Fertility by Choice

In less than two centuries, which is sudden if one considers Homo sapiens’ two hundred thousand year destiny, a twofold change has modified humanity in a way which is certainly fundamental and probably irreversible. It stems, I believe, essentially from man’s aptitude to understand Nature better and to partly dominate it: what is called Science.

In the first place, demography since the nineteenth century, hygiene, nutrition and medical treatments have reduced the mortality of babies, small children and pregnant women and can keep many old and very old patients alive. Demographic evolution obviously depends both on the number of births and the number of deaths. If one progresses without the other, or if one is modified in the opposite way to the other, then there is a “transition”. The traditional persistence of a relatively elevated number of births (presently – 3.1 per woman on average for the whole world) and the decrease in mortality (life expectancy is at present increasing by almost 0.3 years per year as a world average) are responsible for the recent explosive increase in the world population, whose considerable evolution will persist for a long time whatever is done. The Malthusian viewi, suggesting that food resources are a factor limiting population increase1, must be modified given technological advances, but it remains evident that the whole of the ecosystem imposes limits on the number of inhabitants that can people the earth.

The problem must be resolved in such a way as to help, as much as possible, women, families and the children themselves, in each economic, social, geographical, cultural, psychological and health context.

Or course there is a timelag of almost 100 years between the demographic evolution in some countries and that in others, as is shown by the decrease in natality that has developed in the industrialized countries and that which is beginning in the developing countries. But there are still big differences among the latter and the situation is and remains tragic in many cases, of which the dramas in Rwanda and Zaire are one of the most recent examples. The slowing down of demographic growth, with a percentage of births relative to the population which is diminishing and a decrease in the birth rate which is becoming faster than that of mortality, should not however comfort us: the world population will grow by around 90 million inhabitants per year for the next 20 years.

Even if we immediately had, which is impossible, 2.1 children per woman in order to ensure the simple replacement rate for couples, it would take more than half a century for world stabilization, at around 8 billion* – incidentally, we must not forget the effect of the increase in life expectancy. Between 1980, a year which all our readers can remember, when there were 4.4 billion individuals on earth, and the moment that I am writing, when there are 5.7 billion, there are over a billion more people, an increase of over 25%! In the second place, women, also as a consequence of the unprecedented advances in science, new means of domestic help, of information and of communication are progressively becoming accessible, and women in most societies are beginning to escape from a condition of being restricted to the domestic situation; they work outside the home and can vote. (With reference to SDGS Goal 5 and SDGS Goal 16)

And this although most often it does not make the headlines, the media taking note of punctual incidents in society without extracting their meaning. We are living in a truly revolutionary epoch: the number of humans and the age pyramid, the relations between men and women, everything is changing rapidly without a rapid awareness of these “simple” problems and without mastery over reproduction, the factor that one can truly and rapidly modify, the demographic changes may be catastrophic for our descendants, their societies and their environment, and hundreds of millions of women and children are still going to suffer and often die prematurely for several generations. It is time to improve the reproductive health of women above all, and for that, although it is also an objective in itself, establish their “human condition” at the level it should be, equal to that of men.

Let us 100k, at some of the terms of these questions. Everybody knows, it took approximately 2000 centuries to reach the first billion humans in about 1800, only another 120 years to reach the second billion (in 1920) and then 33, 14 and 13 years for each of the succeeding billions, and from 5 billion in 1987 we shall reach 6 before the year 2000. Where are we going? We need to consider some of the factors involved. The overall number of people, depending on the balance between the numbers of births and deaths, will still continue to increase (approx. +90 millions/year for 20 years). However this demographic increase will have causes with which we would all be in favour. For example, there is still progress to be made in saving the lives of babies: globally, approx. 20% of babies less than one year old died in 1800 and less than 9% in 1980, but in the industrialized countries the figure is only around 1.6%.

This gap should be reduced. The approximate mean life expectancy is over 75 years (men plus women) in developed countries, but this is 15 years more than in many developing countries. The age pyramid is currently such that the number of young women able to procreate will double before the year 2015 (approx. 2 billions) and their potential reproductive behaviour will be crucial for the evolution of our species.

Global demographic growth peaked at approx. 2% around 1960. Since then it has decreased to approx. 1.6%, thanks to the success of fertility control in many countries, particularly in China, Thailand and several South American countries. In the last 30 years, even though difficult to implement, the use of modern techniques of contraception has passed from <10% of the people of an age to do so, worldwide in 1970, to 50% in 1995, thanks to scientific progress in contraceptive methods, to the efforts and guidance of the World Health Organization (WHO) (particularly its “Special Program of Research, Development and Research Training in Human Reproduction”, the United Nations Development Programme, the United Nations Population Fund (UNFPA), the World Bank and many non­governmental organizations. In developing countries, most costs have been met by the people themselves and their governments. In spite of this improvement, the world’s population is still rising and also it is estimated that more than one hundred million couples have unmet contraceptive needs, particularly in sub-Saharan Africa, Asia and Latin America, and adequate services are far from being provided to all women even when they are “officially” installed.

