Margaret Sanger arrived at the apartment building to find 28-year-old Sadie Sachs unconscious from complications of a self-induced abortion, with three crying, under-nourished children around her. Her husband Jake spent the last of his meager earnings to pay Sanger and a doctor, who worked together for hours to defeat the infection that had set in. After three weeks under Sanger's care, Sadie Sachs recovered.

Mrs. Sachs then begged the doctor for some way to prevent further pregnancies. "Tell Jake to sleep on the roof!" was his reply.

She then turned to Sanger for help. "Please tell me the secret. I'll never breathe it to a soul! Please!"

I did not know what to say or how to convince her of my own ignorance.... I promised to come back in a few days to talk with her [but] I was helpless to avert such monstrosities. Time rolled by and I did nothing.

The telephone rang one evening three months later. Mr. Sachs begged me to come at once. Mrs. Sachs was sick again from the same cause.... I hurried into my uniform...and started out....

I turned into the dingy doorway and climbed the familiar stairs once more... Mrs. Sachs was in a coma and died within 10 minutes. I folded her still hands across her breast, remembering how they had pleaded with me, begging so humbly for the knowledge which was her right.... Jake was sobbing.... Over and over again he wailed, "My God! My God!"

When I finally arrived home...I looked out my window upon the dimly lit city.... I could bear it no longer... I went to bed, knowing that no matter what it might cost, I was finished with palliatives and superficial cures. I was resolved...to do something to change the destiny of mothers whose miseries were vast as the sky.

Margaret Sanger, nurse,
US family planning pioneer,
founder of Planned Parenthood Federation of America (290).

	Improve health. In the nations with the best health care, the life expectancy of women is 10% longer than that of men (243, 331, 347). In developing countries, however, women's life expectancy is closer to or shorter than men's (203, 331). This occurs because women receive less than their fair share of health care and food, often beginning in childhood (57) (see side-bar, Son Preference, Daughter Neglect). As adults, many women do not get the food and health care needed for healthy childbearing (306, 371, 374, 380).
	Encourage education. Over the last 20 years more and more girls have been going to school, but boys still get more education than girls. An estimated two-thirds of the 300 million children without access to education are girls. Two-thirds of the 960 million nonliterate adults are women (329).
	Ensure job opportunities and fair pay. Most women work long and hard, and they earn less for it than men do (341). Even in developed countries, for example, women earn 75% or less of what men earn (326). Much of women's work is unpaid. Women's unpaid household labor accounts for about one-third of the world's economic production (306). When unpaid agricultural work and housework are considered along with wage labor, women work more hours than men (196, 326).
	Guarantee legal protection. Legal codes often sanction inequality between husband and wife (341). They may allow marriage of very young women, marriage without the woman's consent, unequal ownership and control over family assets including land and other property, unequal inheritance rights, and unequal access to divorce and to support after divorce (103, 105, 146, 287). In many cases the law does not recognize women as adults with the same capacities and right to make decisions as their husbands (105, 106). Laws that do protect women's rights often are not enforced (127).
	Permit access to reproductive health care. The International Planned Parenthood Federation (IPPF) has reported that 46 of 94 surveyed countries require spousal consent for contraception, abortion, or voluntary sterilization—services used primarily or exclusively by women (147). Worldwide, 54 countries require a woman to obtain her husband's approval before voluntary sterilization, but only 20 of these countries also require a man to have his wife's approval (283). Young women and unmarried women often have little or no access to reproductive health services. Yet surveys in eight sub-Saharan countries, for example, find that 20% to 47% of adolescent women become pregnant before marriage (73).
	Prevent violence against women. Many women live every day in fear of violence, often from their husbands (341). In surveys in Chile, Colombia, Kenya, India, Mexico, Pakistan, Papua New Guinea, San Salvador, South Korea, and Thailand, 40% to 99% of women reported physical abuse by their husbands (43, 133, 264). Most of these women have no choice but to live with this abuse and fear. Leaving the marriage is often not a realistic option when women, denied education, jobs, and inheritance rights, are economically dependent on their husbands (43). Unwanted sexual intercourse is a major form of violence against women (326). In a US national sample survey, 13% of women reported that they had been raped at some time in their lives, not counting marital rape (229). This amounts to one woman raped every minute (133). Half of these women were under age 18 when raped, and 75% knew the man who raped them (229). Detailed data on rape are not available from developing countries. Fear of desertion or violence prevents women from acting in their own best interests. For example, in Egypt many women do not seek care for gynecological problems such as vaginal discharge or fistula because they fear that their husbands will divorce them for spending time and money on their own health (167). Threats of violence prevent some women even from participating in development projects (43, 150).
	Increase respect for women. Since most societies value females less than males, many women grow up believing that they are inferior to males. Such perceptions are difficult to change. For example, China has promoted equal roles and rights for women for 40 years. Still, 30% of Chinese women surveyed in 1990 thought that men are born to be more important than women, and 33% agreed that women should hold back so that they are not more successful than their husbands (52).

