Dr. Stanley Henshaw’s Acceptance Speech

Society of Family Planning 2015 Lifetime Achievement Award

Stanley Henshaw, PhD, serves as a consultant to numerous nonprofit organizations, including the Guttmacher Institute, from which he retired after 34 years in 2013. He has authored or co-authored more than 125 articles, book chapters, and encyclopedia entries, principally on abortion statistics, teenage pregnancy rates, and family planning services. Dr. Henshaw published the first detailed report of unintended pregnancy and abortion rates in relation to women’s demographic characteristics in the United States.

Dr. Henshaw has served as an expert witness in more than 20 federal court challenges to restrictive abortion laws, most recently in Alabama and Wisconsin against requirements that physicians providing abortions have local hospital privileges. Other cases concerned parental involvement for minors, waiting periods, Medicaid payment for abortion, and a requirement that second-trimester abortions be performed in hospitals.

He has been concerned about population growth since the early 1960s, even before Paul Ehrlich’s The Population Bomb was published. It never made sense to him that humanity could keep expanding exponentially without someday reaching an environmental crisis. His abortion and family planning studies were motivated by the desire to reduce the burden of unwanted children on society and the planet. Availability of the full spectrum of reproductive health services reduces population growth by allowing couples to space their children and limit family size. Writing his presentation for the Society of Family Planning reenergized his concern about the population problem and led him to Population Connection. He became a member in 2015.

Dr. Henshaw has been honored with the Association of Reproductive Health Professionals’ 2008 Alan F. Guttmacher Lectureship and the 2006 Carl S. Shultz Award in Recognition of Outstanding Contributions to the Field of Family Planning and Reproductive Health from the American Public Health Association’s Population, Family Planning, and Reproductive Health Section. He also received the 2004 Ipas Champion of Reproductive Health Award and the National Abortion Federation’s 2000 Christopher Tietze Humanitarian Award.

Dr. Henshaw received his A.B. in physics from Harvard College, and his PhD in sociology from Columbia University.

Today I would like to talk about a topic of great concern to me: the environment, the future of the planet. Think about this: What will happen when all peoples of the world have achieved a standard of living equal to that of ours in the United States today? People in developing countries aspire to a high standard of living, as they have every right to do. I am sure you know that the gross national product of China has been rising at more than 7 percent per year. It is also rising almost as rapidly in other developing areas, including India, Southeast Asia, Latin America, Africa—pretty much everywhere.

So what will it mean if their standard of living is as high as ours? What about motor vehicles? The world will have five times as many motor vehicles as it has now. Worldwide electricity production will increase by a factor of four if per capita consumption is to equal that of the U.S. The production of meat will have to triple, which means the production of grain will have to expand enormously. The same with minerals like iron, copper, potash for fertilizer, and others.

But wait, the problem is actually worse. The world population is now 7.3 billion [7.4 billion in 2016] and is growing at the rate of 1.1 percent per year. At that rate of growth, the world’s population will increase by 41 percent in 30 years, which most of you will be alive to witness. By the year 2100, at present rates, the population will increase by 165 percent, to 19 billion.

Take Nigeria, for example. The current population growth rate is 2.7 percent per year. Compared to 1980-1985, the growth rate is actually higher even though the birth rate is slightly lower. This is because people are living longer. The population in 2015 is estimated at 182 million. If Nigeria continues to grow at 2.7 percent per year, the population will be over 400 million in 30 years. By 2100, the population will be 1.8 billion. Take the Philippines. The current population is about 101 million and the current growth rate is 1.7 percent per year. At this rate, the population will be 167 million in 30 years and 422 million in 2100.

The United States is also growing. At current rates, today’s population of 322 million will grow to 400 million in 30 years and 600 million in 2100. Most of this growth is from immigration, so to that extent it doesn’t add to the world’s population.

Already, overpopulation is a problem in many countries. Rwanda, for example, is the most densely populated country in Africa. It is generally believed that the tribal conflict that resulted in genocide was motivated by competition for land on which to grow food. Burundi is on the verge of a civil war, basically for the same reason.

So if current rates of growth continue, 30 years from now, to raise standards of living to the U.S. level, the world will need seven times as many motor vehicles as it has now, six times as much electricity production, four times as much meat, and comparable increases in other natural resources.

