Birth rates can be lowered by any one of a variety of practices: by late marriage and not marrying, as in Ireland; by induced abortion, as in Japan and the eastern European countries; or by contraception, as in all the western countries. An increase of five years in age of marriage in India would result in a decline of about 20 per cent in the birth rate; a decrease of 15 per cent in the proportion of people married would result in a corresponding decrease in the birth rate. But the marriage practices of a society are closely bound up with its social and cultural institutions and hence are not easily or quickly changed. Such shifts probably have to come as part of those long-term and basic changes in the very fabric of a society that accompany the transition from traditional to modern status.
Induced abortion is widely and legally practiced in some countries, and it is quite widely but illegally, and badly, practiced in many others. It is, however, unacceptable to most societies on religious or moral grounds. Indeed, the very fact of widespread abortion is itself an important argument for voluntary fertility regulation. (It is estimated that there are over six million induced abortions a year in the world, and quite possibly double that number.)
The most accessible means of fertility regulation, then, appears to be contraception. Currently available methods of contraception and their bio-medical characteristics are discussed in the next section of this report. Here we are concerned only with the social aspects of their acceptance and use—with attitudes about family size and family limitation and the bases thereof, spread of information about repro-
duction and contraceptive methods, and the practice of family planning.
Against the background of the demographic argument, presented in the preceding section, we must inquire into the social factors, broadly defined, that are involved in population growth and its control. Here we deal with many of the basic elements affecting human behavior: cultural institutions, religious beliefs, economic arrangements, family organization, sexual practices. All these and more are involved in the determination of attitudes and practices related to human fertility and in any effort to change such attitudes and practices.
It is encouraging to note that the norm of the small family and the practice of family limitation have been established across a wide range of societies: across religious affiliations (Catholic Southern Europe and Protestant Northern Europe); political ideologies (the United States and the Soviet bloc); industrial and agricultural economies, rich and poor nations, better-educated and poorer-educated societies (all European); the West and the East (as in Japan); and, just beginning, the tropical countries as well as the temperate ones.
Almost every survey on attitudes toward family planning, from urban areas in the United States to villages in India, shows that a large proportion of people say they are favorable to the idea of limiting family size, and especially after the third or fourth child—roughly 60 to 80 per cent over all, both men and women. The figures vary somewhat from one locality to another and, of course, the interview questions are varied, but there is an impressive body of favorable interview responses from Mysore and Singur in India; from low-income women in Pakistan; from Mexican factory workers; from Ceylon and Japan; from Jamaica and Puerto Rico; from the United States and Great Britain. Many persons of the world are now persuaded, at least in principle, of the desirability of limiting family size—limiting the birth of children to the number wanted, when they are wanted. The major single reason for this attitude toward family planning, in all areas where it exists, is concern for the economic welfare of the family—a better standard of living and a better chance in life for all children.
Information about family planning is unevenly disseminated in all countries, especially in the less-developed areas; it is usually sparse
and rudimentary among the large, poorer, rural masses. Studies in certain districts of India have shown, for example, that even elementary knowledge about contraceptive methods is limited to approximately 20 to 25 per cent of the married population, and is even more limited among the illiterate in rural areas. Among such populations, most people do not know of the possibility of birth control except by abstinence; such knowledge of contraceptive methods as there is is poor; folk superstitions are abundant.
The use of contraception is also uneven throughout the world. In the United States, 70 to 80 per cent of all married couples have used contraceptive devices. In Puerto Rico, the figure is approximately 40 per cent; in the Far East, except for Japan, perhaps not over 10 per cent. Given the prevailing conditions of life in the less-developed areas, only the simplest methods can be employed.
In every population, the urban, the better-educated, and the more modernized groups accept and use contraception earliest, most often, and most effectively. Such people are a small minority among the populations in less-developed areas, of course; even a large decrease in their birth rates would have little effect upon the total national figures.
This quick review begins to suggest some of the social factors that in different areas stand in the way of family limitation in emerging nations.
High marriage rates: Almost all mature women are married.
Early marriage: Virtually the whole range of reproductive years is available for childbearing.