Programs to Improve Women's Lives

Development planners have developed two broad approaches to assessing women's needs and designing programs to address them:

• The status of women approach compares the positions of women and men in a society or cross-nationally. After identifying the areas in which women are disadvantaged, planners design programs to address the problems.
• The empowerment of women approach aims to help women gain more control of their lives. This approach often begins with women identifying and prioritizing their own needs. Program organizers then help women to design programs that meet those needs.

Using both approaches could speed improvements for women, and in practice the two approaches are not always distinct. Program organizers can use the status-of-women approach to influence policy nationally and to evaluate its impact and at the same time can use community-based empowerment programs to begin change locally. Some of the most successful community programs at first address a need that women clearly recognize, such as the need for income, and then build skills that women can use in many areas of life.

Women's advocates are asking that development plans pay more attention to the effects of planned changes on women's lives. Some development plans have required, for example, male labor migration or female volunteer labor, which place additional burdens on women (26, 37, 223). "Gender planning," as the approach is called, considers the impact of a proposed program on women, men, and their relationship (198, 217, 245, 268). Its goals are to ensure that development programs do not inadvertently harm the lives of men or women and to see that women's situation is improved.

"...we were very poor when I was a child. We were six children, and my father didn't earn much. That is why I want just two or three children. I don't want my children [two daughters] to grow up like me—without an education. I feel very ashamed and bad about not having any education. I want my children to go to school and learn many, many things.... I want them to be independent and proud of themselves."

—19-year-old Mexican woman using contraception without her husband's knowledge (144).

Extent of Son Preference

Reasons for Son Preference

Economic security. In many developing countries sons are their parents' only source of security in old age. Particularly where women have little economic independence or cannot inherit property, sons are insurance for a mother against the loss of her husband's support due to death or desertion (39, 267). Where women have few opportunities to earn income, investing household resources in female children, who will marry and leave the family, is likely to have little pay-off, and so poor families tend to invest what little they have in sons (177, 193). In cultures with dowry systems, such as India's, daughters are more expensive to marry off than sons (80).

Cultural factors. In many countries kinship systems, tradition, and religion value males over females. In parts of Bangladesh, China, Egypt, India, and Tanzania, for example, traditional patrilineal kinship systems require women to marry out of their families of origin and then not to provide financial or even emotional support to their own parents (126, 177, 211). In both Hindu and Confucian traditions, practiced throughout Asia, only sons can pray for and release the souls of dead parents, and only males can perform birth, death, and marriage rituals (21, 284).

Effects of Son Preference on Female Children

Nutrition. In some places boys get more and better food than girls (44, 48, 69, 72). Breastfeeding and weaning practices also seem to favor boys in some countries (44, 330). In the Indian state of Punjab, for example, boys from both wealthy and poor households are better nourished than girls (374). An analysis of DHS data from 18 countries, however, found few significant differences in the nutritional status of boys and girls (12).

Medical care. Girls are sick as often as boys, but boys sometimes receive more treatment and more medicine. For example, boys were seen 66% more often than girls at a diarrhea treatment center in Bangladesh even though the center provided free ambulance transport and treatment (48). Parents bought drugs and sought medical care three times more often for boys than for girls (141). Girls often receive less preventive health care, as well. Studies in Latin America and India show that girls often are immunized later than boys or not at all (119, 296).

