Abortion,Family Planning,and Population Policy: Prospects for the Common‐Ground Approach

For the past several decades those engaged in shaping the Program of Action documents at international conferences on population have muted their voices when the topic of abortion has been raised. In a desire to side‐step entanglement in a bitter debate over the morality of abortion, great care has been taken to define “family planning” in ways that explicitly exclude abortion. The “common‐ground” approach to treating abortion can be summarized in two directives found in all contemporary international population documents: “in no case should abortion be promoted as a method of family planning”; and all governments should work “to reduce the recourse to abortion through expanded and improved family‐planning services.” This article has three goals: first, to examine the appropriateness of these directives with respect to what is currently known about the relationship between abortion, family planning, and population policy; second, to trace how this “contraception‐only” definition of family planning became de rigueur at international population conferences; and third, to discuss the prospects for the emergence of a more appropriate “common‐ground” approach to abortion and population policy.     

Combining vertical service with horizontal service to promote family planning]

How Bazhong County of Sechuan Province, China, carries out family planning through a combination of what are termed vertical and horizontal services is described. Vertical service refers to assistance such as premarital education, prenatal hygiene, child health care, and family planning, while horizontal service refers to household assistance for married women. Premarital education is designed to help young people acquire sufficent knowledge about family planning, hygiene, and eugenics, and stresses the disadvantages involved in marriages between close relatives. Prenatal hygiene provides safe and convenient medical accommodations for delivery of the child as well as maternal care. Child health services assure that the best facilities are to be made available for physical examinations, vaccinations, and medical treatment. The family planning program involves comprehensive measures such as distribution of contraceptives and safe sterilization. In addition, the county provides medical assistance for couples unable to have children. Horizontal service providing household assistance for married women promotes scientific farming (e.g., how to use fertilizer), helps people increase their income by teaching them skills, and provides social services to improve life style and education. These vertical and horizontal services have brought about substantial improvements in the standard of living, family harmony, and population control.     

Family planning practice and women's fertility decision-making power

This paper investigates the effects of family planning practice on fertility decision-making power in South Korea. The log-linear analysis of the 1981 survey data by the Institute of Population and Health Services Research, Yonsei University, Seoul, Korea, shows that those urban and rural women who practice family planning or have experienced abortion exercise greater influence on a couple's fertility decision making than those who do not practice family planning or who have had no abortion experience. In addition, there is the interactive effect of abortion experience and contraceptive use on fertility decision making among urban women. This finding is significant because regardless of how birth control is available within a society, birth control use enhances women's decision making power where fertility is concerned.     

Adolescent fertility: worldwide concerns

There is growing concern over the adverse health, social, economic, and demographic effects of adolescent fertility. Morbidity and mortality rates ar significantly higher for teenage mothers and their infants, and early initiation of childbearing generally means truncated education, lower future family income, and larger completed family size. Adolescent fertility rates, which largely reflect marriage patterns, range from 4/1000 in Mauritania; in sub-Saharan Africa, virtually all rates are over 100. In most countries, adolescent fertility rates are declining due to rising age at marriage, increased educational and economic opportunities for young women, changes in social customs, increased use of contraception, and access to abortion. However, even if fertility rates were to decline dramatically among adolescent women in developing countries, their sheer numbers imply that their fertility will have a major impact on world population growth in the years ahead. The number of women in the world ages 15-19 years is expected to increase from 245 million in 1985 to over 320 million in the years 2020; 82% of these women live in developing countries. As a result of more and earlier premarital sexual activity, fostered by the lengthening gap between puberty and marriage, diminished parental and social controls, and increasing peer and media pressure to be sexually active, abortion and out-of-wedlock childbearing are increasing among teenagers in many developed and rapidly urbanizing developing countries. Laws and policies regarding sex education in the schools and access to family planning services by adolescents can either inhibit or support efforts to reduce adolescent fertility. Since contraceptive use is often sporadic and ineffective among adolescents, family planning services are crucial. Such programs should aim to reduce adolescents' dependence on abortion through preventive measures and increase awareness of the benefits of delayed sexual activity. Similarly, sex education should seek to provide a basis for intelligent, informed decision making. Programs tailored to reach teenagers in schools, recreational centers, and the workplace have particular potential.     

