World Population Day – 11 July 2021
“In no place in the world today are all people fully empowered to realize their own fertility goals and reproductive rights” – ‘The State of World Population 2018’, published by UNFPA, the United Nations sexual and reproductive health agency.
11 July marks a special day. We are not talking about football and the Euro 2020, although it would be remiss not to mention England has got through to their first final since 1966 after beating Denmark 2-1 in extra time! No, we want to discuss how 11th July is World Population Day – a day that seeks to focus attention on population issues. As we grow closer to seeing COVID -19 restrictions lifted in England on 19 July, many of us are wondering what impact the global pandemic will have on the world’s population and issues of demographics. We also want to highlight the importance of acknowledging that during such crises, marginalised communities suffer disproportionately, and this is no exception. The data thus far presented (PDF) clearly indicates that the virus has had a disproportionately adverse impact on Black, Asian and other racially minoritised people. As Vaughn and Obasi observe: ‘COVID-19 has not only revealed, but has exacerbated existing structural or systemic racial inequalities that are in need of urgent attention’ (PDF). Thus, it is important, on this year’s World Population Day, that we examine what impact the pandemic has had locally on demographics and in particular marginalised groups in the context of reproductive health, gender equality and racial equality.
According to the most recent United Nations estimates, the current world population is 7.9 billion. During the 20th century alone, the population in the world grew from 1.65 billion to 6 billion. Whilst the world population will continue to grow in the 21st century, the broad global consensus is that it is at a much slower rate compared to the recent past. Growth slowing down has not abated concerns surrounding population growth and the impact it is having on our world. Consider the popularity of the 2020 British documentary narrated by David Attenborough, ‘A Life on Our Planet’, which highlights the unbridled destruction of nature caused by human population growth and unsustainable consumption, as well as the practical measures we must take to save it. (It is showing on Netflix and is a highly recommended watch!)
Concerns around the impact population growth is having on the world have long been voiced, and in general, they have been surmised by Bavel as falling into three main inter-connected consequences, namely: 1) the growing poverty in the world and famine; 2) the exhaustion and pollution of natural resources essential to human survival; and 3) the migration pressure from the poor South to the rich North.
In England, the pandemic occurred amidst decreasing fertility trends in the UK. There were 640,370 live births in England and Wales in 2019, a decrease of 2.5% since 2018 and a 12.2% decrease since the most recent peak in 2012. However, there may well be more births as a result of the lockdown as couples spent lots of time together! Fertility treatments are also likely to have been accessed less and also suffered disruption. In addition, the disruption caused by the covid -19 pandemic may have further hindered access to contraceptive and family planning. There were similar concerns in England, although this was mitigated to some extent by the NHS move to tele medicine, where unless there was clinical or practical reasons necessitating in person visits, consultations took place over telephone and video calls in order to minimise the risk of infection for staff and patients. In England, the government approved temporary measures to limit the transmission of COVID-19 by approving the use of both pills for early medical abortion at home, without the need to first attend a hospital or clinic. Furthermore, early indications from 2020 show that the rate of abortion increased. The Department of Health and Social Care reported in 2020 there were 209,917 abortions for women resident in England and Wales, the highest number since the Abortion Act was introduced in 1967.
Noting how past epidemics and pandemics have had lasting effects on the structure of the population, Sarah Crofts from the ONS Centre for Ageing and Demography in 2020 considered the potential impact of COVID-19 on the future population of the UK. Whilst acknowledging the likely impacts on births and migration as well as deaths, she noted at that stage that the full impact of COVID-19 on the UK population is unclear and that it may be many years before we can measure the full impact. Leading expert Peter McDonald, who is a professor of demography at Melbourne University claims that whilst the pandemic ‘will have some impact’ on the planet's future population, he notes that ‘it's not the deaths, it's the births that will make the difference’. He claims this is because ‘the number of deaths so far is equivalent to 1 per cent of the 60 million that would have been expected to die of all causes in the normal course of events’. For the remainder of this blog, we focus on reproductive health and fertility.
Gender equality and greater recognition of women’s reproductive autonomy is fundamental when discussing fertility and reproductive health. The decision to reproduce, or not, is a central and integral part of an individual’s private and family life. Whilst one day off into the future we may see babies birthed by machines (ectogenesis) and male contraceptive pills, for now, gestation takes place in women’s bodies. Women should have the right to decide if they have children, when they have them, and to determine the timing and spacing between their pregnancies if they choose to have them. Comprehensive sex and family planning education and implications on their health and well-being is key. Health services need to provide a meaningful choice of contraceptives and be easily accessible to all. As the UNFPA has acknowledged: ‘Fertility matters for societies because it can impede or accelerate progress towards greater prosperity, equitable and sustainable development, and well-being for all’.
Thus, respecting women’s reproductive choices and investing in their reproductive health has to be at the centre of any discourse on population control. It has been argued that if family planning and contraceptives were made universally available, the evidence is that population growth would stabilize and then start to decline.
There is a widespread consensus acknowledging that matters of demographics, economic and social development and reproductive rights are inextricably linked and mutually reinforcing. As far back as 1994, 179 governments endorsed the Programme of Action of the International Conference on Population and Development in which they committed to enabling people to make informed choices about their sexual and reproductive health as a matter of fundamental human rights that underpin thriving, just, sustainable societies. It was agreed that that progress depends on advancing gender equality, eliminating violence against women and ensuring women’s ability to manage their fertility.
