Married men and married women tend to live longer lives than people who are not married. Getting married reduces risks of dying and becoming divorced or widowed increases them. Married men and women in the US tend to have better emotional and mental health than the unmarried. And married men and women have, on average, higher levels of happiness than the unmarried.

We know less about the health of cohabitors than of married people BUT recent research on Sweden and Norway suggests that there (and I would guess in the US) cohabitors are LESS committed than married people, on average and are more likely to break up. Marriage both signal commitment and undergirds it with legal and social supports. But a couple committed to staying together for the very long term, with social and legal support, might do quite well. What matters is how much they invest in each other and in their relationship.

Ron--

You betcha! this is certainly the case. people who have any of poor habits or attributes you mention are less likely to get and stay married. But IF they get married, they are likely to be healthier than if they did not. There have been fascinating studies of young men with histories of serious delinquency that follow these men into adulthood. those who stumble (the authors' words) into a pretty good marriage show much more pro-social lives than those who don't (Sampson & Laub). Men tend to reduce drinking, drinking and driving and other risky behaviors when they marry, to work more, to earn more, to spend less time in bars and more in church. So there is both some selection of the better catches into marriage and some change for the better in habits and behaviors.

Chandra

Western societies have moved toward more freedom for individuals over the last 100 years and one of those freedoms is the freedom to end a marriage that one no longer wants. That comes with advantages and disadvantages. children often suffer and adults probably invest less in their marriage and more in themselves when divorce is common and easy to obtain. Most adults who divorce remarry and most stay remarried, although the chances of divorce are slightly higher than for first marriages.

So people in most western societies are not willing to give up the freedom to leave a marriage for lifelong marriage.

Dr. Affandi

We know that at least in the US and similar countries those who marry quite young are more likely to divorce. But no one has asked your first question quite that way, so we don't know if those who marry young get more benefits from marriage than those who wait.

On the relationship between the length of marriage and health, some studies suggest that men and women get benefits from each year they are married, which we would expect if they lead healthier lives. But I don't think that this has been settled.

Melody

Yes, the health of the marriage affects the health benefits it produces. Conflict-riven marriages create stress and stress can damage health. Distant marriages may provide few emotional or instrumental supports. But good enough marriages seem to be better than being single. It appears that only the poor quality marriages damage health and are worse than being unmarried. And people get benefits besides emotional satisfaction from marriage and these must be weighed in deciding whether a marriage is worth it.

Marriage brings many things to spouses, one of which is sexual access. In most societies spouses share a sex life and in the US, married men and women have sex more frequently and are more satisfied with their sex lives than are the unmarried. However, abuse of one's spouse creates stress, which harms health, may cause physical injury, which harms health in the long run, and certainly lowers the benefits of marriage. But even an abusive spouse may be a good provider and protector. Recent research on the US suggests that those leaving an abusive marriage do not, on average, see an improvement in their emotional well-being.

Kalmijn, M. and C. W. S. Monden (2006). "Are the Negative Effects of Divorce on Psychological Well-Being dependent on Marital quality?" Journal of Marriage and Family 68(6): 1197-1213.

Janet

Yes, as far as we can tell. Although some of my recent work suggests that the process of divorce or widowhood is so stressful that it leaves a sort of scar on physical health and functioning even years later.

Meskerem

Happy marriages seem to deliver more health benefits than those that are pretty good but not great. But those that are poor quality--full of conflict or very distant--seem to be worse for health than being single.

Hi Stan

Scholars have tried a bunch of tricks, most of which involve following men and women over a long period during which some of them get married, some get divorced or widowed and some get remarried. Then we look for discrete changes in the likelihood of dying when there is a change in marital status. If we see a decline in the likelihood of dying for all men who become married, regardless of their characteristics and the age at which they changed status, then we feel pretty good about the social processes going on. See some of these efforts to address the issue:

Lillard, L. A. and C. Panis (1996). "Marital Status and Mortality: The Role of Health." Demography 33(3, August): 313-327.

Lillard, L. A. and L. J. Waite (1995). "Til Death Do Us Part: Marital Disruption and Mortality." American Journal of Sociology 100: 1131-1156.

Ramesh

We think that marriage affects health differently for men and for women. For men, getting married is associated with changes in their behaviors away from risky and unhealthy behaviors like drinking and poor diet toward healthier behaviors. Men's wives also tend to manage their health and their interactions with the health care system and to act as a confidant. Women tend to get financial support for themselves and their children from marriage, including, in the US, access to health insurance.

Marriage usually means legal marriage. Cohabitation tends to be less committed and to bring some but not all of the benefits of marriage.

Kennedy

Kids whose parents divorce face higher risks of poor outcomes (although many do quite well). they are less likely to finish high school, less likely to finish college, less likely to marry, more likely to divorce. They are more likely to have poor emotional health. I don't know so much about single mothers vs single fathers. I think both can do well. And no, you can't look at a child and tell he or she is from a broken family. There are lots of advice books for divorced parents raising children. Most say to forget your grievances against each other and cooperate in raising the children.

It probably can't improve one's health, although it may still bring financial and instrumental support.

Rahat

I don't think we know much about differences in health benefits for those in different socioeconomic strata. And I haven't seen any research on developing countries on this topic. It seems like an important set of studies to do.

there have been some comparisons of the mortality advantage of marriage and it is greatest where the most people get married, like Japan or Korea, because those who do not get married are so unusual and probably unhealthy or otherwise quite disadvantaged.

Researchers try to compare the same people before and after they get married to see if marriage has an effect on health and mortality

A scholar named Janet Kiecolt-Glaser has looked at physical changes that happen to married men and women when they discuss something unsettling or something neutral. And Richard Davidson has looked at pain sensitivity when married women hold their husband's hand; they feel less pain when they do than when they don't, especially if they rate their marriage as very good or excellent. So yes, emotional support, companionship and love are key mechanisms through which marriage improves health.

No one has looked at the spatial or socioeconomic dimensions of spouses. We take them into account but have no looked separately at those with high education or low income.

Even where marriage is universal some people lose their spouse to death and may face higher mortality themselves. Those whose spouses live in the city while they live in the village may get different benefits from being married than spouses who live together. One could also consider polygamous marriage to see if that brings the same benefits.

It is certainly the case that virtually all the research on the health benefits of marriage has been done in developed countries. We know much less about less developed countries. And female disadvantage may occur in some societies regardless of whether the woman is married, so the problem is treatment of women not marriage. Poor nutrition is a terrible problem for all, with especially troubling effects on infants and children that may last all their lives. The question is, given all this, does a child do better if raised by two married parents and do women and men do better if married than if single? I don't know the answer for developing countries.

Longer life, better physical health, better functional health at older ages, and better emotional health. On average. Of course there are plenty of very health singles; it's just that the chances of good health are lower for singles than for the married.

Married men tend to have better health behaviors, work more and have higher earnings. Married women have more money and, in the US, better access to health insurance. Both have better emotional health, on average.

Marriage requires some sacrifice of one's own goals for the goals of the marriage or the spouse. It constrains people's behavior (which is generally good for men). If things go badly for the other person, like he gets a chronic illness, you are tied to his fortunes.

Anima

Marriage is certainly only one factor that contributes to health and longevity. the question has been "does marriage contribute at all?" and the research on the US and similar countries suggests it does. But we know much less about less developed countries.

Moses

Researchers have defined health in many different ways, including longevity, physical health, emotional health, incidence of diseases or a particular disease, or recovery from disease. No one has looked at the differences between heterosexual and gay unions or polygamous unions in health benefits.

They probably don't deliver the same health benefits as better marriages and if they are unhappy and conflictual enough, they may be worse than being single.

I guess it depends on the alternatives. Certainly childbearing at very young ages is not good for the health of the young woman or the child.

THAT is a good question! I guess you have a conversation with him or her. And remember that marriage is good on average; that doesn't mean it is better for any particular person.

No one has done a study of health benefits of gay or lesbian marriage. It would be interesting to see. If health benefits of gay and lesbian marriage work like the other attributes of marriage that have been studies, like sexual activity and earnings, then gay marriages will tend to have characteristics more common among men and lesbian marriages will have characteristics more common among women. So gay marriages would have higher incomes but less attention to health habits and lesbian marriages would have more support and emotional sharing but less money.

Andrine

No, very little on cohabiting couples and health. On one of the other benefits of marriage for men--higher earnings--cohabiting men fall somewhere between single men and married men, so they get some of the benefits of marriage but not all.

I would guess it works the same way for health.

THAT'S a question for a psychologist or marital therapist. There are some really terrific programs to teach couples how to disagree constructively. One is called PREP and the other is called PAIRS. Take a look.

Married men have better health habits than the unmarried and take fewer risks. Their wives often check their health and get them to the doctor. Wives often provide emotional support and in the US provide the link between men and their families. Husbands provide income and other support for the household, companionship, and some emotional support.

Unmarried people need to work hard on their support networks, helping others and accepting help in return. Find people to talk to, join groups of others with similar interests.

Look for materials from the Institute for American Values. They have published a number of very accessible pieces on marriage. Also try the National Marriage Project.

Karin

Women seem to do better with widowhood than men do, at least on some dimensions. Widowed men often have trouble with running the household, since in this generation their wives often did most of that, and widowed women have trouble with managing money, fixing stuff, and tend to be poorer than widowed men, since their husbands were likely to do THAT stuff. No matter how couples specialize, if you depend on your spouse for anything, if he or she dies you don't have much experience doing it. That's part of why widowed people are more likely to die (and have poorer health) than married people.

This research is not about how you perceive relationships between young people (with whom you associate) and elders, and it does not try to determine who is responsible for actions occurring in political conflict. This research focuses on the political instability that is associated with youthful population age structures (a distribution in which young adults make up a large proportion of the adult population). To hear more about this relationship, I recommend that you listen to Eric Zuehlke’s excellent interview of Henrik Urdal of the International Peace Research Institute in Oslo (PRIO) on PRB’s website: http://www.prb.org/Journalists/Webcasts/2009/youthurbanizationconflict.aspx).
A great deal of research has been conducted on the political volatility of populations with a “youthful age structure” (called youth bulge populations by political scientists) using data from over 150 countries over the past 40 years. The conclusion of that research, by several authors, is that countries with a large proportion of young adults are more prone to a new outbreak of low-level political violence and instability than countries with more mature age structures. This result remains, even after filtering out the effects of income per person and different types of governance. The research on liberal democracy builds upon the work on civil conflict conducted by Henrik Urdal and colleagues at PRIO, Jack Goldstone (George Mason U.), Christian Mesquida (York U.), Elizabeth Leahy Madsen (Population Action International) and others.
My recent research (with John Doces, Bucknell U.) uses the category “FREE” in annual Freedom House assessments (www.freedomhouse.org) to indicate the presence of a liberal democracy, and we use data published by the UN Population Division to measure the youthfulness of national populations. We find that countries have a much smaller chance of being assessed as a liberal democracy when their age structures are young, than when those populations are more mature.
There are two effects. The first is the “advent effect”: countries with very youthful age structures are less likely to rise to the FREE category (liberal democracy) until fertility has declined significantly and, almost two decades later, the age structure has matured. This effect can be seen in the rise to high levels of democracy by countries in East and Southeast Asia (South Korea, Taiwan, Indonesia, and until recently, Thailand). The second, stronger effect is called the “maintenance effect”: countries that become liberal democracies when they have a very young age structure have trouble retaining that assessment.
In a demographic sense, “youth bulge countries” that become liberal democracies arrive at this regime type too early. These democracies tend to be fragile. Within 10 years, most shift to lower levels of democracy (“PARTLY FREE”) or become authoritarian (“NOT FREE”). Examples of countries that reached liberal democracy “too demographically early” include countries in South America (Venezuela, Colombia, Ecuador, Peru, Bolivia and Chile). Some became liberal democracies in the 1960s and 70s, but suffered through electoral violence, military take-overs, and insurgencies. Most of them retreated to more restrictive regime types. Chile is a good example. It rose to liberal democracy with a very young and radicalized population, then suffered a military coup and authoritarianism at the height of it youth bulge. As Chile’s age structure matured, however, its authoritarian regime became less popular—and ultimately it was replaced by a resilient liberal democracy.
Our theory predicts that, as their population age structure matures, the political environment of other Latin American countries will become less volatile and less fractionated, and will follow Chile’s lead. If governments take advantage of their “demographic bonus”, job growth is likely to occur, the pervasiveness of “youth culture” is likely to fade, and with fewer unemployed young people, political organizations (and government security services) will find it more difficult to recruit. Researchers who have studied how countries become democratic (including Samuel Huntington and Philippe Schmitter) have found that when politics become less volatile, when crime drops, and the economic climate improves, elites (big businessmen and property owners) are unwilling to support authoritarians. Why? Because authoritarians, their families, and cronies, are bad for business—they control commerce and trade, and extract wealth and favors.
Interestingly, our theory is consistent with the view of Thomas Hobbes (a 16th century political philosopher) who recognized that citizens tend to trade their political rights for greater security—a relationship that has come to be called the “Hobbessian bargain.” When there are external and domestic threats, citizens seem willing to give up their freedoms to someone who can guarantee their security. When threats disappear, citizens typically desire a more free society. Youth, who have not yet acquired material wealth, built a family, or organized a commercial network, are less interested in this tradeoff and can afford to be risk-takers.

Please see my response to your previous question.

Please see my response to Emeka Nwosu.

Mario,
This research, so far, does not find a clear relationship between population size and liberal democracy In fact, we do not find a relationship between population size and any type of regime—authoritarian, partial democracy, or liberal democracy.
The focus of the research is on the age structure of a county’s population. Several measures indicating the population’s degree of youthfulness provide a good indication of the likelihood that a country will be assessed as a liberal democracy, even when national income per capita, population size, and resource wealth are statistically taken into account. The measure that I have used is called the “youth bulge proportion”, which I measure as the proportion of young adults (15 to 29 years of age) in the working age population (15 to 64). I have tried other measures of age structural youthfulness, including the one that Henrik Urdal uses (15-24 year olds divided by all adults, 15 and older) and the one that Elizabeth Leahy has used (under 30 divided by the population). They produce similar results.
In order to create a “novel” way to test the hypothesis, I have used the ex-Soviet and Eastern European countries as a type of test of this hypothesis (see the paper linked to this website). It passes the test.

Anima and Meskerem:
This research often surprises readers. However, it doesn’t surprise demographers who are familiar with the way that development and political reform typically follow after progress through the demographic transition (declines in fertility and childhood mortality) and subsequent changes in age structure. The effect of age structure on regimes is a population-level effect, not one that is necessarily reflective of individual feelings, nor should it necessarily correspond to your perceptions of young adults whom you know. I recommend that you read my response to Emeka Nwosu and listen to PRB’s interview with Henrik Urdal.
Also, please try this thought experiment: Identify a country with a youthful age structure that underwent a “youth-led” democracy movement. Did it become a liberal democracy (with Western European style freedoms)? If the uprising succeeded, it probably became much less than liberal democracy—for example, Iran’s 1979 revolution (led to theocratic authoritarianism), the Russian and Chinese Revolutions (led to authoritarian communist states), the French Revolution (led to Napolean’s empire), the American Revolution (initially led to a partial democracy that restricted voting and tolerated slavery). Often youth-led movements are met with backlash that is meted out using equally idealistic youth recruited by the state—for example, the Basij militia in Iran’s suppression of the June demonstrations, and the PLA’s suppression of the Tiananmen
While idealism is, indeed, a quality associated with adolescents and young adults, we all need to remember that idealism takes many forms—many of which are not shared by our circle of friends and relatives. Popular notions of ideal communities—like those generated by religious fundamentalism, communism and ethnic nationalism—are not conducive to the rise and stability of a liberal democracy. Interviews of “suicide bombers” who survived because their vest-bomb did not explode, indicate that they are intensely idealistic rather than religiously suicidal (seeking the afterlife). Most young soldiers and police are also intensely idealistic.

Meskerem, I addressed your question in my response to Anima Sharma.

Robert,
I addressed your question in my response to M.E. Scherer.

Juanita,
You’ve brought up an interesting point. There are two types of comparable effects. You’ve mentioned the first: cohort effects, which arise from mass behaviors associated with a group in which individuals were born around the same years and went through similar experiences (such as, motorcycle riding by baby boomers). And then there are life cycle effects, which are patterns of changing behavior over the lifetime (for example, drivers’ risk-taking declines with age).

