspective on the potential for support for IFP services to saves women's lives by reducing the rates of illegal and low-grade abortions can be gained from the following:

• 40% of abortions performed worldwide are unsafe. Nearly 90% of unsafe abortions occur in developing countries (WHO release, 5/17/99).
• A large fraction of the 600,000 pregnancy-related deaths reported yearly occur to women in developing nations, and 70,000 (13%) of these deaths are related to complications from unsafe - usually illegal - abortions (99G1). Almost half of these 600,000 annual deaths could have been prevented by family planning alone (01I1).

IFP can significantly reduce maternal mortality. But the above logic and data address only one facet of the issue. Raising public awareness of the consequences of over-population, and providing developing-world women with more life-shaping options works in the direction of making abortions legal (See Chapter 1). This reduces rates of illegal abortions, further reducing maternal mortality.

Other Aspects of Maternal Health: A compelling commentary on the effect of funds for IFP on women in developing nations is by Pamela White, "House Turn its Back on Women's Suffering". It appeared in the Colorado Daily on 9/12-14/97 and is reprinted below (with permission from the Colorado Daily). It appears to reflect the feelings of many women on the issue.

About 600,000 women and girls die worldwide every year from pregnancy and childbirth - a figure equal to US casualties in World War I, the Korean War and Vietnam combined. Most of these women are in their teens and early 20s, forced by their societies into bearing children at a young age and far too frequently.

According to UNICEF figures, 140,000 women bleed to death each year, hemorrhaging violently from uterine arteries meant to sustain life. Tragically, many die within reach of medical facilities because their relatives refuse to allow them to be treated by male doctors. 75,000/ year die from trying to end their pregnancies. The UN estimates that worldwide 50,000 women and girls try to induce abortions on themselves each day (18.3 million/ year), inserting sharp objects into their bodies or taking poisons. Many of those who survive face life-long, crippling pain. 75,000 more die from complications of eclampsia - a condition that can cause brain damage and kidney failure. Choked to death by high blood pressure, organs gradually fail, condemning both mother and fetus.

Approximately 100,000/ year die from sepsis, as toxins creep from infected wombs into their blood streams, causing fever, severe pelvic pain and organ failure. Another 40,000/ year die from the unspeakable agony of prolonged labor, following days of futile contractions repeatedly grinding down the skull of an already asphyxiated baby onto the soft tissues of a pelvis that is just too small. Some of those are left to die alone and untreated, as men in some cultures believe prolonged labor to be proof of adultery. And those are only the fatalities. UNICEF statistics show that for every woman who dies, 30 face gruesome injuries and disabilities: prolapsed uteruses, incontinence, pelvic inflammatory disease, genital injuries, back and hip disorders, and paralysis. That's more than 17 million women/ year.

About 0.5-1.0 million women suffer from a condition called fistula. In these cases, vaginal tissue, deprived of its blood supply by the pressure of a baby's skull during a prolonged labor, has rotted and fallen out, leaving rifts in the muscle through which urine and excrement leak from the bladder and rectum into the vagina and out of the body. Lacking the ability to control the passing of their body's wastes, women who suffer fistula become pariahs, thrown into the streets by husbands who are repulsed and no longer want them around. UNICEF reports that these women don't live long. They die from infection, starvation and suicide.

Then there's anemia. And untreated genital injuries, especially perineal tears, that leave a woman dreading sex for the rest of her life because it has become a painful ordeal. Add to that the exhausting burden of repeated pregnancies and births, which even when free from complications are no picnic, and you have a global picture of suffering on the part of women that demands global response.

These figures come from 1995, a year in which US foreign aid for IFP clinics was firmly in place. Without contraception to prevent pregnancies, these figures would skyrocket.

How can such a heavy burden of death, disease and disability have continued for so long with so little outcry? If hundreds of thousands of men were suffering and dying every year, alone and in fear and in agony, or if millions upon millions of men were being injured and disabled and humiliated, sustaining massive and untreated injuries and wounds to their genitalia, leaving them in constant pain, infertile and incontinent, and in dread of having sex, then we would all have heard about this issue long ago, and something would have been done. And something should be done. Something is being done, albeit on a small scale, with the aid of international population assistance that over 100 men in the US House of Representatives vote against yearly.