Female infanticide. Some unwanted female children are killed or abandoned soon after birth. It is not clear how common or widespread the practice is, but some demographers have long suspected its existence. They base their conclusions largely on reported sex ratios at birth (310). Others argue that underreporting explains the discrepancy. In China, where sex ratios show that 5% of all infant girls born are unaccounted for, some observers suspect that female infanticide accounts for at least some of these missing girls, although informal adoptions, sending girls to faraway relatives, or raising the girls covertly probably explain most of the cases (10, 382, 383).

Abortion of female fetuses. Selective abortion of female fetuses reportedly is widespread in such Asian countries as China, India, and South Korea (11). Increasing use of prenatal ultrasound and amniocentesis procedures, which make selective abortion possible by revealing the sex of a fetus, may be contributing to a growing gap in the number of males and females born in some countries (153, 181). Although governments in China, South Korea, and three Indian states have banned prenatal gender tests to prevent selective abortions, illegal tests are available, and females are more often aborted than males (10, 11, 21, 181, 225, 382, 383).

Son Preference, Fertility, and Contraceptive Use

A recent study in Matlab, Bangladesh, indicates that son preference can have a strong effect on contraceptive use and fertility. In Matlab, where intensive family planning services are available, contraceptive prevalence now tops 50%, and couples average four children, researchers calculated that eliminating preference for sons would increase contraceptive use by 10% and continuation rates by 15%. These increases would avert nearly one birth for every two couples (266).

What Can Be Done?

• Are older when they have their first child,
• Complete their childbearing earlier,
• Spend fewer years pregnant, and
• Spend fewer years with young children in the household.

Age at First and Last Births

Last births come sooner in countries where contraceptive use is above average levels. Where contraceptive use exceeds 40%, most women had their last births in their early thirties, while in countries with lower levels of contraceptive use, women last gave birth in their late thirties. Table 2 reports age at last birth for women ages 40 to 49 at the time of the survey, the age group most likely to have completed childbearing. This analysis may underestimate the impact of contraceptive use on average age at last birth, because women in this age group are the least likely to have been affected by recent rises in the use of contraception in many countries.

The median age at last birth ranges from 31 years in a few Caribbean countries where contraceptive use is widespread to 38 or 39 years in several African countries where there is little use of contraception. Of course, other factors besides contraceptive use help to determine the age at last birth, including age-related sterility, divorce, widowhood, and reduced coital frequency at older ages.

The number of years that women can expect to live after the birth of their last child varies tremendously (see Table 2). This difference reflects both a woman's age at the birth of her last child and her life expectancy. Life expectancy tends to be longer in the more developed countries, where also age at last birth is lower. In all surveyed countries where contraceptive prevalence is above 40% except Peru, a woman still has more than half of her life ahead of her when she last gives birth. In contrast, in most countries where contraceptive prevalence is below 40%, women average fewer years of life after their last birth than before it.

Duration of the Childbearing Years

Differences across countries. The interval between average ages at first and last births among women ages 40 to 49 ranges from just 11 years in Trinidad and Tobago and in Thailand, where contraception is widely used, to nearly twice as long in Zambia and Senegal, where contraception is little used (see Table 2). In Trinidad and Tobago women ages 40 to 49 averaged four children. The first child was born when the mother was 20 years old, and the last, when she was 31. In contrast, in Zambia women ages 40 to 49 had given birth to an average of seven children. The first was born when the mother was 18, and the last, when she was 38. Because contraceptive use is increasing in nearly every country, the childbearing years probably will be shorter for women who are now in their 20s or 30s.

By comparison, US women have fewer children over a shorter period of time. In the US, where about three-quarters of married women use contraception, those born between 1940 and 1949—and thus about the same age as women ages 40 to 49 in DHS surveys—married at a median age of 20.5 years. They first gave birth a little over a year after marriage and had their last child at age 30. They gave birth to an average of 2.8 children over the course of approximately eight years, and their life expectancy at the time of their last birth was 47.5 more years (325).