So what can be done? Obviously developed countries will have to learn to live with fewer motor vehicles, less energy consumption, less meat, and fewer natural resources per capita. We will need to find ways to utilize more renewable resources and find substitutes for depleted minerals. Technological advances will help but will require a huge investment in research. The changes will be difficult and painful. Despite our efforts, global climate change will continue and may well accelerate. And there will continue to be a large income gap between poorer and richer countries.

But there is one important change that will make the problem less severe than I have described—a change that is not difficult or painful, costs little, and improves people’s lives. That change is increasing contraceptive use, which reduces family size and population growth. This change is already taking place, though at a slow pace. Based on past trends, the UN predicts that contraceptive use will grow worldwide, especially in countries that now have high fertility rates. The United Nations estimates that increased contraceptive use will result in world population growth of 29 percent in 30 years, not the 41 percent if current growth rates continue. By 2100, the world population will be 11 billion, not the 19 billion that would result if current growth rates continue. But 11 billion is still a huge number, and we can do better.

Worldwide, there are about 150 million women in developing countries who do not want to get pregnant but are not using any contraceptive method, and another 75 million who are using less effective methods. Many more women would undoubtedly want to postpone or end childbearing if they were fully informed about contraception and knew it to be safe, convenient to use, and easy to access. The Guttmacher Institute estimates that if all unmet need for contraceptive services was met, there would be 21 million fewer unplanned births and 24 million fewer abortions each year.

But isn’t contraception readily available to most women? After all, there have been family planning programs in developing countries for 50 years or more. The answer is no, for a couple of reasons. First, virtually all programs make only a few contraceptive methods available. Often they focus on only one or two methods. In India, for example, among couples using any method of contraception, 67 percent are using sterilization, and virtually none are using the injectable or implant. Only 10 percent are using a reversible modern method other than the condom even though many young women would like to postpone their next birth. Historically, the family planning program in India focused almost exclusively on sterilization in furtherance of a population control program. Today, other methods are sometimes available, but the emphasis is still on sterilization.

In Indonesia, the pattern is very different. Only 5 percent of users rely on sterilization, while 52 percent use the injectable and 22 percent use the pill. Similarly, in Bangladesh, only 7 percent use sterilization. Many women in these and other countries want to have no more children, but most are not offered permanent contraception or even the IUD.

And in many countries, couples rely heavily on traditional methods, mainly withdrawal. This is the case for two-thirds of users in Albania, Azerbaijan, Bosnia, Macedonia, and Serbia, all former Communist countries where modern contraceptives were not readily available. More than one-third of couples use traditional methods in a range of other countries, including Bolivia, Congo, Greece, Italy, Libya, Nigeria, the Philippines, Turkey, and others. Although highly motivated couples can use these methods effectively, in some countries they result in high abortion rates.

The differences among these countries cannot be because the women are that different from each other. To a large extent, they reflect the history of their family planning programs and current differences between the contraceptive delivery systems. If a method is not available or providers are not trained in its use, women cannot use it. As you know, for any given woman, one method is likely to be more compatible with her needs than other methods. If that method isn’t available, she may go without. If a woman wants to postpone her next birth but the only methods available are permanent, she will risk a mistimed pregnancy. In populations where couples want a large family, as in much of Africa, women may appreciate a way to postpone the next birth but not a way to end childbearing. My point is that women need to have available and to understand the benefits of the full range of contraceptive methods.

The second way that many family planning programs are inadequate is that barriers of cost, distance, and convenience remain. We have seen how even in the United States, until recently the high cost of the IUD has prevented its use by many women for whom it is the optimal method. The situation is much worse in most developing countries. Many women can’t afford services from the private sector. Family planning clinics often run out of supplies because of inefficiency or cost constraints. For a woman with no means of transportation, a relatively short distance to a service provider can be an insurmountable barrier.

So what can be done? The Guttmacher Institute estimates that the cost of serving all women in developing countries who need modern family planning services at $5.3 billion per year in addition to what is being spent now. The actual cost might be more if we want to make every method truly accessible without barriers, but even double the cost—$11 billion—is a tiny amount to the world economy, or even to the U.S. economy. This amounts to less than 2 percent of our defense budget. And this is much less than the cost of other measures to protect the environment, such as building windmills or replacing coal-fired power plants. And it would prevent abortions as well as unintended births. Because it would reduce health, education, and other expenditures on children, it would save money for developing countries. One economist has estimated that one dollar spent on family planning services would ultimately save $120. This may be high, but the point is that family planning services save more than they cost.