Status of women: Few alternatives to the domestic role are available; the customary male dominance confines women to care of home and children.
Desire for children, especially sons: This may be for familial reasons (care of parents in their old age), economic reasons (workers in an agricultural economy), or status reasons (many sons implying a manly father). A wide range of social values has traditionally supported the appropriateness of the large family, especially when coupled with traditionally high mortality rates.
Little differential fertility: The model of the small family is not apparent within the society.
Housing facilities: There is little or no privacy for parents, and there are few facilities for sanitation, storage of contraceptive supplies, and other personal requirements.
Social support: In some societies there may be little conversation about the subject because of its personal nature, and hence little opportunity for the development of necessary social rapport and support; the occasional practitioner of family planning may therefore feel that he is an alien in his own community.
Absence of social rewards: As a consequence of the above, the innovator in family planning does not receive the social rewards needed to encourage his innovating behavior (as he might, for example, in connection with innovation directed toward improving agricultural practices), and the reward of not having unwanted children is both remote and, with many traditional methods of contraception, problematic.
Religious, moral, political, or ideological objections to fertility control: These often apply to particular contraceptive methods, and sometimes to any method whatever.
Peasant inertia, apathy, resistance to change: These tend to color the whole of life in many societies, and thus to make innovation of any kind difficult.
Strength of motivation: The highest motivation for fertility control may be felt when nothing needs to be done, i.e., during pregnancy or soon after delivery. With some contraceptive methods, it may even be that motivation declines with successful practice, through carelessness and false confidence.
Ignorance of purposes, means, and consequences of family planning: The concept of voluntary fertility control is often accepted when presented, but communication is sometimes difficult.
Low literacy: Especially when women are illiterate, informational programs are handicapped from the outset.
Perception of lowered mortality: Decline in the death rate is not always quickly apparent, so considerable time is required to establish the recognition that it is no longer necessary to bear several children in order for some to survive; in some cases, a decline in infant mortality within the community is viewed as an increase in births, with no appreciation of the fact that the death rate has been reduced.
Lack of communication between husband and wife: The necessary joint decision may be difficult when sex and reproduction are not considered appropriate topics of conversation between husband and wife.
Dispersal: Populations are typically divided into many small villages, complicating the problems of communication and supply.
Lack of trained personnel: The necessary administrative leadership and technical competence to support a mass program are often lacking.
Lack of distribution facilities: Economic arrangements are typically inadequate to cope with problems of distribution, partly because of the dispersal of populations noted above and partly because of the rudimentary character of economic systems.
Costs: These may be too high for the individual or the society.
In short, a program for voluntary fertility control often faces an apparently insurmountable barrier of traditional behavior in traditional societies, reinforced by social customs and cultural arrangements of long standing. These are formidable obstacles to the success of any effort to promote voluntary fertility control in the type of society that needs it most. The difficulties are altogether real and discouragingly numerous. Only the importance of the task would appear to justify the necessary effort.
But there are also some favorable factors in the situation that should not be overlooked or underestimated. The first is the growing recognition of the problem by major social institutions, including governments, and their consequent support of study and action programs on population control. Among the governments most involved,
India, Pakistan, and Korea have taken steps toward a solution. During the long decline of the birth rate in the West, there was active resistance by major legal, governmental, medical, and religious institutions, but family planning was nevertheless undertaken by individual couples without institutional support. In many of the less-developed areas, there is now active institutional support, and governments are in the forefront of the movement rather than lagging behind.
Another favorable factor is large-scale social change. The pace of the modern world is being felt even in the most backward areas, and there are accelerating trends toward industrialization, rationalization of agriculture, better health and sanitation, greater literacy and education, the freeing of women—in short, toward modernization of societies in general. Fertility regulation is part of this movement and hence benefits from whatever advances are made. Unfortunately, such progress is slow.
In the past decade or so, there have been several systematic attempts to study the impact of efforts to spread the practice of family planning. (By “systematic” we mean more or less controlled experiments in natural settings with reasonably careful measurement of the consequences beyond clinical activity.) Eight to ten such efforts are now going on, some of them continuations of earlier efforts. Such studies have been or are being made in India, Pakistan, Ceylon, Taiwan, Japan, Puerto Rico, Jamaica, and the United States. In spite of the critical importance of the problem, however, only about fifteen of these limited efforts have been made to find out whether and how voluntary regulation of fertility can—with presently available techniques—be implemented among populations that need it most.