Geoff,
My answer to your question is somewhat controversial. I credit the unwillingness of senior demographers to promote or publish this work is a “cohort effect” (Clearly a senior demographer at PRB has broken this taboo!). Today’s senior demographers—most of them baby boomers—were trained by academics whose careers began shortly after World War II or even before. Before World War II, demographers ventured into topics in eugenics, which can be broadly defined as "the study of all agencies under human control which can improve or impair the racial quality of future generations." While this field included legitimate studies of heritability, it also harbored individuals who sought to explain the world in terms of genetic inferiors and superiors. This latter perspective was used in all corners of the globe as a justification for institutionalized racism, and became the ideological foundation of political fascism in Europe. To distance themselves from eugenics, post-war demographers distanced themselves from any type of demographic study of mass behaviors. Then along came another controversy: the resurgence of the Malthusian thesis in the 1960s and early ‘70s as an explanation for evolving world conditions and environmental degradation. As result, I believe, demography turned inward toward census and survey-related studies, and to influencing public health and sociology (and here demographers have succeeded).
Nonetheless, the pathway into demographic studies of state behavior had already been launched with Ansley Coale’s early work on age structure. His book (with Edgar M. Hoover) in 1958 predicted the demographic bonus (or demographic dividend). Economic demographers (including Ronald Lee, Andrew Mason, David Bloom, David Canning and others) have taken Coale’s thesis even further—and now the demographic bonus is accepted by international agencies as a product of fertility decline (see the recent article in the Economist, Oct. 31, 2009). But demographers, trained to stay away from topics that dealt with ‘mass behaviors” refused to venture into “Coalean” studies of conflict and governance, or to encourage its publication or promote it among students.
I believe this was a mistake. Demographic research on civil conflict suggests that a youthful age structure substantially increases the risk of an onset of civil conflict, but it does not find that age structure solely determines conflict or that it is powerful enough to “doom” states to failure. In addition, the conclusions of the research suggest that, after fertility declines and age structure matures, countries with youthful age structures will experience a reduction in “civil conflict risk” and an increase in the probability of being assessed as a stable liberal democracy. In other words, “the youth bulge thesis” does not assert that any country or region is necessarily war-like or undemocratic by nature—each country should experience some risk reduction as it goes through the age structural transition. There’s evidence that this is occurring: the geographic distribution of civil conflicts is shrinking as the number of “youth bulge” countries decreases (see the National Intelligence Council’s “Global Trends 2025” report, which illustrates this on page 20 as the “demographic arc of instability”; at: http://www.dni.gov/nic/PDF_2025/2025_Global_Trends_Final_Report.pdf .
Another fascinating aspect of this research: To a large degree, changes in women’s role in society, from child bearer and homemaker to participant in the workforce and public life, drives the age structural transition. This presents a powerfully optimistic image of a “demographic peace” that might emerge in a future time when the world’s women are fully participating in their society, and making their own choices, and the age structures of all the world’s countries have grown mature. It’s a nice image, but there are a few complications looming along the way (see Neil Howe and Richard Jackson’s article, “the Battle of the (Youth) Bulge”. See my comments on these issues in the Environmental Change and Security Project’s blog at: http://newsecuritybeat.blogspot.com/2008/10/guest-contributor-richard-cincotta-on.html

G.
Please see my response to Laura Underwood's question. It addresses some of the same issues.

Laura and G.,

The study does not focus on birth rates (the number of babies born for every 1000 people in the population), nor does it try to figure out the role of communications. It draws a simple conclusion—one that is obvious to those who understand how the demographic transition has spread around the world and how youthful age structures are currently distributed: countries with a mature age structure are more likely to become liberal democracies and stay liberal democracies than countries with youthful age structures.
What about the US? At the time of its founding, the US could not be considered a liberal democracy. Voting was originally restricted to land-owning white males, and one-third of the population of the southern region was enslaved. According to US Census Bureau, by 1800, half of the US population was under the age of 16 (comparable to Afghanistan and Democratic Republic of the Congo today). The two most recognized “regime data sets” (Polity IV and Freedom House assessments) many more years of political infighting, civil war, Indian wars, and racial and criminal violence passed before US citizens lived under a liberal democratic regime.
When did the US reach the liberal democracy mark? The Freedom House dataset begins in 1972, so it is impossible to determine when their assessment system would have deemed the US a liberal democracy from these data. Interestingly, when I’ve informally interviewed democracy researchers who use this scoring system, some argue that the US should not have made its present very high democracy rating until 1965—after the Voting Rights Act of 1965 was in place (which was used by the federal government to overturn local regulations (primarily in southern states) that restricted a significant proportion of African Americans from voting. I’m still not sure when this assessment would have first considered the US to have become “FREE”. My demographic model tells me there was a 50-50 chance in about 1920 (the year that women received the vote in federal elections).
In the late 1969s and early ‘70s, however, the US “youth bulge” was on the rise, driven by a surge in US fertility after the end of World War II, and the transition of those baby boomers from adolescence to young adulthood. Did the youthful US age structure contribute to the experimental youth culture and political unrest of the time, and ultimately to the conservative backlash that followed? Some researchers believe that it did. As the baby-boom generation entered the adult years, the US youth bulge proportion (the population of 15-to-29 year olds in the working age population, 15 to 64) rose to its highest level, 0.41—which is around the values that Malaysia has today; and it is higher than Indonesia’s current youth bulge proportion (0.39; Indonesia is now a liberal democracy). This value is still much lower than current values in Afghanistan (0.53), Iraq (0.50), or Nigeria (0.52). Despite that “border-line” sized bulge, this period was politically tumultuous and fractious. Public demonstrations by the Left were met by a backlash of voting that pushed the political system to the Right. However, the US has not declined from Freedom House’s category “FREE” from 1972 (when the Freedom House system was initiated), to today. Thus, age structure is not the only issue. It does, however, provide some insight into political dynamics in many countries.

Elizabeth,
As you well know, we can’t be sure that fertility will decline to much lower levels soon in all countries in the western, central and eastern regions of Africa, or in Afghanistan and parts of Pakistan and northern India. The UN Population Division and US Census Bureau projections assume slow rates of fertility decline in these countries, but these assumptions are based on the history of trends in other regions where, very often, women’s traditional and legal status was higher, where political systems were more stable, and where outlets for contraceptives and information where more accessible. Recent surveys show fertility trends in some of these countries to be “plateauing”—stalling after a short period of decline. And even if rapid fertility declined rapidly (as it did in Iran in the 1990s), these youthful countries would still experience at least another 20 years of “youth bulge”, until a younger “small family generation” came of age.
If fertility remains high in sub-Saharan Africa, the age-structural youthfulness that contributes to its countries’ political fragility will be extended further into the future. Without some slowdown in the ongoing surge of children and young adults, weak infrastructure-poor states will be continuously challenged to provide their rapidly growing numbers of young citizens with needed services and jobs. Failure to provide these will undercut the already tenuous legitimacy of the region’s weak states.
On the other hand, let’s not be too pessimistic. Three decades ago, few Western demographers would have predicted that the Middle East/North Africa Region (MENA) would now include countries near or below replacement fertility, such as Tunisia, Iran, Turkey, Lebanon, and Algeria. And others, including Morocco, Egypt, Syria, and Libya have experienced substantial fertility decline. According to my calculations, the age structures of Tunisia, Lebanon and Turkey are very close to the point where countries have had a 50-50 chance of being assessed as a liberal democracy (when the youth bulge proportion is about 0.39; the youth bulge proportion is measured as the population, aged 15 to 29, divided by the working-age population, 15 to 64).
Even with its very young age structures, sub-Saharan Africa has several liberal democracies—although the proportion of the total number of countries is relatively small (which is consistent with predictions). There are four liberal democracies in West Africa: Ghana, Benin, Mali and Cape Verde—Senegal recently dropped out of this category (this instability is also consistent with predictions). All four of the liberal democracies—South Africa, Botswana, Namibia, and Lesotho—are countries with a high prevalence of HIV and significant AIDS-related mortality.

M.E. and Robert,
As I’ve written to Emeka Nwosu and Meskerem Bekele, this research is about an age structural effect, not about individuals or groups within the population. As the age structure of a country becomes more mature (as it moves through th age-structural transition), its chance of becoming a liberal democracy, and remaining one, improves.
Personally, I believe that the “ease of recruitment” effect is the principal driver in this relationship. However, it is not clear that it is all that matters. Changes in age structure run in parallel with key societal changes that are difficult to define measure. These include: modernization (perhaps related to your observation), increases in parents’ perceived value of their children, and the improved status of women. Our research cannot demonstrate that these are influential in the “democratic transition”. However, it seems reasonable that each of these are associated with progress in the demographic transition and the shift from very young to more mature age structures.

Alberto,

My research only looks at very high levels of democracy, which researchers call liberal democracy (the Freedom House category "FREE"). However, by looking at the data, you do get a sense of how demography and economics influence the political stability of countries.
If you're thinking about Colombia, the data suggest a very positive future for your country. Colombia is going through dramatic changes in its age structure that are driven by a fairly rapid fertility decline. If age structure can be considered a clue to the future, I would suspect that the timeline for FARC is running out. With Colombia's youth bulge declining it will be more and more difficult for FARC to recruit. Improvements in educational attainment and job prospects should help speed this transition to a more peaceful and democratic state.
Here's a prediction from my work on civil conflict: the age-structural model suggests that insurgency (FARC) will be increasingly difficult to sustain. I believe FARC will be "out of action" in 5 to 10 years. When that happens, Colombia is likely to be assessed as a liberal democracy (it is very close now).
Actually, many poor countries are able to sustain low levels of democracy quite well. High levels of democracy (liberal democracy, with total freedom of the press and assembly, and organizational rights given to extremist parties) may be unadvisable.

Your question is well beyond the scope of my research. I will say, however, that it should help countries if all minority groups and regions were provided with educational opportunities (particularly for women), health services and economic activities. When large minority groups and regional groups lag in the demographic transition, they retain their "age-structural youthfulness" -- and they continue growing rapidly. This can produce ethnoreligious ... which exacerbate existing political tensions and produce new ones.
The most obvious example is Lebanon. While Christians and Sunni populations have passed rapidly through the demographic transition, Shiites have languished in poverty and been marginalized politically. The result has been a very youthful and politically active Shiia population capable of changing Lebanon's political balance.
Another example is India. UP and Bihar remain very youthful while South India and India's cities are passing through the age structural transition. If UP and Bihar continue to [be] left out of the educational, economic and fertility transitions, I think it will mean significant problems for the Indian state. Some say that this problem is already manifesting itself in migration to city slums and the re-emergence of the Naxalite Movement.

Usha,

The "youth bulge" research does not have answers for all your questions. Its scope is very limited. However, demographers note that India is a difficult case to categorize: Perhaps because of its size and heterogeneity, and perhaps because of its development policies, it seems to be going through several demographic transitions simultaneously.
The earlier and more rapid transition is occurring in the southern states and urban areas. Age structure is indeed maturing rapidly and education, mostly provided by the private sector, has produced an extraordinary generation of qualified workers and professionals in teh south and in the major cities.
On the other extreme is UP and Bihar. Fertility decline has stalled, and this should be of concern to the Indian government. Oddly, many Indian policymakers seem unconcerned; they see this youthful, poorly educated population as future workers. I believe this is a mistake. Instead, sustaining this youthfulness and population growth is likely to feed India's ongoing insurgencies and its slums.
India has an amazing record as a "liberal democracy", but it is one that is tarnished by several retreats from high levels (the Emergency period, 1977-78; and a few years during the BJP government). And no state in the world (except maybe Mayanmar) can compare with India's ability to fight off multiple ongoing insurgencies. I wish I could be more positive about India -- it's a very mixed picture.

Ghazy,

This is not about individuals. The relationship between age structure and liberal democracy is a population-level effect. The demographic transition, and the age structural transition that it drives, have large scale influences on countries. When the age structure is young, politics tend to be fractious and volatile; the risks are higher for civil conflict than at other times (80% to 85% of all civil conflicts in the last 40 years have begun in states where more than 60% of the population was under age 30).
When the age structure matures, it becomes easier for the state to provide services and jobs. It's a "demographic bonus" provided by fertility decline. With many workers, there are more opportunities to produce and tax.
When age structures amass large numbers of seniors --when age structures become very mature -- the state is again challenged to provide adequate services, particularly health services and pensions. In this stage of the age structural transition, workers may find themselves burdened by the demands of seniors. The challenges of this stage of the transition are yet to be realized. Japan and numerous European countries will encounter them in the coming decades.

Noel,

You may be correct. For most industrial countries, the last 60 years have, indeed, been the demographic good times. As Japan and Europe age, the needs of their senior citizens will grow and the size of their workforces will slowly decline. Can liberal democracies continue under these conditions?
On this, our research is completely mute. We don't know. One issue in Europe that may be significant is the influx of non-European workers. Some Europeans believe that these immigrants are creating divisive tensions that will eventually force some of Europe's liberal democracies to be "less liberal". On the other hand, many immigrants to Europe believe that they can be good citizens if [the] European notion of citizenship is expanded.
Good question.

Scott,

I'm guessing that your question is about "cohort effects" versus "lifecycle effects". In this research we have assumed that the lifecycle effects that make political mobilization/recruitment easy (such as risk-taking, sensitivity to peer pressure, idealism, naive acceptance of ideologies) dominate. The literature suggests that these "youth effects" decline rapidly during the 20s. While the amount of criminal violence varies greatly among countries, in nearly every country in the world, 15 to 30 year old young men account for 85 to 95 percent of all criminal violence. They are also the principal victims of that violence.
After that, they become far less important as perpetrators of violence. So, if you want to demonstrate future murder trends, just plot the proportion of young adults (15 to 29) in the adult population (15+). It works very well. There's a nice paper on this by Cohen & Land (1987) in American Sociological Review. I've followed the trend since then, and it fits very nicely. With all the talk about guns and drugs, few policymakers take the time to look at the demography of violence.

Hazel,

Some work has been done on this topic by Henrik Urdal (PRIO) and Bilal Barakat. It is now easier to include education in the mix because of a recently published dataset offered online by the International Institute of Applied Systems Analysis (IIASA) and the Vienna Demographic Institute (VDI). IIASA and VDI have generated age structures that show the educational attainment levels in each cohort. This is important because: (1) age structures vary significantly, even within some regions; and (2) age cohorts have varying impacts on production and politics, depending on how old they are. For example, a highly educated group of 70 year-olds is unlikely to contribute very much to workforce productivity, but they are likely to be considerably more healthy than a much less educated cohort of similar age.
In the Urdal-Barakat conference paper, I remember them finding that seconday school education was important, but it didn't take too much education to get them up to the level that reduced the proportion of conflict. You'll have to talk with Henrik on that one. It was not a finished paper and the authors may have done more work and reached other conclusions.
I think the big question was: Does education make people more likely than less educated people to be discontented in opportunity-sparse populations? Many political scientists think that educated people are more apt to be discontented and therefore politically extreme. I think the jury is still out on that one. And I'm not sure the issue will be easily resolved. As I've said before, there are "individual effects" and then "populaton-level effects", and those can be very different. Mixing them up creates the type of questions that you've seen on this particular forum ... and some people satisfied with this answer.

Ron,

Apparently, the age structure of the electorate is relevant to the ability of states to "consolidate" a liberal democracy ... in other words, to make high levels of democracy (and the civil liberties and political rights that compose it) the only choice that interests the electorate. The results of this research suggest that it helps to have a significant proportion of older adults to produce a political environment that a liberal democratic system can manage and remain in place.
This doesn't mean that leadership and institutions do not matter. They do. There are two countries that have overcome the "youth risk" and cruised through their youth bulge while maintaining Freedom House's "FREE" rating: Costa Rica (the most amazing outlier); and Jamaica (which experienced a considerable amount of political violence). They are both small countries, of course. But that's it. Even with India's dedication to liberal democracy, it has fallen twice from the FREE rating over the last 40 years (not bad for a huge, poor and heterogeneous country).
On the other hand, there are countries that this age-structural model suggests should be liberal democracies, but aren't: China, Russia, Cuba, and now Thailand (what happened there?). That's the beauty of this model; it produces statistical expectations about liberal democracy. Even when they are wrong, it makes you wonder why.
I believe that two types of countries can resist this demographic shift: (1) where a single party is synonymous wiht the state (China, and probably Iran); and (2) where a charismatic leader has been able to capture or inculcate popular support (Russia, Singapore, North Korea). Hugo Chavez is trying to follow this model, but he may not succeed. Venezuela, while behind other Latin American countries in the age structural transition, is maturing rapidly.

Ghazy,

There are differences between (1) the way that you observe the behavior [of a ] person or people, and (2) the influence of those people, in large numbers, on a population or system.
For example:

Observation of individuals: I notice that Americans buy fast cars. Individually, they love fast cars.

Observation of the population: The average speed of those car owners is about 50km/hr.

What happened? Lots of owners of fast cars create enormous traffic jams. There are population effects that do not mirror individual effects.

Henry,

I hope more research will be conducted on populaton effects of high educational attainment and the stability of high levels of democracy. However, we haven't tried that yet. Please look at my answer to Hazel Denton's question. I refer to a new dataset published by IIASA and Vienna Demographic Institute. They have generated data for educational attainment (4 categories) by sex and by age (5 year age groups). In the future, I hope I'll have a chance to add this to the model.
However, I have tried to see if it mattered in the transition to democracy among the ex-Soviet/Eastern European states, and it didn't seem to matter. I don't believe that result can be generalized to less developed regions.
You asked about education in democratic countries. One demographic point: in mature age structures, it is easier for governments to spend more on each child because the school age population is either growing slowly or declining. This is one of the rewards of the "demographic bonus" years. Thus, countries that advance through the age structural transition are likely to vastly increase their human capital stock. To find out more about that, see work by Wolfgang Lutz (IIASA), Anne Gujon (VDI) and colleagues.
You're right, of course, it takes more than demographic change to attain and maintain liberal democracy, but our research suggests that a mature age structure certainly helps.

Luz Maria,

A very nice quote. The research is solely concerned with the population-level effect, so it cannot validate hypotheses about individual and small group behavior within a population. However, Mr. Cicero touched on an interesting relationship that extends through human history. The young fight, the elders govern. Even in youth-led movements, this holds constant. In Cicero's model of a democracy, the young men provided the security and then were rewarded with political rights. The elders were then obliged to govern democratically. It was a "bargain".
About 1600 years later, Thomas Hobbes composed a more generalized (and somewhat more cynical) model of this bargain. He suggested that political rights and security were intimately related. Citizens desired political and civil rights -- their freedoms. But when citizens required a great deal of security, they were willing to forfeit their political rights to a sovereign. This is the general model that underlies the youth bulge theis on liberal democracy.
However, your quote brings up the subject of the importance of older adult generations. The results of the research suggests (to me, at least) that the older generation has to feel secure in order to opt for liberal democracy. If they do not feel secure, if they feel that a youth-led change risks their family and property, they will likely support "less-democratic" leadership. By nature, young people are excited by innovation and change. Ultimately it is the older generation that accepts change or decides not to stand in the way.

I believe that all religious leaders have a big responsibility within their own communities to address the issue of violence against women in general and explain how all religions call for the respect and equal treatment of women.

I am an optimistic person and I am hopeful that this crime will end one day. It will take some time because we have to work on changing people's attitudes towards these crimes and encourage more people to speak out against violence against women. And governments have a big responsibility to address violence against women and children and to keep it a priority on its agendas.

I think this is part of the patriarchal society that these women and men come from. Men are brought up to think they they have powers and control of their female relatives' rights. And because they think so, sometimes their control could lead to a so-called honor killing. Again, this is an issue that needs to be addressed from a broader manner and we have to encourage governments that have school text books that are filled with stereotypical images of women to work on it and improve women's images. In the meantime, focus should be also on teachers as well who are victims of the weak education system. So it is a long battle but things will also change eventually because women are going out much more to work because of the family's need for money. As one sociologist once told me, violence and killing of women will decrease before it increases, because of the changes that the world is witnessing on all levels and women going out to work and perform other activities.