Both the number of children that women have and the spacing of their births influence the number of years that mothers spend with young children. In countries where use of contraception is widespread, women spend an average of 14 years with at least one of their children under the age of six. Where contraceptive prevalence is low, women have young children for an average of 20 years (see Table 2).

Changes over time. Women's childbearing patterns have changed as contraceptive prevalence has risen. In 16 countries at least two comparable surveys have been conducted since the 1970s (see Table 3).

Where contraceptive use has increased most, the childbearing period has decreased most. Also, in all 16 countries the time that women had a child under age six in the household decreased, but in some countries the decline was small.

The changes are most obvious in the five countries where three surveys have been taken. For example, in Morocco, where the level of contraceptive use more than doubled between 1979-80 and 1992, women's average childbearing period decreased by almost two years. The number of years spent with a child under age six fell by almost three years. In the Java-Bali region of Indonesia, contraceptive prevalence rose from 26% to 53% between 1976 and 1991. Over the same period the childbearing period decreased by 3.5 years, and the amount of time spent with at least one young child at home declined by five years. Age at last birth declined substantially in Colombia, the Dominican Republic, and Peru, and so did the length of the childbearing period.

Because the DHS are internationally comparable surveys, they offer a unique comparison of women's lives across a large number of countries with varying levels of contraceptive use. But they cannot tell the whole story. Cross-sectional surveys such as the DHS cannot explain much of how contraceptive use affects individual women. This is because surveys usually have not recorded the sequence of events such as the timing of contraceptive use, births, and employment. Also, surveys can reveal full childbearing patterns only for women whose reproductive years have ended. As noted, these women's experience is least likely to reflect recent changes in contraceptive use. To complete the picture, other, more detailed studies are needed.

The Rockefeller Foundation funded early research on the relationship between the status of women and fertility. Findings indicated that the status of women is defined differently in different cultures and that multiple factors affect both fertility and women's status (206, 207, 250). The researchers did not find any universal relationship between the status of women and fertility.

Assessing current understanding of this issue, Sawon Hong and Judith Seltzer observed, "1) good data and rigorous analysis are scarce; 2) the relationship is complex and varies by social, cultural, and economic setting; and 3) no simple conceptual model has yet been set forth" (140).

To improve understanding of how contraceptive use affects women's lives, the United States Agency for International Development has funded a 5-year, US$8.6 million research project, begun in late 1993 by Family Health International. Its purposes are (1) to support social and behavioral research on the immediate and long-term consequences for women of both family planning programs and contraceptive methods and (2) to help improve family planning and related reproductive health policies and programs through increased knowledge of the needs and perspectives of women. The project will support qualitative and quantitative research in six to eight countries. In-country advisory committees will help establish the research agenda (360). Based on its findings, the project will recommend improvements in program design and implementation from the perspective of women's interests and needs (339).

Complex Situations, Complex Decisions

As this example illustrates, the extended family or the community is often the ultimate decision-maker in matters of reproduction, even in countries as diverse as China, India, and Mexico (29, 125, 262, 282, 297). Such influence can extend even to decisions about what contraceptive method to use (222) (see Table 5).

While the web of influences on decision-making is complex, people nonetheless have perceptions of who actually makes decisions in the household or who has the most say. Here and there surveys and focus-group research have asked people who makes household decisions including decisions about reproduction.

When Men Decide

When Women Decide

Some women decide to use contraception without telling their husbands. In DHS in African countries, a small minority of women report doing so because they think that their husbands would disapprove. In rural Nigeria, as elsewhere around the world, some women secretly use contraceptives, use patent medicines as abortifacients, or make secret trips for abortions even though they risk eviction from their homes if found out (272, 273).

Many unmarried women make reproductive decisions by themselves, of course (193). These decisions add up; in many countries women spend much of their lives outside marriage. For example, in Botswana women older than age 20 spend an average of 46% of their remaining reproductive years unmarried. In Colombia women spend an average of 40% of their entire reproductive lives unmarried (193).