“Human reproduction influences the health of women and children, the status of women, population level, in the global environment. The pillars of reproductive health are identified by family planning, maternal and child care and the prevention of sexually transmitted diseases. Considerations of human rights, reproductive health and family economy are all vital and inextricably linked to women’s status and development”

World Health Forum, vol. 15, 1994
“Reproductive Health: towards a brighter future”

Beside and beyond global numbers there are other considerations: the demographic trend is radically different in different countries. In Africa the population increase is still 3% per year, with all its consequences for women: inferior status, health problems, loss of children. In Europe and the USA, where many families have only one child, there is still a growth of 0.6% per year, though the level of replacement is low, with well under two children per couple on average, and particularly low in certain countries such as Italy (paradoxically).

Does this evolution prefigure the future of human reproduction? In any case one should not oversimplify the problem of fertility control which certainly depends greatly on the standard of living – more children often being associated with low income in order to ensure greater manpower in the family – but also depends on political and ideological incentives. Thus, for instance, in Bangladesh, fertility control is more effective than in the richer Pakistan, while their populations are very similar, including in terms of religion.

Men and women have always wanted to determine the number of their children for themselves. We all know of people who want a lot of children despite the possible difficulties and of others who only want one or two, or even none. Basically, reproductive freedom is essential, whatever the political regime and the declared goal of a society. In ancient times, given the expectancy of disease and the deaths of the majority of children, it was essential to have a high number of births just to maintain a society in demographic equilibrium. This was associated with contradictory consequences: for example, while having a large family was associated with conventional morals, infanticide (largely performed until recently, and passive infanticide of girls still occurs in many places) and illegal abortion were the most used methods of fertility control. In fact, in the past, abortion was a relatively sophisticated attempt to regulate fertility in the absence of a science of contraception, but until the end of the nineteenth century it remained not only psychologically painful (as it still is and will remain) but physically very dangerous (as it should not be when performed legally, and therefore under medical supervision and according to modern techniques).

Family planning versus reproductive health

As already indicated above, family planning is the most direct way to demographic control. Its application is all the more important that the increase in life expectancy ought not to stop, even in the industrialized countries where infant and maternal mortality has now reached its lowest level to date and will not decrease much more. For the last 25 years there has been an increase of over one year in life expectancy every four years in 70 year old subjects, and this will also apply to the developing countries when they have reduced mortality in young subjects. Family planning is and will remain a necessity for public health, to prevent unwanted pregnancies and those occurring under unfavorable circumstances. It gives a better chance of survival to the children and of the development of those children under improved conditions, and it should lead to a decrease in the number of abortions which, at present, number around 50 million per annum and are responsible for the death of one woman in the world every 3 minutes, which certainly shows that the needs of fertility regulation are not being met.

Over and above family planning strictly speaking, which essentially means contraception, women have the right to the care of their “reproductive health “. This does include the problems associated with not only reproduction, but also with sexual life, the follow-up of pregnancies and the care of the children.

“All couples and individuals have the basic right to decide Freely and responsibly the number and spacing of their children and to have the information, education and means to do so”.

International Conference on Population, Mexico (United Nations, 1984)

Basically, there is a “natural” component to the concept of birth planning: puberty occurs relatively late in humans, providing parents with a physical and mental maturity and enough time for transmission of an intergenerational non-genetic heritage. The amenorrhea during lactation is equally a mechanism for spacing births, and the occurrence of the menopause well before the end of life allows the upbringing of children to be improved without adding others. Human beings have added social rules and laws to these natural phenomena, by regulating marriage, for example.

