I’m glad to see the recognition of the link between population growth and climate change. However, the statement regarding the first proposed solution is demonstrably false. The statement reads, “The U.N. Population Fund estimates that 215 million women worldwide who desire modern contraceptives are deprived of them. Access to contraceptives would reduce unintended pregnancies by more than two-thirds, from 75 million to 22 million per year, and save $5.1 billion in pre- and postnatal healthcare.”
Large family norms and the cultural and informational barriers to use of contraception are now the major impediments to achieving lower fertility rates, not lack of access to contraceptives.
In Kenya, which was the fastest growing country in the world in the 1980s, contraceptives were within reach of nearly 90 percent of the population by the late 1980s. Yet currently, only 39 percent of married women use them. "Unmet need” is used to describe women who want to delay their next pregnancy by at least two years but are not using a modern method of contraception. In the minds of many, “unmet need” is equated with “lack of access” to contraceptive services. However, demographers Charles Westoff and Luis Hernando Ochoa, in a review of numerous Demographic and Health Surveys, determined that about half the women categorized as having an “unmet need” have no intention of using contraceptives even if they were made freely available.
The situation in Kenya is illustrative of findings in numerous countries recently. In Kenya, according to the 2008-09 Demographic and Health Survey, 96 percent of currently married women and 98 percent of husbands know about modern contraceptives. Of the married women who are non-users, 40 percent do not intend to ever use contraception. Among all non-using married women, 8 percent give as their reason the desire for more children. Among the reasons given for not using contraception by women who are not pregnant and do not want to become pregnant, only 0.8 percent cited lack of availability of contraceptives, and 0.4 percent cited cost. The top four reasons among those who are still fecund:
1. Concern with the medical side effects of contraceptives (31 percent)
2. Religious prohibition (9 percent)
3. Personal opposition (8 percent)
4. Opposition from the husbands (6 percent)
These are all issues that are best addressed by information and motivational communications.
Country by country, the Demographic and Health Surveys show a similar pattern. Lack of access is cited infrequently by those who are categorized as having an unmet need for family planning.
Pakistan’s 2006-2007 Demographic and Health Survey found that the most common reason for non-use of contraceptives is the belief that God determines family size. This answer was given by 28 percent of the respondents. Since the fertility rate in Pakistan is 4.0 and the mean desired number of children among currently married women is 4.1, it is clear that family size norms are also a major factor in driving high fertility.
The tradition of large families is a deciding factor in fertility rates in most of sub-Saharan Africa. For example, the 2008 Demographic and Health Survey in Nigeria, Africa's most populous country with 161 million inhabitants, found that the average ideal number of children for married women was 6.7. For married men, it was 8.5. The fertility rate in Nigeria is 5.7 children per woman, which is below what people say they actually want.
Of all births in Nigeria, 87 percent were wanted at the time and another 7 percent were wanted, but not until later. Only 4 percent were unwanted. Nationwide, 67 percent of married women and 89 percent of married men know of at least one modern method of contraception. Yet only 10 percent of married women report they currently use modern family planning methods.
Of the non-users, 55 percent report that they never intend to use family planning. The top reasons given are the desire for as many children as possible (17 percent), opposition to family planning (39 percent), fear of health effects (11 percent), and not knowing a method (8 percent). Lack of access and cost were cited by only 0.2 percent each. Only about a third of women have discussed family planning use with their husband.
Changing this situation takes more than provision of family planning services. It requires helping people understand the personal benefits in health and wealth for them and their children of limiting and spacing births. It also involves role modeling family planning use and overcoming fear that contraceptives are dangerous or that planning one’s family is unacceptable. It requires getting husbands and wives to talk to each other about use of family planning—a key step in the process to begin using contraceptives.
Delaying marriage and childbearing until adulthood and educating girls are critical. According to a 2003 report by the Nigerian Population Commission, in northern Nigeria, the mean age at first conception is 15 years. Teen births increased 50 percent between 1980 and 2003 in Nigeria, mostly attributable to adolescents in the northern regions.
The above should not be interpreted as suggesting that the level of effort in providing contraceptive services be reduced. Both quality and quantity of contraceptive choices and services are in need of improvement throughout much of the developing world. But access to family planning methods is not sufficient if men prevent their partners from using them, if women don't understand the relative safety of contraception compared with early and repeated childbearing throughout the reproductive years, or if women feel they cannot take control of their own lives.
Japan achieved below-replacement-level fertility (1.5 children per woman) in a country where the oral contraceptive pill was illegal until recently. The United States achieved below-replacement-level fertility in the Great Depression, before the invention of most modern contraceptives. Similarly, fertility dropped to near-replacement level in the 19th century in Western Europe and the U.S.
An illustration of the importance of motivation is the fact that the contraceptive prevalence rate in Malawi (38 percent) is four times higher than it is in Macedonia (10 percent), but the total fertility rate in Malawi (6.0 children born during a woman’s lifetime) is quadruple the rate in Macedonia (1.5).
Not enough is known about family size preferences of the men and women of the world—particularly among those who are not using any method of contraception. Papers on family size preferences by demographers John Bongaarts, Charles Westoff, and Warren Miller and David Pasta point to the need for much more in-depth, interdisciplinary research on the relationships among ideal family size as viewed by men and women at each age level, fertility intentions and actual achieved fertility.
