Gender Equality as a Sustainability Strategy – a MAHB Dialogue with Physician and Medical Demographer Ndola Prata

‘Well-conceived and designed family planning programs are actually relatively inexpensive compared with other preventive health care programs.’ – Ndola Prata

Geoffrey Holland – The biosphere we depend on is being stressed to the limit by a range of existential threats driven by humans. What are some of these threats and why is the expanding human population a primary driver of these threats?

Ndola Prata – The threats driven by rapid population growth include overcrowding in the cities, the ability for diseases to spread faster. It becomes more challenging for countries to address poverty issues in an effective manner. Population growth means poverty is growing much, much faster. Migration to cities increases while cities don’t expand to accommodate low-income populations. That makes poverty and disease worse. So, the ability to serve a rapidly growing population, both with social services and economically, is very challenging. Economies usually don’t grow as fast as population numbers grow, especially in Sub Saharan Africa.

Humans have to survive, and we’ve adapted to survive by taking from the environment; you know, fishing, animal consumption, from natural habitats, like forests. The pressures on nature required to keep humans alive have tremendous impacts on the environment. We consume because we need to survive, but at the same time, we create threats for ourselves by massively overusing the resources we take from nature.

GH – How have traditional gender roles impacted human fertility? 

NP – If you think about traditional gender roles; for women that means to stay at home, marry early, make babies, and care for them. They often have many babies. That drives rapid population growth. More recently, contraceptive technologies were made available to the populations. We encourage society’s understanding of the benefits of birth control. We want people to see that a woman’s role in society goes beyond staying at home, having children, and raising them. Women can and should be seen as productive members of society in the formal or informal sector of the economy. That affects human fertility because, as women go to school, find jobs in the formal sector of the economy, have professional careers, they tend to have fewer children. They’re more empowered when they have access and better use of contraceptive technology. The desired family size changes, they tend to have fewer children. In the past, dominance has created an imbalance. In a partner situation, the male has traditionally had the power. Decisions are made by men, whether it’s how many children the couple should have, or how to allocate resources in the household. That has affected not just women’s empowerment and its role in society, but also health in general.

GH – What are some of the factors contributing to high pregnancy and birth rates in countries that continue to have high fertility rates such as in sub-Saharan Africa? 

NP – In too many places, it’s not easy to get what you need to manage your own fertility. The options can be too expensive. They are often not readily available. In some places, there are too many restrictions on who can get what and where. So that limits access. A key factor is the knowledge about where to get, what to get, and at what stage of life you get a certain method. There is patriarchal pressure on women to have as many children as possible, rather than the number they really want. Pregnancy in most developing countries, specifically in Sub Saharan Africa, is actually quite a risky proposition. Maternal mortality, even though it has declined in the last 20 years, is the highest in the world in Sub Saharan Africa. Too many women die during pregnancy, in childbirth, or just after. Therefore, every single pregnancy in those circumstances needs to be wanted. The recommendation is to space pregnancies to protect the life and health of the mother and the health of the previously born child. The most effective strategy is education. Formal school education, and also education about contraceptive use, contraceptive methods, where to get them, how to use them; knowledge of reproductive systems, and also how to choose from existing technologies to help decisions on when to have a child, and how many children to have. For reproductive services delivery, you can have clinic-based, mobile clinics, social marketing of contraceptives, and community-based distribution of contraceptives. There are various modalities in which services can be provided to women. When you make choice available; when women are part of a network of other women that choose to control their fertility, they see the benefits of contraception. They can have a good and open discussion with their partners about the benefits of contraception, of spacing pregnancies, and for limiting or delaying childbirth. This is a very effective way to decrease fertility.

GH – What strategies are most effective in decreasing fertility rates?

NP – It all starts with empowering women and provide greater access to contraceptives and safe abortion. In addition, women are more likely to have fewer children if they start having children later in life. Longer schooling, especially for young girls could delay childbearing. With an education, women are more likely to get jobs. Employment makes a very, very important contribution to a decline in fertility. So, creating greater opportunities to increase the number of women in the workforce is extremely important. This, in addition to greater access to contraceptive methods and safe abortion.

GH – What needs to be done to further these strategies as time goes on? 

NP –What we need right now is the kind of political commitment that will come with adequate financial resources, to actually put programs in motion on a large scale. It should be a priority in countries, where fertility decline is part of a national strategy for development. It should be about better health, women’s empowerment, and gender equality. When countries have adopted strategies like that, they have shown declines in fertility.

GH – How do gender equality, girl’s education, and access to contraception contribute to smaller family size?

