World Development Report 1984

eastmilk until the late 1960s. As the advantages abortion, physical well-being. Moreover, except
of breastfeeding became better known, breastfeed- for complete abstinence and infanticide, they do
ing increased among better-educated women. In not always work. Under these circumstances, riskthe
United States, for example, college-educated ing an additional child may seem less costly than
women are now most likely to start breastfeeding preventing a birth, and even the stated "desired
and continue it for the longest periods. family size" may be higher than it would be if birth
Apart from providing more information on the control were easier.
advantages of breastfeeding, medical authorities in It fo]lows that programs to provide publicly subdeveloping
countries can restructure hospital and sidized information and access to modern methods
clinic routines that discourage breastfeeding by of contraception can reduce fertility. They do so in
separating mother and child and offering unneces- several ways: by making it easier for couples to
sary supplementary bottlefeedings. In Malaysia have only the children they want; by spreading the
government family planning clinics that encourage idea of birth control as something individuals can
breastfeeding have a positive effect; women who do; and by providing information about the prigive
birth in nearby private maternity clinics are vate and social benefits of smaller families, which
less likely to breastfeed, all other things being may itself alter desired family size. The next chapequal.
Legislation to control the promotion of pow- ter looks at how family planning programs can be
dered milk can also be effective. In Port Moresby, run to best meet people's needs for safer and more
Papua New Guinea, changes in hospital practices effective contraception. The rest of this chapter
and restrictions on the advertising and distribution examines the evidence that support for family
of powdered milk increased the proportion of planning services (delivered by both public and
breastfed children under two years old from 65 to private agencies) has helped to reduce fertility.
88 percent in just two years, between 1975 and
1977. EFFECTS OF FAMILY PLANNING PROGRAMS ON
Without such efforts, breastfeeding seems likely FERTILITY. Measuring the impact of family planning
to go on declining. In this case-unless contracep- programs is less straightforward than it seems. To
tives are used more widely-fertility will rise. As distinguish the specific impact of a program, anaan
example, reducing the duration of breastfeed- lysts must estimate how fertility would have
ing from an average of three years to one month changed in its absence. That requires systematicould
double a mother's fertility from five to ten cally eliminating other possible causes of a counchildren.
In the mid-1970s, if all mothers in Thai- try's fertility decline-such as increases in income,
land had started menstruating three months after education, and life expectancy in the same period.
each baby was born, contraceptive use there In addition, information on the change in the availwould
have had to double to prevent fertility from ability of family planning services is needed (not on
rising. In Indonesia, contraceptive use would have change in the use of services, since use is related to
had to more than double; in Bangladesh it would people's fertility goals and does not indicate the
have had to increase sixfold, and in Pakistan difference services alone would make to people
eightfold. who now have no access to them). Such information
has, until recently, been patchy and inade-
Making conttraception easier quate.
Given these analytical difficulties and the lack of
As shown in Figure 6.5, fertility declines every- good information, it was not surprising that a
where have been eventually tied to increasing use decade ago policymakers and planners could not
of contraception. Use of contraception is partly a completely agree on the relative importance to a
function of a couple's wish to avoid (or to post- fertility decline of the supply of family planning
pone) additional children; the number of children services versus the "demand" factors-increasing
desired is related to the social and economic factors education, lower infant mortality, and the like.
discussed above. But use of contraception is also Early family planning programs in Korea, Hong
related to its costs, that is, to the costs of limiting or Kong, and other areas of East Asia had been estabpostponing
births. People have regulated family lished in countries where a marked fall in fertility
size for centuries-through abortion, withdrawal, was already in progress; some of the continued
sexual abstinence, and even infanticide. But these decline might have occurred even without official
methods are all costly in terms of reduced emo- programs. In other countries (such as India and
tional, psychological, and, in the case of traditional Pakistan), where programs were also established
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