Reproductive freedom of choice as key to development

Utrecht, december 2015 Auteurs: Reinier van Winden Projectnummer: Š Rutgers 2015

Reproductive freedom of choice Key to development

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Reproductive freedom of choice as key to development Rutgers 2015

3 Arthur van Schendelstraat 696 3511 MJ Utrecht Postbus 9022 3506 GA Utrecht +31 (0)30 231 34 31 office@rutgers.nl www.rutgers.nl www.rutgers.international BIC ABNA NL 2A IBAN NL18 ABNA 0496 3238 22 KvK 41193594

Reproductive freedom of choice as key to development Rutgers 2015

Reproductive freedom of choice Key to development

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Reproductive freedom of choice as key to development Rutgers 2015

Content Introduction

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Lack of freedom of choice

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Importance of free choice

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Efforts made to achieve freedom of choice

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Discussion on influencing population growth

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Conclusion

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Reproductive freedom of choice as key to development Rutgers 2015

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Reproductive freedom of choice as key to development Rutgers 2015

Introduction Reproductive freedom of choice as key to development Reproductive freedom of choice is the freedom to decide on when to have children, how many, and with whom. In the Netherlands, we have this freedom but in many developing countries people do not. This is largely due to a lack of knowledge regarding birth control and access to safe contraceptives such as condoms. This means that people often have little influence on the number and planning of children which often leads to high rates of fertility 1, large families and population growth.

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This not only affects the opportunities of parents and children, it also influences the economic development of the countries concerned. Large population growth leads to greater demand for education, healthcare and employment, provisions that are often lacking in developing countries 2.

These are, however, important conditions for sustainable economic development, especially in countries with a young and therefore fertile population. Freedom of choice is thus key to development.

Reproductive freedom of choice as key to development Rutgers 2015

1 Number of children per woman.

2 Integrating population issues into sustainable development, including in the post-205 development agenda (February 2015) UN Economic and Social Council.

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Reproductive freedom of choice as key to development Rutgers 2015

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Lack of freedom of choice

Freedom of choice in developing countries is generally limited due to the lack of knowledge in relation to birth control and access to safe contraception which enables people to practice family planning. This knowledge allows people to choose the conditions in which they want to have children. Due to an absence of education and contraception, having children is mostly determined by external influences of an economic, cultural/religious nature.

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Children as old age support People in developing countries often have limited financial resources and an uncertain future.

Children are therefore often seen as old age support for when the parents are no longer able to generate their own income. This is especially the case in rural areas where families are involved in agriculture. Having many children is therefore important is this context. This idea is further strengthened by the fear of child mortality which leads to people wanting more children in order to provide enough children for old age support 3. The importance of children as elder caregivers however declines as fertility decreases. People invest more in their own old-age care, especially if their health improves 4.

Religion About 84% of the world population belong to a particular religion 7; in Sub-Sahara Africa this percentage is around 97% of the population 8. Many religions are against birth control because it is seen as unnatural. This means that having large families is a given for many people and they don’t have the opportunity to choose.

Consequences of lack of freedom of choice High fertility rates Because of the lack of freedom of choice, people in developing countries cannot practice family planning and women have many children (and in quick succession) 9. While on average every woman should have 2.33 children in order to maintain the replacement rate of the population, African women have on average 4.7 children per woman. In comparison, in the Netherlands women have on average 1.7 children. The ten highest fertility rates in the world are to be found in Africa. Niger is at the top of the list with an average of 7.6 children per woman with Zambia following at six children 10. Despite an expected decrease to 2.2 between 2095-2100 11, over the next 35 years, 2 billion African births are expected.

3 Determinants and Consequences of High Fertility; A synopsis of the Evidence (June 2010) World Bank.

4 By choice, not by chance, UNFPA State of the World Population report 2012.

5 Demographic and Health Surveys data - Determinants and Consequences of High Fertility; A synopsis of the Evidence (June 2010) World Bank.