NP – So, gender equality…I see gender equality as a basic human right and one that is necessary for development. However, to achieve that we need to confront gender norms that promote unequal treatment of men and women; Treating individuals, any single individual, regardless of gender, the same way should be a priority in every country. It is not by accident that the Sustainable Development Goals have as Goal 5 – Gender Equality. So, men and women have equal footing, equal participation in decisions, on all levels. To accomplish that, the way the world is at this point in time, we have to address issues of education, employment opportunities, equal pay opportunities. That can lead to better gender equality. With education and employment opportunities, we will also definitely see declining fertility.

GH – What are the trends on infant and maternal mortality in places with high fertility, and does a reduced mortality translate to lower birth rates?

NP – High fertility places tend to have high maternal mortality and many high fertility places also have high infant mortality. However, there are contexts where we can see a decline in child mortality that is more rapid than fertility decline. One thing is certain from a Maternal and Child Health perspective, declines in fertility are accompanied by declines in both maternal and infant mortality. Declines in fertility affect not just the total number of births but can also affect the spacing between births that are key to the survival of the children. Studies show that the spacing of pregnancies is extremely important to the decline of maternal mortality and child mortality. Just the fact that women will have two to three years of spacing between deliveries alone is good. Everything else being equal, spacing is very important. When that happens, we see better health indicators for the previous child, better health indications for the mother, and reductions in both maternal and infant mortality. Mothers, who have time to recover between pregnancies, have less chance of dying in pregnancy or childbirth in a subsequent pregnancy. So, if you have lower birth rates, each woman on average will have fewer pregnancies throughout the course of their reproductive life. The probability of dying in pregnancy or during delivery increases exponentially with each birth. That probability would increase if you have from one to two, and two to three, and three to four pregnancies, and so forth. So, the more children on average the women have, the higher will be the maternal mortality.

GH – Who are the key leaders and stakeholders we need to engage and/or partner with in order to make a significant impact in population and family planning efforts over the next decade? 

NP – There are many stakeholders. The priority for them will depend on if a given country has declining fertility. Take a country like Rwanda, which has made significant progress in maternal health, gender empowerment, gender equality, family planning, etc. The stakeholders in this case will be those community groups that represent the women’s voices because at the policy level, and at the program level, there is an understanding of what must be done. The needed changes can be made quickly. Well-conceived and designed family planning programs are actually relatively inexpensive compared with other preventive health care programs. Also, investments in family planning programs will create savings. This is demonstrated well empirically in different areas like education, water, and sanitation. So, if births decrease this year, or have been decreasing, let’s say in a given country for the last five years, you will need fewer investments in education for the next five years.

GH – In your opinion as a medical demographer, when and at what level will the Earth’s human population stabilize? 

NP – Oh, that is a million-dollar question. I tell you that even though I am a demographer, I don’t really work on population projections, but I do follow them. Let’s just take the UN population projection numbers giving the changes and the adjustments that had to be made because of our assumptions of how fertility was coming down. We’re still not correct in many places. We still have a large number of countries where the population is growing very rapidly. Fertility has stalled in a number of countries while the population continues to grow. I don’t have a date to give you for when the population will stabilize, because we’re still growing. Another thing we must think about is the concept of population momentum. Even if all countries that are still growing, that have high fertility, would tomorrow go to fertility averaging two children, two on average per woman, the sheer volume from growing at 2.5% a year, in some places 3% a year – That’s a lot of women that before the end of their reproductive life will have two children – so, these countries have built-in population momentum. They will still grow for many, many decades, before stabilizing.

GH – How can we inspire humans to embody the responsibility we have to protect and restore land and oceans as part of any sustainable, life-affirming vision for the future? 

NP – We have to focus on our young people. We, the adults still have a lot to learn through education on the benefits of taking care of our planet. But the real investment needs to be made in schools and in young people to learn from early ages about the value that they bring to this planet, but also that they must value the importance of living, of coexisting with nature, and the importance of not harming other lifeforms. We must instill a responsibility from very young ages that carry into adulthood. To change the planet, I don’t think it’s too late. The damage that is done is done, but it’s not too late to change our ways. We need to do this on a very large scale. Parts of the curriculum from elementary school should focus on valuing the biosphere. We need to teach the importance of planetary health, and how each individual child, regardless of social class, can and must contribute to making a healthy planet.

Ndola Prata, MD, is the Chair of the Bixby Center for Population, Health, and Sustainability at the University of California, Berkeley. She also has an M.Sc. in Medical Demography from the London School of Hygiene and Tropical Medicine.

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