Celebrity philanthropists such as Bono, Angelina Jolie, and George Clooney have shined their star power on global issues like AIDS, genocide, and refugees. In last month’s Vogue, supermodel Christy Turlington turned the light on one of the most overlooked problems: maternal mortality.

“The world is awakening to a powerful truth: Women and girls aren’t the problem; they’re the solution,” write Nicholas Kristof and Sheryl WuDunn in the lead article of this Sunday’s The New York Times Magazine.

In this special issue devoted to “Saving the World’s Women,” five articles document global failures and personal horrors, but also offer forward-looking solutions from the individual to the institutional. As the subtitle says—“changing the lives of women and girls in the developing world can change everything”— this vital effort can help us not only improve the lives of women, but meet larger goals including international security, global health, and economic development.

“Knowing is not enough; you must act and let your government know that family planning is a right and saves lives,” said Maurice Middleberg of the Global Health Council at a recent event in Chapel Hill.

The other panelists at “How Can Family Planning Efforts Help Us Achieve the Millennium Development Goals?” (Dr. Martha Carlough of UNC, Dr. Ward Cates of Family Health International, and Pape Gaye of IntraHealth International) all provided compelling statistics demonstrating the effectiveness of family planning as an intervention that addresses the Millennium Development Goals (MDGs).

MDGs 4, 5, and 6 – reducing child mortality; improving maternal health; and combating HIV/AIDS, malaria, and other diseases, respectively – all have obvious connections to health and woman’s reproductive health. An unmet need for family planning, which is measured as the percentage of women of reproductive age who desire to space or limit their births but are not using contraception, can undermine the achievement of these goals.

For example, very early motherhood not only increases the risk of dying in childbirth, it also jeopardizes the well-being of surviving mothers—and their children, too. A child born to an adolescent mother has a greater risk of dying in infancy or childhood.

“Contraception is the best-kept secret in HIV prevention,” said Dr. Cates, who cited research that found that “current contraceptive use in sub-Saharan Africa prevents an estimated 577,200 unplanned births to HIV-infected mothers” and thus prevents the birth of an estimated 173,000 HIV-infected infants each year.

Family planning can help meet the other MDGs, including ending poverty and hunger (Goal 1); providing universal primary education (Goal 2); and promoting gender equity (Goal 3). Young mothers frequently miss out on education and socio-economic opportunities. Being able to make their own decisions about family planning and reproductive health can empower women and improve gender equity. When women are given equal opportunities for education, health, and employment, they are more likely to invest in the education and care of their children. This helps them break the cycle of poverty, hunger, and disease.

Although the MDGS don’t include any formal targets for sexual and reproductive health, the UN Millennium Project has stated that the MDGs cannot be achieved in low-income countries without access to sexual and reproductive health services, including family planning. The panelists agreed that family planning is a cost-effective intervention that provides broader positive benefits for development.

But the real strength of their presentations lay in the personal stories behind the statistics. Middleberg closed the discussion with a story about a woman in Latin America who told him that she loves her husband but was afraid of him every time he touched her. Now, after having undergone sterilization, she no longer worries and can love her husband with no fear of becoming pregnant.

A mother of six interviewed in a 2009 news article about the Philippines’ new family planning bill said, “How can one keep on having children? We don’t earn enough to feed them, much less send them to school.” New York Times columnist Nicholas Kristof interviews a Haitian woman with 10 children in a dramatic video interview, “Saving Lives with Family Planning.”

Underlying all of these facts and stories is the belief that one’s health and well-being, including access to family planning, is a right. But as Middleberg said, believing is not enough.

EngenderHealth, an international reproductive health organization working to improve the quality of health care in the world’s poorest communities, is asking Americans to create a video explaining why we should care about international family planning. Contribute your thoughts on YouTube’s Video Volunteers project.