We can draw some tentative conclusions from these studies:
There is a wide range of motivation for family planning in all societies investigated. Substantial numbers of people at the lower end of the economic and literacy range perhaps cannot be interested, at least within a period of five years or so, but a significant number at the other end (especially those with large families), representing at least a fourth to a third of the community, appears to be ready now. Voluntary fertility regulation in such countries, at least with traditional methods, is thus much more a matter of stopping childbearing than of spacing it. In all probability, the best way to motivate new users is to satisfy those that are already motivated.
Clinical programs alone do not appear to be sufficient for the task.
Continued promotion in the field is necessary for continued effect; the point of self-maintaining activity is hard to reach. At the same time, it seems clear that it is not necessary to reach an entire population in order to achieve substantial effect. In some areas the people themselves help to spread information through informal and often highly effective channels.
Personal communication between field workers or local leaders and the people is apparently the best single influence for the adoption of voluntary fertility control in many areas, though mass communication may become increasingly important.
Experimental efforts to promote family planning with traditional contraceptives that require sustained motivation and preparatory action often fail. The number of people willing to accept the idea is not large and the number of continuing users is even smaller.
Results of the few successful efforts so far suggest that the use of traditional contraceptives can be expected to produce an average reduction of five to seven points in the birth rate in less-developed areas in a period of five years (for example, from 42 births per thousand population to 35–37 per thousand). Because of the backlog of interest among large families, the reduction is often greater in the first year than in subsequent years.
Despite all the difficulties, successful results can be obtained. In a set of Indian villages, continuous personal contact by field workers providing information, support, and supplies led to a five-point reduction in the birth rate in a period of four years. In some villages in Ceylon a similar program has apparently produced a seven-point decrease within three years. In a county of Taiwan, personal contact through a health service resulted in a birth rate for the users of contraception ten points below that of a matched group. In some Japanese villages a similar program was successful in turning a substantial proportion of couples from abortion to contraception. In Puerto Rico, an informational program increased the use of contraceptive methods by 10 to 20 per cent, and the distribution of free supplies through volunteer leaders attracted new users among those with many children. A similar informational program in Jamaica doubled the proportion
of users in urban but not in rural areas. As a result of a current effort in the United States among deprived groups with birth rates as high as India’s about 20 per cent of the subjects with two or more children have so far undertaken family planning.
But there have been failures as well as successes. As yet, we have an extremely small and tentative body of knowledge on social factors with which to attack an extremely large and complex problem. In contrast to hundreds of demographic and bio-medical studies, there are only a few social studies.
The above listing indicates a great disparity between what we know and what we need to know in order to deal effectively with the problem. Further study is certainly needed. More specifically, experimental efforts in natural settings, conducted with resources available locally on a mass basis, must be multiplied many times in order to learn how family planning can be implemented in all societies that recognize the need for it. Such efforts, across a range of countries and with a range of methods, should produce knowledge and techniques on which general programs can be based.
Such efforts must be closely tied to the local administrative machinery by which such programs must ultimately be managed in particular countries and districts. That machinery is typically based on or in the health services. A new type of professional practitioner, the family-planning administrator, is needed to develop programs; training institutions and programs for such administrators in both health and the social sciences should be high on the list of priorities.
Effective programs also require the services of specialists in information and education from such fields as agricultural extension, audiovisual methods, marketing, and advertising, to disseminate information effectively and provide motivation for broader use.
In no other social problem is the interconnection between human and technical factors so critically important as in fertility regulation. The better the contraceptive—better in ease of use and in effectiveness—the less the social resistance to the acceptance of family planning and the greater the efficiency of implementing voluntary fertility regulation where it is needed. Thus the two sets of factors, the social and the bio-medical, are closely interwoven, and the social acceptability of family planning depends heavily on the development of applied knowledge in the bio-medical field, to which we now turn.