When men march to war and fall in numbers equal to those listed above, it becomes the stuff of legend, or at least TV news broadcasts and protests. Songs are composed. Stories are told. Monuments are erected. People march and commemorate.

But women, who are killed and maimed everyday, are ignored by a male-dominated world that refuses to see, let alone acknowledge, their suffering. Outside of ancient Sparta, you won't find any society infusing these women's deaths with the inflated significance and puffed-up glory that becomes attached to men's battle deaths.

What is most infuriating, however, is that these deaths and tragic injuries are entirely preventable. Some legislators might be able to turn their backs on these women and dull their ears to their cries, misogynist and arrogant as they are. These are, after all, only women -Third World women at that.

Section (2-A) gives estimates of the unmet need for family planning services in terms of numbers of people in developing nations with unmet needs. Here the same issue is taken up, but in terms of the financial costs of filling these unmet needs. Also of interest is the financial cost of the unmet needs for basic reproductive health services in developing nations. (Dollar figures below pertain to $US.)

Total expenditures on family planning in developing nations are about $10 billion/ year ($2/ capita/ year) (98B1). This money comes from five main sources: (1) individual households in developing nations, (2) programs paid for by developing-nation governments and non-governmental organizations (NGOs), (3) contribution from governments in developed nations, (4) charitable foundations and (5) development banks (mainly in the form of loans). A recent history of funds provided by Sources (3), (4) and (5) for "population assistance" is given in Table (2-A).

The $1.4-billion contribution from the developed world in 1999 is only 2.5% of all official development assistance from developed nations in 1999 ($56.2 billion (00U2)).

Table (2-A) ~ A Recent History of External Sources of Funding for "Population Assistance" in Developing Nations ~ (UNFPA data (00U2)) (millions of US dollars).

# Gates (48%), Ford (13%), Packard (11%), MacArthur (6%), Rockefeller (6%), Wellcome Trust (5%), Hewlitt (4%). Mellon (3%) (1999 data) (00U2).

The "population assistance" figures above include expenditures on sexually transmitted diseases, HIV/AIDS activities, basic research and population- and development policy analysis. Figures are available from the UNFPA (00U2) for extracting donor expenditures purely on family planning services and basic reproductive health services during 1995-99. The corresponding data applicable to development bank loans are not available, but it seems reasonable to apply the same multipliers as were applied to the donor data. The results of this analysis (in millions of dollars) are given in Table (2-B) below. The UNFPA (00U2) also provides data for Source (2) - expenditures by developing nation governments and national non-governmental organizations (NGOs) on family planning services and basic reproductive health services, but only for 1997-99. These data are also given in Table (2-B).

Data on Source (1) (developing world citizens purchasing their family planning methods from a commercial source) are sparse. An estimated 12% of developing world women who use modern contraception methods obtains their method from commercial sources (34% if China and India are excluded) (99P1).

Table (2-B) ~ Recent history of funds provided by external providers, developing nation governments and developing nation NGOs for family planning services and basic reproductive health care in developing nations ~

(UNFPA data (00U2)) (All figures are in units of millions of US dollars).

# Not meant to cover emergency obstetric services.
Note: Expenditures based on funds received from developed nation donors and development bank loans are not includes in the developing-nation figures above.

Bulatao (98B1) states that expenditures on family planning in developing countries were estimated by several sources for 1990 at $4-5 billion (93W1), and that these figures are higher now. In another estimate (96G1), about $3 billion of the roughly $4 billion/ year spent (around 1995) to provide family-planning services in developing countries is borne by the countries' own governments and by those using these services. The remaining $1 billion/ year is contributed by developed countries (96G1). The reason for the disparities between these figures and UNFPA data above is unknown. The 1994 Cairo population conference set a goal for 2000 of $10.2 billion in public expenditures for family planning services, and $5 billion for reproductive health services. These expenditures were to be split 1/3: 2/3 between outside donors and developing nation governments themselves. Regardless of which data are used, Table (2-B) shows that large gaps exist between government commitments and performance. A rough analysis of these gaps is given in Table (2-C) below. The world's governments, as a whole, appear to be about $10.7 billion/ year short on what they committed to at the 1994 Cairo population conference. Both developed and developing worlds would need to triple their contributions to come close to what they committed to.