Discussion Between Partners and Joint Decision-Making

In many places such communication is the exception rather than the rule, however. In Kenya, for example, lack of communication between spouses proved to be a more common obstacle to contraceptive use than male opposition (237). In a study of monogamous couples in Ghana, 35% of the wives and 39% of the husbands reported discussing family planning during the previous year. Even among women who said that they had discussed family planning with their husbands, however, 39% reported their husbands' attitudes to be different from what their husbands independently told interviewers. Still, contraceptive use was higher among the couples who had discussed the subject (289).

Focus-group discussions in Tanzania found that different people had different reasons for not discussing contraception (309). Older people did not discuss using contraceptives because they believed that God determined the number of their children or because they used abstinence or herbal medicines to space pregnancies. Women did not discuss the topic because they thought that their husbands did not approve of contraception. Married men said that discussion was unnecessary because the women decided on their own the number and timing of pregnancies. Young people did not talk about contraceptives for fear of being considered promiscuous.

Program managers need to be aware of the variety of ways that individuals and couples make decisions about contraception—a variety that reflects not only the social position of women relative to men but also the different types of sexual relationships, from longterm monogamous marriages to one-time contacts between strangers. Communication campaigns and counseling are most likely to be effective when they recognize existing patterns of communication and decision-making. In some cases that means reaching out to couples. At the same time, communication needs to address men and women as individuals (289). In many cases communication programs may seek to influence men's and women's roles in the decision-making process as well as its outcome.

"By the time [my father] died, we were already full of pride, self-respect, and the belief that women were not less than men in any way—or rather, as he said to us, that 'they are not better than you.' He wanted us to be everything that men can be. He wanted to give us all the opportunities possible."

Her husband also encouraged her when she began to write and decided on a career as a journalist.

"You see, there were no women in the press then. I was the first one to do it.... I was engaged to my husband and he was a great help.... From the very beginning he was supportive of my career and helped me a great deal."

Source: Huston (144)

International Leadership

In 1979 the UN General Assembly adopted the Convention on the Elimination of All Forms of Discrimination Against Women (64). The Convention specifies steps to prevent discrimination against women in education, employment, public life, health, family planning, and other areas. It also suggests actions to change laws and attitudes. As of June 1993, 116 countries had ratified or acceded to the Convention (149). Many nations attached reservations to their acceptance, however. For example, Austria, Brazil, Ireland, Jordan, Libya, Malta, Thailand, Tunisia, Turkey, and the United Kingdom attached reservations to Article 15, which gives women full legal capacity. Some 52 countries have not yet signed the Convention, including India, Pakistan, South Africa, and the United States (149, 315).

The UN called attention to the need to improve women's lives by declaring 1976 1985 the Decade of Women. The 1985 World Conference on Women set forth strategy to achieve equality between men and women by 2000, and the UN General Assembly endorsed the plan (64). This endorsement obligates all UN members to implement measures ending discrimination against women in such areas as access to education, rural development resources, legal protection, marriage, and access to health and family planning services (105). In 1995 the UN will convene the Fourth World Conference on Women, in Beijing.

National Initiatives

Specific efforts vary widely. Recently, for example, Barbados gave priority to reducing violence against women; China reported programs to involve men in family planning; and Guatemala adopted a policy to incorporate women into development efforts through specific projects (346).

Of course, such policies make a difference only when government leaders have the political will to carry them out. Some national leaders have championed legal reforms on behalf of women. In Tunisia President Habib Bourguiba issued a new Personal Status Code in 1956 requiring that a bride consent to her marriage, abolishing polygamy, giving women the right to divorce while limiting men's ability to divorce at will, setting minimum ages for marriage, and establishing equal rights to custody of children (19, 118). Bourguiba's government also provided family planning services for men and women. In Zimbabwe the courts have enforced the 1982 Legal Age of Majority Act, which asserts equality between men and women even in matters covered by customary law (106).

Often policy-makers' opinions are divided, however, and inaction results. In Kenya the constitution asserts equality between men and women but at the same time allows customary law to take precedence in cases of alleged discrimination. Revisions to the Marriage Act proposed in 1979 would have required a first wife's permission for her husband to take a second wife, given women a share of the couple's property at divorce, and recognized the possibility of a woman's having custody of her children after divorce (106). Heated debate arose, and the bill has never passed. As a result, customary law, which grants women few rights, takes precedence in these matters. In some cases legal advances have even been reversed. Laws giving Egyptian women the right to seek divorce within a year after her husband's taking a second wife were passed in 1979 but repealed in 1985 (81).