6 Interview with Akinyinka Akinyoade, Senior researcher at the Africa Study Centre in Leiden.

7 The Global Religious Landscape, Pew Research Center (2012).

8 Pew Research Center, http://www.globalreligiousfutures.org/regions/sub-saharan-africa .

9 By choice, not by chance, UNFPA State of the World Population report 2012.

10 2014 World Population Data Sheet, Population Reference Bureau.

11 UNDESA World Population Prospects: 2015 revision.

Reproductive freedom of choice as key to development Rutgers 2015

Culture Culture also has an important influence on family forming. People in countries with high rates of fertility often marry at a young age leading to the birth of many children during their fertile life. In countries with the highest fertility rates (five or more children per woman) people get married on average when they are 17.7 years of age 5. Moreover, a large family adds status, especially in African countries because it is seen as an expression of masculinity. Many cultures have a preference for sons 6, and families sometimes continue to grow until the desired son or the desired number of sons has been born.

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While population growth is seen in all regions of the world, with the exception of Europe, Africa shows the largest growth because of the high fertility rate 12. This growth will continue for some time because of the large young population who are at or near a fertile age. From 2050, Africa will be the only region in the world with a growing population 13. From now until 2050, the UN expects the African population to double from 1.2 to 2.4 billion. One billion of these people will be under 18 years 14. At the moment 1.8 billion young people, of the worldwide total of 4.2 billion, live in Africa. At the end of this century this will be half of all young people.

Consequences large population growth for development High fertility rates not only lead to problems at micro (household) level (less opportunity for people’s development) but also at macro level (economic development). Population growth leads to a greater demand for investment in public services, such as healthcare and education. Governments in developing countries are very often unable to satisfy this need. Because of this, the governments concerned, being mindful of an average population growth of 2.3%, will spend approximately 40% more on education in 2030 15. The services are not only necessary for people’s development but also for sustainable economic development in a country 16. People can contribute most to the economic development of a country when they are healthy, educated and employed. This is particularly of importance for countries characterised by high fertility rates because of a young, fast growing population.

Health A high fertility rate greatly influences the health of women 17. Lack of family planning not only leads to an increase in the number of children born in close succession 18, but also the number of unwanted and high-risk pregnancies. This leads in turn to a greater risk of maternal mortality 19. In fact child mortality decreases by 10% when girls fail to become pregnant at a young age 20.

Reproductive freedom of choice as key to development Rutgers 2015

Education It is expected that the number of five year olds in Africa will increase by 34% between 2015 en 2030 21. This entails a growing demand for education. However, children have less opportunity to be educated if they are from large families in which the children are born in close succession and the mother is pregnant 22. Parents have to divide their limited resources, with many mouths to feed 23 and less time and money per child available for education 24. High fertility also greatly influences the education of women 25 and moreover pregnancies interfere with the education of girls 26. In fact, girls who do not marry at a young age and become pregnant, on average stay longer at school 27.

Consequently, not only does high fertility limit the general development of children, it also constrains their access to the labour market. Every year spent at school improves their job prospects and increases their future earnings by about 10% 28.

12 Integrating population issues into sustainable development, including the post-2015 development agenda (February 2015) UN Economic and Social Council.

13 UNDESA World Population Prospects: 2015 revision.

14 UNICEF Generation 2030 Africa, August 2014.

15 Integrating population issues into sustainable development, including the post-2015 development agenda (February 2015) UN Economic and Social Council.

16 Addressing population dynamics in the Post-2015 Development Framework (March 2013) EuroNGO. 17 By choice, not by chance, UNFPA State of the World Population report 2012.

18 Determinants and Consequences of High Fertility; A synopsis of the Evidence June 2010) World Bank.

19 By choice, not by chance, UNFPA State of the World Population report 2012.

20 UNICEF. (1996). Girls’ education: A lifeline to development: www.unicef.org/sowc96/ngirls.htm.

21 Integrating population issues into sustainable development, including the post-2015 development agenda, (February 2015) UN Economic and Social Council.

22 Family Planning, Fertility Reduction and Economic Development in Africa, Abiba Longwe-Ngwira (2013) Radboud University Nijmegen.