Actual values are rough estimate (All figures in millions of $US.)
Committed totals are expected to grow at the rate of growth of the reproductive-age population, 2%/ year until 2015, and 1%/ year thereafter.

Financial Costs of Meeting Unmet Needs
The financial costs of meeting the unmet needs for family planning services and basic reproductive health services were expressed in terms of numbers of people in Section (2-A). One might expect that the goals that were set at the 1994 UN International Conference on Population and Development in Cairo would have been based on the UNFPA's estimates of the financial costs of meeting these unmet needs. But the political give-and-take at conferences attended by representatives of 180 governments does not assure this. An evaluation of the goals established in Cairo is given below.

Consider the goal of $10.2 billion/ year for family planning services in developing nations in 2000. Translating this goal to 1994 gives $9.0 billion/ year (2%/ year is the rate of growth of the population in its reproductive years.). The difference between this and the amount being spent by foreign donors and developing nation governments around 1994 was about $1.6 billion/ year (Table (2-A)). This indicates that if the goal had been set at the assumed cost of meeting unmet needs, the assumed cost of meeting the unmet needs for family planning services the UNFPA would have been $7.4 billion/year (9.0 minus 1.6). Worldwide, over 350 million of the 1.1 billion couples of reproductive age lack access to a full range of modern family-planning information and services (UNFPA estimate) (95U1). According to Bulatao (98B1), the cost of program-supplied modern methods of family planning may be roughly estimated at $20/ user/ year. This suggests a total cost for 350+ million couples of $7.0+ billion/ year - fairly close to $7.4 billion. Thus it appears that the goal for family planning services set in Cairo was indeed set at something approximating the estimated cost of meeting the unmet needs of the estimated number of couples with unmet needs. Data are not available for performing a similar analysis for basic reproductive health services. But it seems fairly safe to assume that, if one of the goals was set based on unmet needs, the other one would also.

Translating Financial Shortfalls into Physical Terms:

• UN figures translate the above-mentioned $10.6 billion/ year shortfall into 42 million unintended pregnancies, 17 million induced abortions, and 90,000 maternal deaths annually (99U1).
• A shortfall of $740,000 that would otherwise be spent on safe contraceptives in developing nations has been translated into 360,000 unwanted pregnancies, 150,000 unsafe abortions, over 800 maternal deaths and 11,000 child deaths." (Chicago Tribune, 11/14/00)
• Elimination of $25 million of US funding for UNFPA in the FY1999 US budget has been estimated to translate into 870,000 women deprived of effective contraception, 520,000+ people ending up not using any contraceptive method, 1,200 maternal deaths, 22,500 infant deaths, 15,000 life-threatening maternal illness and injuries, 500,000 unwanted pregnancies, 234,000 unwanted births, and 200,000 abortions.
• Congressional cuts in IFP assistance in 1996 (35% reduction in funds) translate into an additional 1.6 million abortions, 4 million unintended pregnancies, 8,000+ maternal deaths, and 134,000 infant deaths (according to analyses by five population organizations).

About $7.1 billion per year (in 2003 dollars) is spent in the developing world on modern contraceptive services (including labor, overhead, capital, and contraceptive supplies). For the 270 million women in the developing world who use modern contraceptive services, this money prevents (04S1):

• 187 million unintended pregnancies,
• 60 million unplanned births,
• 105 million induced abortions,
• 22 million spontaneous abortions,
• 2.7 million infant deaths,
• 215,000 pregnancy-related deaths - 79,000 from unsafe abortions and 136,000 not related to induced abortions,
• 685,000 children from losing their mothers as a result of pregnancy-related deaths,
• The loss of 60 million "disability-adjusted life years" (16 million among women and 44 million among infants and children).

Preventing these health consequences also reduces the need for services such as treatment of the complications of unsafe abortions and care for orphans.