Women have few opportunities to change laws and policies because their political influence is limited. So is their direct participation in policy-making. In 1987 women comprised no more than 35% of members of parliament and government ministers in any country. In fact, women rarely made up even 25% of parliamentary representation (326).

Women's Organizations

Around the world women (sometimes joined by men who believe in equal rights) have formed groups to see that women receive fair treatment under the law. For example, in Brazil women's rights advocates began a campaign in 1985 to influence legislators writing the new constitution. They organized vigils, sent letters to newspapers, and aired television spot announcements. As a result the new constitution gives women equal rights and protection from domestic violence (251). Women's advocates in Brazil, Malaysia, and Zimbabwe have helped to train police to handle domestic violence and to involve police in drawing up laws to prohibit domestic violence (85, 95, 307).

The Route to a New Role

"At the beginning some of my neighbors and relatives were against my work," Zanati recalls. "They felt working as a family planning worker, going house to house and talking to people about it, was degrading. They also didn't think it was right for a wife to earn for the family. A wife's taking up a job was a sign that her husband wasn't capable of supporting his family, they thought."

But now the neighbors' attitudes are changing. "Now people realize that women, too, can take up jobs and help their communities and families," Zanati says.

Sarkee has become increasingly committed to his wife's work. At first he thought only that her small income as a field worker would benefit their family. He also knew that his friendly and energetic wife would get satisfaction from working with others. But after Zanati began discussing her work with him, he became interested in the problems of her clients. Now he feels that she should be a field worker even if she were not paid. In fact, he tells her that, if a household task would keep her from her work, he will do that task for her. Her work, he says, will prevent hunger and hardship in the community.

Sarkee is not troubled that some might criticize him. "If my wife...can do good for the society, I will allow her [to work]. No matter what obstacles come, I will overcome them. And if anyone comes and asks me directly, 'Hey, how come you allowed your wife to go outside the house?'...I will explain to them why I allowed her to do that." Besides, Sarkee says, men now recognize that small families are necessary. "Even in the men's circle...everyone says the same thing, 'We have no choice but to adopt this.'"

Learning New Skills

Zanati uses her new skills in other areas of her life. "...There are things which I'd never done before, for example, going house to house, holding meetings, keeping records of each day's work.... I do try to use these skills in my personal life and even to teach them to my neighbors."

As a result of her training in counseling, Zanati encourages women to talk and ask questions. "There are certain techniques we learn in counseling.... We learn that during counseling we must give the client greater opportunity to speak.... I should help a client to select a method according to her taste--according to her likes and dislikes." Zanati feels that she has done a good job when the women whom she counsels are willing to tell their friends openly that they use family planning.

Changing Attitudes Toward Women

"Society's attitudes toward women going to work have also changed. After I've taken up a job, people have begun to realize that there is nothing wrong with women going to work and that, like men, they can contribute to their societies, localities, and families...."

Many women have become interested in Zanati's work. Some have asked her advice about working. "Two of them are now teachers at the BRAC [Bangladesh Rural Advancement Committee] semi-formal education center," Zanati observes. "Women are no longer working only at home, as they have been doing for a very long time. The reason is an increasing awareness of their place in society and the family. For example, there are women in my family who say with regret, 'If we could only take up a job like you, we would have greater value in the family and society. Most of us who look after our families don't have any authority. Our opinions are never heeded.'"

Men's attitudes are changing, too. "After I began working in the field, the men have also given up their age-old ideas about women and their place in society. For example, they used to think that women should only look after the household affairs and their children, husbands, and mothers- and fathers-in-law. But now many of them realize that women should also be educated and allowed to work outside the home and that their work can bring prosperity to the family."

Zanati and Sarkee have two daughters. They do not plan to have more children. In Bangladesh most couples wish to have sons for support in old age. But Zanati and Sarkee say that, if parents can give daughters a good education, daughters can do just as much for their parents in their old age. Zanati says that her mother-in-law used to advise her to have a son, but no longer. "I explain to my mother-in-law that since my parents educated me and since I have a job, I can give my mother two saris every year if I want. I can take all the burden."