<Emphasis Type="Bold">Women’s Progress for Men’s Gain? Gender-Specific Changes in the Return to Education as Measured by Family Standard of Living, 1990 to 2009–2011</Emphasis>

This study investigates gender-specific changes in the total financial return to education among persons of prime working ages (35–44 years) using U.S. Census data from 1990 and 2000, and the 2009–2011 American Community Survey. We define the total financial return to education as the family standard of living as measured by family income adjusted for family size. Our results indicate that women experienced significant progress in educational attainment and labor market outcomes over this time period. Ironically, married women’s progress in education and personal earnings has led to greater improvement in the family standard of living for married men than for women themselves. Gender-specific changes in assortative mating are mostly responsible for this paradoxical trend. Because the number of highly educated women exceeds the number of highly educated men in the marriage market, the likelihood of educational marrying up has substantially increased for men over time while women’s likelihood has decreased. Sensitivity analyses show that the greater improvement in the family standard of living for men than for women is not limited to prime working-age persons but is also evident in the general population. Consequently, women’s return to education through marriage declined while men’s financial gain through marriage increased considerably.     

Integrating reproductive health services into family planning programs

A recent Population Council publication, Reproductive Health Approach to Family Planning, discusses integration of reproductive health into family planning programs in a series of edited presentations that Council staff and colleagues gave at a 1994 meeting of the US Agency for International Development (USAID) cooperating agencies. The presentations reflect the Council's view that family planning programs ought to help individuals achieve their own reproductive goals in a healthful manner. The report discusses four areas of reproductive health: reproductive tract infections (RTIs), including sexually transmitted diseases; prevention and treatment of unsafe abortion; pregnancy, labor, and delivery care; and postpartum care. Christopher Elias (Senior Associate, Programs Division) argued that family planning programs ought to provide services that target RTIs, given that these illnesses afflict a significant proportion of reproductive-age women. The family planning community has an ethical responsibility to provide services to women who experience an unwanted pregnancy. They must have access to high-quality postabortion care, including family planning services. Professional midwives are ideally suited to serve as integrated reproductive health workers trained to combat the five major maternal killers: hemorrhage, sepsis, pregnancy-induced hypertension, obstructed labor, and unsafe abortion. This was demonstrated in a highly successful Life-Saving Skills for Midwives program undertaken in Ghana, Nigeria, and Uganda, and soon to start in Vietnam in conjunction with the Council's Safe Motherhood research program. Family planning services should be viewed as part of a comprehensive set of health services needed by postpartum women, which include appropriate contraception, maternal health checks, well-baby care, and information about breastfeeding, infant care, and nutrition. Family planning programs should incorporate breastfeeding counseling into their services. When programs aim to help individuals meet their own reproductive goals in a healthful manner, this implies that services will not increase clients' risk of morbidity.     

中国省级人工流产的决定因素分析

利用省级数据对中国社会经济发展和计划生育对人工流产的影响进行了分析。因子分析将20个社会经济和计划生育变量合成了3个分别代表经济发展、社会发展和计划生育侧面的因子。多元回归分析的结果表明,经济发展和社会发展因素对各省各孕次人工流产比例都有显著而重要的影响,尤其是第1孕次人工流产比例与计划生育无关。而随着孕次升高,计划生育的独立作用不断增强。     

The South African fertility decline: Evidence from two censuses and a Demographic and Health Survey

Inadequate data and apartheid policies have meant that, until recently, most demographers have not had the opportunity to investigate the level of, and trend in, the fertility of South African women. The 1996 South Africa Census and the 1998 Demographic and Health Survey provide the first widely available and nationally representative demographic data on South Africa since 1970. Using these data, this paper describes the South African fertility decline from 1955 to 1996. Having identified and adjusted for several errors in the 1996 Census data, the paper argues that total fertility at that time was 3.2 children per woman nationally, and 3.5 children per woman for African South Africans. These levels are lower than in any other sub-Saharan African country. We show also that fertility in South Africa has been falling since the 1960s. Thus, fertility transition predates the establishment of a family planning programme in the country in 1974.     