Lisa Basalla, MPH, is a research associate with the Carolina Population Center. She graduated from Case Western Reserve University with a MPH focusing on reproductive and adolescent health. She has worked with Johns Hopkins University’s Center for Communications Programs on its reproductive health knowledge management project as well as a HIV-prevention behavior change communication project in Malawi.

Photo: A billboard promoting family planning in Phnom Pehn, Cambodia. Courtesy flickr user olerousing.

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President Mahmoud Ahmadinejad might have blamed sinister “foreign powers” for fomenting post-election civil unrest in Iran, but some analysts have fingered another culprit: demography. According to Farzaneh (Nazy) Roudi, program director for the Middle East and North Africa at the Population Reference Bureau, two phenomena “provide a backdrop for understanding Iran’s current instability.” First is the country’s youthful population age structure, or “youth bulge”; over 30 percent of Iranians are between the ages of 15 and 29, and 60 percent are under the age of 30. Second is Iran’s surprisingly comprehensive family planning program, which has empowered women to make their own reproductive choices and enter higher education en masse.

Earlier this week in New Delhi, Secretary of State Hillary Clinton praised an “enlightening” roundtable discussion with India’s minister of environment for opening her eyes to climate change’s links to population and family planning.

“One of the participants pointed out that it’s rather odd to talk about climate change and what we must do to stop and prevent the ill effects without talking about population and family planning. That was an incredibly important point. And yet, we talk about these things in very separate and often unconnected ways,” said Clinton.

Congress is taking steps to tackle this issue. The version of the bill approved by the Senate Appropriations Committee last week links family planning and reproductive health to climate change.

On page 153, $628 million is alloted for “family planning/reproductive health, including in areas where population growth threatens biodiversity or endangered species or exacerbates human vulnerability to the effects of climate change.”

In addition, in the report accompanying the bill, the Senate committee “directs USAID to review the relationships between population growth and climate change to determine how experience in implementing population-environment activities applies to climate change adaptation and to efforts to increase the resilience of local communities to climate change.”

These comments certainly increase the volume on this overlooked link. Some background resources that might help those new to the discussion:

• In the latest ECSP Report, Suzanne Petroni of the Summit Foundation proposes some ethical ground rules, calling for “a thoughtful and deliberative dialogue around voluntary family planning’s contribution to mitigating climate change.”
  A recent PAI factsheet points out that “areas of high population growth and high vulnerability to climate change impacts overlap.”
• Another handy factsheet includes a brief description of how community-based programs that integrate population-environment activities can strengthen resilience and reduce vulnerability to the effects of climate change.
• PAI’s working paper “Projecting Population, Projecting Climate Change” warns that “population growth is not adequately accounted for in the emissions scenarios” used by the IPCC.
• The Center for Global Development’s David Wheeler recently argued that family planning could be a relatively inexpensive part of solving the climate crisis.
• A paper in Global Environmental Change estimates the extra emissions of fossil carbon dioxide that an average individual in the United States causes when he or she chooses to have children.

To promote the 20th World Population Day on July 11, the United Nations Population Fund (UNFPA) tied this year’s theme—“Fight Poverty: Educate Girls”—to combating the ongoing financial crisis. It’s a no-brainer that, as UNFPA points out, “women and children in developing countries will bear the brunt of the impact.”

“Statistics should be the intellectual sidewalks of a society, and people should be able to build businesses and operate on the side of them,” said Gapminder Foundation Director Hans Rosling at a discussion hosted by the Wilson Center’s Environmental Change and Security Program on May 26, 2009. In his spirited and often humorous remarks, Rosling praised the 25-year-old Demographic and Health Surveys (DHS) program, which is funded by the U.S. Agency for International Development (USAID) and implemented by Macro International, Inc., as “public-private partnership at its best.” The DHS program works with countries’ health ministries to collect data on family planning, child and maternal health, disease prevalence, and other health indicators, and makes the data freely available for public use.