1. Meeting unmet need by identifying and overcoming the institutional, cultural, and personal barriers to family planning that women face (see Chapter 7.2).
2. Widening the clientele to serve neglected groups such as young people, unmarried people, and men (see Chapter 7.2).
3. Training personnel to respect and communicate with clients, provide good technical care, and ensure informed choice (see Chapter 4.1).
4. Offering more services to meet a broader range of reproductive health needs (see Chapter 4.2).
5. Seeking women's opinions, including involving women in program planning (see Chapter 7.3).
6. Helping men and women to communicate, cooperate, and share responsibility by informing and educating men as well as women about men's and women's reproductive health and by providing convenient services (see Chapter 5.2).
7. Presenting new images in the mass media of competent women and caring men communicating and collaborating (see Competent Women and Caring Men:).
8. Adding criteria for evaluation of programs and personnel to assess how well clients' needs are met .
9. Promoting capable women employed in family planning programs (see Chapter 6.1).
10. Speaking out on behalf of women and in favor of policies that support women's rights to personal autonomy and more opportunities.

At the International Conference on Population and Development...

In preparation for the International Conference on Population and Development (ICPD) in Cairo, September 1994, many voices have spoken up, advocating differing, but not always mutually exclusive, priorities.

Population growth. Those concerned about rapid population growth emphasize that:

• Rapid population growth threatens the progress of all other efforts to improve the standard of living.
• Environmental resources are threatened by increasingly large populations.
• Family planning programs should provide services to as many people as possible as soon as possible.
• Family planning programs should focus first and foremost on providing contraceptive supplies and services.

• The preferences, satisfaction, and safety of current family planning clients should receive higher priority than increasing the number of contraceptive users.
• Family planning services should be part of programs that help women and men not only with avoiding pregnancy but also with a range of other reproductive health needs.
• Reproductive health care programs should devote more attention to improving the quality of care that they offer.
• Family planning programs should help women to achieve equity in society as well as to meet their reproductive goals and health needs.
• Environmental degradation and resource conservation should not be addressed primarily by emphasizing limitation of childbearing in developing countries.

Ethical considerations. Those concerned primarily about ethical considerations emphasize that:

• All individuals and couples should have the right to make their own decisions about their fertility, free of coercion or pressure.
• Family planning programs should not set targets for numbers of new contraceptive users, incentives for contraceptive use, or field workers' quotas that might result in pressure on people to use contraceptive methods.
• Clients should be given an informed choice of contraceptive methods.

• Abortion is not acceptable.
• Only married couples should have access to contraceptive methods because sexual activity outside marriage is immoral.

Labels Polarize Positions

Seeking Common Ground

Can population policies both satisfy demographic goals and advance individual rights? A growing number of experts and policy-makers argue that conflicts, although they cannot be completely resolved, need not be as great as they sometimes appear. Suggested approaches include:

• Base national population policy on human rights as well as economic concerns. Policy often focuses on the economic benefit to all citizens of slower population growth. Policy-makers can emphasize more strongly, at the same time, that control over one's own fertility is a human right and that providing services that satisfy clients is as important a program goal as reducing total fertility rates (62, 74) (see Chapter 7).
• Focus on unmet need. Millions of women do not want more children, want to delay their first or next pregnancy (25, 355), or need better reproductive health services (78). High-quality services that meet these people's existing needs would increase use of contraception, lengthen continuation, and in the process often reach demographic goals (303).
• Support public policies that indirectly reduce population growth. If policies support roles for women other than childrearing and make these roles socially acceptable and economically independent, some women may choose to have fewer children. Also, women who can provide for themselves and their children can better protect themselves from coerced sex and unwanted pregnancy. Changes that support more options for women include ending policies that encourage parents to favor sons over daughters, eliminating arranged marriages of young girls, enacting and enforcing minimum marriage ages, eliminating policies or tax provisions that favor large families, and assuring equitable male financial responsibility for women and children during marriage and after divorce (74).