Family Planning Helps the World

Abstract

It is generally recognized that voluntary family planning is essential for the lives and health of individuals in today’s world. What is less frequently acknowledged is that family planning has decreased the growth of human population over the past decades. Despite many wonderful advances since the industrial revolution, humans have caused massive deterioration of the natural world. Examples include climate disruption caused by the increase in greenhouse gases and the sixth mass extinction of species. Without modern, voluntary family planning, these negative effects would have been greater. This chapter recommends increased attention to the global public health benefits of family planning by reducing the numbers of unintended births and thus the number of people contributing to our environmental deterioration.

1. Introduction

Family planning is the most humane vehicle for achieving sustainable social and environmental justice.

Jensen and Creinin

We are accustomed to think of the advantages of Family Planning (FP) to individuals and perhaps to families, but not of the global benefits. This chapter mainly focuses on these benefits to society and to our environment. Throughout the chapter I include access to safe abortion services along with FP [1].

First, I would like to mention the need for more methods of FP, especially for men. At present we have a large variety of methods for women. However, no method is acceptable to all women, and no method is failure-free. Hopefully, improved FP methods will continue to be developed, for both women and men.

In addition, I need to admit to the lack of equity. FP is available to most people in rich countries. However, even in one of the richest countries, the USA, there are geographic locations where it is difficult to access FP services. This has been improved by telemedicine and also by the ability to get FP, including birth control pills, by mail. Nevertheless, there are “abortion deserts”, where a woman has to travel long distances in order to abort an unwanted pregnancy. With today’s political climate in the USA, access to safe abortion services even is more difficult.

One might think that distance should be no problem in countries with good transportation, however, this is not so. A study performed in the USA has shown that when there is a FP clinic is close to a high school, female students are less likely to drop out of school [2].

Access to FP services in developing countries is often difficult if not impossible. The difficulty is because of multiple factors including distance, language differences and “stock outs”. Often cultural and religious beliefs are serious barriers to accessing and using FP [3].

It is unfortunate that there is no perfect contraceptive method for women, and there is much less available for men. As I write this (April, 2023), I am pleased to note that new oral contraceptive is available that may be safer than past combination pills. Drospirenone/estrol (Nextstellis®) is available in the USA, but is very expensive for those who do not have adequate insurance coverage. Progestin-only oral contraceptives have been around for decades. The have a record of great safety, although breakthrough bleeding and pregnancy rates may be higher than with combined oral contraceptives. Despite the excellent record of safety, the FDA currently requires a prescription for a woman to purchase progestin-only pills. Thanks to the organization “Free the Pill” in the USA our FDA is looking at making this pill available over-the-counter, which will help reduce its cost and make it more accessible.

2. Benefits to the individual

Contraception allows women to enjoy sex with little worry about unintended pregnancy. This permits a woman to finish her education and to start a career before parenting, if that is what she chooses to do. The role of women in developed countries has changed markedly in the 60+ years since oral contraceptives first became available. Although there have been many other factors causing these changes, certainly “the pill” has had a major effect.

Family planning has been called one of the top 10 public health achievements of the 20th century by the US Centers for Disease Control [4]. It allows for longer intervals between the births of children and for smaller family size. By decreasing the number of pregnancies a woman has in her lifetime and increasing intervals between pregnancies, FP has also reduced the mortality and morbidity of women. Because of the longer birth interval, and because each child can receive more resources, FP has helped to save children’s lives—especially in developing countries. Improved barrier methods, such as female condoms and nonlatex male condoms, have decreased transmission of HIV and other sexually transmitted infections.

We now have LARCs—Long-Acting Reversible Contraceptives, including hormonal implants and several IUDs. LARCs have very low failure rates, partly because they do not require doing something (such as taking a pill) on a regular basis. Most of the IUDs available in the USA are hormonal. These are being evaluated to find out if they are effective for use longer than their original approval [5]. In addition, they may be useful for postcoital (emergency) contraceptive use [6].