The Beauty Behind the Data

Rosling uses Gapminder’s signature “moving bubble” Trendalyzer software—which Google purchased and made available as “Motion Chart”—to graphically demonstrate global health, economic, and environmental trends. Gapminder uses data from several sources, including DHS surveys, to generate its illuminating displays.

“Sweden, during the last hundred years, didn’t achieve [the] Millennium Development Goal rate” for yearly reductions in child mortality, Rosling explained. “We are putting goals for Tanzania, Bangladesh that [were] never…achieved by any country in West Europe or North America.” The remarkable thing, said Rosling, is that many low-income countries are achieving or even surpassing these demanding targets.

Free Access, Unified Formatting Are Top Priorities

Rosling stressed that access to data must be free, and admonished the World Bank, the Organisation for Economic Co-operation and Development (OECD), and others who charge for their statistics. “They say, ‘No, we can’t give the data to the people because they will make wrong comparisons, and they will make wrong conclusions,’” Rosling continued, “and I say ‘Yes, we call it freedom.’”

Rosling cautioned against “database-hugging disorder,” or statisticians’ tendency to guard their data because of concerns about budgets or misinterpretation. A better approach, he insisted, is to embrace innovations like the Creative Commons license, which encourages sharing information by offering a range of easy-to-understand legal protections and freedoms for creative works, data, and information.

In addition, “we don’t have a unified format for data,” Rosling said, and “that’s why the transaction costs are so enormously high, and that’s why those who put data together in unified format charge for it.” He cited YouTube as an excellent medium for broadening public distribution of data. To the audience’s delight, a live Google search for “sex, money, and health” returned a YouTube clip of one of his own presentations as its top hit.

Improving Lives With Data

“The worst environmental problem today is that two million children die of diarrhea [each year], and that billions of people drink their neighbors’ lukewarm feces,” said Rosling, and yet “water and sanitation data is very, very weak.” Collecting information from remote areas—often the most impoverished—is difficult. Measuring access to potable water is complicated because it requires community-based calculations, which do not fit into DHS’ household-centric methodology.

Rosling called upon young adults to work to “eradicate unnecessary disease and poverty in the world.” He also advocated improved post-graduate training in statistics, particularly in low-income countries.

Better statistical data will foment more effective solutions to development challenges—provided there are ambassadors like Rosling willing and able to unveil the beauty behind the numbers.

Photo: Hans Rosling. Courtesy of Dave Hawxhurst and the Wilson Center.

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Any veteran of the international development field will be familiar with the disclaimer that no single intervention, no matter how effective, is a “silver bullet.” But in The Means of Reproduction: Sex, Power, and the Future of the World, journalist Michelle Goldberg argues forcefully that there is one change that is key to solving environmental degradation, food insecurity, water scarcity, global health challenges, skewed gender ratios, poverty, and both under- and overpopulation: women’s empowerment.

Malthusian Anxieties

As Matthew Connelly documents in his book Fatal Misconception: The Struggle to Control World Population, the family-planning movement sometimes lapsed into questionable moral territory during its early years, when women’s rights were not among its chief motivations. Fortunately, it turns out that family planning is actually more successful when motivated by a larger desire to empower women than when spurred by fears of overpopulation (The Means of Reproduction, pp. 74-76; 84-85). Educated women are more likely to delay marriage, have fewer children, obtain good maternal care, and be less vulnerable to HIV/AIDS, write Caren Grown et al. in a literature review of gender equality and women’s health in The Lancet.

A Birth Dearth—or an Empowerment Dearth?

As Goldberg points out, empowering women is also the solution to slowing the rapid population decline being experienced in many European countries and some wealthy Asian ones. “In contemporary developed societies, birthrates are highest where support for working mothers is greatest, a fact conservatives simply ignore in their doomsday surveys of future European decrepitude,” says Goldberg (p. 204).

