Global Policy Forum

By Abimbola Akosile

A newly released World Bank report has warned that poor countries, wealthy donors, and aid agencies are losing sight of the value of contraception, family planning, and other reproductive health programs in helping to boost economic growth. The same process, according to the global financial group, claimed high birth rates are strongly linked with endemic poverty, poor education, and high numbers of maternal and infant deaths. According to the new report titled, 'Population Issues in the 21st Century: The Role of the World Bank', 35 countries, mostly in Sub-Saharan Africa, have birth rates of more than five children per mother, and that of the estimated 210 million women who become pregnant every year worldwide, more than 500,000 women die during pregnancy and childbirth.

The report also said about one in five women resorts to abortion because of poor access to contraception, and that some 68,000 women die each year as a result of unsafe abortion, while 5.3 million suffer temporary or permanent disability, and many end up being ostracised within their own communities. The report, which was displayed on the World Bank web-site, also claimed that because fertility rates have declined significantly in most low-and middle-income, countries, outside of Africa, "the priorities of donor countries and development agencies have shifted toward other issues, and global funds and initiatives have largely bypassed funding of family planning, with less attention being focused on the consequences of high fertility, even in those countries that are lagging in achieving sustainable population growth".

"Poor women endure a disproportionate burden of poor sexual and reproductive health because they run into financial or social barriers getting access to these basic but vital programs," said Mrs. Joy Phumaphi, the World Bank's Vice President for Human Development, a former WHO Assistant Director General, and a former Health Minister in Botswana, 1999-2003. "Their full and equal participation in development depends directly on accessing essential sexual and reproductive health care. The Bank is committed to helping these women, along with the UN Population Fund, WHO, and the technical health agencies, to make voluntary and informed decisions about fertility."

Phumaphi added that falling birth rates cannot be achieved through better health programs alone. She says that improved education for girls, equal economic opportunities for women in society, and fewer households living below the poverty line, are also vital parts of a strategy to achieve sustainable reductions in birth rates. The new report said the world is in the middle of major demographic changes. During recent decades, fertility levels have declined more rapidly - even in some of the poorest countries - than had been expected by most demographers.

The widespread decline in fertility, coupled with reductions in mortality in most countries, have resulted in changes in the age structure and population growth rates that have far-reaching consequences for sectors such as health, education, labor markets, and social protection. During the second half of the 20th century, world population more than doubled to reach six billion, an astonishing 3 billion increase in population in just 40 years. Although this rate has now slowed to 1.2 percent a year, an additional 75 million people are being added every year this decade. The world's population is projected to reach 9.1 billion by 2050, with the majority likely to live in the world's poorest countries.

The report says that the globe's highest birth rates are found in Sub-Saharan Africa, where average fertility remains above five children per woman. While demographic patterns are converging in many regions, countries that are lagging in fertility decline and mortality reduction are increasingly different from the rest of the world. Similarly, the report says that fertility can also affect women's jobs in the workplace. One cross-national study has suggested that the percentage of women in the labor force is directly related to national birth rates and that, for example, in Bolivia, there were strong links between women using contraception and women jobs outside of the home.

The new report argued that family planning is an integral part of reproductive health-care, and it is now increasingly acknowledged that provision of such comprehensive programs serves as a proxy indicator of a functioning health system. Moreover, it claimed an effective health system also reduces child mortality, which in turn has been linked to declines in fertility levels. In addition, addressing "dual protection" (protection against sexually-transmitted infections (STIs) and HIV/AIDS, as well as unintended pregnancies), as well as offering family planning programs and HIV counseling in a synchronised manner is more likely through a well-functioning health system.

The Bank, with its sector and fiscal analysis capacity, as well as engagement in policy dialogue with senior stakeholders, can help address this critical issue through donor harmonisation, aid alignment, and mainstreaming family planning financing needs within a country's national health plan. Another factor limiting contraceptive supplies, according to the report, is the inadequate state of logistics in many poor countries. At the country level, a sound logistics system can distribute contraceptive commodities and other supplies smoothly and efficiently so that each clinic or pharmacy has enough stock on hand to meet clients' needs, it said. Changing household behaviors is also recognised as vital for increasing the use of family planning programs. Social and cultural factors such as disapproval by family and communities, and men's roles in deciding family size, can deter women who might otherwise be interested in family planning help, while in some countries, providers and even programs may deny such care to vulnerable groups such as unmarried adolescents.

"The low status of women often poses a barrier because in many societies, women lack the power to make their own decisions about using contraceptives or using other reproductive health-care," said Phumaphi. "Educating girls, improving economic opportunities for women, while giving them control over the design, management, and oversight of reproductive health programs, are very important ways to encourage better access to these essential health programs."