Women must have the right to choose

First there was Mexico City in 1984. Then there was Cairo in 1994. Now there is Nairobi in November 2019. The global community has dealt with the issue of population in these mega-conclaves. Not all left their mark. The Mexico City event was notable more for the US absence. The Cairo event did mark a watershed, a sort of paradigm shift from bureaucratic notions of population control to empowering notions of choice and enabling conditions. Now twenty-five years later, there is a buzz and new expectations as the curtain is lifted today (November 12) on ICPD25 in the Kenyan capital Nairobi.    

How will this summit come to be remembered? A timely reminder on "unfinished business"? An honest soul-searching on "mission confusions" that may have crept in the wake of initial successes? An occasion for "voices" particularly of the youth in search as much for new questions as for new answers? It may indeed be each or all of these and more. It will be patently unfair to pre-judge the outcome of a gathering whose deliberations are just starting today. But with the participation of a large contingent from Bangladesh, it may be useful to marshal thoughts and ideas to be a shaper—rather than only a recipient—of the core global messages likely to emerge from the Nairobi conclave.

As an economist, I have been appreciative of the remarkable decline in fertility—from 6.3 births per woman in 1975 to 2.3 births per woman now—that was an outcome of both demand and supply side drivers. A social campaign approach galvanised the demand. A decline in child mortality due to ORS success against the killer diarrhoea gave the confidence to reproductive-age women to opt for smaller families. An effective and accessible supply chain on contraceptives played its due role.

The fertility decline was not only a signature social achievement but contributed to economic success too. Between 1990 and 2010, a quarter of the incremental per capita income growth can be attributed to the fact that there were lesser people to divide up the economic pie than there would have been if we had continued with the 70s-80s fertility rate.

Nairobi, however, cannot only be about the long view. Equally important is to unpack near-term trends and the implications for future strategies. Early successes appear to have triggered a discourse ambivalence particularly among policy-makers about the urgency of maintaining an unwavering focus on population policy. A dominant perception of being "on track" actually belies the complexities of the "last mile" challenges. The population density within the scarce land mass is rapidly reaching its sustainable limits. On current TFR (total fertility rate), the population of Bangladesh will hit 200 million by 2031. Much of this population growth will be located in the cities and, in particular, the burgeoning urban slums. Coping with unsustainable densities stands to jeopardise the policy attention required for the critical agenda of human resource development to reap the demographic dividend of a preponderantly young population. While the annual addition to the workforce is around 2 to 2.3 million, employment creation—both domestic and external—currently can accommodate only half of this number.

At another end, a vicious circle of consequences is in danger of becoming entrenched. Unmet need for family planning is leading to unwanted pregnancies which is leading to unsafe abortions, which in turn is contributing to a slowing in the decline of the critical SDG indicator of maternal mortality rate (MMR). The persistence of child marriage coupled with a very poor state of education on sexual and reproductive health rights (SRHR) is leading to a disproportionate unmet need for family planning among the 15-19-year olds. A further twist in this near-term trend is that the rate of unwanted adolescent pregnancies is highest among the urban slums.

The "last mile" challenge pertains not only to the adolescents. Another near-term trend of concern is the spike in post-partum pregnancy of the older married group in their late 20s and 30s, due to an absence of integrated health-FP service in facilities. Nearly 44 percent of post-partum women have an unmet need for family planning. Further unpacking the near-term trends, one sees another hidden statistic of concern—the preponderance of short-term methods that contributes to a high discontinuation rate of nearly 30 percent. The short-term methods are mostly accessed from the private sector while the private sector is the principal provider of long-acting methods.

Are the near-term trends in population policy highlighted above unique to Bangladesh or are, in fact, reflective of a more general phenomenon across the developing countries? Be that as it may, there are serious implications for how the way-forward strategy in the Nairobi conclave is most meaningfully framed. If the language of "unfinished business" merely energises a bureaucratic drive to increase the contraceptive prevalence rate (CPR), this may fall far short of re-igniting the global imagination on the population policy introduced twenty-five years ago in Cairo. Three key constituencies have come into focus around whose needs a holistic re-thinking can come to mark the Nairobi conclave—the adolescents, the urban poor, and the post-partum women. And for each of these, the underlying unifying agenda is that of women's empowerment.

Research is showing that lack of access to family planning is not the major explanation for unwanted pregnancies. Adolescent pregnancies are driven as much by the continuing propensity for child marriage as by the very poor state of exposure to SRHR norms and knowledge. For the urban poor, the reality is as much of policy neglect of a robust and affordable health and reproductive services infrastructure as of endemic exposure to sexual violence and intimidation. For the post-partum women, the issues are as much of lack of knowledge as of sensitive and trusted service facilities.

An issue which appears to have virtually disappeared in the population discourse is that of male contraception. Ultimately, this too pertains to the agenda of women's empowerment because the loss of focus on male contraception essentially indicates an implicit acceptance that the contraceptive burden has to be mainly, if not solely, borne by women. Why should this be so? Why should one readily accept the transparently untenable argument that convincing males of contraceptive use is more difficult? Isn't there a lurking shadow of patriarchy behind such arguments?

There will, and should, be many issues discussed at this global summit on population. But summits are remembered for their signature message. For Nairobi, this can be the cross-cutting agenda of women's empowerment. Not just lip service. But substance and teeth. I learned a valuable lesson on this from my young adult daughter Umama Zillur who works on innovative SRHR education at high schools. Such education will go nowhere if seen only as packaged content delivered mechanically. There are many text-books which are not read and "adolescent corners" which are not visited. A meaningful impact can only come from understanding SRHR education as conversations of trust ideally driven by peers. An atmosphere of trust is the ultimate guarantee that needs will be expressed and understood, services sought and delivered, and mutual learnings enhanced to keep the goal in view and progress on track.

Hossain Zillur Rahman is Executive Chairperson of Power and Participation Research Centre (PPRC), and Convener of Healthy Bangladesh SRHR Network (HBSN).