More research is needed to measure the effects of non-medical interventions, such as efforts to raise women's status, mandatory education for children and mass media communications designed to affect desired family size.
Bill Ryerson wrote this commentary in response to Fighting Climate Change with Family Planning, an article published at Sierra Club Magazine dealing with the deleterious effects of rapid population growth and proposing five ways to achieve a global population stabilization.
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It's going to be back-to-school time soon, but will children go into the classrooms?
The American Academy of Pediatrics (AAP) thinks so, but only as long as safety measures are in place.
Keeping Schools Safe<p>What will safer schools look like?</p><p>In a <a href="https://jamanetwork.com/journals/jama/fullarticle/2766822" target="_blank">JAMA article</a> published last month, <a href="https://www.jhsph.edu/faculty/directory/profile/1781/joshua-m-sharfstein" target="_blank">Dr. Joshua Sharfstein</a>, a pediatrician and professor at the Johns Hopkins Bloomberg School of Public Health, outlined suggestions — many of which are similar to AAP's.</p><p>Remote learning protocols must stay in place, especially as some schools stagger home and in-building learning. If another shutdown needs to occur, children will rely on distance learning completely, so it must be easy to switch to, he said.</p><p>He suggested giving parents a daily checklist to document their child's health. Kids should be screened quickly on arrival and be given hygiene supplies. Maintenance staff should use appropriate PPE and have regular cleaning schedules. A notification system should be in place if a case is identified, Sharfstein recommended.</p><p><a href="https://www.albany.edu/rockefeller/faculty/erika-martin" target="_blank">Erika Martin</a>, PhD, an associate professor of public administration and policy at University at Albany, said nutrition assistance and health services should be included. She called for tutoring programs with virtual options as well as technology access.</p>
Supporting Staff<p>Teachers and staff will be affected by safeguarding measures, noted <a href="https://directory.sph.umn.edu/bio/sph-a-z/rachel-widome" target="_blank">Rachel Widome</a>, PhD, an associate professor of epidemiology and community health at University of Minnesota.</p><p>"In order for all of the in-school precautions to work well, we'll be asking a lot of teachers and staff," Widome told Healthline. In addition to their usual workload, they'll now be asked to monitor mask-wearing, ensure children are keeping distance, and be aware of any symptoms.</p><p>Along with Sharfstein, Widome called for an increase in financial support. More employees will likely be required so teachers and staff members can keep up with the added demands.</p>
Should Kids Go Back?<p>While these guidelines may help get some schools to reopen, many people don't think children should go back to school over fears they could contract the disease and spread it to other vulnerable family members like grandparents, infant siblings, or their parents.</p><p>In a <a href="https://pediatrics.aappublications.org/content/early/2020/07/08/peds.2020-004879" target="_blank">Pediatrics</a> commentary, <a href="https://www.md.com/doctor/william-raszka-md" target="_blank">Dr. William V. Raszka, Jr.</a>, an infectious disease specialist at The University of Vermont Medical Center, argued that schools should open because school-aged children are far less important drivers of COVID-19 than adults.</p><p>But he says the risk and benefit is not equal among all students ages 5 to 18.</p><p>"Elementary schools are arguably higher priority for face-to-face schooling, since younger children are at lower risk for infection and transmission, and since parental supervision of younger children's distance learning may be particularly challenging," added Sorensen, who penned a <a href="https://jamanetwork.com/channels/health-forum/fullarticle/2767411" target="_blank">June article in JAMA</a> with reopening tips. "That means middle and high schools are more likely to emphasize distance learning."</p><p>Specific student populations, such as special education students and students with disabilities, would also benefit greatly from more time spent in face-to-face environments, Sorensen said.</p>
What Parents Can Do<p>Parents should ask for and receive frequent updates from schools about plans for the fall. They should also be informed about plans if and when COVID infections are identified, Sharfstein said.</p><p>"I'd like to see parents investing now, during the summer, in doing things that can slow and stop the spread of the virus in their communities," Widome said.</p><p>"Now is a good time for kids to practice wearing masks and get used to them as they may be wearing them for longer stretches if school starts up in person," Widome suggested.</p><p>She recommends parents try different mask designs and materials to see what children are more comfortable wearing.</p><p>"If you are using cloth face coverings, it's good to have extras on hand," Widome added.</p><p>Parents should model healthy behavior at home and while out in public — another thing that could affect how well children adapt to reopening practices, Sorensen said.</p><p>"Children may want to know more about face coverings," added <a href="https://www.linkedin.com/in/leescott/" target="_blank">Lee Scott</a>, chairwoman of the Educational Advisory Board at <a href="https://www.goddardschool.com/" target="_blank">The Goddard School</a>. "Dramatic play, such as creating or wearing a face covering, may help some children adjust to this concept." Schools can also show children photos of what faculty members look like in their masks so the students are familiar with that appearance.</p><p>Johns Hopkins University recently released its eSchool+ Initiative, a slew of resources surrounding education during the pandemic. These include a <a href="https://equityschoolplus.jhu.edu/reopening-checklist/" target="_blank">checklist for administrators</a>, report on <a href="https://equityschoolplus.jhu.edu/ethics-of-reopening/" target="_blank">ethical considerations</a>, and a tracker of <a href="https://equityschoolplus.jhu.edu/reopening-policy-tracker/" target="_blank">state and local reopening plans</a>.</p>
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