23 Impacts of population dynamics, reproductive health and gender on poverty (June 2012) UNFPA. 24 Determinants and Consequences of High Fertility; A synopsis of the Evidence (June 2010) World Bank.

25 By choice, not by chance, UNFPA State of the World Population report 2012.

26 By choice, not by chance, UNFPA State of the World Population report 2012.

27 UNICEF. (1996). Girls’ education: A lifeline to development: www.unicef.org/sowc96/ngirls.htm.

28 Women Deliver. Girls Education. http://www.womendeliver.org/knowledge-center/factsfigures/girls-education/.

Labour High fertility limits women’s participation in the work place 29. Through lack of education and motherhood, women generally work in the less well regulated informal sector; a woman’s chance of paid work in fact decreases with every child she gives birth to 30. For women between 25 and 39 years old, this decreases by 10 to 15% for every extra kind 31 and further decreases as the spacing between each child becomes smaller.

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Young people in developing countries, as newcomers in the labour market, see themselves particularly confronted by low employment which is exacerbated by population growth 32. Due to population growth the number of young people in developing countries has in fact grown while their future prospects have further decreased. According to the International Labour Organisation, two thirds of young people in developing countries are unemployed or working in low paid jobs as a result of this 33. The IMF estimates that, up to 2035, 18 million jobs will have to be created in order to meet the demand of the growing labour force 34.

Social unrest Youth participation in the labour force stimulates the economy and furthers investment and savings 35. However, if young people do not get the opportunity to participate, this can lead to social unrest. Young people often feel strongly about their social economic situation and problems such as inequality, low pay and unemployment 36. Moreover, unemployed youth are more vulnerable to armed conflict and illegal activities, and many of them become victims of armed organisations 37. Examples of this are the often young male victims and participants of armed struggles in West-Africa and the Middle East. Youth unemployment is also an important cause of migration from Africa 38 as many young people, given the opportunity, will try to make a living elsewhere 39.

In phase 1, fertility is high and the population is relatively young. In phase 2 the fertility rates decrease and a relatively large young working population exists because of the earlier high population figures. If the people concerned have access to education and jobs, this gives the economy a boost, the so-called demographic dividend. This was the basis of the economic growth of the emerging economies in South East Asia (Asian Tigers) in the 90s. To achieve this, a decrease in fertility rate and sufficient employment are essential. Lastly, in phase 3, the fertility rate is low and the population relatively old. Many parts of the western world have arrived at this third phase and

29 By choice, not by chance, UNFPA State of the World Population Report 2012.

30 Number and spacing of children and women's employment in Africa, Abiba Longwe, Jeroen Smits, Eelke de Jong.

31 United Nations Population Fund (2012). Marrying Too Young: End Child Marriage.

32 Perspectives on Labour Economics for Development, ILO (2012).

33 Global employment trends for youth, 2013, ILO. 34 IMF Economic Regional Outlook Sub-Sahara Africa 2015.

35 Demografische veranderingen en ontwikkelingssamenwerking, Advisory Council on International Affairs (AIV) advice No. 66, July 2009.

36 IMF World Employment and Social Outlook – Trends 2015.

37 Population Reference Bureau, Youth Unemployment and Underemployment in Africa Brings Uncertainty and Opportunity (2009).

38 African migration: from tensions to solutions (January 2006) Africa Renewal online. http://www.un.org/africarenewal/magazine/january-2006/african-migration-tensions-solutions.

39 Demografische veranderingen en ontwikkelingssamenwerking, Advisory Council on International Affairs (AIV) advice No. 66, July 2009.

40 Determinants and Consequences of High Fertility; A synopsis of the Evidence (June 2010) World Bank.

41 Demografische veranderingen en ontwikkelingssamenwerking, Advisory Council on International Affairs (AIV) advice No. 66, July 2009.

42 Demografische veranderingen en ontwikkelingssamenwerking, advice No. 66, July 2009.

Reproductive freedom of choice as key to development Rutgers 2015

Consequences for the economy When looking at the relationship between fertility and economic development, it is important to consider the three stages of demographic transition 40. Demographic transition occurs when a population changes from a situation of high mortality and birth rate to low mortality and birth rate.