Copper containing IUDs, such as the T 380A (Paragard®), are also very effective for emergency contraception, if inserted within 5 days of unprotected intercourse. Other emergency contraceptive methods include levonorgestrel tablets (which are available without a prescription in many countries) and ulipristal. Although supplanted by more effective methods of emergency contraception, in some areas the only available method may be the Yuzpe regimen. This is using oral contraceptive pills containing ethinyl estradiol and norgestrel, although other formulations may also be effective. Current research has found that emergency contraceptive pills do not work by causing an abortion.

There are many good sources for information about birth control. One that is objective and geared to people in the USA is: www.plannedparenthood.org. The World Health Organization (www.who.int) is a good worldwide source for information.

3. Abortion

There are estimated to be 121 million unintended pregnancies worldwide each year [7]. Some of these are miscarried, some intentionally aborted and some go to term. The World Health Organization states that, globally, about 60% of unintended pregnancies are aborted, and almost half of the abortions are “unsafe”. They estimate the total number of global induced abortions at 73 million annually [7].

“Unsafe abortion” is the term that is often used for abortions that are performed outside of the medical system. Usually these abortions are expensive, exploitive and dangerous. Women choose to have an unsafe abortion when they live where abortion is illegal or severely restricted. The risks of an unsafe abortion include serious illness such as hemorrhage or infection, and may result in sterility or death.

It is interesting that abortion is no less common in countries where it is illegal [7]. Perhaps this is because many of these countries also limit access to contraception. Many of the countries where abortion is illegal have high levels of patriarchy and religiosity, with the beliefs that sex should only happen within a marriage. This goes along with limited or no sexuality education, so young women are likely to not be prepared to deal with aggressive males.

4. Global benefits of family planning

The main thrust of this chapter is the benefits of FP to humans, other species and to the environment. I will look at examples in order to make the point that, in addition to helping us, FP helps us to preserve biodiversity and decrease environmental impact.

Most of the world’s environmental problems, including climate disruption and loss of biodiversity, would be improved if there were fewer people on the planet. During the past century we have seen remarkable decreases in the rate of population growth, largely due to the use of voluntary FP. Unfortunately, the importance of FP and its relationship to population growth has been largely overlooked by medical and public health people. Furthermore, some people involved in the social sciences seem to actively deny that the planet is overpopulated [8]. Much of this denial comes from religious beliefs and from the regrettable past history of genocide, forced sterilization and eugenics [9].

The good news is that almost half of the world’s countries have a total fertility rate (TFR) of less than 2.1, which is the number for replacement fertility [10]. This means that their population will decrease, if the fertility stays below that number, although it may take several decades for that to happen.

How large can the human population be and still be sustainable? I like to use the Ecological Footprint (EF) to compare how we are using Earth’s resources with what is available. In short, the EF breaks down our use of resources to land area—land on which to live, to raise food, to develop resources and to dispose of waste.

Globally, there are about 12.2 billion hectares of bioproductive land and of water. Shared evenly among the current roughly 8 billion people on earth, that would be about 1.5 hectares (3.75 acres) for each person. However, many people use more than that. For instance, the average EF for a person in the USA is about 7 hectares (17.2 acres). The average Ecological Footprint for everyone on Earth is 2.77 hectares—significantly larger than the 1.5 acres that are available. As a consequence, we are using the earth’s resources faster than they can regenerate. Calculations suggest that it would take 1.8 planets Earth to support all the humans at the rate at which we are using resources and generating waste. The excess over what the planet can support sustainably is called “overshoot” [11].

One way to calculate a sustainable human population is to divide our current population by the overshoot fraction—8 billion divided by 1.75, or about 4.5 billion people. Unfortunately, one of the shortcomings of the EF is that it does not allow any resources for nonhuman species. With a small allowance for all other flora and fauna, we might find that 4 billion humans would be a sustainable population. If we want the planet to be really healthy, the human population should be about 3 billion people.