I agree with you. There is no connection between religion and so-called honor killing. Most people kill because of "wrongful" cultural beliefs and traditions. And this phenomenon is ancient and occurred during the ancient civilizations times.

I believe we have to work on all aspects of the problem. Not just the lenient punishments. It is a comprehensive process that starts with improving education, to increasing the level of awareness to encouraging religious and community leaders to speak out to improving services to help women in need, amending laws that discriminates against women and continue to address the issue in the media and elsewhere in the society among school and university students.

I think most of what you said could be the same inmost countries. But in the Arab region, men are not usually killed. It is very rare for a family of a female relative to kill a man (presumably her partner) because of the legal complications. The victim's family might refuse to drop charges and demand money instead. Also, they might want to revenge so most families try to avoid killing the man. Now on many occasion men do not exist because the murders are committed for financial or inheritance reasons or because the woman was a victim of rape, rumor, suspicion or incest.

Hi dear

I believe the killing of women happens in all societies and is not restricted to one society or religion. Violence against women is an international phenomenon and one in three women is subjected to some form of violeence during her lifetime.

I think we need to always focus on moderate religious leaders and encourage them to address issues that are related to gender equality in their societies.

Changes in Jordan are happening. Although the law itself was not changed, we see more awareness among judges and criminal prosecutors regarding this matter. Now killers are getting tougher punishments and almost 10 days ago a court sentenced a man to 15 years in prison, the highest so far for killing a sister in the name of family honor. So there is hope, but we have to constantly work on it. On the other hand, most of the deputies are conservative and when the issue was up for debate in the late 1990s and the government then offered some amendments, it was done in the wrong manner and many deputies thought that we were backed by the west to destroy the morals of the society and sexually liberate women. And were immediately attacked and the draft bill was defeated. Most countries in the region have similar laws.

Well women could lose their lives for several factors that includes becoming pregnant out of wedlock, being a victim of rape, incest, rumor or suspicion, marrying the man of her choice, taking to a stranger, being involved in an affair, gone missing from her home and sometimes for financial or inheritance reasons. There is no indicator of it happening in some countries over others.

Hi dear

I think I have answered your questions in the previous answers :)

I think that most countries in the world have signed and even ratified many conventions, but this does not mean that they will abide by it. There are many violations committed by countries on many levels though they signed many conventions. We need to encourage governments that signed to abide by what is in the convention and others who have not signed and ratified to do so.

I agree with you and there is recognition towards what you mentioned.

I think that the campaign that was conducted in Jordan was a great successful story. There is also campaigns in countries such as Turkey and Pakistan that also helped raise awareness there. I have included these experiences in my book for people to read and learn from other countries' experiences, success and failures.

We strengthen the values of human rights among these generations with the many ways I have mentioned earlier to combat this issue, which a comprehensive manner that deals with all aspects of life and the society, starting with school children, of course.

Hi dear

I think what you have just said is a true story and most of the pregnancy that results from 'illegitimate" or extra-marital affairs end in social homes where they are raised without knowing who their parents are. The result is a sad story as the one you said. I agree with you that their voices should be heard and their stories should be told.

Hi dear

Yes the book does include my experience and some stories that I have reported for The Jordan Times. There are also some stories and examples from Iraq. I have never heard of or read a story whereby a woman was killed for talking to an American soldier or UN troops. but it could happen.

Thank you very much for your encouraging words. I agree, these crimes are not on the decline and there are cases that could be forced suicide and accidental deaths that in reality are so-called honor killings. I believe that the term should be changed and that is why I call them so-called honor killing. And I do not have figures of incest.

i believe all countries should work on addressing domestic violence in a global perspective because if we pinpoint one or two countries we will face resistance.

As mentioned before, this is an issue that needs to be discussed from a global perspective and we have to focus on moderate religious leaders to speak out and explain the true meanings and values of all religions.

I do know that both men and women are killed in some parts of India, Pakistan and Bangladish. But this is not the case in other countries were these crimes take place.

I believe the first part is answered. The second part I am afraid I did not understand what you meant by it. Sorry :)

Fertility in the low birth rate developed countries does appear to have "bottomed out" and is rising again in some but remains at low or very low levels. Thus far, there have been a few cases of modest increases in the former USSR "Stans" countries but, generally, no one expects any large increase. It could ultimately happen when some of those countries also decline to very low levels.

Your point is well taken except we do have to keep in mind that there remains a large amount of population growth in many countries. Sub-Saharan Africa will certainly add more than a billion before growth stops and even India could reach two billion despite having a moderately low birth rate. So, numbers are still an issue.

I think the last concern Africa has is an insufficient labor force but rather too many untrained people entering the labor force year. In most countries, Africa would seem to already have enough people to develop if economic opportunities were there. But the lack of investment and widespread corruption would seem to preclude that.

The difference between the U.S. and Brazil is primarily due to migration. Will migration to the U.S. continue? In the long run, I would think it definitely would as the "pull" factor of higher incomes in the U.S. will always be there.

The projection for Spain assumes little long-term migration and, with a total fertility rate below 1.5, Spain will not have positive natural increase for much longer.

According to the 2009 World Population Data Sheet, HIV prevalence has decreased from 5.7% in 2007 to 5.0% in 2007/2008. Prevalence figures represent the percentage of the population that is estimated to be infected with HIV at a specific point in time--it is not the same as incidence, which is the number of new cases estimated during a specific time interval.

The decline in prevalence could be due to several factors. Many of the older estimates of HIV prevalence in African countries have been recognized as being too high and the historic estimates were never recalculated, which means that the baseline figures are artificially high.

Also, without access to treatment, people living with HIV/AIDS may have died and are no longer in the population, which means that they do not contribute to either the numberator (people infected with HIV) nor the denominator (the total number of people, in this case, between ages 15 and 49).

Another factor contributing is that prevention programs are having the desired effect and fewer new cases of HIV are occurring; although these cases contribute to the prevalence, if the number of new cases is fewer than deaths, then prevalence will decrease.

If you look at the data sheet, you will see that the estimated prevalence in many countries has gone down, but has also increased in some countries. For a more comprehensive view of what's going on with HIV in sub-Saharan Africa, it would be useful to look at UNAID's annual report.

Thanks for your questions...they raise some important issues about getting information to policymakers, media, and the general public about the importance of family planning. It is interesting that what got your attention was thinking about population density, and perhaps the link between population growth, the environment, and food security--and they are all interrelated. And it is great to hear that through your interest, you are becoming a champion for family planning, which is linked to economic growth, better health, and better opportunities for the future.

There has been a lot of attention put on family planning in many African countries. Many donors are putting more and more attention on increasing political commitment, funding, and access to services in African countries. In Ethiopia, work with community health workers is increasing access to services, and we can see that it makes a difference--prevalence has gone up tremendously in the past few years.

But there is no magical combination to make family planning programs work. It does require political commitment, as has been seen in Rwanda in recent years; it takes services and commodities, which requires funds; it takes communications efforts to get positive messages out about benefits of smaller families, the health benefits of birth spacing, and the economic benefits of slower population growth. I think it requires a concerted effort with each sector playing a part: government, NGOs, community members, the commercial sector, media.

Regarding side effects of family planning methods--there are many different types of methods--hormonal, barrier, fertility awareness, permanent. Some women are better suited for certain methods, which is why good counseling and follow up are important. If a woman has problems with a certain method, she should return to her provider so that she can get a different method that responds better to her body and lifestyle.

Women and couples should be able to decide on the timing and spacing of pregnancies and birth. Family planning programs are designed to help achieve this important goal. As you can tell, this is something that I could write on and on about. I hope that you will go to the PRB web site and take a look at some of the publications we have put out in recent years that focus on why family planning makes sense for better health and wellbeing (www.prb.org).

Now that is a straightforward question! And I think it has a straightforward answer--no. Who would promulgate such a law? How would it be enforcable? And who would support it?

The decision to have children is very personal and should be respected. Historically, large families were important for economic and social security reasons. Although the world has changed, people have different reasons for having the number of children they have.

But many women end up having more children than they want, and many women do not want to get pregnant, but do are not using an effective contraceptive method. Perhaps a better alternative to a law or rule is to increase access to and knowledge about family planning, work to empower women so that they have more say in decisions about family size, work with men to be more constructively involved in fertilty decisions, and work with policymakers to enact policies that support well designed and implemented programs in health, education, and economic growth. I think that the solution is not is a heavy-handed law, but rather in empowering people with the tools, skills, and services they need to decide for themselves.

a.) Rapid population growth in less developed countries is due to high birth rates and a young age structure. In more developed countries experiencing population growth, immigration plays an important role. In the U.S., replacement level fertility and immigration both contribute to population growth.

b.) Part of the increase in the teen birth rate in the U.S. is due to an increase in the share of teens from high fertility subgroups such as Hispanics and immigrants from high-fertility countries. Some data also indicate the teen birth rate is up due to a slight increase in sexual activity, a decrease in the use of contraception, and continued decline in abortion rates.

Because poverty may represent different things in different countries and the values of international currencies vary, it is difficult to come up with a measure that is comparable internationally. The World Bank uses several measures of poverty, including the distribution of income within countries, which is just as telling as the national average.

The World Bank measure we used on PRB's 2009 World Population Data Sheet is based on the percentage of a country's population that lives on less than US $2 a day-- calculated as purchasing power parity (PPP). PPP is the amount of a country's currency required to buy the same amount of goods and services in a country's domestic market as a U.S. dollar would in the United States. The World Bank also estimates the percentage of a country's population living on less than US $1.25/day.

These estimates are based on surveys and other information about consumption and income gathered from each country.

The poverty report can be found at http://siteresources.worldbank.org/DATASTATISTICS/Resources/WDI08supplement1216.pdf. See the World Bank's World Development Indicators for more information.

We are on track to reach 7 billion before the end of 2011, and will likely add another 2 billion by 2050. These projections assume fertility will continue (or start) to decline in developing countries with high fertility today.

But couples in high-fertility countries need access to family planning services and information for fertility to decline further. There is currently a great unmet need for these services--an estimated 200 million women want to control the timing or number of their pregnancies but are not using an effective method of family planning.

The developed countries with very low fertility may or may not increase their fertility levels in the next few decades, but this will not have a great impact on world growth.

Thanks for an interesting question. To answer it, I'm going to step back to the proximate determinants of fertility framework, which indicates that fertility is a function of age at marriage, contraceptive use, sterility, abortion, and postpartum insusceptibility. In many developing countries, many young women are married at early ages and have limited access to family planning. These two demographic behaviors are driven to a large extent by culture--certainly early marriage is, and in many places, social pressures to start childbearing as soon as the young woman is married is also a cultural force to be addressed. Young women often lack access to family planning and are socially encouraged to have many children within marriage. Are these the types of false traditions that you are referring to that contibute to higher fertility among young women?

In many of the places where young women marry at young ages and are encouraged to have many children, religion is also one of the dominant forces that shapes demographic behavior. I am not clear if your issue is early childbearing, which has a lot of adverse effect on health and future opportunities, or early fertility outside of marriage. Regardless, the risk factor for adverse health outcomes is the woman's age.

I am not an expert on adolescents, but the attempt to constrain some behaviors may have a counterproductive effect. Perhaps programs that focus on youth need to start at an age that helps shapes their attitudes and values so they make good choices. Some will become sexually active--that's a fact of life; but when they have necessary information and access to services, they are better equipped to avoid adverse outcomes, such as unplanned pregnancy, HIV, and sexually transmitted infections.

You bring up some good points. Countries have an opportunity to benefit from a rapid and substantial decline in fertility -- the "demographic dividend"-- because there are more working-age people to support dependent-age people (the very young and very old). This may have helped South Korea's rapid economic growth in previous decades. However, reaping this dividend requires a skilled, educated labor force and favorable political and economic conditions.

Where there are not enough jobs for youth entering the labor force, educational levels are low, and the goverment is ineffective, there is no "dividend." Often there is widespread unemployment and underemployment, and as you point out, this is often a greater problem in urban areas.

Hi John,

The projected 2050 population on the data sheet is necessarily different from the UN since we use a variety of sources (including some of our own projections) such as official national projections of countries where available. We don't know where it's going end up until we add it up! The data sheet's 2050 population is 271 million higher than the UN but half of that difference is accounted fior by our higher projection for India.

Of course, all countries are not all going to follow any variant of the UN but I think it's practical to use a uniform assumption within each variant. That way, at least one readily knows what is being assumed. It's also obviously possible to select countries from different variants and come up with your own total. One, might, for example feel that the medium variant is too optomistic for Africa, too pessimistic for some other countries, etc.

Craig, I have to be frank and say that I did see that article and was a little puzzled why such a simplistic attempt to explain fertility trends was attempted. A country's birth rate is the result of a complex group of influences, such as governments' support of young families, the social acceptance of childbearing outside of formal marriage, the labor market, and so many more. Factors that influence fertility in different countries do have some commonality but also vast differences. One of the faster rates of fertility increase in Europe is in Russia which has a fairly low income level. That's apparently due to the government's recent offer of $9,000 for the birth of second and subsequent births.

While no one predicts such things, the pressure will certainly be there. What, for example, will happen when Uganda approaches 75 million or 100 million? People will have had to have moved to towns and cities seeking some form of income. I would imagine that could lead to considerable unrest.

First, the global economic recession is likely to have a temporary effect on both fertility and mortality that could slow population growth, especially in the poorest countries. But it is not likely to have a big long-term effect on world population growth.

Concerning Mexico's future fertility levels, I don't see that it will necessarily follow Spain's model and fall to very low levels. However, with Brazil's fertility now the same or slightly below that of the US, it would not be surprising if Mexico's TFR fell to 2 children per woman or below within the next decade. Of course, the US TFR may fall as well.
The UN projects that Mexico's TFR will be 1.85 by 2025.

Current projections don't show world population doubling. Long-range projections show a leveling of growth in the second half of this century.

However, if the world's current growth rate of 1.2 percent continued for at least 58 years, world population would double.

Well, doubling would suggest that it would approach 14 billion at some point. As risky as it is, I'd predict that won't happen but that growth may end at somewhere around 11 billion and possibly not until the next century.

You might want to look at some of our publications on nutrition and to look at the work done by the International Food Policy Research Institute and other groups working on agricultural productivity issues (http://www.ifpri.org/)

The question of ideal size comes up frequently and, of course, can never really be answered given the huge number of variables. However, Joel Coen did publish a book collecting many estimates of how many people the Earth might support and an average of all of those, as I recall, was around 11 or 12 billion.

The underlying sources are, of course, censuses but data availablity has improved greatly, beginning with the World Fertility Surveys. Today we have many surveys such as the Demographic and Health Surveys and many others that provide good estimates of a variety of demographic measures. Some developing countries do have good registration of births and deaths while India has a Sample Registration System that is likely much like your DSS.

The reasons can vary a great deal by country but a fairly constant thread is economic: the actual state of the economy and the confidence couples have in it. The fact that buying or renting a house requires a full-time permanent job, not a temporary one (a problem in Italy). And there is an elusive, not easily measured, factor such as a change in young people's expectations and tastes that simply makes starting a family far less automatic than it once was.

Education for women has been linked with many benefits, for the individual woman, her family, and community. Research shows that women with more education are healthier and have healthier children, for example. They are more likely to use effective family planning and have the number of children they want.
If women in Afghanistan are able to improve their educational levels, they and their families will reap these same benefits.

While Sub Saharan Africa is experiencing fertility rates among the highest in the world, the prevention interventions targeting maternal and new born mortality in this part of the world focus mainly on antenatal care and undermine family planning as an effective means for the reduction of maternal and child mortality.

A major obstacle is at the policy level, which in most sub saharan africa, do not allow task shifting from the upper to the lower level of the health care system. There is a medicalization of prevention interventions and there is not enough involvement of community actors and other sectors of development.

To make these programs more successful, a holistic approach to address the social and economic conditions that cause maternal and child mortality need also to be considered. Causes of maternal mortality such as women’s hard domestic work, malnutrition and nutrition deficiencies, malaria, low access to primary health care need to be taken seriously into account. As Kishore said, women empowerment is of paramount importance if we want to improve women and child health.

I share your point of view that mother-child health care needs to integrate ethnic practices. Unfortunately, health policies are too often based on research from the western world and they do not always use research results from ethno/anthropologic in africa. There is a lot of ehtnographic research done by university scholars but they are not well disseminated among the public health community in Africa. In addition funding for MCH/FP programs comes from outsiders and concepts are not enough adapted to the african context by african public health program managers. There is a need to use more ethnic evidenced-based information to develop appropriate policies and programs.

La litterature montre que les methodes de longue duree sont le moyen le plus efficace de relever la prevalence contraceptive. Cependant si l'on observe le programme de PF des pays ouest africains, on se rend compte que les taux d'utilisation du DIU (2% ), des implants (1% ), de la sterilization (0,3% )sont tres bas (donnees de l'EDS Senegal). Or ces methodes de longue duree ne sont disponibles qu'au niveau le plus eleve de la pyramide sanitaire (hopital, centre de sante, ou cliniques privees).

Si l'on regarde les besoins non satisfaits selon le quintile de bien etre, on voit que les pauvres et les plus pauvres (Quintiles Q1, Q2, Q3) ont plus de besoins non satisfaits que les populations les plus riches (Quintiles Q4, Q5). L'acces a l'information sur la PF est plus faible chez les couches desavantagees (radio 41% pauvre vs 49%; TV 10% pauvre vs 52% riche;...). Donc les pauvres ne sont pas touches.
Ainsi dans la plupart des pays ouest africain les programmes de PF gagneraient a se reorienter vers les couches desavantagees du mileu urbain et rural, pour accroitre rapidement la prevalence contraceptive et reduire les inequites dans l'acces aux services de sante.

I agree with you that the HTSP arguments is more acceptable to both policy and community levels. From my experience in West Africa, this argument is used since the 80s as program managers quickly understood that the population rapid growth justification couldn't work.

