Elsevier

The Lancet

Volume 380, Issue 9837, 14–20 July 2012, Pages 165-171
The Lancet

Series
The economic consequences of reproductive health and family planning

https://doi.org/10.1016/S0140-6736(12)60827-7Get rights and content

Summary

We consider the evidence for the effect of access to reproductive health services on the achievement of Millennium Development Goals 1, 2, and 3, which aim to eradicate extreme poverty and hunger, achieve universal primary education, and promote gender equality and empower women. At the household level, controlled trials in Matlab, Bangladesh, and Navrongo, Ghana, have shown that increasing access to family planning services reduces fertility and improves birth spacing. In the Matlab study, findings from long-term follow-up showed that women's earnings, assets, and body-mass indexes, and children's schooling and body-mass indexes, substantially improved in areas with improved access to family planning services compared with outcomes in control areas. At the macroeconomic level, reductions in fertility enhance economic growth as a result of reduced youth dependency and an increased number of women participating in paid labour.

Introduction

In 2006, universal access to reproductive health by 2015 was added as a target to the Millennium Development Goals to help to improve maternal health. According to our analysis, access to reproductive health and family planning can also help to achieve some of the other Millennium Development Goals, such as those to eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality and empower women, and ensure environmental sustainability.

According to the Malthusian argument, population growth puts pressure on scarce resources, leading to hunger and high mortality.1 Economic studies have focused on whether demographic change is a result of more than just population growth.2 Population increase resulting from health improvements and increasing life expectancy can have very different economic consequences from population growth resulting from high fertility or immigration; therefore, the source of population growth needs to be known to predict its social and economic effects.3, 4

Improvements in reproductive health and access to family planning can benefit the economy by improving general health and reducing fertility. Antenatal and postnatal care can improve the health of mothers and children. Access to family planning not only reduces total fertility (ie, the average number of children that would be born to a woman over her lifetime, in accordance with reported age-specific fertility rates), but also reduces the numbers of high-risk births for women of very young maternal age (ie, those younger than 18 years) and women at high parities. Contraceptive use can also improve birth spacing, which can further benefit the health of mothers and children, reducing maternal and child mortality.5 Parents can invest more money and time per child in health, nutrition, and education when they have fewer children. Early childhood investments in health and nutrition can have large effects on physical and cognitive development and educational outcomes and income in adulthood.6, 7, 8

Key messages

  • Family planning programmes can reduce fertility in resource-poor settings such as rural Bangladesh and Ghana

  • Fertility declines are associated with an increase in women's health, earnings, and participation in paid employment

  • The children of women who have had frequent home access to family planning and health services are healthier and better educated children than are those of women without such access

  • Reduced fertility and child mortality lead to an increased proportion of working-age people within the population, with positive outcomes for economic growth

  • Household-level behavioural effects on the female labour supply, child health, and education can lead to large macroeconomic demographic benefits

Although fertility decline is driven mainly by reductions in desired fertility,9 reproductive health and family planning interventions can help families to achieve their fertility goals. A reproductive health, child health, and family planning intervention in Matlab, Bangladesh, and a similar intervention in Navrongo, Ghana, both led to reduction in total fertility of about one child per woman compared with control areas.10, 11 Reproductive health and family planning services can thus be effective even in resource-poor settings.

Access to family planning and maternal and child health services is likely to have economic repercussions for families, extending beyond the reductions in fertility and improvements in health. For example, improved control of fertility and health of women and children will give women more opportunity to acquire skills that could raise lifetime earnings. Additionally, a reduction in total fertility might lead parents to accumulate more physical assets than they would have otherwise done, particularly if the assets are a partial substitute for the support and care they expect from a child. Moreover, human capital investments parents make in each of their children's health and schooling might rise as a result of reproductive health programmes that provide information and access to family planning.12, 13, 14 Finally, general equilibrium effects might occur at the community or aggregate level if fertility declines exceed increases in child survival, leading to fewer young people in the community than in previous generations. Within two decades after a decline in fertility, fewer young adults than previously would reach working age, possibly causing wages to rise, at least for young people, because of a scarcity of workers (assuming the supply of other productive factors and technology does not change).

Acquisition of skills to boost earnings, accumulation of physical assets, and investments in children's health and schooling would take place only if resource substitutions occurred at the family level, which is plausible, but causal relations such as these are difficult to measure with purely observational data. The effects of fewer young adults reaching working age on the labour market would occur at the aggregate level, although the magnitude or importance of these effects in the era since the industrial revolution is questionable.15

Microeconomic evidence derived from survey and census data at the household level in areas where family planning and reproductive health programmes have been implemented as social experiments helps to assess the expected effects of these programmes. In these areas, household savings in the form of adult human capabilities might increase for women, the human capital of children would tend to rise, and physical capital might be accumulated for retirement. Increases in women's health and productivity would give families more resources for their children than they would have in areas without a family planning and reproductive health programme, and the resulting investments in child health and education should increase prospects for the next generation, alleviating poverty by boosting labour productivity and capital accumulation, which adds to aggregate economic growth.

Section snippets

Effects at the household and community level

To estimate the empirical importance of increased access to family planning and reproductive health resources, a method is needed to identify variation in fertility and family health that is attributable to the effects of the particular family planning programme or policy rather than parents' preferences, economic and social endowments, opportunities, or unobservable determinants of the family's labour supply, investment behaviour, and other outcomes of interest. Outcomes in areas where family

Macroeconomic consequences

In theory, the effects of family planning interventions at the household level should add up to measurable effects on national income at the aggregate level, although interactions between effects might influence the final outcome, and some effects might occur only at the aggregate level. For example, population growth could put pressure on food and land prices, which affects everyone, not just families with many children. The interventions in Navrongo and Matlab were regional and captured

Conclusion

Declines in fertility and decreases in population growth have played a central part in countries that have escaped from the Malthusian trap and whose economies are now growing.58 Evidence from Asia and Africa suggests that access to family planning can have substantial effects on fertility. The resulting reduced fertility and improved birth spacing directly benefit maternal and child health and children's physical and cognitive development, educational outcomes, and adult productivity.

Fertility

Search strategy and selection criteria

We searched Web of Science and Research Papers in Economics (RePEc) for relevant work, published between 1980 and 2012, in any language, with the search terms “population and economic growth”, “demographic dividend”, “family planning and economic outcomes”, and “fertility and economic outcomes”. We also did searches for the two experimental family planning interventions discussed in this paper with the search terms “Navrongo and family planning” and “Matlab and family planning”. We focused our

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