There are other, perhaps more accurate ways of calculating the size of a sustainable human population. Mostly they end up with estimates in the range of 2 to 3 billion people, as stated above. For a readable review of this subject, I suggest the book “A Planet of 3 Billion” by Christopher Tucker for more information about a sustainable human population.

The bottom line is that our current human population is not sustainable. In fact, our current population, with the average consumption, is about 2 or 3 times what could be maintained indefinitely. Without modern FP, our numbers would have been much, much larger than the current 8 billion!

Let me explain why I focus on population rather than on consumption. In the formula that describes human impact on the environment, I = P × A × T (Impact equals Population times Affluence (or Consumption) times Technology), population is just as important as affluence. However, remember that there are more than 120 million unintended pregnancies every year! [12]. That means that there are many, many women who wish to have control over their fertility—but I know very few people who wish to decrease their affluence. Indeed, globally we live in a sea of advertisements and other media that urge us to buy and consume more, not less.

I do not give the T in the above formula much attention. For instance, I’ve replaced the lightbulbs in our home with compact fluorescent light bulbs, then with LEDs. We have solar panels on our roof that make most of our electricity and also power our plug-in hybrid vehicle. However, my wife’s and my Ecological Footprint is still much larger than 1.5 acres, since these technological modifications only reduce our impact slightly.

To sum up, it would be great to have everyone decrease their footprints down to what is available (1.5 hectares) if we all shared equally. Unfortunately, that is very unlikely. For the average person in the USA it would mean shrinking their footprint by almost 80%, from 7 to 1.5 hectares! Imagine what it would take to have such a small footprint. There are so many things you could not do, and so many things you’d have to do without to have such a small footprint. You would probably have to live in a small house, eat primarily beans and rice or other simple foods with very little meat or none at all. You would have to walk, bike or take public transportation; a car would be impossible. You would have no frills, no TV and probably lots of hard work. It is no wonder that people are not enthusiastic about decreasing their consumption!

On the other hand, millions of people already are trying to control their fertility. Over half a million abortions are performed every year in the USA [13]. It is estimated that there are about 121 million unintended pregnancies globally [7]. The number of women who do not have access to effective contraceptive methods is estimated to be 218 million [14]. Access to voluntary contraception and abortion are certainly the “low hanging fruit” when it comes to decreasing human impact.

There are other, more quantitative ways to appraise the role of FP in lowering our impact [15]. In this part of the discussion, I would like to use climate disruption caused by carbon dioxide (and other greenhouse gasses) as a proxy for all anthropogenic environmental problems. This is because climate disruption is in everyone’s mind—as well it should be. Furthermore, climate disruption has been studied a great deal, and in more quantitative ways, than other environmental problem.

For various reasons, the potential for FP to help solve the evolving disaster of climate disruption has been given much less attention than it deserves [16]. An article written in 2010 claims: “Using an energy–economic growth model that accounts for a range of demographic dynamics, we show that slowing population growth could provide 16–29% of the emissions reductions suggested to be necessary by 2050 to avoid dangerous climate change” [17]. Although it may be too late to achieve such a benefit by the year 2050, there are still large advantages to supporting FP for further in the future. Another study suggests that not only is FP effective, but it may be the least expensive means to slow climate disruption [18]. Another article gives an overview of CO₂ emissions in the past and projections using demographics [15].

However, there are other environmental problems than just climate disruption. Extinction of species, global toxification and other impending tragedies may be as bad as, or even worse, than climate disruption. Working together, all this deterioration of the environment will cause problems that we can only begin to imagine. Do not forget that all of these problems are anthropogenic!

5. What could be worse than climate disruption?

Most people understand the CO2 that we emit is caused by people using fossil fuels. However, the connection between human endeavor and the extinction of species may not be so obvious. What is the association between humans and extinction of species? There are a half dozen ways that we are accelerating the loss of species. Paleontologists have known that species have always become extinct, and estimate that the baseline rate is in the range of 1 per million living species per year. The current estimated rate is at least 100 times that, and probably 1000 times or more. One estimate is that there are 8.7 million species on earth and in the oceans [19]. Using the most likely rate of extinction, that would suggest that more than 8000 are being driven to extinction each year. This has been called the “sixth mass extinction” [20].