On the biological level, if men have always had control of coitus interruptus, women had to wait until very recently in order to dispose of a means of control over reproduction without having to risk their health or modify their lifestyle. Bygone methods with vaginal plugs and code condoms are only anecdotal. It is probable that this delay in contraception for women allowed patriarchal societies to control female sexuality better, and this until very recently. Demographic problem helped to impose another attitude at the same time as science, in a decisive way, has offered new means. We insist that in all cases, what must be sought in methods of fertility control is the respect of the freedom of men and women and as complete a physical and psychological acceptability as possible: scientifically, and thus practically, the last word on the matter is far from having been said. I think that contraceptive methods must essentially allow women who desire it to retain mastery over any situation whatsoever. After all, they bear by far the greatest burden, both physiologically and socially. Inversely, it is not equitable to impose the sole responsibility for, and all the eventual side effects of the methods of contraception on women unilaterally. Moreover, there are men who wish to share the reproductive responsibility. The development of contraceptive methods for men should go beyond sterilisation by vasectomy (I am unfavorable because of its practical irreversibility), the condom (a technique for couples which is very far from perfect, including in its efficacity) and methods for suppression of spermatogenesis using hormones (which is slow to become efficacious and whose safety has not yet been established). But there is practically nothing else, and we lack an instantaneous, or at least very rapid, inhibitor of the fertilising activity of spermatozoa, whatever the mechanism (modified movement, failure to interact with the ovum, etc. …). Little research is being done in this scientifically difficult domain whose popularity is low among its potential users, including and especially when they direct pharmaceutical company! Effectively, without counting the cultural aspects, the wave of liability problems affecting drugs in the United States is particularly harmful for everything having to do with the control of reproduction. For women “ the pill ” whose tolerance is of course very much improved since it was first formulated by Pincus 40 years ago, remains both a superb symbol of the convergence of scientific progress and the cause of women and a very much used method in the developed countries (from 30% to 70% of women concerned), although in the United States especially sterilisation by obturation or section of the Fallopian tubes, whose practically irreversible nature I also dislike, has overtaken reversible hormonal contraception . Does the limited progression of the pill’s use derive from the constraint of a daily intake or from the fear of side effects? I do not know. In the developing countries only a few percent are consistent users, and perhaps the price of the method plays a role in this case; methods involving hormones administered as injections with a delayed effect or as pellets seem to be better adapted for use, in the developing world.

Intra-uterine devices (I.U.D.), often very efficient especially when they are associated with a hormonal component which is locally released into the uterus, may not be indicated if hygiene is insufficient, because of the possibility of infectious complications. All the “natural” methods, without a drug, are essentially based on the monthly calendar and are difficult, if not impossible, to apply on a large scale in a very efficient manner.

On the basis of studies carried out on primates with an anti progesterone compound (RU486) at the Jones Institute of Reproduction in Norfolk (G. Hodgen) and taking preliminary clinical trials into account, especially those of H. Croxatto (Santiago), S. Yen (San Diego), D. Baird (Edinburgh) and M. Bygdeman (Stockholm), I think ovulation and the hormonal cycle can be conserved if one uses a small dose of RU486 which, however, makes pregnancy impossible by acting on the endometrium and perhaps the gametes. The most simple hypothesis is that RU486’s effect is to impede implantation. The continuous administration of the compound (released from microspheres, for example) would avoid problems of forgetfulness without causing any undesirable secondary manifestation. However, for the necessary studies to be carried out in order to open up this new method of contraception, which would probably be superior to the one we know, the necessary means are required. Not only does this work not in general meet with any interest, probably for fear of litigation as mentioned above, but also the Roussel-Uclaf company, which owns the patents and the manufacture, has declared its opposition to the use of RU486 (the compound is distributed by Roussel-Uclaf for voluntary pregnancy termination in France, Great Britain and Sweden, and synthesized and used largely in China).

It is striking that there is no desire to develop a molecule which, let it be underlined, has other applications than abortion and contraception since it permits the facilitation of difficult deliveries (what an apparent contradiction with abortion!) or to treat as frequent a disease as uterine leioma. Worse, others are stopped from developing it in all its indications by the company refusing to furnish the compound, even in return for payment, while it could render inestimable limited services. That is an anomaly, if not a scandal, which deprives women of potential treatments and a possible new method of fertility control.

As well as the financial / commercial difficulties that RU486 might meet (but which remain to be demonstrated), one may wonder if the question of abortion is still blocking its development. Evidently the problem of abortion raises controversies of a religious and moral order, and these obliterate its public health dimension. Risky abortion is one of the most neglected questions among the health problems in developing countries, since probably half the abortions in the world are carried out illegally. It is strange that the 500 daily deaths of women due to unsafe abortion do not provoke more reaction. And however, contrary to what is generally believed, most often the victims are married and already bringing up several children. The problem of adolescents is also terrible. As Professor M. Fathallai said, “women may not want abortion, but they need it”. Of course, in any case a woman should have the right to use, or not to use, RU486 as she should be able to ask for or not to ask for, a surgical abortion. The fact that up-to-date research is responsible for the synthesis of an active and safe antiprogesterone compound probably meets the hostility, while it may be unconscious, of men who are not in favour of a method that relieves some of the worst difficulties of women in a delicate situation.

As can be seen, a compound such as RU486 almost becomes an archetype of what a recognized medical advance from which women can profit. Here we move from an extremely important, but circumscribed, aspect to a concept that brings a more general light on the feminine condition, the concept of reproductive health. Of course this does not only depend on the availability of a compound or even on the entirety of methods based on the molecular, physiological and pharmacological knowledge of hormones.

