Family Planning

Given the massive increase in population in the south hemisphere countries since World War II, much of global family-planning efforts have been directed toward those poor countries of the so-called Third World. The followers of Malthus, the neo-Malthusians, have extended his thinking, blaming global poverty, political insecurity, and environmental degradation on the "population explosion" and calling for population control as the primary solution to these problems. Their efforts have helped turn family planning into a vast establishment of governmental and nongovernmental organizations with financial, technological, and ideological power emanating from the capitals in the north toward the remote corners of the south. Within countries in the south, the hierarchical family-planning model spreads from professional elites in the cities to the poorest men and women in the villages. In India alone, there are an estimated 250,000 family-planning workers. Every year vast amounts of money are spent to promote "contraceptive acceptance" among the poor populations in the world. Contraceptive use in the "developing world" has increased from less than 10 percent of couples of reproductive age in the 1960s to more than 50 percent (42 percent excluding China) in the 1990s. The rapidly falling birth rates in the Third World are generally attributed to the "family-planning revolution" represented by expanding use of modern contraceptives.

The International Conference on Population and Development (ICPD), held in Cairo in 1994, is generally considered to have ushered in a new approach to population and development, upholding reproductive health and rights of women over meeting numerical goals for reducing fertility and population growth. Departing from earlier positions and upholding voluntary choice in family size, the ICPD Programme of Action states that demographic goals in the form of targets and quotas for the recruitment of clients should not be imposed on family-planning providers and expresses disapproval of the use of incentives and disincentives. It acknowledges the setting of demographic goals as a legitimate subject of state development strategies to be "defined in terms of unmet needs for [family-planning] information and services" (United Nations, 1994). But, as human rights activists concerned with continued abuses in family-planning programs point out, there is still a long way to go in establishing policies and ethical standards to ensure that the new health and women's rights objectives are achieved.

Notwithstanding massive spending and extensive family-planning promotion over three decades, many poor people in the Third World remain reluctant to use modern contraception in the early twenty-first century. Attitudes and the need for children among the poor are often quite different from that of family-planning enthusiasts, who are mostly middle-class professionals. Even when poor people use modern contraceptives, their continuation rates are often low due to lack of access to health care, side-effects of contraceptives, and other reasons. Given these realities and the urgency to reduce fertility, international family planning continues to rely on the use of economic incentives and disincentives as well as highly effective, provider-controlled, female methods.

Although male sterilization (vasectomy) is a much simpler operation than female sterilization (tubectomy), female sterilization is the most favored method of family planners and the most widely used method of fertility control in the world. Tubectomy is more common than vasectomy because the men in many areas refuse to have vasectomies, leaving the women little choice if they don't want more children. Female sterilization constituted about 33 percent and male sterilization 12 percent of all contraceptive use in the developing countries at the end of the 1980s. In terms of the numbers, sterilization is an increasing success, and for many women and men in the north and the south, sterilization represents a choice to be free of biological reproduction. But closer examination of conditions under which most women consent to be sterilized shows that sterilization abuse continues to be a pervasive problem for poor women.

Poverty and adverse social conditions—including lack of information and access to other methods of birth control, threats of discontinued social benefits, and economic constraints—set the conditions for abuses in family-planning programs. Targets and economic incentives/disincentives have defined the operation of many Third World family-planning programs from their inception. They have also been associated with programs directed at poor communities of color in the United States. In the early 2000s a nonprofit organization known as C.R.A.C.K. (Children Requiring A Caring Kommunity) promised a cash incentive of $200 to drug-addicted women upon verification that they had been sterilized or were using a long-term birth control method such as Norplant, Depo-Provera, or an IUD (American Public Health Association).

While targets and incentives in other realms of social policy are not necessarily wrong, the pressure to meet targets and the offer of economic incentives in family-planning programs have resulted in a highly techno-bureaucratic and monetarist approach obsessed with numbers of acceptors and financial rewards. Within such a quantitative approach, the complex psychological, sociocultural dimensions of sexuality and reproduction are easily overlooked. Not only do poor people lack much relevant information, but also, in many cases, the desperation of poverty drives them to accept contraception or sterilization in return for payments in cash or kind. In such situations, choice simply does not exist. Direct force has reportedly been used in population-control efforts in some countries, including China, India, Bangladesh, and Indonesia. But coercion does not pertain simply to the outright use of force. More subtle forms of coercion arise when individual reproductive decisions are tied to sources of survival, like the availability of food, shelter, employment, education, health care, and so on.