A multilevel model of family planning availability and contraceptive use in rural Thailand

This paper assesses the ways in which the availability of family planning program outlets influences the likelihood of contraceptive use in rural Thailand. It focuses on a village-level measure of actual availability of sources rather than respondent perceptions of availability. Individuallevel and village-level data collected as part of the second Thailand Contraceptive Prevalence Survey are used to test three hypotheses about the effects of actual availability: that (a) availability of family planning outlets increases the likelihood of contraceptive use; (b) it enhances the effect of a desire for no more children on the likelihood of use; and (c) it weakens the positive relationship between education and the likelihood of use.     

Social and economic factors in Hong Kong's fertility decline

Abstract In both developed and underdeveloped areas, many attempts have been made to alter the course of fertility through family planning intervention. Doubtless the availability of such services facilitates birth control for those who already desire to use it. Whether or not such exogenous interventions have any independent effect upon the operation of endogenous forces in the economy and society is, however, more problematical. Where fertility declines have been observed, family planning services have often been made widely available only after the decline in fertility had already set in. Nonetheless, observers have often attempted to attribute some fraction of the continuing decline in fertility to the operation of family planning activities. One especially notable case is that of Hong Kong, which provides some of the more persuasive evidence about the independent effects of family planning intervention.     

Evolution of fertility and mortality

Historical and current fertility trends in both Quebec and Canada as a whole are surveyed. While fertility among French Canadians was higher than that in neighboring provinces until the mid-20th century, in 1968 Quebec's crude birthrate was the lowest in Canada, and in 1972 it was 13.8 vs. 15.9 (the national birthrate). This reversal is explained in terms of the demographic transition theory, the declining influence of organized religion, and new opportunities for social mobility for minority groups. The birthrate throughout Canada is also declining. Although recent cohort studies are incomplete because women have not yet finished their reproductive years, it appears that completed family size will be lower than at any time in Canadian history. The period total fertility rate indicates an average family size of 1.8 children in 1976, but it is unclear whether this represents an actual reduction in family size or the postponement of childbearing. The sharpest fertility decline has been among women aged 35-49, but peak fertility rates have shifted from the 20-24 age group to those aged 25-29. Fertility is negatively related to education, and the lowest fertility is found among the intermediate income groups. Since the 1969 lifting of the ban on contraceptive sales and advertising, family planning activities have been stepped up. Also removed was the total ban on abortion. In 1975 there were 14.9 therapeutic abortions per 100 live births, but it has been charged that abortion standards are being applied inequitably from hospital to hospital.     

Pakistan: family planning expands in non-governmental organizations

The Family Planning Association of Pakistan has begun a program of integration of family planning activities with other voluntary welfare agencies. 1 of the more successful projects has been in cooperation with the Family Welfare Cooperative Society of Lahore. Volunteers have provided facilities to very low-income women to help supplement income. At 1st it was knitting, embroidery, and cloth manufacture, but over several years it developed into a complex of several buildings with a comprehensive vocational training center, a showroom, schools for the children of mothers in training, a secretarial school, and a hostel for homeless women there. There is a medical unit, a full-time doctor, and family planning services.     

Publicity and education are fundamental to China's family planning programme

This article summarizes and discusses the documents concerning family planning promulgated by the Communist Party, National People's Congress and the Government of China since the start of China's family planning program. In 1955 a document was issued entitled the Directive Concerning Population Control pointing out that the public should be made aware of birth control. In 1965 the summary of the 2nd Conference on Urban Work discussed ways of explaining the significance of family planning, to make it a voluntary action of the people. In 1980 the necessity of 1 child per couple was pointed out and policies were formulated regarding ideological and political education. During the 80's several documents were issued which stressed the voluntariness and initiative of the people in practicing birth control, and that any type of coercion was prohibited. For 30 years the fundamental practice of strengthening publicity and education and opposing coercion has remained unchanged no matter how birth policies have been scored in population control since 1979.     