However what is new is that there is data from several research that shows this benefit. So we should take advantage of these recent data to reinforce our programs. However we should keep in mind that this element alone may not be sufficient to increase CPR.

There are many programs that seek to fight against illiteracy by giving education to kids especially to girls. Many studies have shown that keeping girls at school reduces their vulnerability to early marriage, early sexual activities and pregnancies which have a positive correlation with maternal mortality and morbidity.

But we need to recognize that we do not have good RH/FP programs for schools, due to several socio-cultural and religious barriers. And unfortunately an unnacceptable number of school girls are getting pregnant which jeopardize their future. I aggree with you that we need also to address some current trends on sexual abuse, rape and incest and discrimination against girls and women.Gender based violence (GBV)programs are also better structured these days but a lot of work still need to be done.
A better integration of GBV issues into FP and FP into GBV programs is key. Emergency contraception (EC) is one FP method that needs to be promoted within anti-GBV interventions. Several countries are succeeding in making EC available in post rape services (e.g Zambia, Mexico, Guatemala..). Specialized centers staff, police staff, social services personnel, and health facilities providers need to be trained to provide quickly EC to girls and women that have been raped.

Senegal demographic transition is mainly due to the increase of the age of marriage due to the improvement in girls education and also urbanization. Senegal is more urbanized than Mali, BF, Niger with about 50% of the population living in urban cities.

There is no doubt that education, women's empowerment and human development in general are powerful forces that bring about development and move countries through their demographic transitions. However some poor countries are stuck in a poverty trap in which rapid population growth and high fertility contribute to poverty and vice versa. Breaking out of this trap is difficult and requires investments in human development, women's empowerment and family planning/reproductive health

Past studies have shown that greater choice of methods leads to higher contraceptive prevalence, lower unmet need and greater user satisfaction. The problem is that many poor countries lack the resources to provide wide access to many methods.

There are three general reasons why married women don't use contraception. The first is that they still want more children. This is an important reason in sub-Saharan Africa where desired family size is typically around five. Second some women are not exposed to the risk of pregnancy (e.g husband away, infecund). Third are women with an unmet need i.e. they are not using even though they don't want to get pregnant. Among the main reasons for this are fear of side effects, lack of knowledge and access, costs and opposition from self, spouse or others). Well designed FP programs attempt to address all these obbstacles by providing quality care and counceling and through appropriate media messages.

Reductions in fertilty can make important contributions to economic growth through several mechanisms:
First, according a recent UN report ” For every dollar spent in family planning, between 2 and 6 dollars can be saved in interventions aimed at achieving other development goals
Second, as women spend less time on childcare they can become wage earners outside the family thus boosting income and reducing poverty.
Third, fertility decline leads to a so-called demographic dividend which refers to a rise in the rate of economic growth due to a rising share of working age people in a population. Reduced fertility also increases expenditures on children’s education and health, and encourages savings thus giving economic growth a further boost.

It is true that many people know about methods of family planning, but access at low cost and/or method choice is still limited in many parts of Africa. The next step is to address the reasons women give for their unmet need in particular fear of side effects and opposition from self or others. See answer to question from Akintunde

I agree that conditions in western central and eastern regions of SSA are particularly unfavorable to fertility decline. High child mortality, low literacy, low status of women and pervasive poverty all support desires for large families. Nevertheless there are reasons to believe that such high preferences can be changes rapidly once the right messages and conditions are put in place. For example the implementation of the family planning program (and its IEC component) in Kenya since the 1960s coincided with a large decline in desired family size from 7.2 in the 1970s to less than 3.8 in 2003.

On unmet need, see answers to questions by Yeatman and Akintunde.

The HIV/AIDS epidemic has indeed received more attention than FP. In the past many governments believed the dire predictions that the AIDS epidemic would result in a decline in population and therefore gave lower priority to FP. In fact however the epidemic has peaked and in many countries it has had only a minor impact on population growth. The population of SSA is expected to increase by 1 billion by 2050. It is increasingly clear that the neglect of FP has been a mistake.

See earlier answers to Yeatman and Akintunde

Q1: No one has established a credible carrying capacity for our planet and the concept is now considered problematic, because the number depends on the consumption level, the development of new technologies etc. In general however fewer people is better.
Q2 Africa is one of the fastest growing regions in the world. Population growth is expected to continue throughout this century adding well over a billion. See projections made by the UN population division

I think that we should do all these things. In particular I see FP not only as a health but also as an economic investment.

Mbagnick, je suis d'accord avec vous que les produits contraceptifs sont supportes par les bailleurs de fonds. C'est du a ce constat que l'alerte a ete donnee en 2005 pour repositionner la PF. C'etait non seulement pour lui redonner de l'importance dans les programmes de sante publiques, mais c'etait surtout pour que le sgouvernements s'impliquent plus dans l'achat des contraceptifs, puisque la tendance au niveau international etait a la reduction des financements pour la PF.

Je ne peux pas envisager pour le moment un retrait des partenaires au developpement. Au contraire, avec le changement d'administration aux Etats Unis et les initiatives telles que celle-ci pour attirer l'attention des politiques, et des populations, on assiste a une augmentation des financements alloues a la PF. Le congres americains a recemment accorde plus de financements. Je susi persuade que cette tendance va continuer, afin que les pays puissent mettre en oeuvre leur programme de relance de la PF. Cependant les gouvernements doivent aussi allouer des lignes budgetaires, si ils sont convaincus que l'utilisation de la contraception par les populations contribue aussi au developpement economique de leur pays.

Thanks for your thoughtful comment

Yes unsafe abortion remains a major cause of maternal deaths. I am not aware of studies that have measured declines in maternal deaths after the changes in the laws in SA Zambia and Ethiopia, but I would expect the impact to be substantial.

There is increasing concern that the huge amounts of funding for AIDS are overburdening the health care system and are taking attention away from other more cost-effective health interventions. The FY 2010 budget includes a substantial increase for international family planning so that is step in the right direction.

I agree with you that there is a huge inequity in terms of access to family planning services. In most african countries DHS data shows that poor and very poor women (quintile 1,2,3) have a higher unmet need than wealthy women (quintile 4,5). This means that our safe motherhood programs are not reaching the poor. Only countries like Bangladesh were able to reduce these inequities. Recently I read that the Brazilian MOH is also reorienting the program to reach disadvantaged groups.
I think that the first step is to draw governement attention to these facts, using research results that show what are the gaps in their program coverage. the second step will be to develop and implement interventions that will reach the poor in urban slums, and poor remote areas.

You are right simple access is only one of many reasons for having an unmet need. For women who are exposed, fear of side effcts and opposition from others are key factors.

You can look at the recent exemple of Rwanda who is really operating an incredible shift and improving the use of services. Madagascar is another example. I encourage you to look at the litterature on these 2 countries

Economic development is a complicated process that depends on many factors. Among these is the age structure of the population. This has been a neglected determinant of economic growth and development. But by no means are we suggesting that demography or age structure is destiny.

Institutions respond to real economic conditions. Insofar as labor becomes increasingly scarce, we should expect labor market institutions to respond. The responses won’t be instantaneous; there is a great deal of inertia when it comes to institutional change and innovation. In addition, high unemployment in Europe represents a supply overhang on the market, so it will take a while until employers experience the need for more labor.

One such example concerns retirement policy. A striking fact about the normal/legal age at retirement is that it has barely increased in most countries over the past 50 years, even in the face of a roughly two-decade increase in global life expectancy. The post-War baby boom has alleviated much pressure for the age of retirement to increase, but this will likely change as labor markets tighten with the entry of smaller cohorts. We can also expect to see the elimination in public and private pension systems of incentives for “early” retirement.

This question also rests on a premise about the unemployment rate in Europe relative to the US. Based on http://www.cepr.net/documents/publications/US-EU-UR-2009-05.pdf this premise may not be entirely well founded. In particular, unemployment in the US is now higher than in most European countries. For a number of years, it was higher than in Austria, the Netherlands, Norway, and Switzerland.

The birth rate depends on the age structure of the population and age-specific fertility rates. The larger the population share at the very young and old ages, the lower the fertility rate, holding age-specific fertility constant. The higher the age-specific fertility schedule, the higher the birth rate, holding age structure constant. Insofar as fertility rates increase in the face of labor shortages, it could be expected that a high elder share will lead, over the long run, to an increase in the age-specific fertility schedule. On the other hand, labor shortages might reduce the demand for children, because work alternatives are so favorable. The bottom line is that this is a complicated question to answer.

This question makes an important point. Gruber and Wise do indeed cast doubt on the hypothesis that young and old individuals compete for jobs. Put another way, the young and old seem to be more complements in the labor market than substitutes.

With respect to policy responses to population aging, the promotion of healthy aging will have no discernible effect on economic growth unless people also work longer. Reducing incentives to retire will have a first-order and relatively immediate impact on the macro economy, assuming older workers don’t crowd out, say, middle-age workers from the labor market.

Labor shortages can naturally be expected to encourage higher capital/labor ratios, e.g., automation.

Migration is not likely to affect large enough numbers in the North or the South to substantially alter the age structure or the economic trajectory of either set of countries.

The observation that the demographic cycles are out of phase is fundamentally correct.

With respect to intergenerational justice, the evidence points in the direction of there being no effect of population aging on youth employment. This is one of the main findings brought out by Jonathan Gruber and David Wise.

Many social security systems are indeed very generous to the elderly. In fact, they are so generous that the real issue here has to do with their sustainability in the face of aging populations. If the economic crisis were substantially protracted, it could serve to exacerbate this challenge. But most economists think the crisis will abate in the next two to three years, which means that it won’t have any fundamental implications for the long-term solvency of social security systems. Of course, a bit of humility is in order here, since the bulk of the economics profession failed to anticipate the current crisis.

It’s certainly true that most of the world’s population is not covered by a pension plan. But that doesn’t mean that all of those people will suffer substantial hardship in old age, since the elderly can still rely on family networks, private savings, and continued work. The democratic process can be expected to exert pressure on public policymakers to initiate programs in the area of pensions. In addition, insofar as policymakers can strengthen market institutions, private insurers are more likely to perceive profit potential and offer pension services. Renewed, long-term economic growth will abet all of these processes. Economic development that is inequality-reducing would also likely play a positive role in addressing this challenge.

This is a complicated question. I would start by noting that there is no evidence or reason to believe that US immigration (documented and undocumented) will have an appreciable effect on the age structure of the US population. I would also point out that immigrants pay taxes, but they also receive social services. Finally, I question the basis for assuming that non-immigrant fertility will be low for several decades into the future. Insofar as non-immigrant fertility rises, we could see non-immigrant workers funding the pension receipts of retired immigrants.

Yes. See previous answers, which call into question the force that immigration will exert on population age structure in the US.

Demographic changes in Taiwan will tend to lower per capita economic growth. But the effect is not likely to come even close to overwhelming other forces that favor growth. Changes in policy that affect, for example, retirement, human capital accumulation (via education and health), and the labor force participation rate of women could further ameliorate the impact of aging on economic growth.

The main effect of global aging on sub-Saharan Africa will operate via increasing opportunities for emigration. Emigration will tend to reduce Africa’s surplus labor. It will also promote economic development insofar as emigrants send home remittances. At the moment, though, there is little basis for thinking these will be large effects for sub-Saharan Africa as a whole. They may, however, be significant for some particular countries, especially smaller ones.

As we’ve noted in the response to an earlier question, population aging poses challenges to the capacity of pension systems to maintain benefits at current levels of generosity. The conventional wisdom is that fully funded systems are the best from the standpoint of sustainability. However, Adair Turner, former chair of the U.K. Pensions Commission, has offered some compelling arguments against the superiority of funded systems as compared with PAYGO. See http://www.imf.org/external/pubs/ft/fandd/2006/09/turner.htm

With respect to the options they have for providing for the economic security of the elderly, the distinction between developed and developing countries is important. For example, the rich countries have relatively more effective institutional structures for transferring resources between income groups and between generations. This means that pension systems are much easier to design and implement in those countries. By contrast, poor countries are forced to rely more heavily on traditional family networks and continued employment by the elderly. The bottom line is that developed and developing countries will indeed have to adopt different approaches to providing population-wide old age economic security.

We should also not lose sight of the fact that the challenge faced (in terms of the elderly proportion of the population) is more formidable in the wealthy industrial countries – at least for the moment. But those countries can also bring to bear much greater resources to address this issue.

I agree that family networks are being subjected to increasing strain. The severity of this strain is likely to increase as a result of continued fertility decline and increased mobility within countries.

Under these and related circumstances, people typically look to the state to safeguard the well-being of the elderly. The substantial vacuum that exists with respect to pension and healthcare systems in many developing countries means that such institutions will need to be designed and implemented. It would be folly to design such institutions in the absence of an appropriate evidence base. The Health and Retirement Studies that are under way in more than two dozen countries (including India and China) offer a promising step in this direction. These studies will contribute to increased public consciousness about the situations and the needs of the elderly. In this way, they may be expected to help inform and catalyze a process of institutional development that has the potential to improve the well-being of the elderly. More generally, a set of policies and institutions that promote equitable economic growth will facilitate greater savings and will increase the government’s ability to effect transfers of resources. These are the most likely sources for pension funding and, I believe, the most likely scenario under which they will be forthcoming.

Many thanks to you. Your questions and comments (and those of the others as well) were terrific! I, too, would welcome further opportunities like this and, even better, meeting you in person.

With the support of NGOs and also donor agencies such as UNFPA and Population Foundation of India, a number of activities, using various media, messages about valuing girl child, and promoting various schemes towards education of girls are being spread. As a result, awareness about the Act banning sex determination test and female selective abortion has increased a great deal among people throughout the country.

I know of qualitative studies that have been carried out in Punjab, Haryana and Gujarat states, to understand social impact of adverse sex ratio, where the female deficit has been one of the worst in the country and which have historically practised other modes of eliminating girls. The available information is very limited based on case studies and so nothing generalisable can be discerned. But typically, in female deficit communities, girls are brought on payment from poor lower caste households, often from other regions. As a result, language, food habits, social customs etc. become huge issues. However, the few reports I have seen indicate that most girls do adjust over time, and accept the fact that their parents could not have been able to marry them well otherwise. Some girls have run away but once children are born, the women stay on. Another interesting thing that has been noted is that such women are not brought alone but other girls known to them also are married and so they have some companions from their own region.

The only strategy in my opinion that would in the long term work is start with children. The education material should be based on gender equality from the primary stage itself and designed very carefully. We have to inculcate the gender equality norm among children from a very early age and stage.

The age-specific sex ratio of India's population (knowing fully well that age misreporting and digit preference resulting from not knowing age are part of age data) has indicated that underenumeration of women is not a huge issue. The increase in deficit of girls between 1981 and 2001 cannot be attributed to increase over time in under enumeration. In my opinion, population count has improved over time.

I believe we have to work with children using whatever acceptable means that we can use to demonstrate that girls are as valuable as boys are. For this we have to start very early.

I am afraid yes, if the son preference persists and is not addressed through education and other mass media. Yes, also if the sex determination technology such as ultrasound imagery becomes widely and cheaply available, and if abortion becomes legal and the practitioners are willing to perform second trimester abortion at nominal cost. Abortion should be a woman's right but awareness among both medical fraternity and population should be created to avoid what has happened in India.

I am not aware of the article. What are the insights that Pongou provides? Available evidence I am familiar with indicates that sex imbalance in India results from parental preference for sons and not desiring many daughters due to social factors.

Banning sex determination test is not THE only remedy as is quite clear in the Indian case. Behavioural change leading to valuing girls as equal to boys is needed and that can be achieved through education that helps young people to internalise it from very early age.

The deficit of females in India has been convincingly explained by the prevailing neglect of girls and women after carefully examining all possible reasons or factors. The recent (from around 1981) steady increase in the deficit of girls is explained by the increase in use of female selective abortion once the sex of foetus is detected through use of modern medical technology. The traditional son preference is leading to take advantage of newer methods to avoid daughters.

I personally feel that laws or acts cannot go very far in changing the mindset of people. Gender sensitive education that starts at very early age that consistently conveys the message through examples that girls are equal to boys only can help inculcate the value of girls.

The age-sex distribution of population available from the decennial Indian censuses gives indirect estimates of the trend over time of the increase in deficit of women. However, given the fact that since 1994, India has passed an Act banning the use of medical technology such as ultra sound imagery to find out the sex of the foetus has made it very difficult to compile data on the extent of the use of the technology. Some hospital birth records from metro cities, where a large proportion of births take place in institutions, do suggest that the sex ratio of births is adverse to girls.

In India, where 50-60 percent of births still take place at home, it is difficult to precisely estimate sex ratio at birth. However, efforts to monitor all pregnancies in some states in small areas where the deficit of women has been pronounced, do suggest further deficit is arrested or there has even been some improvement. The ban on sex determination test may partly explain it but multi-pronged efforts to create awareness about the Act and also the value of girls also is responsible for it.

This is an interesting question. However, what has been estimated in the Indian context is that the sex ratio of the last birth is much more adverse to girls implying that when the couples have a son, after having had one or more children, they stop having additional children. The impact of this observation or evidence on the sex ratio of the population, to my mind, has not been estimated.

The Indian states where deficit of girls is quite pronounced are also the states which are better developed and have good road network and transportation facilities enabling rural women to travel to nearby urban centres to undergo sex determination test or abortion.

I have argued that unless we start changing the mindset of young children in schools, through gender sensitive text books, etc. I do not expect that we can reverse the situation very quickly or easily.

Within the states with adverse female to male sex ratio, it has been noted that the situation is much worse among those who are better educated, landed, belong to higher castes compared to those who are illiterate, landless, etc. The former group has the resources to obtain the needed services, also want smaller families with at least one son.

Women have the right to know about the development of the foetus in India. The ban is on informing them or their partners about the sex of the foetus. This ban is imposed because of the prevailing strong son preference and not wanting daughters, which can be eliminated in the situation where abortion is legal.

I believe that one cannot project on the basis of the current scenario that it will continue in foreseeable future. There are perhaps some self-correcting mechanisms that would come in force, there are efforts by governments and civil society groups to create awareness about gender equality norms which may impact the behaviour of some.