This scientific knowledge is decisive, but reproductive health also includes, in the most general way, women’s knowledge of the phenomena of reproduction, of their potential mastery over the conditions under which they bear and bring up children, over the major components of sexual life, and finally an equitable recognition of the social equality of women being brought to the forefront of consciousness.(With reference to SDGS Goal 13)

No-one seriously thinks that the physiological differences between the two sexes are going to change greatly and, in particular, that it will no longer be women who have children! But it is certainly possible, socially and thanks to biomedical science, to palliate the differences between the sexes, especially by mastery over reproduction and, at the same time, over the reproductive health of women.

In any case it is not acceptable that more than 500,000 women die every year in the world through pregnancy and that between 10 and 20 million suffer Ione term disability as a result of pregnancies. Such dramas are almost exclusively observed in the developing countries. Maternal mortality is not in fact merely to be considered a medical anomaly, it is a matter of a human rights issue with respect to those who perpetuate the species and which must be considered as a priority; after all maternity is not a disease! Need it be added that spacing out births, by only 2 or 3 years, considerably reduces infant mortality for the under-5s (over 10 million per year at present; the chance of children dying before the age of 5 is 50% greater when births follow each other rapidly) and even more so for the first week of life. It is evident that physiological difficulties, nutritional insufficiencies and thus the economic status of families are interwoven here.

Among the measures to be taken to improve women’s reproductive health and the health of their children, it is advisable to favorize delaying the age of marriage, which is still often imposed on young girls. In most cases, favorizing this delay means diminishing the number of marriages “arranged ” by the family and, as well as implying more respect for the human person, it would allow the young girl to finish her education, to acquire a greater maturity and consequently both more independence and a heightened sense of responsibility.(With reference to SDGS Goal 13).
Here it can be seen that we are touching on traditions which are often difficult to get round. The child or a teenage mother is 24% more likely to die in its first month of life than one born to a mother of over 25 to 4. It is equally difficult, but necessary, to fight against the sexual mutilations imposed on girls, doubtless based on a restrictive conception of their freedom of sexual behaviour. Practices of this kind can be found in almost 40 countries and affect over 80 million people! Reproductive health cannot avoid also considering sexually transmitted diseases (STDs) which increasingly affect women in their millions, with AIDS obviously being the most serious of these diseases. Women, probably contrary to general opinion, suffer much more from STDs than men, especially because of their prolonged pathological consequences, as shown when STDs are studied quantitatively, by counting the “disability adjusted life years” (Dalys). In the developed countries there has been a temporal coincidence between the contraceptive revolution, the sexual revolution and the epidemic explosion of STDs. But these things are not linked in an automatic way: in Africa contraceptives are little used and there is a great deal of STDs. In China there is a great deal of contraception and little STDs. One of the consequences is infertility, whose causes are of course multiple. Need it be said that the treatment of infertility is a part of the care given for women’s reproductive health. Reproductive health also includes the treatment of a certain number of diseases such as cancers which, with great frequency, affect the organs implicated in female reproduction and far which it is desirable to carry out the necessary tests for their early detection. Also must be added the post-menopausal hormonal modifications which must be compensated. On a completely different, but not negligible, register it should be added that the reproductive health of women also includes the physical and psychological troubles caused by farms of violence of which they are most often the object, rape and beatings.

Is it not a human and medical duty to consider this ensemble which may confront our mothers, sisters and daughters? Of course, up to a certain point, it occurs in the context of the insufficient economic and social level at which women are held in most, if not all, societies. The questions are not made simpler by the present evolution of questions of population such as urbanisation and emigration. This is one more reason that we should use all biomedicine can offer us: it is there, we must use it.

Some final considerations

The generalized, or at least the greatly expanded, use of contraception is very recent in human history. It was first developed in the northern industrialised countries even before modern contraception (by the practice of coitus interruptus and abortion). At present science offers possibilities which are much more satisfactory far couples. It is clear that the populations of the developed countries have grasped these, but also the development of contraception is beginning in the southern developing countries where contraceptive technology is playing a primordial role. In all countries, industrialised or developing, the great change is that biomedicine offers women mastery over the process. In fact, we have also passed from a concept essentially based on demographic concerns, as promoted by men, to a concept where the reproductive health of women and consequently their status comes to the forefront. It is a quite remarkable change and all the more so that, after the demographic transitions, stabilization arises and, to maintain the equilibrium, it is and will be necessary to continue to practice a family planning which will be in the hands of women, and hopefully offer more options than currently. Women will control more than they are controlled. Women will have the choice whether to have children or not, the number they desire and the period that they want and neither coercion not to have a child nor coercion to have one will be acceptable. Now we have to close “the gap between women’s aspirations and their reproductive experiences” (The Alan Guttmacher Institute)i. The constitution of the United Nations of 1946 must now be supplemented by the recognition, without distinction, of rights of “gender “, something which was forgotten in the first definition of human rights. This is a new civilising step for humanity and it will have been initiated and lead by science. I believe it is irreversible because the feminine condition will at last be freed of its prehistory.

References

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