Effect of declines in mortality on the birth rate and related measures

In December 1961, the government of the Republic of Korea adopted a programme of family planning as part of its public health services. In 1962 a pilot research project was begun, under university auspices, with the object of demonstrating and assessing what can be achieved through intensive family planning education and services. Wondang Myun near Seoul, with a rural population of 9,000 in seven villages, was chosen for the study. A baseline survey covering attitudes and practices related to family planning was made of the population under study, as well as of a similar population in the control area of Kimpo Myun. This report outlines the design, the programme of education and services, and some of the preliminary results of the study. After eighteen months of the programme, acceptance of birth control measures increased fourfold among the married women in the fertile age range. Acceptance was highest among the 25–39 age group, and among high-parity women. Economic considerations were foremost among the reasons given for adopting family planning. Among the traditional methods offered, the condom was the favoured method of choice, indicating that husbands were taking the initiative in contraceptive practice. A decline in the crude birth index was observed; whether the decline was due more to contraceptive practice or to abortion, at least an increase is reflected in the effective desire for family limitation. The high failure rate among Users should be investigated further. Continued effort is needed to provide more information and detailed instruction to users, and to develop social circumstances that support the practice of family planning. Along with an effort to achieve more effective use of traditional methods, other methods, including intra-uterine devices, deserve trial.     

The dynamics of contraceptive adoption in Bohol,Philippines: 1976-1978

A researcher analyzed 1976 and 1978 data on 414 rural women who had never used a family planning method to prevent pregnancy and lived in the predominantly Catholic island province of Bohol in the Philippines to look at the influence certain aspects of the family planning program, begun in 1976, as predictors of changes in contraceptive behavior. 34.5% accepted contraception between 1976-1978. The researchers learned that couple traits (e.g., age, income, education, and religiosity) had only an indirect effect on change in contraceptive behavior. A desire to stop, limit, or space births (motivation) was a strong predictor of family planning method acceptance (p.001). Further couples who clinic providers contacted the most often or who had received more family planning services (services) were much more likely to use contraceptives (p.001). Indeed a significant relationship existed between motivation and services (p.001). Moreover couples who were truly motivated to use family planning methods did not let distance to family planning services prevent them from seeking these services (p.001). On the other hand, couples who confronted personal obstacles to family planning including social, psychological, and other subjective costs (cost index) tended not to accept family planning methods (p.001). A negative association existed between services and location of households vis a vis the intervention program (p.001) which indicated that the program did have an effect in the area of the province where it was located. In conclusion, the strongest predictors of change in contraceptive behavior included motivation, services, and cost index. Services and cost index indicated the great importance of interpersonal and/or client staff contact, especially since they were more important in influencing behavior change than distance and family planning site.     

The evolution of family planning in an African city: Ibadan, Nigeria

Summary Data drawn from a 1973 probability sample of 6,606 Yoruba females, 15-59 years of age in Ibadan City, Nigeria, are employed to analyse changing family planning practice over time. Usage and method rates are calculated for broad age groups from 1930 to 1973. Contraceptive practice is shown to have increased rapidly during the 1960s and early 1970s, from a very low initial base with a doubling period for the proportion of contraceptors of about four years, so that by 1973 one-sixth of the women had practised contraception and one-ninth were currently doing so. The major determinant of contraceptive practice is education. Oral contraceptives and IUDs account for an ever larger proportion of all contraception over time and together made up over 50 per cent by 1973. The Ibadan data give strong support to a suggestion emanating from scattered findings elsewhere that there is a special pattern of sub-Saharan contraceptive use: it begins with use in pre-marital and extra-marital relationships; then is increasingly employed as a substitute for post-marital sexual abstinence, and only later becomes the means for limiting the size of the family. Hence, the success of a family planning programme is indicated by rising average parity among the acceptors. Most couples in Ibadan will probably be practising contraception at some time in the 1980s, but even then such rates will probably still be low in rural areas.     