In India, more girl babies than boy babies are put up for adoption. However, 'selling' or adoption cannot be a long term solution.

First and foremost the confusion between abortion as a woman's right and a ban on knowing the sex of the foetus needs to be removed. Education about the value of girls in every sphere of life must start very early.

I do not believe that making rules about the use or availability of technology more stringent is the answer to prevent further decline in female to male sex ratio. Future developments in technology may even make it easier for women to know the sex of the foetus without going to an ultrasound imagery centre. I am even willing to venture a guess that lifting the ban on sex determination test altogether would not significantly worsen the female to male sex ratio.

The note should have said ban on sex determination test and not sex selective abortions.

It is difficult to enforce the law against sex determination test. There are loopholes, no matter how and how many one attempts to plug. However, a ban alone cannot bring about social or behavioural change. There is a law against giving and receiving dowry in India; however, the practice does continue.

Women have internalised gender bias to such an extent that the role of mothers-in-law in enforcing it is not very important.

I agree that due to discrimination, neglect in health care and a range of other factors, women experience both unnecessary mortality (that could be avoided) and also higher mortality than men at several ages. In fact, the age-sex specific death rates for India have shown that at ages from six months to almost the end of reproductive period, death rate among women has been higher than among men.

In spite of this understanding, the cause of death data suffer from many data-related problems and tend to be very tentative and are based on very small sample size. Efforts are being made to increase the sample, quality of diagnosis or reporting of symptoms leading to death.

Population size or population growth are not our only concerns. Balanced gender ratio is also important for a healthy nation. Births can be curtailed through means such as effective use of contraception also.

In developed countries, male death rate is indeed higher at most ages than female death rate. Analysis of cause-specific mortality data do give ample evidence of why that is the case. The higher mortality among men compared to women is not a result of discrimination, the way one understands discrimination, which results from bias and prejudice against one group.

The evidence from a few micro studies showing that the women from backward communities and women with little or no education have also been emulating those from higher castes in opting for sex determination tests suggests that there is some demonstration effect.

The federal or national law is applicable in the states and at the lower district levels also. However, certain states add more stringent action points to enforce the law or make it more effective. In 'better governed' states, enforcement is better than in poorly governed states. This applies not only to implementation of the ban on sex determination test but of many other laws.

Female deficit in India, for all the reasons that you mention has been known for several decades. Many have termed it as an anomalous situation. Added to this is the increasing use of medical technology, which has aggravated the situation further as evident from the sex ratio of children aged 0-6 years. I do not know of other reasons that can be singled out. Under enumeration of girls or women is often discussed in literature but it has been found not accounting for any significant impact. Sex ratio at birth in South Asia is not any different from that observed or reported in other countries to account for the deficit of women.

I do not think so. I feel that mankind can change its value system and behaviour by giving up son preference and value girls as much as boys.

Along with gender-sensitive education, provision of education to girls as much as given to boys is also important. Economic independence also helps. The question is how do we provide women greater access to assets and employment?

how would trafficking of women and girls contribute to their overall deficit at national level unless they are sent to other countries? We do not even have any estimates of the volume of trafficking to estimate its contribution.

Hi Issa. You have asked an interesting question. While many programs promote post-partum family planning, so often the attention shifts from the woman to the child during that time frame. Mothers may be likely to bring their children in for immunizations and well-child care, but less likely to return for post-partum care for themselves. To help avoid closely spaced pregnancies, programs should encourage women to return for postpartum care for their own health and to raise attention about family planning. However, they should also incorporate messages about family planning into antenatal care so that women have a clearer idea of what they will do to avoid a closely spaced, unplanned pregnancy.

According to the website of the “Maximizing Access and Quality Initiative”, very few women (3%-8%) want another child within two years after giving birth; and 40 percent of women in the first year postpartum intend to use a FP method but are not doing so. What a missed opportunity! Tale a look at the data from Jordan to see what is happening—I wouldn’t be surprised if there are a lot of postpartum women who are not using family planning and who are not ready to get pregnant again.

Hi Esther. In recent years, Rwanda has made some incredible advances in family planning. According to DHS, use of modern family planning methods has increased from 4 percent in 2000 to 27 percent in 2008. A number of factors are attributed to this incredible growth:

• Government commitment to family planning was especially important to getting things going. The President and members of parliamentarians recognized the importance of addressing rapid population growth and supported policies that would foster family planning. Addressing population growth was also incorporated into Rwanda’s poverty reduction strategy, establishing ambitious goals for to address population.
• Coordination among donors and partners also helped in leading to a common set of objectives. The government began to support the purchase of contraceptive commodities and created a line item for contraceptives in the national budget. Services improved through in-service and pre-service training, which contributed to a larger number of family planning providers.
• Performance-based contracts were also put in place as a way to motivate better performance at health facilities. Under this type of program, facilities receive payment based on achieving key targets, such as percentage of women counseled on family planning; percentage of deliveries in health centers; percentage of children under age five sleeping under insecticide-treated bednets.
• In addition to these factors that affect the availability of family planning, efforts to increase the demand for modern methods have contributed to contraceptive uptake. Messages related to responsible parenthood, good health and family development, and the economic benefits of smaller families have been effective in generating demand for birth spacing among Rwandans.

Regarding successes in male involvement in family planning, there have been a number of successful programs that have addressed male involvement in different aspects of reproductive health:
• The Male Motivation Campaign, implemented in Guinea, with the objective of reducing unintended pregnancy;
• The Men in Maternity Care, implemented in South Africa, with the objective of involving men in antenatal care; and
• Stepping Stones and Sonke Gender Justice are programs in South Africa that involve men in HIV prevention.

Dear Agunbiade Ojo,

I’m so glad you brought up this important topic! Having lived and worked in several sub-Saharan Africa countries over the years, I am very concerned about seeing so many of the same perceived risks, myths, and misunderstandings about contraceptives persist over the decades. There are several issues here: (1) understanding the potential benefits and risks of using contraceptives versus pregnancy; (2) the problem of a distorted fear of side effects; and (3) negative rumors and myths associated with contraceptive use that are unfounded.

Over the last decade, family planning in many sub-Saharan African countries has lost focus and resources amid shifts in development priorities. One casualty of reduced resources has been fewer (or less vigorous) information and education programs to inform the public and address misinformation about contraceptives. Revitalizing these programs, with a special emphasis on messages that directly counter rumors and accurately convey the potential benefits and risks of contraceptive use to the health of women and children could help. There is also evidence that women and their partners may be less knowledgeable and harbor more misinformation about long-term methods (IUD, implants) than short-term methods (condoms, oral and injectable contraceptives). Unlike short-term methods, there has not been as much marketing support for IUDs and implants to counterbalance negative myths.

Information efforts need to include comprehensive provider counseling programs that aim to counter misinformation during client visits, and more innovative ways of communicating the facts about contraceptives in general. Engaging well known champions who can discuss their own experiences with selected contraceptives and serve as local models is one approach that has worked in the past. Another may be to develop a compelling presentation or street theater show devoted to this topic that can serve as a point of discussion from national to village level, providing accurate information on different contraceptive methods and correcting the myths and rumors. It would be interesting to hear how others are addressing this issue!

Rhonda Smith

Hi Michael,
I completely agree that the links between family planning, economic growth, and poverty reduction have been largely lost from the debate. While the message that “family planning saves lives” is one that continues to play an important advocacy role in engendering support for family planning among selected audiences, it is not sufficient—particularly for high-level officials.

Promoting family planning from the economic angle does seem to be gaining some ground recently. USAID is once again supporting the development of RAPID presentations in several countries in sub-Saharan Africa. These presentations explore the impact of high fertility and rapidly growing populations on the investment needs of different development sectors, including the costs of meeting future needs in education, health care, etc. USAID has also just supported the publication of a policy brief entitled “Family Planning and Economic Well-being: New Evidence from Bangladesh (available at www.prb.org/pdf09/fp-econ-bangladesh.pdf) that shows how families in communities where an integrated family planning and maternal and child health program was implemented over several decades became wealthier (and healthier!) than families who lived in areas without the program.

In addition, we have found that one of the policy advocacy challenges in demonstrating the family planning/economic link is trying to show the short-term benefits of investing in family planning. Policymakers are often most interested in short-term results. Through private funding, PRB is attempting to convey both the longer-term economic benefits (“demographic bonus”) as well as some short-term benefits, especially improving economic well being and building assets at the household level in one generation. The project features multimedia presentations using new software technology (video testimonials, country comparisons). One of our participating countries in this new advocacy project is Uganda!

Rhonda Smith

Good question, as constructive male engagement has been a very important issue in the reproductive health/gender work for several years. There was a recent meeting in Rio de Janeiro, Brazil on the topic and I think there will be materials forthcoming—keep an eye on the website of the Interagency Gender Working Group (www.igwg.org) for upcoming postings.

That said, there have been a number of programs and studies that look at how to involve men more effectively in family planning and reproductive health issues. A recent assessment of several of these interventions identified “Together for a Happy Family”, implemented in Jordan, as one that is effective in engaging men in family planning and that works to transform gender norms. In addition to increased use of family planning, the intervention contributed to increased discussion between partners and shared decision-making about use of methods. Another effective program has been “Men in Maternity”, conducted in India between the Employees State Insurance Corporation and the FRONTIERS Project. This project led to greater couple communication about FP/RH decisions, increased use of post-partum family planning, increased knowledge of condom use for FP and dual protection, and higher levels of client and provider satisfaction.

I encourage you to look on line for additional information and contacts for both of these programs. These and other similar programs may provide good examples of how to improve men’s involvement in FR and RH issues.

Dear J. Kishore,
Yes, education and higher levels of family income are linked to lower birth rates. Although education and income typically drive down fertility levels, they don’t take the place of family planning methods or the need for strong family planning services today. I agree with you that some health providers may not fully understand the benefits of family planning or the importance of including family planning as an esssential component of women’s broader health care needs. It is also of great concern that so many women have an “unmet need” for family planning. These are women who say they want to space their births or avoid having any more children, but are not using any family planning methods. Studies show that as many as 200 million women in developing countries have an unmet need for family planning, and one of the consequences of this “unmet need” is large numbers of unplanned pregnancies.

Reaching women and their partners who have a stated need is the first step in reducing unplanned pregnancies. While ensuring access to family planning services is one dimension of this challenge (services close to home, variety of methods, congenial setting, low cost, few barriers to eligibility), women and their partners also need information and they need to be encouraged to discuss family planning. Strengthening community education and behavior change programs is crucial. Within the health system, taking advantage of every opportunity to integrate family planning into other heath services (maternal and child health, HIV/AIDS services) is another essential step, with the integration focus on no missed good opportunities!

In reference to your comment about the increasing numbers of unnecessary Cesarean section in urban settings—this is alarming for several reasons including the shift of resources to non-essential interventions in resource-poor settings and the additional health risks to mothers and newborns following a cesarean section. We have the same problem across the country right now in the United States. Although clearly beneficial and life-saving in selected circumstances, the absolute indications for cesarean section apply to only a small proportion of births. Reasons for the increase appear to rest more with professional styles and practices rather than the health needs of mothers or babies. If you are interested in more on this topic, see: http://www.childbirthconnection.org/pdfs/evidence-based-maternity-care.pdf; and Community factors affecting rising caesarean section rates in developing countries: An analysis of six countries, Social Science and Medicine, Vol. 67, Issue 8 October 2008, pages 1236-1246.

Rhonda

Hi--The Reproductive Health (RH) costing model is designed to help countries estimate how much it would cost to scale-up a basic package of reproductive health services - ranging from family planning, antenatal and delivery care to emergency obstetric care and STI treatment - from current to universal coverage levels. I have to say that I am not familiar with it. However, I am familiar with the SPECTRUM Suite of models, which includes modules on demographic projections, effect of family planning, HIV, and safe motherhood. The safe motherhood model includes input on costs of different types of services, and builds on the demographic and family planning modules. SPECTRUM can be used to estimate reductions in maternal mortality ratios based on interventions selected and budget amounts. Scott Moreland and colleagues at Futures Group used SPECTRUM in their analysis of how reducing unmet need for family planning can contribute to achieving the MDGS, including the reduction in maternal mortality ratios. Sorry I can’t answer your question about the RH costing model, but I hope pointing you in the direction of SPECTRUM will provide you with a useful tool as well as a way of comparing results obtained from the RH costing model.

Jay

Dear Huma,
Although we have no way of knowing for sure what the effect will be in 50 years, we can speculate on the following:

Between now and then, the fertility rate will determine the degree of population aging in Europe and the US. Over the next few decades, Europe’s and the U.S.’s population structure will change substantially. The baby boom generation (1940s to mid-1960s) will gradually move into retirement, swelling the ranks of the over 60s. Aging is most advanced in Europe where the number of people 60 or over surpassed the number of children a few years ago. By 2050, Europe could have twice as many older persons as children. The U.S. still has a larger number of children under 15 than elderly today, so the population will not age as quickly.

In Europe, the fertility rate will greatly influence the degree to which populations decline in size in many countries. The majority of European countries are well below replacement level fertility (2.1), which signals a continuing decline in population size, as compared to the U.S, which is at replacement level. The exceptions are France and some of the northern European countries (Denmark, Iceland, Norway, Sweden) where the current total fertility rates are around 2.0 and similar to the current fertility rate of the U.S.

The fertility rate will also influence the degree of shortages in the labor force, leading many European countries to consider increased immigration.

Rhonda

Dear Bhola Koirala,

Thank you for your question. It is not always easy to see the direct link between family planning and women’s health. While most women welcome pregnancy and childbirth, the risks of illness and death associated with these events are very high in some parts of the world. In developing countries we know that a woman’s lifetime risk of dying due to pregnancy and childbirth is 1 in 75, or almost 100 times higher than in developed countries where the lifetime risk in only 1 in every 7,300 pregnancies and childbirths.

Lack of access to good prenatal care and delivery services plays a big role in the health outcomes of pregnancy and childbirth. But we have also learned that family planning could prevent as many as one in every three maternal deaths by helping women to avoid high-risk pregnancies that are:
- too early (girls under the age of 18 face a higher than normal risk of death or disability from pregnancy)
- too many (women who have had many babies are more likely to have problems with their later pregnancies, and face increased risk of complications and death).
- too late (women over age 35 have a higher than normal risk of death or disability);
- too frequent (women who have babies too close together have a higher risk of illness and death. Woman should wait at least two years after giving birth before trying to become pregnant again. This birth interval protects the health of the mother).

Research also shows that may women who are not using family planning and have unplanned or unintended pregnancies, turn to abortion. Since abortion in not legal or is still highly restricted in many countries, women turn in desperation to persons lacking the necessary skills to safely conduct an abortion, or who work in an environment lacking the minimal medical standards, or both. Tragically, many of these unsafely performed abortions lead to disability and death. If more sexually active women who want to avoid unplanned pregnancies and high-risk births were using family planning, many more lives could be saved.

Rhonda

Hi,
One of the ideals that emerged from ICPD was that women and men should be able to choose the timing and spacing of their children, and have access to family planning methods that help them achieve those goals. This idea puts women and men into the role of decision maker about reproductive decisions. Information about the health benefits of family planning can also help inform their decisions, as can evidence that shows the importance of family planning as an important part of poverty reduction strategies. Globally, women and men are increasingly recognizing the costs of children and the economic benefits of having fewer children.

Most family planning and reproductive health programs focus on having fewer children and avoid setting targets, such as 1-2 children. In a country with very high fertility, it’s likely to be difficult to persuade people to have 1-2 children; however, they may see the benefits of having fewer children. Ultimately, it is the choice of the woman and man to decide, but information about the health and economic benefits of family planning can be useful for helping people with the decision.

Jay

Dear Subhas Yadawad,

Family planning means planning when and how many children to have and how to prevent unintended pregnancies. It covers areas as varied as when and why to get pregnant, the number of children that are wanted, what to do when an unintended pregnancy occurs, and the types of family planning methods to use to delay, space, or avoid a pregnancy (modern contraceptives as well as traditional methods).

Essential components of family planning programs include counseling clients on all available methods of family planning, the provision of contraceptives, follow-up and referral systems for all clients, maintaining adequate records for each client, supervision of all providers to ensure that client needs are met, and maintaining an effective logistics and supply system for contraceptives.

Family welfare generally defines a broader set of issues and needs. Family welfare programs can include the provision of basic human requirements such as food, clothing, and shelter as well as the provision of health care services or other critical social sector services such as as care of the elderly, education, sanitation, etc. Family planning services could be supported under a broader family welfare program.

I hope this provides some clarity!
Rhonda

Hi—and thanks for an interesting question. While we often focus our attention on family planning, we usually put it in the context of a broader reproductive health framework. Your point about integrated programs makes a lot of sense because it allows all of the woman’s reproductive health needs to be handled through the same program. I recently heard an interesting fact: if a woman who wants to have four children, she will spend 16 years of her reproductive life avoiding pregnancy; which suggests that there is a long time—and many opportunities—to have her become a client at a family planning program. With an integrated program, there are more opportunities to reach women with antenatal care, delivery services, and postpartum care. Another important aspect of an integrated program is that it can provide more comprehensive information; for example, including information about family planning during antenatal care is an important time to reach women who experience an unplanned pregnancy—especially in places where use of postpartum care is low. And you are right again about quality being important—if services are poor quality, what incentive is there for clients to return?

I also appreciate your perspective about multidisciplinary teams working together in designing health programs. A combination of medical, social science, communications, and administrative staff all have complementary roles in creating and operating health programs.

Jay

Hi Agatha,

This is a good question! Early childbearing poses serious health risks. Maternal death rates for young women ages 15 to 19 are twice as high as for older women. Children born to adolescent mothers also face higher risks of illness and death than those born to mothers in their 20s.

Research shows that lack of information, fear of side effects, and other barriers—geographic, social, and economic—prevent young people from obtaining and using family planning methods. Other studies in sub-Saharan Africa (including Nigeria) reveal that nurses’ attempts to stigmatize teenage sexuality, their scolding and harsh treatment of adolescent girls, and their unwillingness to acknowledge adolescents as contraceptive users, also undermine the effective use of contraception by girls. Youth need better information on reproductive physiology and sexual health, and detailed information on contraception. They also need youth-friendly services and providers who are open and willing to serve youth with respect as clients.