Yet writing in 2021, gender equality remains more illusory than real. The United Nations 2021 Population Reports state: ‘Despite constitutional guarantees of gender equality in many countries, worldwide, on average, women enjoy just 75 per cent of the legal rights of men (United Nations Secretary-General, 2020)’. The 2021 Report named ‘My Body is My Own, Claiming the Right to Autonomy and Self-Determination’ (PDF) is aptly themed around respecting women’s bodily autonomy, and notes how the low level of participation in political arenas and other form of decision making, often means women and girls in many instances lack the power to contest these disparities. This economic marginalization can detract from a woman’s financial independence, which in turn can weaken her authority to make autonomous decisions about sex, health care and contraception.
The Importance of Women's Rights
Photo by Giacomo Ferroni on Unsplash.
Lack of access to family planning and contraceptive services places women’s lives at risk, unintended pregnancies representing an important cause of maternal deaths. Maternal mortality remains a top cause of death among women of reproductive age in developing countries. Approximately 350,000 women die each year due to pregnancy-related causes, despite recent improvements and international commitments to reducing maternal mortality.
We know that in the UK there is a disproportionate number of BAME women dying of maternal morbidity. In November 2018, MBRRACE-UK (a national audit government commissioned programme to collect information about all late fetal losses, stillbirths, neonatal deaths and maternal deaths across the UK) reported BAME women were almost five times more likely to die from pregnancy and childbirth related causes. Asian women were nearly twice as likely. Thus in comparison to White women, BAME women are more likely to have negative, or even worse outcomes and poorer prognoses from treatable and avertible conditions during the intrapartum and postnatal period.
Given that pre-pandemic the death rates for BAME women dying from pregnancy and childbirth related causes were already astonishingly high in comparison to white women, it is no surprise that BAME pregnant woman have also been more negatively impacted by the pandemic. BAME pregnant women have shown to be more susceptible to Covid -19 than child-bearing women from other population groups. A recent UK wide exploration on the impact of COVID19 on a sample of pregnant women (PDF) revealed that pregnant women admitted to hospital with coronavirus from a Black, Asian or Minority Ethnic background amounted to 55% of the sample.
As the UN 2021 Population Report (PDF) highlights, inequalities have been exacerbated by the pandemic:
The hardships brought on by the COVID-19 pandemic have only made matters worse. For some women and girls, the impact of gender inequality is amplified by multiple sources of discrimination based on age, race, ethnicity, sexual orientation, disability or even geography. When diverse types of discrimination intersect, they leave women and girls even more at risk of not realizing bodily autonomy, not enjoying their rights, and even further away from gender equality.
This is echoed in the 2020 Policy Briefing, co-authored by Dr Leona Vaughn (UoL) and LSTM’s Dr Angela Obasi (PDF), who noted that ‘COVID-19 has not only revealed, but has exacerbated existing structural or systemic racial inequalities that are in need of urgent attention.’ One of the key takeaways from Vaughn and Obasi’s policy paper is how COVID-19 has impacted disproportionately on Black, Asian and other racially minoritised people due to decades of structural racism and a failure to adequately tackle this in policy and practice.
How do we tackle this inequality?
Photo by Srephanie Martin on Unsplash.
Vaughn and Obasi rightly point out that individual and structural racism is a public health challenge which leads to significant adverse physical, mental and economic health outcomes for Black, Asian and other racially minoritised people which needs to be addressed as a strategic priority. They highlight the importance of meaningful and well-resourced multi-sector partnership in the design and implementation of strategies for recovery and the need for such strategies to be co-produced with communities to help counteract the impact of racial inequalities.
In the context of delivering maternal care, Professor Jacqueline Dunkley-Bent, Chief Midwifery Officer for NHS England and NHS Improvement and National Maternity Safety Champion for the Department of Health (Maternity and Midwifery Forum, 2020a) speaking at a conference in 2019, echoed that Midwifery led continuity of carer model has shown improvement in clinical outcomes for women from ethnic minorities and those living in deprived areas. She further concurred that during the antenatal period, women, who are looked after by a known midwife or the same team of midwives, report satisfaction with information and advice and care given to them, feeling empowered, in control of their care, their birth plans, and other intricacies of their labour and birth journeys (PDF). Going forward it is imperative for midwives to fully understand the healthcare needs of the women they care for and recognise how health and well-being are impacted by identities and experiences of marginalization (PDF). Follow up with BAME women who miss appointments is vital within maternity care and they must be provided with supplementary appointments where necessary to mitigate this.
In the face of such disparities in health outcomes, Service providers should aim to empower women to make choices and should treat these choices with respect and must involve service users in discussions about their care in order to address inequalities (NHS England, 2019).
If we are serious about tackling population control, we argue the way forward is to tackle such inequalities and to fully respect and support the reproductive rights of all. This necessitates dismantling barriers which impede access or exercise of these fundamental rights and freedoms and allow free and informed choice in this vital domain.
We teach Reproductive Justice on the LLM in Health Care and Ethics in the School of Law and at undergraduate level students undertaking a LLB in Law can select Medical Law and Ethics modules in their final year where we also discuss reproductive ethics.