Thinking about several problems of the research of our family planning strategy]

On the basis of 1982 census data, it is estimated that from 1987-1997 13 million women will enter the age of marriage and child-bearing each year. The tasks of keeping the population size around 1.2 billion by the year 2000 is arduous. Great efforts have to be made to continue encouraging one child/couple, and to pursue the current plans and policies and maintain strict control over fertility. Keeping population growth in pace with economic growth, environment, ecological balance, availability of per capita resources, education programs, employment capability, health services, maternal and child care, social welfare and social security should be a component of the long term development strategy of the country. Family planning is a comprehensive program which involves long cycles and complicated factors, viewpoints of expediency in guiding policy and program formulation for short term benefits are inappropriate. The emphasis of family planning program strategy should be placed on the rural areas where the majority of population reside. Specifically, the major aspects of strategic thrusts should be the linkage between policy implementation and reception, between family planning publicity and changes of ideation on fertility; the integrated urban and rural program management relating to migration and differentiation of policy towards minority population and areas in different economic development stages. In order to achieve the above strategies, several measures are proposed. (1) strengthening family planning program and organization structure; (2) providing information on population and contraception; (3) establishing family planning program network for infiltration effects; (4) using government financing, taxation, loan, social welfare and penalty to regulate fertility motivations; (5) improving the system of target allocation and data reporting to facilitate program implementation; (6) strengthening population projection and policy research; (7) and strengthening training of family planning personnel to improve program efficiency.     

The child survival hypothesis

Summary Because of current interest in the child survival hypothesis, we have reviewed available evidence bearing upon the relationships of infant and child mortality to fertility and contraceptive behaviour. The evidence is drawn from time series data for local and national vital events, from special in-depth studies of the infant mortality-fertility relationships in family formation, and from service statistics from health and family planning programmes. As a result of this review, we suggest five clarifications which should be made in redefining the child survival hypothesis and assessing its potential programme implications. The child survival hypothesis states that improved child survival will contribute to increased family planning motivation and consequent fertility decline. The evidence presented here suggests that the effect is not automatic and probably not a necessary pre-condition for fertility decline. There is certainly not a reflexive one-to-one replacement, but a partial effect may still be important. In the clearly demonstrated reduction in inter-pregnancy intervals after a child death, the major component is undoubtedly the removal of the biological protection of lactational amenorrhoea. A separate but somewhat smaller effect has been demonstrated in situations where lactation did not seem to have been the explanation. It is expected that increased child survival will contribute to fertility decline mainly in countries experiencing rapid mortality decline and population growth. The replacement of children who die is probably not so much 'volitional' as a result of alterations in sub-conscious expectations. It is apparent that in traditional agrarian populations, few direct and manipulable means of influencing motivation for fertility limitation are available, and, therefore, it must be stressed that integrated health and family planning programmes do provide opportunities for immediate programme development. By making parents aware of improved changes of survival through health services in which they develop confidence, the spontaneous linkages between mortality and fertility can presumably be reinforced. Family planning services must be provided as an essential initial step in programme development, but they can be made more effective, as well as politically more acceptable if appropriately integrated with maternal and child health and nutrition services.     

Service station established at villages and towns in Fufeng County pushed forward the family planning program there]

In 1985 the 15 villages and towns of Fufeng County, Shanxi Province, established service stations to promote family planning. The County invested over 90,000 yuan in an x-ray machine, operation table and necessary medical supplies. The service stations provided fluoroscopy, surgical and propaganda rooms. The purpose of each station, staffed by female physicians and family planning cadres, was to develop contraceptive birth control, teach eugenics, and counsel women. The establishment of service stations obviously proved significant and useful, as seen from the following data: for the years 1983-85, the county birth rate fell 2%; the multiple child rate dropped 7.7%; the birth control rate rose by 12.6%; the sterilization rate rose by 1.3%. By October 1986, these figures showed even more improvement. The success of the service stations was also due to: taking its services to the people, their homes, and their workplace; making family planning work a service, rather than a management; systematizing family planning work and making it available at all times.     

Demographic Research in Britain 1936–1986

We use data from the nationally representative 1997 Demographic and Reproductive Health Survey to examine use of maternity services in rural China. The data indicate that roughly 60 per cent of women had at least one prenatal visit, while 40 per cent had a professionally assisted birth over the period 1988–97. Despite China's shift from a more socialist to a more privatized health care system, use of maternity services increased over this period. These increases are consistent with the push toward integration of reproductive health into family planning that emerged after the 1994 International Conference on Population and Development and the 1995 Fourth World Women's Conference held in Beijing. At the same time, we find indirect evidence that the target-based population policy may well have exerted downward pressure on use of maternity services; differences by parity are marked and multilevel models predicting use of maternity services indicate underdispersion at the individual level.