For teenage girls and BOYS(!), experts in the field believe we need to be much more proactive in reaching out to young people, taking the messages and information to where they are—schools, community groups, clubs, churches. One example in Nigeria is the “Kyautatawa Iyali” or Family Welfare Project in northern Nigeria state. Since 2001, CEDPA (a U.S.-based NGO) has supported a program to improve reproductive health. Working hand-in-hand with faith-based organizations and community groups, the program engages families and entire communities to recognize the benefits of family planning for improved health and the need to meet the reproductive health needs of young people. A hallmark of the program is the delivery of door-to-door information and services to families and youth. If you are interested in finding out more about this effort go to: http://www.cedpa.org/content/news/detail/1993

~Rhonda

Hi--Historically, countries that have gone through the demographic transition have started with reductions in infant and child mortality, which contributes to population growth during that window when fertility remains high. Basic child survival interventions have been around and are generally accessible, and we have seen that infant and child mortality has decreased.

Poverty in urban areas is likely to lead to smaller fertility because parents see the costs of raising children—food, clothes, education, etc. Your point may be focused more on rural poverty, where children may provide labor for the family’s livelihood. But even in most rural areas, families also experience costs associated with raising children. As family lands get subdivided through the years, what might have supported a larger family is likely only to support a smaller family. Larger families may not be as feasible as they once were.

As you point out, family planning contributes to saving lives through reducing high-risk pregnancies—it saves the lives of mothers and children. I have seen evidence about the toll that maternal mortality takes on child mortality—that if a mother dies, her infant and children are much more likely to die. In the more usual case of the mother surviving child birth, family planning contributes to saving lives of children through promoting birth spacing, reducing the number of birth to young women, older women, and women who have had many children.

One final comment—recent research from the rural area of Matlab, Bangladesh indicates that long-term investment in family planning and maternal-child health also contributes to economic well-being of families and communities. So not only is family planning a “best buy” health intervention, but it is also an effective part of poverty reduction strategies.

Jay

Hi--The memories of the women you talk to may be clouded by what they remember or were told, and not necessarily informed by what actually happened. You can start by telling these mothers that there is new evidence that indicates that early marriage and childbearing is detrimental to the health of women and children. In Family Planning Saves Lives, we present a lot of evidence about the health benefits of family planning—for birth spacing, HIV prevention, and reducing abortion rates. As you point out, there is also the financial/economic case to be made, too. Costs associated with raising children today—health care, education, food, etc—are higher than they used to be. You also mention the social implications of family responsibility—I think you can also tie population growth to environmental degradation, which has en effect on communities, countries, and the world.

Let me also point you to a tool that may be useful for reaching different groups about family planning. Repositioning Family Planning: Guidelines for advocacy action is a recent publication that includes a set of briefs on focusing attention on family planning. You can find it online at http://www.prb.org/pdf08/familyplanningadvocacytoolkit.pdf.

Jay

Hi--We found the calculation in a publication by the Guttmacher Institute--Unintended Pregnancy and Induced Abortion in Uganda: Causes and Consequences. I'm glad you found it interesting--we did!

Hi Paige,

Here is a technical brief that provides examples of successful programs in which mid-level providers have been trained to insert IUDs and implants, and to provide tubal ligations: http://www.fhi.org/NR/rdonlyres/erkqubqp3hh3hvt6fhp4zvp64ocu2tazrxypd3lxvv2hntamiv5qf54ervujpmgfpsusrlouvgfbep/LAPMbrief4.pdf

While mid-level providers have been trained to successfully insert implants, there is evidence that training more skilled providers in IUD insertion may be a better approach. While in principle someone with minimal training can insert an IUD, in actual practice such providers may lack the proficiency or may lose them rapidly wiout a large volume of IUD clients.

Having said that, I should add thay a group that focuses on long-term and permanent methods may be in a better position to answer the pros and cons of these policies than we are. Family Health International has done a significiant amount of research in this area.
Rhonda

The most important change would be an increase in warm and wet areas allowing malaria-transmitting Anopheles mosquitoes to flourish. Warm and humid temperatures favor a shortened time for the parasite to develop within the mosquito--and a longer life for the mosquito to live, bite and infect people. Of course, more rainfall increases places where Anophelines can lay their eggs. A recent example is the increasing elevation where malaria is transmitted in the Kenya highlands and on Mount Kilimanjaro in Tanzania.

The use of fish that eat Anopheles larva for malaria control has been widely studied and used in many pilot projects. Experiences in India and nearby countries have shown that the approach works best in urban areas and elswhere where there are large ponds or other mosquito breeding sites. Use of local fish species that adapt to and replicate easily in the environment is better than importing the fish. Care is needed as some types of larvivorous fish eat other fish--and humans also like to eat some species of the fish! In Africa, Anopheles msosquito breeding sites are many, small, and widely dispersed providing a challenge to this type of approach.

This question is key, Rahat. Despite the challenges, there are scientific, operational, financial, and political solutions to malaria control and elimination, and they are being implemented. Communities at risk must participate in malaria programs--assuring compliance by taking their drugs, using and maintaining their bed nets, participating in spraying of houses and understanding why. Presidents of endemic countries and ministers have met to establish global and national goals. Is essential that the current tools for malaria are affordable--free in many low-income countries--and that research for new drugs, insecticides, and vaccines is well supported financially. Perhaps most importantly, we need to train many more malariologists and others--in clinical, service delivery, managerial, laboratory, and research disciplines to confront the huge malaria problem.

Great, Kakaire. Each African child has 4 to 12 fever episodes a year--about half or more due to malaria in some areas, but variable, especially with the success of control programs. We would soon run out of the artemisinin combination treatments (ACTs) and other drugs if every such event received treatment--resistance would also be a concern. Microscopic exam of blood is good in health units with careful supervision, but not readily available or precise in most endemic communities. Rapid diagnostic tests (RDTs) for malaria parasites are simple to do and give immediate results. Yes we need to get the price lower than about $1 per test. Most importantly, major efforts need to be made to improve the lab and clinical diagosis to find out what causes all the febrile conditions--many of which are life threatening--and treat them properly.

There are many reasons why high-income countries are getting interested in malaria because it is mutually beneficial to do so. On a basic level, ten of millions of travelers go from rich to poor malarious countries for visits or to work. A healthy workforce in endemic countries provides opportunity for successful investments. Successful malaria and other disease control programs add to social and political stability. The fact that 1-2 million children die yearly from malaria--perhaps 150 to 300 an hour, has finally got some attention. I think it is very wise to subsidize malaria treatments. The new Affordable Medicines Facility for Malaria (AMFm) advised by a committee convened by the U.S. Institute of Medicine is finally getting off the ground.

Dr. Manuel Pattaroyo and collaborators in Colombia have been working several decades on different types of vaccines against malaria. The early vaccines were synthetic peptides directed against the blood stage of falciparum malaria. After initial promising highly publicized results in the 1980s, the vaccine did not prove immunogenic or protective in Aotus monkeys, the animal model for P. falciparum. More recently, Dr. Pattaroyo is working on P. vivax vaccines and is again enthusiastic about a subunit-based, multi-antigen, multi-stage product.

This is not my area of expertise. For part 1. Obviously, within each country the malaria control program or central pharmaceutical office can give some guidance. To find which malaria medicines exist in which countries try UNICEF, the Roll Back Malaria (RBM) Partnership, and the U.S. President's Malaria Initiative (PMI)websites. For part 2, major funders are the Global Fund For AIDS, Tuberculosis and Malaria (GFATM), and the PMI, along with bilateral support from USIAD and many other nations--and contributions from the Gates Foundations and many NGOs.

Effective use of biological larvicides have been the major tools for the successful onchocerciasis control program where the black fly breeds near flowing rivers and streams. I am familiar with Bti but not Bsph. As mentioned above, Anopheles breeding sites in Africa are many and widely dispersed--some may be as small as "the hoof print of a cow". I think that there may be some use in breeding sites near urban, periurban areas, refugee camps, construction sites. Research will be essential, not just on entomological indices of effectiveness and transmission, but on the impact on human infection and disease as well as on the social aspects of community acceptance, and toxicity if the product to fish, animals and humans if ingested. Develop a strong and clear hypothesis, Erica. Seems a good research project.

Correct, Dr. Alumah. That is why bed nets, insecticide residual spraying, and environmental management (draining and filling pools of water), particularly in urban/periurban areas is crucial. Also, intermittent preventive treatment (IPT) of pregnant women (IPTp) (and, possibly, children) is an important prevention because this combats low birth weight due to malaria infection and maternal anemia and mortality from hemorrhage. Most countries have preventive policies for malaria and are trying to increase their coverage and use rates. Intensified research on drugs and vaccines to interrupt transmission is essential

Important, questions, Sophia. 1. Work has gone into this by several manufacturers. The newer long-lasting insecticide treated nets (LLINs) should help respond to the need and be the only products now used. 2. Sustainability is always key and donors and countries and communities should have a long-term (more than 5 year) time frame to assure good nets. They are an essential public good--everyone benefits if one family uses the nets 3. 21 countries still have malaria in the Americas, but true, there is less of it and many countries are near elimination. Insecticide residual spray, prompt treatment of presumptive malaria cases, environmental management, and superior surveillance systems were/are important as well as continuing economic prosperity and political stability. I agree with your resounding call to arms!

Get, use, and maintain your long-lasting insecticide treated bednets, keep your compound and community free of mosquito breeding sites, respond to any fever episode by taking your family member to a health worker right away. Find out what your government and local non-governmental organizations are doing to combat malaria and ask how you can help them do a better job. If they are not doing anything demand that they do so with your village or community committee.

Tanzania has one of the most successful bed net producing factories and the manufacturing site is receiving support to assure a high grade product in large quantities. this can serve as a model. Research on local products as insect repellents and insecticides has occurred in many endemic countries and ICCIPE in Nariobi, Kenya is a leader in this area.

I am sorry I don't know which "nouvel" drug you are referring to. Malariologists now agree that combining drugs for treatment (as done for HIV, tuberculosis and many cancers) is better than using a single drug. Each drug has a different chemical action on the parasite, thereby decreasing the chance of resistance developing to any of the drugs. This is the basis of ACT to treat malaria, where artemisinin (derived from a plant/Artemesia annua and known to the Chinese for centuries as a cure for "fever") is combined with lumefantrine, sulfadoxine-pyrimethamine, amodiaquine or other drugs.

Exceedingly important, Lily--and I am not an expert by any means. UNICEF is. Creativity will be essential to getting the new antimalarials to "the end of the road" and "where there is no road". I don't have the answer... I usually go to the people in the country, in the community, in the household, and ask them how essential medicines get to them and, most importantly what motivates proper use. I would find out if and how oral rehydration salts, antipyretics, condoms, and other health needs are distributed. I would go to the local dispensaries, pharmacies, patent medicine stores, village markets, private/NGO/business clinics and see what they are using and how they receive their meds. There are different systems of distribution, formal and informal. Two problems, partial dosing and sham drugs need attention, the former could be addressed by having blister packets with all drugs combined in one tablet if possible and the daily regimen illustrated on the packet for dosing children and adults; for the second, control of quality needs building into the purchase, receipt, and distribution system. Newer drugs are being developed and tested: the process is long (the FDA just approved artemisinin-lumefantrine for in adults in the U.S.). The ominous finding of decreased sensitivity of falciparum malaria to artemisinin (not ACTs)in Cambodia mandates that the WHO ban on monotherapy/repeat monotherapy with artemisinin compounds be enforced more strictly and that development of newer antimalarial drugs be accelerated. In particular, drugs that interrupt transmission by acting on gametocytes and their maturation should receive priority. The new AMFm plans a novel approach to bring ACTs prices down by subsidizing bulk purchases and flooding markets with good products at fixed affordable prices for countries (perhaps free for patients). see above. The Clinton Foundation has been successful in negotiating lower prices for such essential drugs. We can learn from the HIV/AIDS, tuberculosis, diarrheal diseases and other programs on this one.

Some of this was discussed above:
The strategies are provision and use of: drugs to treat patients and prevent disease (IPT) in pregnant women and children (being evaluated); personal protection with LLINs; classical vector control with IRS, larviciding, drainage and filling of anopheline breeding sites, and other environmental management steps; research to develop new tools and assure the current ones are used optimally; for this, surveillance/monitoring of human disease and core entomological and parasite indices is needed, including resistance testing; and, long-term funding and collaboration. Sustainability requires training and support of large numbers of malariologists--for operations and research. Community understanding, and their active participation in every aspect of the control program is essential for elimation and eradication to be reached.

Some boundaries are well-established (Baby Boom from 1946 to 1964)--others are new but fairly similar to those used by Strauss & Howe a generation ago. The basic criterion was fluctuations in the birth rate/birth totals, so that boundaries set off large and small generations from one another following the logic of Easterlin's "Birth & Fortune" book. Some historical events help define boundaries, but these also often influenced birth rates so it all works together. Details are described in the 2nd chapter of "The Lucky Few: Between the Greatest Generation and the Baby Boom."

The PRB Bulletin on "20th Century U.S. Generations" doesn't go into a lot of detail on number of brothers and sisters by generation; it looks mainly at the presence of parents in children's homes as far as childhood goes. The Lucky Few (the book) does have a graph and a discussion in chapter 3 on number of children in families, including one-child families (which were particularly numerous in the Lucky Few generation).

The trick with international comparisons of generations (especially when using demographic criteria like numbers of people in each year of age) is that the birth rate fluctuations and episodes of mass migration that have affected some countries were not always at the same time or of the same duration or magnitude in different places. The MOST replicated one would of course be the baby boom heard 'round the world at mid-century, but even that didn't really get everywhere--Eastern Europe pretty much skipped that postwar boom, or at least postponed it a decade or more. I haven't looked into it, but I'd also bet that the small Lucky Few generation born during the Great Depression and World War II years could be found in many countries all over the world.

Hi, Fran! I'm so glad to see your question here! I did play around with some sub-dividing of generations (as have some of our colleagues, who have talked, for example, about the "depression kids" and the "wartime babies" as separate groups within the boundaries of the Lucky Few). But I've tried to resist the temptation to make every single annual birth cohort into its own "generation"--the logical end-point of such dissections. The generations in this PRB Bulletin are about the same length as those sketched (a GENERATION ago!) by Strauss and Howe, and have quite similar boundaries as well, even though the dividing line criteria were different in the two approaches and developed independently. But yes, I'd agree that such boundaries are only as good as the subject you are addressing with them. Since I was looking first and foremost at the demographic dimensions of generations, grouping together large and small series of annual birth cohorts seems to give the most "bang for the buck." I have heard the criticism that President Obama, for example (born on the cusp of the END of the Baby Boom) is hard to include as a Boomer, while Presidents Bush and Clinton were definitely, clearly Boomers. I guess one shoe never fits all feet, does it!?

This is a very interesting question, but I have absolutely no idea what the answer may turn out to be. Maybe YOU have access to some wonderful data set that collected this kind of attitudinal information far enough back into the past so that we could actually compare many generations and answer the question? The trouble with so many of the issues I wanted to address with this study of generations is that we've only started to collect so many kinds of detailed information in the quite recent past, and so we can compare Generation X and sometimes Baby Boomers on a lot of dimensions--but as soon as we start trying to go back to the Lucky Few, or Brokaw's Greatest Generation (who I called the Good Warriors) we rapidly find ourselves staring at a blank canvas with no data in sight. I would be fascinated to find out this answer somehow, though!

Your idea about RELATIVE circumstances, comparing what you find as an adult with what you were expecting based on your childhood experiences, is precisely the concept that lies at the heart of Easterlin's book Birth and Fortune; he uses it to explain why the Lucky Few became parents of the Baby Boom. Personally, I would probably define "lucky" in the same way that most other Boomers like myself would--and it would be in many cases by looking at what we in the Baby Boom lost out on--plenty of space in the classrooms while we were in school, easy entry into careers with lots of people crowding around to offer us jobs, unexpected good fortune in early adulthood that led to the earliest marriages and most universal parenthood of any generation in U.S. history, widespread access to defined-benefit pension plans provided by companies that actually survived long enough to deliver on them, and so on. In short, the things that the Lucky Few enjoyed and the Boomers saw evaporate before their eyes. On the other hand, though, women's education advanced dramatically in subsequent generations, each new generation is living longer than the previous one (with less disability in old age)--one of the caveats we probably have to take away from this subject is that each generation re-defines "lucky" based on their own era and their own world-view!

Using 1964 is certainly not the only possible boundary (see questions above) and every boundary will bring up anomalies. Latchkey arrangements actually started pretty early, though, when mothers of school-age children headed into the labor force in response to incredible demand from a growing economy (see the work of Valerie Kincaid Oppenheimer in particular). I'd guess many Boomers, not just the last few, shared some of the experiences you're talking about. There IS a pretty clear boundary between the boomers and Gen X based simply on generation size, though, and in a lot of way, "size does matter." Richard Easterlin's wonderful little book, Birth and Fortune, outlines a very large number of such systematic differences, ranging from individualized personal attitudes to macro-economic conditions like the unemployment rate, that can usefully be defined in terms of these generations and their boundaries.
Further, however, there's also another answer to your question--there are at least two COMPLETELY different ways to define generations, in addition to birth year. The PRB Bulletin mentions one of these--the "family generation" that is individual and unique for each parent/child dyad, and does not translate into any kind of larger patterns in the population, would be one of these alternatives. The other alternative, NOT mentioned in the Bulletin or in my book The Lucky Few either one, is an unusual hybrid of these others: when we study immigration, it is the migration event itself that defines "generations" rather than birth year, and we talk about "first-generation" immigrants, their "second-generation" native-born children, and even the "1.5 generation" of people who came into this country as small children accompanying their parents. Here the timing of the border crossing trumps birth year in defining generations!

Thank you, Ladi--what generation are YOU, by the way?