The biggest reason for extinctions is loss of habitat. Many species of plants and animals require specific conditions to thrive. There are also species, called “endemics”, that only live in small areas. If their habitat is disturbed, they die. This is the reason for the Endangered Species Act in the USA. Before any significant development is allowed to occur, the Act requires a survey looking for endangered species. It is sad that all other countries do not have similar laws, and that often the laws (where they exist) aren’t always enforced. Unfortunately, the press of the growing human population has already caused the extinction of many species. Joni Mitchel sums it up well in her song, Big Yellow Taxi: “They paved paradise and put up a parking lot [21]”.

Each human on the planet requires a place to live and food to eat. The species who had lived on the land before us are evicted; unfortunately, those individuals who survive the bulldozers frequently have no place to go. Often the land used to grow our food is treated with chemicals that are incompatible with the life that had been there [22]. Nonhuman species are being challenged and too often killed off by our civilization in a variety of ways.

Briefly, here are the five other ways that we are causing species to go extinct: (1). The changing climate makes it difficult for some species. For instance, the pika is sensitive to heat. It is a small mammal that lives in cold, mountainous regions. As the climate gets hotter, it can move up in altitude to stay cool. However, they will have no place to go when the mountain tops aren’t cold enough. (2). Humans have introduced diseases, such as the fungus that causes white nose syndrome in bats. It is killing susceptible species of bats—which destroy untold numbers of pest insects. (3). We have also introduced exotic species that out-compete vulnerable local species. An example is the salt cedar or tamarisk, which has locally displaced native trees such cottonwoods. (4). In the last century chemists have synthesized thousands of new chemicals. Even though they are given cursory testing for safety before being marketed, some of them have had disastrous unintended consequences. DDT is an example of a chemical with severe unintended consequences [23]. (5). Finally, human greed has killed off some species. Carolina parakeets were numerous at one time, but their colorful plumage became fashionable for ladies’ hats. These beautiful birds were hunted to extinction.

We do not know how we will be affected by the mass extinction of other species. We do know that we are a part of the web of life, and that all parts of the web are interdependent. To some extent, all species are important, although some are much more important than others. As our understanding of this web increases, we find out that some species that we thought were of little import are actually essential. Slime molds are an example. They appear unbidden in gardens and woods as unwelcome guests; some of them look like someone vomited on the ground. However, they are helpful because they recycle nutrients [24].

Humans have invested in developing just a few species for our nourishment. Much of our food comes from only a few crops, such as wheat and rice. Likewise, much of the meat we eat comes from just a few species of animals, such as pigs and goats. Although this permits efficient factory farming, it makes us very dependent on just a few species of plants and animals. When there is a disease such as the potato blight in Ireland, this lack of diversity may cause a famine. This is just one way that decreasing biodiversity can affect us. Some experts worry that the mass extinction may be even more problematic to humankind than climate disruption [25].

6. What can we do?

I have several suggestions. Perhaps my strongest recommendation is to support people and organizations that work in the field of reproductive health. This might mean making donations to organizations and clinics that provide FP services. It could mean lobbying politicians who recognize the importance of FP—and it certainly means remembering the importance of FP when it is time to vote.

For those of us in the field of family planning, here is encouragement:

“As family planning specialists, we should devote part of our effort to educating policy leaders and the public about the importance of our work from an environmental standpoint” [1].

Although an individual cannot cure the ills of the world single-handedly, supporting access to family planning is one way that each of us can work to help with climate disruption and also with loss of biodiversity.

Summary

Most of the readers of this chapter are already aware of the advantages of modern family planning—the ability to have sexual intercourse with little fear of an unintended pregnancy. Contraception and abortion have slowed the growth of the human population. Nevertheless, the human numbers are currently 2 or 3 times what would be sustainable. It is important to recognize the important role that family planning plays in helping the non-human portion of the world, in addition to the how it serves people.