The relationship between the proportion of youths (under 15 years), the working population (15 to 65 years) and the aging population (above 65 years) has important implications for government policy and development perspectives 41. Youth participation in the working population stimulates the economy and furthers investments and savings 42.

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have an aging population. Asia and South America are, however, still in the second phase and generally experience strong economic growth because they can deploy their workforce. Large parts of Africa, on the other hand, are still in the first phase and countries with high fertility rates in particular are limited in their economic development.

Despite the worldwide economic crisis, economic growth (Gross National Product) is expected to continue in Sub-Sahara Africa, 4.5% in 2015 and 5.1% in 2016 43. In many sub-Sahara countries this growth is however vulnerable and extreme poverty still exists, especially in countries with high fertility rates. For example, Niger, the poorest country according to the UNDP Multidimensional Poverty Index, has the highest fertility in the world.

Reproductive freedom of choice as key to development Rutgers 2015 43 IMF Economic Regional Outlook Sub-Sahara Africa 2015

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Importance of free choice

In order to counteract the above-mentioned problems, it is important to invest in population, healthcare and education by focussing on the essence of the problem: population growth. By decreasing this, a great deal more can be done for people’s development. Increasing freedom of choice can contribute greatly to respect for human rights in this context.

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Increasing freedom of choice is not about imposing choices, but about making choices possible on the basis of knowledge and access to contraceptives. If people with freedom of choice still choose large families then that is their right. Practice shows however that fertility rates decrease as people’s income increases. The need to have children for elder care decreases and people will sooner choose the number of children they can provide for. By allowing them to be able to choose themselves whether to have children, when and how many, they will in practice only choose to have children if they can offer them a good future. This will ensure a better balance between population growth and the provisions needed to achieve optimum population size.

This will not only be advantageous for women, it will also create opportunity for economic development. Freedom of choice is thus one of the keys to social economic growth.

44 Adding it up; The Costs and Benefits of Investing in Sexual and Reproductive Health 2014, Guttmacher Institute.

45 United Nations Population Fund (2013). Empowering People to Ensure a Sustainable Future for All. http://www.unfpa.org/webdav/site/global/shared/documents/news/2013/Post%202015%20Position%20Paper.pdf.

Reproductive freedom of choice as key to development Rutgers 2015

Income and expenditure The importance of freedom of choice can also be substantiated by looking at income and expenditure. For instance, investing $1 in the provision of contraceptives results in a saving of $1.47 on the costs of pregnancy-related care, including care for women with HIV 44. Moreover, investments in contraception and family planning services have led to a saving in costs in other sectors, including education, food provision, healthcare, housing and sanitary facilities. In Zambia an investment of $1 led to a saving of $4, while in Egypt it was even $31 45.

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Reproductive freedom of choice as key to development Rutgers 2015

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Efforts made to achieve freedom of choice

In order to achieve freedom of choice, education on family planning and access to contraception are essential. Without this knowledge and the necessary services, people cannot make a choice.

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Comprehensive Sexual Education (CSE) In order to have a good understanding of sexuality and reproduction, Comprehensive Sexual Education (CSE) is important. People are informed about the possibilities of choosing for themselves when to have children and how many. CSE not only focuses on sex and sexuality but also emphasises the importance of healthy relationships. This increases people’s confidence and they are better informed on how to protect their sexual and emotional wellbeing. Not only does one better understand the consequences of sex, but also how important safe sex is 46. UN research into CSE programmes demonstrated that these programmes lead to the postponement of first sexual experiences, less intercourse and partners 47.

In this regard, it is important to take account of cultural/religious factors that influence the degree of choice that people have. This can be done by making people aware through CSE of their right to selfdetermination, a universal human right which people in developing countries are very often unaware of. If people are aware that they are in control of their own body, they are all the stronger when faced with influences that violate their self-determination and they have more reproductive choice. It is also important in this regard to focus on the social context in which people live. This can be done by giving CSE in groups so that the importance of freedom of choice is widely accepted in communities.

However, in many countries, CSE programmes are not available and freedom of choice often remains limited.