Every country has periods of high birth rates and/or rapid immigration, and periods of declining birth rates--these demographic swings can produce fluctuations in the sizes of successive generations in India as anywhere else. Just look at an age-pyramid of the Indian population, and you will see "bulges" of large generations and "gaps" where smaller generations occur. This changing supply of people can have dramatic effects on the lives of the people involved.

At least two of the previous questions above were on this same topic; the comments I offered for those questions are also relevant here. Please see the earlier comments?

Richard Easterlin originally thought that the small size of Generation X would work to the advantage of its members, and it may actually have done so. However, the record for Generation X (continued marriage delays, few children born later in life, problems with men's careers, and so on) testify to the importance of OTHER factors in addition to just generation size. We don't live in a "ceterus paribus" world where all other influences remain unchanged, and things like an economic melt-down are bound to enter into the picture as at least as important as generation size! The New Boomers are now in school, with the oldest of them just starting to emerge and look for jobs and careers. They are the biggest generation so far in U.S. history, and this is not the best of times. It seems like we can make some pretty solid guesses about how that will work out, and personally, I don't like the look of it very much.

This is a fascinating question, and one that gets more complex the longer you think about it. The waves of immigrants in the mid-1800s probably would NOT be the luckiest--many of them ended up fighting in the Civil War for the Union army. The even larger wave of immigrants who poured into the country at the beginning of the 20th century might be good candidates for "luckiest," as they came to a country still actively expanding across the continent and "filling in" the population of the Great Plains and the West; life was unimaginably better for them than the world they left behind.
On the other hand, maybe we should call the people who have come to the United States in the quarter-century and a little more after the mid-1960s the "luckiest," for they had the good fortune to be trying to immigrate when the old racist quota system was demolished, and new opportunities for entry brought millions of people here in time for the long post-war economic "boom times." It's a tough call! What do you think?

I have the sizes of each generation immediately available (in spreadsheets) from all of the censuses of the 20th century down through the census of 2000, and for a lot of the years in between after 1962 when the Current Population Survey begins to be available as an on-line resource. In fact, YOU also have these figures available to you, thanks to the Integrated Public Use Microdata Samples prepared at the University of Minnesota, and available to all of us as a public resource over the internet.
I have NOT done any population projections of these generations; that's an exercise in creative writing that I haven't yet had time to consider. I did use existing projections of estimated mortality rates to calculate how many people in the various generations would be alive at age 70, including Boomers and younger folks who aren't there yet, so I could do the last couple of sections of the PRB Bulletin and the last chapters in The Lucky Few.

Sandy, I certainly hope so! We are learning more about many different kinds of disabilities every day, and the more we learn, the more disabilities we are discovering throughout our society. Along with this greater sensitivity, some trends like the increasing prevalence of obesity and the cumulative effects of drugs and alcohol mean we have a rising share of our population in each new generation with some kinds of identified disabilities. Unless we make up our minds to allow everybody chances to become productive citizens, we will never be able to handle all the new kinds of problems we are learning to identify.

Sometimes a wonder whether I'm "lucky" to be linked so directly to so many people through my computer and my cell phone, but when I consider the alternatives, YES, I think you're right about that. And there is a very clear generational divide in terms of understanding and feeling comfortable with a lot of this new technology. John McCain wasn't comfortable with emails. My mother has said more than once that she feels "left behind" by all this technology that she will never learn how to use. The same advantages (or disadvantages) can be found layered within each generation in terms of education/class/ethnicity differences, but the generational dimension of this contrast is a very important one.

You have zeroed in on my current research, Ashley! The shift in college attendance/graduation has been incredible over recent generations. For the Lucky Few, three men went to college for every two women. In Generation X, it is three women for every two men. There is a lot of research out there right now on WHY this switch has occurred; most of it has been looking at the changing occupations and wages available to men and women, or on the changing attitudes of their parents about college for girls and for boys in each generation. But I like your point more, and I believe that the reversing educational gender gap is very much related to the equally great change in reproductive choices. Now you tell me, which is the chicken and which is the egg? Many scholars are still scratching their heads over that one!

Which years are you talking about, John? What year was the study you mention, and does "this year" mean 2009?

Your question, together with John's previous one, highlights an important difference--between birth TOTALS and birth RATES. We had a lot of babies last year, but mainly because there were so many people in the parenting ages. The actual RATES for women at each specific age are still not very high at all in historical terms. And the New Boomers are already the largest generation of Americans ever in history, not only because they are the "echo" of the Baby Boomers finally having their own children, but also because of all the immigrants who are once again arriving to "leaven the loaf" of American society.
Harriet, I may have a rather unorthodox attitude about population size and ecological sustainability. I believe we CAN live in balance; indeed, that we must! But I also think that there's still room for more people in America, and that we can grow some more in ways that will actually make our world MORE efficient, clean and environmentally sound, rather than worse. We can't add people indefinitely, of course, but if you've been to Europe and come back to the USA, you realize that this country is still mostly empty.

I add my thanks as well, to all the interesting people who joined in and contributed their questions. See you all in cyberspace, I hope!

Let me start by defining birth defects.
A birth defect is a structural or function abnormality that is present from birth.

The causes of birth defects are divided into;
i. Genetic or preconception causes- chromosome abnormalities (numerical or structural), single gene defects and multifactorial congenital malformations.
ii. Fetal environmental or post conception causes. These include teratogens and constraint)
iii. Presently unknown causes

Some birth defects are diagnosable at birth or shortly thereafter, e.g. spina bifida, Down syndrome and cyanotic congenital heart defects. Other birth defects present later in life. Examples include cystic fibrosis, haemophilia, Huntingdon disease, and some congenital heart defects.

With prenatal screening & diagnosis, which should be undertaken after appropriate counselling, certain birth defects are diagnosable in utero. Common examples include major structural abnormalities, Down syndrome and neural tube defects (spina bifida, anencephaly and encephalocoeles). There are many others.

The risks to the fetus of the prenatal diagnostic proceedures (amniocentesis, cordocentesis and chorionic villus biopsy) are operator dependent but usually small.

If a birth defect is diagnosed in utero there are very limited examples of fetal treatment and cure. In specialised units some fetal surgery has been successful for congenital malformations like diaphragmatic hernia. In the case of a mother diagnosed syphilis positive in pregnancy she can be treated with penicillin and this will cross the placenta and also treat the fetus if it is infected. Fetal blood transfusions have been successful in treating anaemia in fetuses affected by blood, particularily rhesus, incompatibility.

However, for most birth defects diagnosed in utero the parents should be offered genetic counselling to fully inform them what the problem is, its cause if known, and what therapeutic options are available to them. These are most often limited to continuing the pregnacy or the offer of selective termination of pregnancy, if warranted and legally available in the country. Counselling should also inform the parents of the risk of recurrence of the problem and how this can be reduced or avoided in future pregnancies.

The maternal effects of alcohol abuse are well described. Fetal alcohol Spectrum Disorder (FASD). The worst component of this spectrum is fetal alcohol syndrome (FAS). Affected individuals have growth retardation, including microcephaly, intellectual disability usually in the mild mental retardation range, behaviour problems which can be severe, and a recognisable pattern of dysmorphic, particularly facial, features.

Todate no physical affects of paternal alcohol abuse have been described, but this is asubject of research. However, maternal alcohol abuse is associated with paternal alcohol abuse.

How best to inform 'potential' parents of these effects. Firstly, the ideal is to inform 'potential' parents in an effort to ensure the parents stop drinking before conception, thus ensuring the problem does not occur. How to do this? Much work is ongoing in this field and the approach needed is probably country, regionally, culturally and individually specific. Certainly a broad based approach starting with community education from school age and through is needed, combined with an individual approach with counselling during opportunities such as family planning/pregnancy prevention and periconception care consultations.

I am not an expert on autism or autism spectrum disorder (ASD). My understanding of the aetiology is that most cases have a strong genetic basis and are considered as a complex multifactial disorder. However, X-linked forms of the disorder are described (OMIM). Autism has also rarely been described in some children affected by teratogens (e.g. in Fetal valproate syndrome)

An increasing prevalence of autism over time has been described in industrialised countries as well. A recent review noted that the prevalence of ASD in the 1950s was 4/10 000 and this has risen to
40-60/10 000 now. No absolute reason for this has been given but consideration is given to the probability that increase public and professional awareness and better diagnostic capability has played a significant role in this increase. I must presume similar factors are at work in India.

You raise an interesting issue.

In my country, South Africa, as I suspect is the case throughout much of the developing world, most newborns are dischared from hospital or clinic within 24 hours of birth, because of pressure on maternity beds. And they are not assessed before discharge by a trained competent professional (primary care doctor or nursing sister/midwife). That is why only 16% of infants with Down syndrome are diagnosed during their newborn hospital or clinic stay in South Africa.

So infants with potentially diagnosable birth defects are sent home only to become ill or have the problem recognised by the mother. Some of these will be fortunate and get back to a clinic or hospital for care. But in the often impoverished and difficult circumstances present in developing nations one can only wonder how many die before this is possible.

I believe that every newborn born in a clinic or hospital, or brought to one after birth, is entitled to an assessment (basic history and examination) by a trained professional (primary care doctor or nursing sister/midwife) before discharge. This should be an intrinsic part of newborn care.

Because many birth defects have externally obvious signs (dysmorphic features) it is possible to train nursing sisters/midwifes to examine newborns externally. Doctors should obtain this expertise in their medical training, but can be trained after graduation with their nursing colleagues as we are doing in SA.

What should mothers look for. Once mothers have recovered from their delivery they begin their own thorough examination of their infants. If they express an concern, this should be taken seriously by medical staff. Unfortunately in the pressurised work environment of these professionals, this is not always the case.

The matter of what national health systems need to do to address these issues requires a book to answer. May I refer you to the March of Dimes Birth Defects Report which you can obtain from www.marchofdimes.com/globalprograms . This covers all your other queries in a simple, easily readable manner.

Congenital heart defects (CHD) are numerically the commonest birth defect globally. There are just over a million children born annually with a CHD. Approximately 960 000 of these children are born in middle- and low-income countries. If you wish to see the numerical estimates by country please access the Modell Birth Defects Database in the March of Dimes Global Birth Defects Report ( www.marchofdimes.com/globalprograms )

In middle- and low-income nations I would suspect that the majority of these children do not get the medical care they need, especially the specialised surgical interventions. The WHO's Global Burden of Disease Programme 2005 is currently investigating the epidemiology of CHD including outcomes. Hopefully recommendations will derive from this.

I am not aware of the case of this 76 year old woman.

The age of the mother in any pregnancy is an issue. The risk of conceiving a fetus with a chromosomal trisomy, particularily Down syndrome (DS), increases with maternal age.

There are many tables available that give the risk for a child with DS and all chromosome risk at specific ages. The one immediately available to me gives the following

Lowest risks
Age 20- DS 1:1734 All chromosomal risk 1:526

Highest risks:
Age 49 DS 1:11 All chromosomal risk 1:8

So maternal age remains relevant

I am aware of no connection between noise pollution and the development of birth defects.

The process of the elimination of communicable disorders and the rise in public health significance of non-communicable disorders is known as epidemiological or health transition. It occured in industrialised countries in the first 60 years of the 20th century. It is currently happening in middle-and low-income nations, obviously at rates that vary according to the rate of improvement of their socioecoomic, educational and healthcare development. In those countries with wars, civil strife and poor governance there is negative health transition. (see March of Dimes Global Birth Defect Report at www.marchofdimes.com/global programs )

The WHO estimates about 34% of under 5 deaths in children occur in the neonatal period. What the WHO labels congenital anomalies (this does not include all birth defects) is the fourth highest cause of neonatal death (8%) after preterm delivery, asphyxia and sepsis or pneumonia.

I agree with you that health cannot improve if we do not give a comprehensive service that includes services for the care and prevention of birth defects. This includes preconception care to try and ensure the conception of a normal embryo and is ongoing health during the early embryonic period (1st eight weeks) until antenatal care takes over for the rest of pregnancy. Post delivery neonatal and childhood care is required.

And it is still true that the public, health care professionals and policy developers still hang on to the myths that birth defects are rare, costly to care for and prevent.

There is now ample documentation to refute these myths and how care and prevention for birth defects can be offered in middle- and low-income nations (WHO Human genetic Programme literature, the March of Dimes Global Birth Defects Report and the Disease Control Priorities in Developing Countries chapter that stimulated this online discussion.

This would take a long and involved discussion. May I refer you to the WHO's Human Genetic Programmes literature on the topic (www.who.int), the Disease Controll Priorities article on the topic (www.dcp2.org/file/230/dcpp-twpcongenitaldefects_web.pdf ) and the March of Dimes Global Birth Defects Report (www.marchofdimes.com/globalprograms . Should you wish to discuss any issues with me after that I can be contacted at arnold.christianson@nhls.ac.za

Birth defects have the following causes:
1. Genetic or preconception
a. Abnormalities of structure of numer of chromosomes
b. Mutations in a single gene- single gene defects
c. Multifactorial disorders. These are due to the interaction of genes and fetal environmental factors. They are called congenital malformations

2. Fetal environmental or post conception factors factors.
In these the genes and chromosomes are normal.

a. Teratogens. Pysical or chemical agents that go through the mother and damage the embryo or fetus.
Include i) Maternal infections like rubella (german measles) and syphilis)
ii) Altered maternal metabolic states or illness (maternal iodine deficiency, maternal insulin dependent diabetes mellitus)
iii) High doses of radiation
iv) Environmental toxins (toluene, methyl mercury)
v) Drugs (therapeutic drugs like warfarin, tetracycline, retinoic acid, valproic acid, phenytoin misoprostil and many more. Also recreational drugs, especially alcohol.

Please look at the answer to Amy Rogers question for the causes of birth defects.

Programs for the control of birth defects are well documented in thw WHO's Human Genetic Programme literature (www.who.int), the March of Dimes Global Report on Birth Defects (www.marchofdimes.com/global programs) and in the book chapter that stimilated this discussion in Disease Control Priorities in Developing Countries (www.dcp2.org)

Control of birth defects is a programme combining best possible care and prevention by means of community education, preconception care, genetic counselling, medical genetic screening, prenatal diagnosis and associated services (i.e. selective termination of pregnancy)if available and legal in a country.

All children with a birth defect are entitled to the best possible care (diagnosis, treatment and genetic counselling) available in the prevailing circumstances. Early death is a reality for many of these infants in developing nations, so treatment may only comprise palliative care. But they are entitled to that.

Prevention programmes are an issue for each country to assess their needs and resources and then put in the programme(s) they choose. With time more programmes can be added as necessary.

I am not aware of a birth defect caused by family planning (contraception) methods. However, when misoprostil is used as an abortificant (often illegally) this can cause birth defects.

The key players in the care and prevention of birth defects and their roles are discussed in the literature I gave above.

Maternal nutrition interventions into antenatal care are TOO late to prevent most birth defects. The majority of serious birth defects are already present by 36 days post conception- before the mother even knows she is pregnant. Nutritional intervention needs to be preconception- that is part of preconcetion care which should be undertaken under the auspices of Women's Health.

All women should obviously eat a healthy diet (macro and miro nutrients) if possible. Note that obesity has been associated with some birth defects.

Specific nutrition interventions should include.

1. Folic acid. Fortification of staple foods in developing countries, including my own S Africa, has resulted in a significant reduction in the birth prevalence of neural tube defects. Folic acid, 400mcg daily, can also be supplemented as part of a peri-conception (for at least 1 month before conception and 3 months after) vitamin regime. There is no harm in supplementing folic acid at this dose if food is also fortified in the country.

Salt fortification with iodine has made a huge impact on the birth prevalence of iodine deficiency disorder in infants over the last 18 years. This has been a very successful UNICEF programme, but there are still countries and regions that need to come on board.

Good nutrition also involves removing harmful substances from the diet. The most important substance is ALCOHOL.

Having done this to ensure preconception and immediate post conception nutrition, the continuation of a good diet and appropriate nutritional supplementation into antenatal care is obviously important.

Let me start this discussion with my belief that 'care is an absolute and prevention the ideal'.

Undoubtedly the care (diagnosis, treatment and counselling) of children with birth defects can be expensive and therefore where possible prevention is very important to reduce that cost. Preconception (primary) prevention is best as it is often the least expensive and has the least social/legal/ethical consequences. However, secondary prevention also has a role to play.

Having said that, in all situations a child born with a birth defect is entitled to the best possible care in the prevailing circumstances.

The issue of how developing countries can approach the matter of developing and integrating medical genetic services into their health care is well covered in
the WHO's Human Genetic Programme literature (www.who.int), the March of Dimes Global Report on Birth Defects (www.marchofdimes.com/global programs) and in the book chapter that stimilated this discussion in Disease Control Priorities in Developing Countries (www.dcp2.org)

The initiation and development of medical genetic servics in resource limited countries is not an all or nothing issue. Each country must assess the problems it has and the resources available to manage these. Some countries start with just 1 disorder- the most significant- develop a care and prevention program and then use the experience gained in developing further programmes. Iran is currently developing an excellent medical genetic service on this basis. Others like my own, South Africa, are initiation a more generalised service and trying to build it up.

Low resource countries need to take a different approach to that in industrialised nations. They need to have their services strongly based and integrated into primary health care. Thes in turn then need to be linked to secondary and tertiary care.

The birth prevalence of birth defects in middle- and low-income countries is on average 20% higher than in industrialised nations.

Maternal malnutrition is certainly one reason for this, particularly maternal iodine deficiency. Maternal folic acid deficiency may also be a factor.

Malnutrition also includes eating or drinking harmful substances. Fetal alcohol syndrome is a significant birth defect in developing countries where alcohol is available and used/abused by women. South Africa is one such country, but there are many more in which the problem has not been recognised.

Severe birth defects cannot be prevented in the womb. They can be diagnosed during pregnancy.

The 2 people most affected by the birth of a child with a birth defect are the affected child, obviously, and the mother. The mother bears a heavy burden for several reasons. Firstly she experiences the grief of giving birth to her child with the birth defect and thus the loss of her expectation of a normal child. She then has the major role in the care of the child. Then, in most societies, especially traditional societies in developing countries, she is frequently stigmatised and blamed for causing the problem.