Of course, developing family planning programs is not always simply a matter of providing the funding, and we must be mindful of the enormous amount we have learned from past mistakes and successes. The most effective programs are in countries where they have strong government support. In Bangladesh, an active government program with foreign assistance has brought contraceptive use to 61 percent. The fertility rate has fallen from 6.9 children per woman in 1970-1975 to 2.2 today, barely above replacement level. In India, with a less-intensive government sponsored family planning program, the fertility rate has fallen to about 2.5 children per woman. In Rwanda, government policy and a vigorous program have increased contraceptive use from 4 percent in 2000 to 44 percent in 2011.

One of the most important lessons we have learned is that coercion or the appearance of coercion in a program, besides being considered unethical by many, can result in devastating backlash, as happened in India in the 1970s. Family planning workers should not be compensated according to the number of contraceptive acceptors they recruit—for example, the number of IUDs inserted or sterilizations performed. Fortunately, most people want to control their fertility when given the information and opportunity, and many couples will adopt family planning without coercion. The desire for smaller families is growing in response to economic changes, especially the shortage of productive land and the need to educate children so they can participate in the modern economy. Of course, attitudes and values must change, but over time this is possible. In China, as recently as the 1960s, the desire for large families was considered a fundamental value that would never change. Today, educated urban Chinese women think it is a little strange to want more than one child. Countries such as Bangladesh have been successful without the use of coercion. They have had remarkable success with information and ready availability of contraceptive services and supplies, although even in these countries not all methods are offered everywhere.

There will be groups that oppose family planning for religious reasons or because they want the population of their particular social group to increase. They believe a higher population will enhance their group’s influence in their region or in the world. They will argue that outside groups are trying to reduce their fertility for self-interested reasons. In reality, it may be in the interest of such groups to provide education, nutrition, and healthcare to a smaller number of children, but they may not see it that way. Every effort should be made to gain the support of local leaders.

Opponents may ask why richer countries are giving full support to family planning when what low-income areas really need is clean water or other basics. One answer is that family planning will make it easier to provide clean water and other necessities to a smaller population in the future. And, in addition, reduced population growth will benefit the entire world, not just the particular country. Family planning programs must be prepared to answer these kinds of questions and overcome or work around resistance. They must also provide information and education to counter the false rumors and misinformation that often crop up about contraceptive methods. And the programs must provide long-term follow-up care so that women are assured that they will be treated for side effects and can have their IUD or implant removed on request.

Above all, programs must make it clear that they are giving people options, giving them what they want, not pressuring them to have fewer children.

In addition to supporting family planning programs, governments of wealthy countries need to finance research to develop contraceptives that are effective, convenient, less reliant on trained medical personnel, and have fewer side effects. Industry is spending relatively little on such research, so the money must come from public sources. For example, injectables are popular in some countries because they are effective and confidential. What about an injectable that lasts a year? Or an IUD that lasts until menopause and takes the place of sterilization while being reversible?

Of course, abortion liberalization and funding can also make an important contribution to helping women and couples have only the children they want. A majority of developing countries with low fertility rates allow abortion on request. However, even where abortion rates are high, contraception contributes more than abortion to limiting fertility.

I know it is politically incorrect to talk about reducing population growth or even to discuss the effect of population on the environment. This is because, historically, population concerns have been associated with coercive policies. But it is an obvious fact that population increase along with inevitable economic growth are contributing to climate disruption, the rise in the sea level, the destruction of forests, the extinction of thousands of species, and possibly to food shortages. We can develop policies to slow population growth without resorting to compulsion or pressure. Voluntary family planning is the most cost-effective way to slow the degradation of the environment, and enormous change is possible without coercion or even incentives. The goal is not to discriminate against people in developing countries; it is to give them something that people in wealthier countries already have: control over their fertility.

We need to change the perception that it is politically incorrect or demeaning to high-fertility cultures to talk about the cost to the environment of population growth and to explain that this cost can be reduced by inexpensive, ethical, voluntary family planning programs. Of course, there are other strong reasons to support family planning: It increases the status and economic well-being of women, reduces food insecurity, makes resources available for education, and improves the health and survival of children. But there are also environmental benefits that may appeal to interest groups and policymakers for whom the status of women is a low priority.

So my message is that what you are doing—promoting family planning and developing better contraceptive methods—is helping not just the individuals you serve but also helping the planet. Keep up the good work.

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