46 http://www.rutgers.international/node/624.

47 UNESCO, 2009. International Technical Guidance on Sexuality Education: An evidence-Informed approach for schools, teachers and educators.

48 PRB World Population Data Sheet 2015.

49 Adding it up 2014, Guttmacher Institute.

50 UNDESA World Population Prospects: The 2012 Revision.

Reproductive freedom of choice as key to development Rutgers 2015

Availability of services Knowledge of course has to be combined with access to services in order to make use of the knowledge in practice. Approximately 34% of women in the least developed countries use contraceptives; in Africa this percentage is a little lower: 30%. In comparison, in the Netherlands the percentage is twice as high: 69% 48. As estimated 225 million women in developing countries would like to use contraceptives but don’t have access49. In 2010, this was 23% of African women while the percentage was considerably lower in Asia and Latin America, 10% and 9% respectively50. The services required should satisfy a number of conditions: available (available in different places), accessible (affordable and nearby), acceptable (respect for medical standards and clients’ cultural values) and accountable (with the possibility of addressing discrimination). Only then can the needs of people be satisfied.

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Reproductive freedom of choice as key to development Rutgers 2015

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Discussion on influencing population growth

During the 60s of the last century, huge famines occurred in poor countries and at the same time it became clear how quickly the world population was growing. This put the relation between population growth and economic development on the international agenda and led to special government programmes aimed at population and birth control. This largely concerned a statistical approach, where little account was taken of people’s freedom of choice. In India in the 70s, for example, women were sterilized against their will and China started in 1979 with its one-child policy which has just recently been abolished.

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However, in Cairo in 1994, the International Conference on Population and Development (ICPD) brought about a big change in the way of thinking on influencing population growth. While before the focus was mainly on statistics, in Cairo the emphasis was for the first time on people’s sexual and reproductive rights, in particular for women 51. This was largely the result of the strong views aired by civil society which won power in the progressive 90s. This resulted in a 20-year Programme of Action that was signed by 179 countries and which formed the newest basis for international development policy in relation to population questions. In September 2014, the programme was officially reconfirmed and the signatories recommitted themselves to this objective 52. However, practical enforcement has proved to be difficult. Twenty years after signing the agreements, not all signatories have complied with the objectives due to the sensitivity of the subject. This is also apparent from the international development goals, Sustainable Development Goals (SDG’s) , recently presented by the United Nations.

Goal 3, ‘Ensure healthy lives and promote well-being for all at all ages’ has as sub-goal 3.7 ‘By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes’. Despite the fact that this goal aims at reproductive health and not reproductive rights, it attaches importance to access to education, or knowledge. This is an important part to achieving freedom of choice.

Goal 5, ‘Achieve gender equality and empower all women and girls’ goes further and aims to promote reproductive health as well as reproductive rights. Sub-goal 5.6 calls to: ‘Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences’. Despite the fact that freedom of choice is not explicitly mentioned, in theory it does fall under this. Because of this, the working out of this sub-goal forms an important starting point for emphasising the importance of freedom of choice. Moreover, goal 5 also focuses on equal opportunities for women, for example through subgoal 5.5 ‘Ensure women’s full and effective participation and equal opportunities for leadership at all levels of decision-making in political, economic and public life’. Opportunities that are lacking due to the absence of freedom of choice but can contribute importantly to the development of a country.

The same applies to equal opportunity for education by which men and women can make a contribution. Goal 4 aims to: ‘Ensure inclusive and equitable quality education and promote lifelong

51 Programme of Action adopted at the International Conference on Population and Development Cairo, 5–13 September 1994 (20th Anniversary Edition).

52 Programme of Action adopted at the International Conference on Population and Development Cairo, 5–13 September 1994 (20th Anniversary Edition).