The solution. Knowledge- both community and individual- about the causes and available care and methods of prevention of birth defects. That takes time,effort and commitment from the medical profession, health and educational authorities, media etc

1.It is estimated that some 9 million children (~7%) are born annually with a serious birth defect. About 7.9 million of these have a genetic cause and the rest are due to fetal environmental problems, mainly teratogens.

Please remember not all people with a birth defcts are diagnosed at birth. Most (~75%) present later in life.

Globally the 5 commonest genetic birth defects born annually are congenital heart disease (~1040000), neural tube defects (~324000) the haemoglobin disorders sickle cell disorder and thalassaemia (~3080000), Down syndrome (~217000) & G6PD deficiency (~177000). They comprise about 25% of the annual number of infants born with a serious genetic birth defect.

Common teratogenic birth defects, for which accurate global information is not available are congenital syphilis, congenital rubella (~100000/year), iodine deficiency disorder and fetal alcohol spectrum disorder.



2&3. Medical genetic services that encompass both care & prevention. Please refer to the following literature:
the WHO's Human Genetic Programmes literature on the topic (www.who.int), the Disease Control Priorities in Developing Countries' chapter on Controlling Birth Defects(www.dcp2.org/file/230/dcpp-twpcongenitaldefects_web.pdf ) and the March of Dimes Global Birth Defects Report (www.marchofdimes.com/globalprograms) .

4. The birth prevalence of serious genetic birth defects in Uganda is estimated to be ~61/1000 live births. This will be about 85-90% 0f all the birth defects. Common individual genetic birth defects include congenital heart defects, sickle cell disorder, Down syndrome and neural tube defects.

Please go to the answers to the questions posed by Amy Rogers and Donna Villareal for the causes of birth defects.

Toxins that cause birth defects are teratogens:
1. Drugs- Therapeutic
i. Anti-acne. Retinoic acid
ii. Anti- ulcer (gastric. Misoprostil
iii. Antibiotics. Tetracyclines, Streptomycin,Thalidomide
iv. Anticoagulants. Warfarin
v. Anti cancer. All of them
vi. Antidepressants. Lithium
vii. Anti-epileptic. Phenytoin, Sodium valproate
viii.Antihypertensive. ACE inhibitors

2. Drugs- Recreational
Alcohol
Cocaine
Methamphetamine
Smoking

3 Environmental toxins
Methyl mercury
Toluene

There is a lot of published work on this

The birth defects in 'non-mutated'individuals are all those caused by conditions other than single gene defects

Mothers first need to consider protecting their unconceived child. They must do all they can to ensure they conceive a normal child.Steps to follow:

Plan the pregnancy.
Before conception ensure they and their spouse are both physically and emotionall prepared for the pregnancy
To do this they should receive preconception care during which a family history will be taken to assess their risk for having a child with a birth defect from a genetic cause.If present they will be offered advice on how to reduce this risk. E.g. carrier screening for sickle cell anaemia or cystic fibrosis. Women over 35 years old should be counselled about their increased risk for a child with Down syndrome
The woman's syphilis, HIV and rubella status can be checked. Syphilis can be treated. If sero-negative the woman can receive rubella immunisation. If HIV positive she can be counselled on the consequences of this for a future pregnancy and receive RX if necessary.
Should she have an illness (e.g diabetes, epilepsy) she can have her medication checked and if necessary adjusted to ensure she has the optimal and least teratogenic therapeutic options.
She can be counselled on optimal diet including not to use recreational drugs like alcohol and smoking throughout pregnancy.
Peri-conception folic acid supplementation should be offered.

Once the babe is conceived she should continue to have a good diet, including Fe and vitamin supplements and regularily attend antenatal care.

The support systems available for children with a birth defect vary widely from country to country and even with a country. No matter what all children with a birth defect are entitled to the best possible available care. Care for children with birth defects is discussed in the MOD Global Birth Defects Report (www.marchofdimes.com/globalprograms)

Very pertinent points.
First, fertility decline is underway in much of sub-Saharan Africa. The declines, where they are occurring or have occurred, began later than most other developing regions and countries, but the pattern of decline is similar in that it begins in the largest cities and only gradually moves out, first to secondary cities and towns and then to the rural areas. In much of SSA, rural fertility decline has yet to begin.
Second, fertility decline began earlier and is further advanced in Anglophone countries than in Francophone or Lusophone countries. This difference is more attributable to when the countries adopted population policies and family planning programs than to any other factor.
Given that by most measures, SSA scores lower on most pertinent human development indicators than other regions, it is not surprising that fertility decline began later and is less advanced in Africa than elsewhere. Fertility is highly related to such measures as infant/child mortality; literacy and school enrollment rates, especially for girls; female employment outside the home; and urbanization. On all such measures, SSA lags behind other regions and one must assume that the pace of fertility decline will be strongly determined by how well SSA governments do in raising living standards, particularly with respect to health, education and gender.
Finally, it should be noted that desired fertility (i.e., the number of children women say they would like by the time they complete childbearing)is still relatively high in much of SSA. Desired fertility is strongly influenced by the socioeconomic factors just listed above. However, there is quite a high level of "unmet need for contraception," measured by the proportion of women who say they want to limit or space future births but are not using contraception. If all the unmet need were satisfied, fertility would decline in most countries by between 15 and 30 percent. In other words, alongside efforts to raise living standards in general so as to reduce desired fertility, there is also a need for family planning programs to help women and couples realize their present fertility goals.

Some are, others are not. Generally the Francophone countries are lagging behind the Anglophone in adopting population policies and reproductive health programs. Serious efforts to provide family planning services have only been mounted in a handful of countries and where they have been provided, fertility has declined. The most well known success stories are in South Africa, Botswana, Zimbabwe and Kenya -- and quite recently in Rwanda. In the first four, much of the fertility decline that followed the development of strong programs occurred in the 1980s and '90s. Since 2000, there has been a real leveling off in Botswana, Kenya and Zimbabwe, mostly because priorities changed and much of the effort that had been directed at high fertility was redicrected to AIDS prevention and treatment -- especially treatment. In fact, family planning effort has declined seriously in several countries as population and family planning has declined as a development priority -- in part because it was not included in the initial version of the Millennium Development Goals (MDGs).

There is no reason of which I am aware to assume that Africans have a different nature than people living in every other region of the world. Fertility behavior in, in fact, highly predictable and responds to the conditions in which people find themselves. As living standards improve, as employment and residence shift from rural to urban, as incomes rise, as school fees and other costs of children increase, generally people throughout the globe, including in Africa, decide to have fewer children. Also, as the case of Kenya in the 1980s shows, when political leaders decide that fertility is too high and ought to come down, and when they repeat this message over and over again, people do begin to think about whether or not they can and should have fewer children and many decide to do so. As the famous Australian demographer John (Jack) Caldwell has said, much of dramatic decline in fertility that we have witnessed in Asia, the Middle East and Latin America over the past 40 years was the result of changing family size norms -- norms that changed in part as the result of communications programs that were deisgned to change them. Another famous demographer, Ronald Freedman, an American, called this "ideational change" and said that it had a powerful independent effect, above and beyond what "development" itself brought about, on fertility behavior.

I have addressed this issue in answwers to the previous questions I answered. In short, urban-rural differentials are very marked in Africa and as the continent continues to rapidly urbanize, I anticipate urbaization will continue to have a powerful impact on fertility. A look at the differential fertility between populations living in urban slums and the rural communities from which they migrated underscores this point quite dramatically. For an excellent treatment of this issues, see Demographic and Health Surveys Comparative Reports, # 18, "Fertility changes in sub-Saharan Africa," MEASURE/DHS. September 2008.

Despite the substantial mortality from AIDS, UN projections for all developing regions, including Africa, predict large further population increases. This is because the annual number of AIDS deaths (2 million) is equivalent to just 10 days growth in the population of the developing world. The population of sub-Saharan Africa is expected to grow by 1 billion between 2005 and 2050 (from 0.77 to 1.76 billion). In fact, no African country is expected to see a decline in its population size between 2005 and 2050 due to high AIDS mortality. Even with the steady future declines in fertility assumed by the UN, most populations in sub-Saharan Africa will more than double in size, several will triple and Niger is projected to quadruple by 2050.

Religion, or the attitude of religious leaders, sometimes reinforces traditional conservative attitudes. It is important to distinguish this aspect of religion from formal doctrine. In fact, only Roman Catholic doctrine specifically opposes some modern forms of contraception. Nearly all other religions are silent on the matter. Islam, as a matter of fact, preaches that a household head should have no more children than he can properly care for and support. And many Islamic countries have been in the vanguard of population policies and family planning programs. I would mention Indonesia (the world's largest Muslim country), Iran, Morocco, Tunisia and Bangladesh as just five among several very prominent examples. In other words, religious leaders can sometimes reinforce attitudes and values that are not part of their religion's formal doctrine. And, as the cases of Indonesia and Iran show, religious leaders can also be very influential in the encouragement of family planning if they choose to do so.

I don't think they are spurious and I think the cause is very clear: the redirecting of resources away from family planning and toward other (usually health-related) programs, most especially HIV/AIDS. The data are very clear that expenditures on family planning have declined dramatically (by at least 30 percent between 1995 and 2005)while expenditures on HIV/AIDS, TB and malaria have increased dramatically (by 300 percent over the same period of time). As M. Michel Garenne says in DHS/MEASURE Comparative Studies Report # 18 on Fertiliy change in sub-Saharan Africa, "The speed of the fertility decline, approximately 1 child per decade, also varied markedly among countries, from 1.5 children per decade to less than 0.5 children per decade. In addition, a stall in fertility decline occurred in six of the countries investigated (Ghana, Kenya, Madagascar [urban areas], Nigeria, Rwanda-rural, Tanzania [rural areas]); in five of these countries, this stall occurred in 1995-2005."

As my answers to several of the preceding questions demonstrates, I agree with this statement.

I think the provision of family planning within health services is extremely important. We have seen that wherever reasonably good health services are offered, if family planning is included it will be used and fertility will decline. Perhaps the most dramatic example is in the experimental program run by the Navrongo Health Research Centre in northern Ghana. There, in one of the most remote and disadvantaged parts of Africa, it was shown that community-based contraceptive services, which also emphasised mother and child health (i.e., good antenatal care, immunisations, etc.)lowered the fertility rate by between 15 and 20 percent, compared with no change in the areas without such services.
Having said that, I think that family planning and community health care must be accompanied by other rural services that improve education, employment opportunities, rural incomes, and women's status. African fertility will only decline if, as nearly everywhere else in the world, it is addressed comprehensively, with an approach that focuses on raising living standards of poor families at the same time that it provides contraceptive services.

Thanks, Rei. Always great to hear from you.

Fertility trends are usually monitored in developing countries through a series of surveys -- the Demographic and Health Surveys. Over a period of years, these surveys track fertility trends in many countries. For example, surveys beginning in 1978 and conducted roughly every five years since showed significant fertility declines in Kenya through the 1980s and the first half of the '90s, but then stalling and remaining essentially unchanged since the late 1990s. A recent DHS comparative study (#18 in a series) by M. Michel Garenne, shows contemporary fertility stalls in six African countries -- Ghana, Kenya, Madagascar (urban areas), Nigeria, Rwanda- (rural), and Tanzania (rural).

I think the principal cause of the fertility stalls in these countries is a decline in the funding for family planning and associated reproductive health services. The experience in Asia showed that most countries maintained strong family planning programs over an extended period, enabling them to bring fertility down from high levels to levels much closer to replacement (slightly more than two children). There were very few stalls in decline until countries began to approach replacement because program support remained constant and strong. In recent years, support for family planning programs in Africa declined as donor funding for sexual and reproductive health has declined, leading to the fertility stalls. In Kenya, the case I know best and the one most closely studied, there seems little question that this is what has happened.

You are quite right that traditional norms mean men prove their strength, masculinity and power through the number of children they father. That is why fertility tends to decline as women gain greater equality with men and are able to have more of a say in how many children they will bear. The education of girls, leading to increasing autonomy and empowerment, is for this reason the single most important determinant of desired fertility. Strong family planning programs then help women to realize their fertility desires.
While the situation varies from country to country, generally fertility is highest in rural Africa where people generally are poorer than those who live in urban centers. Multiple partnerships, such as you describe, don't necessarily mean higher fertility since fertility is measured in terms of how many children on average a woman bears, as opposed to how many a man may father.

Eloquently stated.

Hi John -- I answered the first question just a few minutes ago and you will see the response when my answers are posted.
The second question is much harder to answer, and is not an either/or matter. But generally, I would say that the most effective facilities are not stand-alone family planning centers but neither are they ones that try to offer a full range of comprehensive health services. In other words, in Africa the most effective centers have tended to be those that offer a limited range of the most critical services from the standpoint of protecting women's and children's health. A "selective primary care approach," one that includes a range of services that trained para-professional staff can provide in difficult settings, would include family planning, tetanus toxoid, immunization against major childhood diseases, referrals for obstetrical complications, growth monitoring and nutrition education, and treatment for diarrheal diseases and acute respiratory infections. This was the package offered by the Navrongo project in rural northern Ghana, with dramatic effect on both maternal and child health outcomes, and fertility! I should add that both malaria (esp. bednets) and HIV prevention services (VCT and condoms) need to be included in the updated selective primary care package.

I believe that many countries, such as Niger where at present fertility the population will double in 15 years, would benefit greatly if fertility was lower. This does not mean that Africa needs fewer people. It does mean that strains on African governments would be less and the prospects for sustained economic development would be far better if the rate of population growth were slower. Most African countries, which have committed themselves to achieving the Millennium Development Goals, have practically no chance of meeting any of those goals at present fertility levels, whether one is talking about poverty reduction, reducing hunger, achieving universal primary school enrollments, reducing infant/young child mortality, reducing maternal mortality, reducing new HIV infection rates, or improving the environment.

Men's roles are very important, in Africa and elsewhere. But I don't think the role of men in Africa is different today from what it was in Bangladesh in the 1980s or in Korea in the 1960s and 1970s. Empowering women to negotiate childbearing on equal terms with men is a key factor, and providing women with services that give them a certain degree of independent control over their fertility is equally important. During my time in Kenya, when fertility was falling very fast (1986-1990), I observed that men were especially responsive to the calls of political and other leaders to behave responsibly when it came to childbearing. Helping men to understand the relationship between family size and their aspirations for their children in terms of education and land inhertance played a major role in changing male attitudes, at the same time that family planning services helped women attain greater power in determining the number and spacing of their children.

I doubt it. But if effective primary care programs of the kind I outlined in my response to John Bermingham's question were offered, I think mortality decline would occur at as fast or faster a rate than fertility decline.

I wish I could but this is a huge question. What I will say is that extremely low fertility in Europe will create an increasing demand for labor which Africans and many others will be ready to fulfill. At the same time, very high fertility in Africa creates a large pool of job seekers who cannot find employment at home. If fertility were lower in Africa, the pressure to migrate out would be correspondingly reduced, assuming job creation rates in Africa remain constant or, one could hope, increase. Of course, the most highly educated Africans are the ones most in demand in the low fertility countries, thus contributing to the brain drain that is such a tragedy for African countries. The answer to the brain drain in Africa is not lower fertility -- it is economic development and creation of good employment options in Africa. But economic development itself would be much easier to promote if population pressures were less, enabling governments to invest more in the quality of education and healthcare, thus creating the human capital that is a prerequisite to sustained economic growth.

This is a very difficult question to answer. Fertility goals are generally thought to be influenced not by adult mortality but by under-five mortality. It is the probability that children will survive to adulthood that largely determines how many children a couple will want to bear. So, at the level of individual families, where fertility goals are usually set, I would not expect AIDS mortality to have a major impact. However, at the broader level of societies, one hears political leaders often expressing concern about "de-population" due to AIDS. Where political leaders, fearing the effects of AIDS mortality, withdraw resources from family planning programs, the effect on fertility could be strong, even though fertility desires of families might not change at all.

I believe that female education is an extremely important factor but it may not be enough in a country whose leadership is hostile to family planning.
High birthrates and high under 5 mortality are closely correlated. Bringing down one usually results in declines in the other. If one works on the two together the results are greatly magnified. It's a wonderful example of mutual reinforcement -- or a virtuous circle.
Diet per se is not related to fertility but nutritional status is. Extremely poor and malnourished women have a harder time getting pregnant and carrying pregnancies to term than better nourished women. But what they eat does not affect fertility. Neither am I aware that ART has any impact on what demographers call fecundability -- the ability to conceive.
It is true that PMTCT programs increase the likelihood that children will be born free of AIDS and more likely to survive. Surely that is a good thing! Keeping mortality high is never a good way to approach any population question!

I'm not close enough to the situation to know how the present food crisis is affecting either fertility or migration, nor have I read anything recently that comments on these issues. Certainly economic circumstances have a great deal to do with labor mobility throughout Africa and beyond, and men who leave their families behind often do produce children in the places where they are working. However, this does not necessarily affect fertility rates very much. Men working away from home are also prone to engage in risky sexual practices which can result in them infecting their wives with HIV when they return home -- an increasingly common and tragic phenomenon in many African countries.

Unfortunately, I do not think family planning programs have very often been linked to other social and economic outcomes in Africa, at least not in a programmatic sense. The argument to undertake family planning programs is often made (usually by outside donor agencies) by linking fertility decline to other social and economic goals. For example, today much of the advocacy on behalf of family planning links it to the achievement of the MDGs, with proponents asserting that unless high fertility rates are reduced, the prospects of achieving the MDGs are slim to none. But efforts such as those you describe in the Philippines are few and far between, in my experience. I think, in fact, that family planning programs have suffered to the extent that they are promoted as stand-alone interventions. The more one can associate the benefits of family planning with other aspects of people's lives, the more likely they are to adopt family planning. In Bangladesh, the Grameen Bank and BRAC showed that women involved in micro-enterprise programs were more likely to adopt family planning than women who were not. Likewise, health programs that offer family planning alongside safe motherhood and child survival interventions will be more acceptable than family planning standing alone.

The Rwandan case is Africa's latest "success story." I don't know the story in detail but it's my understanding that it's quite similar to the Kenyan story a decade ago.