Thus, comparatively religious, socially conservative European countries like Italy and Poland have some of the lowest fertility rates on the continent (both 1.3 children per woman), while more secular countries like France and Sweden, with their generous paid parental leave policies, public day care, and after-school programs, have some of the highest (2.0 and 1.9, respectively).

Strong Women, Healthy Families

Women’s empowerment is key to human health. The more education a woman has, the healthier her children are likely to be, explains Goldberg (p. 75). In addition, as Grown et al. point out, “in societies such as Bangladesh, where husbands control most household resources, when women did own assets, household expenditure on children’s clothing and education was higher and the rate of illness among girls was reduced.”

But the connection between empowerment and health also works in the other direction: In sub-Saharan Africa, women constitute 57 percent of people living with HIV/AIDS—a direct result of women’s sexual, social, political, and economic subordination (pp. 224-225). Women often do not have the standing to refuse sex, or to demand that a man wear a condom. They also frequently lack the financial and educational resources needed to leave violent or unfaithful husbands (p. 225).

Bare Branches: Sex Ratios and Security

A preference for sons persists in many parts of the world—especially Asia—and the spread of ultrasound, which can detect the sex of a four-month-old fetus, has made sex-selective abortion hugely popular for couples seeking to have a son. But the growing imbalance between men and women has potentially grave security implications for countries such as China and India, warns Goldberg. As Valerie Hudson and Andrea den Boer point out, Indian states “with high sex ratios, such as Uttar Pradesh, have much higher violent crime rates than states with more normal sex ratios, such as Kerala.”

As Goldberg puts it, “as long as women lack an identity without a husband or a son, sex-selective abortion will continue to deform India’s—and Asia’s—demographics” (p.194). She isn’t hopeful about quick progress: “Like any democracy, India will probably find it easier to slouch toward disaster than to infuriate the defenders of patriarchy. Ultimately, though, unless the country finds a way to break through the encrustations of centuries of misogyny, its democracy itself could be in danger from an unmanageable excess of men” (p. 198).

Toward Nine Billion Hot, Hungry, Thirsty People

Goldberg’s take on the links among population, the environment, and security is admirably nuanced—although I would have appreciated a more extensive discussion of demographic security and population-environment links. She acknowledges that the food riots of 2008, combined with growing concern about water scarcity and climate change, may have generated more attention for family planning and reproductive health.

But she reminds us that the main population-related response to these problems—a commitment to decrease fertility in the developing world—misinterprets the causes. The food shortages were largely the result of growing consumption by middle-income people, combined with continued high consumption in the rich world. Climate change will undoubtedly become much worse if all people in the developing world start to live the high-carbon lifestyles we do in the West, but to date, climate change has been caused almost entirely by industrialized countries.

The Micro and the Macro

Goldberg’s storytelling skills are superb, making The Means of Reproduction both an exciting and enlightening read. She illustrates her broader arguments about women’s rights with compelling stories about individual women and men. She demands that we respect these people’s experiences while arguing powerfully against succumbing to the temptations of political correctness and relativism:

“In thinking about the situation of women in vastly different contexts, there are a number of dangers. One is assuming that Western ways are self-evidently superior and that all women would choose them, if only they could. But another is assuming that women in other cultures are so different from us that situations we would find intolerable—bearing child after child into grinding poverty; being utterly at the mercy of fathers, husbands, and brothers; having one’s clitoris sliced off with a razor—do not also cause them great pain” (p. 9).

Goldberg has pulled off an impressive feat: The Means of Reproduction is accessible enough to serve as an introduction to the debates around population and family planning, but complex enough to inform readers about the latest controversies and battlegrounds in the field. Goldberg does have an opinion, but it’s based on reams of research. Here’s hoping The Means of Reproduction finds a place in the canon.

Photo: Women and children at the health post at Sam Ouandja refugee camp in the Central African Republic. Courtesy of Pierre Holtz/UNICEF and Flickr user hdptcar.

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