Reproductive freedom of choice as key to development Rutgers 2015

Despite compliance to almost 170 goals, including sub-goals, there is no direct focus on the impact of population growth on development. Two goals do, however, focus on related themes, goal 3.7 (universal access to sexual and reproductive health (SRH) services) and goal 5.6 (universal access to SRH and reproductive rights). Because the Sustainable Development Goals still have to be worked out, there is an opportunity, based on these two goals, to incorporate freedom of choice and population growth into development policy. Not only to strengthen these two goals, but also to further other goals. As indicated, freedom of choice forms the key to development and it can also contribute to poverty prevention (goal 1) in this way.

learning opportunities for all’. This goal, however, does not focus on the influence of population growth and the importance of freedom of choice in influencing population growth. Therefore the influence of this Sustainable Development Goal is less relevant.

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Efforts on the part of the Dutch government Despite sexual rights being a sensitive issue, the Netherlands plays a leading role by focussing on the subject in Dutch policy. The Ministry of Foreign Affairs explicitly emphasises the importance of freedom of choice. It even states it as a reason why the Netherlands focusses on SRHR 53 as one of the four spearheads of Dutch development policy. These efforts are shown by the appointment of a special ambassador for SRHR and HIV/AIDS and the financing of organisations that focus on SRHR, such as Rutgers.

The Ministry seems receptive to focussing on freedom of choice in the working out of the Sustainable Development Goals, especially since Minister Ploumen has also spoken out about the lack reproductive rights in the SDG’s. She would “gladly like to have clearer statements regarding subjects such as sexual rights, for example, the right to sexual education, contraception and safe abortion. We, in the Netherlands, will continue to work hard on this subject 54.”

The Netherlands, through its leading role, has built a strong international reputation regarding SRHR and the number of supporters continues to grow. Despite the fact that most African governments give little priority to the right to family planning 55, there are important exceptions. For instance, the UN Ambassador for South Africa presented a statement in July 2014 outlining the importance of sexual and reproductive rights in which he declared these rights as an essential prerequisite for poverty prevention and economic growth 56.

Reproductive freedom of choice as key to development Rutgers 2015

There is thus support internationally for focus on SRHR in development policy, although it still remains a sensitive subject. The statement was signed by 58 countries, including the Netherlands, but only two of the signatories were African. This is worrying, as SRHR in Africa is precisely what influences socio-economic development. Remarkably though, president Musevani of Uganda spoke out in favour of birth control at the end of last year after having announced for years that he would welcome 100 million new Ugandans. 57

53 https://www.rijksoverheid.nl/onderwerpen/ontwikkelingssamenwerking/inhoud/nederlands-beleidontwikkelingssamenwerking/seksuele-en-reproductieve-gezondheid-en-rechten.

54 Duurzame Ontwikkelingsdoelen 2030 luiden nieuwe fase in, https://www.rijksoverheid.nl/onderwerpen/ontwikkelingssamenwerking/nieuws/2015/09/28/duurzame-ontwikkelingsdoelen-2030luiden-nieuwe-fase-in.

55 Family Planning, Fertility Reduction and Economic Development in Africa, Abiba Longwe-Ngwira (2013) Radboud Universiteit Nijmegen.

56 Joint Statement to the Open Working Group on the Sustainable Development Goals (SDGs), 13th Session, July 14-18, 2014 – United Nations, New York.

57 http://www.ippf.org/news/Family-Planning-Good-Country-President-Yoweri-Museveni.

Conclusion Many developing countries would benefit from a decrease in population growth, and to achieve this the high fertility rate has to decrease. It is important, in this regard, to take into account human rights. This can be achieved through policy efforts aimed at freedom of choice based on sexual education (CSE) and access to safe and well located contraception services. People will then be more able to choose for themselves if they want to have children, how many and when, and will more often choose smaller families. This will not only be for the benefit of people, especially women, but also for the benefit of the economic development of countries.

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Despite the fact that population growth is expected to decrease, the issue these days leads to problems that deserve attention on political agendas. As indicated, no explicit attention has been given to this subject in the recently presented Sustainable Development Goals (SDG’s). There is however probably a possibility to address this in the working out of the two SDG’s that aim at education (SDG 3) and reproductive rights (SDG 5). It is of great importance that the Ministry of Foreign Affairs has explicitly underlined the importance of freedom of choice as a reason for its efforts in promoting SRHR.

Reproductive freedom of choice as key to development Rutgers 2015