The cost of meeting the unmet needs for modern contraceptive services to the 201 million women in developing countries with unmet needs would cost $3.9 billion (in 2003 dollars). Meeting these unmet needs would avert an additional 52 million pregnancies each year (04S1). Averting 52 million unintended pregnancies would prevent

• 23 million unplanned births
• 22 million induced abortions
• 7 million spontaneous abortions
• 1.4 million infant deaths
• 142,000 pregnancy-related deaths - 53,000 from unsafe abortions and 89,000 from other causes
• 505,000 children from losing their mothers
• The loss of 27 million "disability-adjusted life years" (9 million among women and 18 million among infants and children) (04S1).

Costs of Reducing Population Growth Rates: The marginal cost of reducing the global population growth rate (currently about 78 million/ year) has been estimated for a variety of strategies:

• Median cost of averting a birth through IFP-maternal-health programs: US$58 (98B1).
• Estimates of the cost of averting a birth by spending money purely on safe contraceptives apparently have not been made, but the data above suggest that the cost is a fraction of the $58/ birth-averted cost via a full range of IFP- and maternal-health services. (Note: Agencies like Planned Parenthood Federation and Engenderhealth contend that this approach is not workable.)
• Radio- and TV "soap operas" (social-content serial dramas) can be influential in reducing Total Fertility Rates. An analysis of data from a radio serial in Tanzania found that the total cost per new adopter of family planning was fewer than 80 cents (US). The translation of this figure into the cost of averting a birth has not yet been made, but it probably is on the order of a few dollars -- a small fraction of the cost by any other presently known strategy. (See the end of Chapter 3.) Research at the University of Sao Paulo Brazil studying TV-Globo's "telenovelas" and their impact, states that they have been the principle force driving Brazil's total fertility rate down from 3.4 in 1989 to 2.3 in 1996 (97P1).
• Another exciting recent, but largely unnoticed, development is the International Service Assistance Fund's (ISAF) Phase III clinical trial of a non-surgical method of female sterilization known as QS (quinacrine sterilization) (06I1). QS has been performed in 50 countries on more than 175,000 women. It is so simple and low-cost that it can be performed by nurses instead of doctors (06B1). It can even be done in peoples' homes (even in the developing world) using a simple, cheap, plastic, disposable tool (06B1). It costs only a tenth of the cost of a normal surgical sterilization, a procedure that has long been the leading contraceptive method worldwide. In the developing world, the cost of a QS procedure is about $5 (06B1). Assuming that each QS procedure averts two births, this would suggest a cost of averting a birth via a QS procedure of about $3. The popularity of surgical sterilization and the potential of QS is all the more impressive when one considers that most women in the developing world do not have access to surgical contraception, and they will not have such access for the foreseeable future. QS could revolutionize contraceptive provision worldwide (07S3). Successful completion of the Phase III trial is expected to reduce maternal mortality and morbidity by 40%, reduce the number of abortions worldwide by 40%, and reduce the number of unwanted births by more than 50%. This reduction in unwanted births would amount to over 25 million births per year out of the 78 million or so annual surplus of births in excess of deaths, and out of the 136 million births per year - a major change in global population growth trends. 25 million fewer births per year (virtually all in the developing world) would represent a savings in infrastructure costs to developing nations of $325 billion/ year. (See Ref. (07S3) for a far more detailed perspective on the quinacrine sterilization issue.)
• Spending $3.9 billion (2003 dollars) to fill the unmet needs of 201 million women for modern contraception services would eliminate 23 million unplanned births (See above) (04S1). This suggests a cost of averting a birth of $170.
• The median cost of averting a birth through female education is estimated at US$548 (88C1).
• The costs of other related alternatives to the family-planning-maternal-health approach to averting births are similar -about an order of magnitude larger than the birth-averting cost associated with IFP-based approaches (98B1).

Thus the marginal cost of averting a birth ranges from a small fraction of $58 to roughly a factor of ten higher than $58, depending on which approach is taken.

Singh et al (04S1) give a review of the literature on the ratio of the direct financial benefits to direct financial costs to governments in averting an unintended birth through family planning: