In the real world, and especially in its poorest countries, an infant's prospects for survival and good health are highly dependent upon his or her mother's health and well-being. Even so, some members of Congress seem bent on exploiting a false dichotomy between these two interests.

On June 7, Rep. Joe Pitts (R-PA) and other committed opponents of family planning, including Reps. Chris Smith (R-NJ), Todd Tiahrt (R-KS) and Frank Wolf (R-VA), introduced the Save the Children Act. The bill would transfer $100 million from the Agency for International Development's (AID's) population aid program, which is primarily focused on family planning and women's reproductive health, to its separately funded child survival program.

The bill makes a compelling case for increased support of essential child survival efforts, such as oral rehydration therapy, immunizations, sanitary living conditions and adequate nutrition. However, by ignoring the critical role that the timing and spacing of births play in saving children's lives, and by acting at the expense of the program that aims to assure the reproductive health of their mothers, the bill is widely seen as having the potential to do much more harm than good.

Interrelated Programs

For some years, family planning opponents have been trying to promote both a conceptual and a legislative distinction between AID's population and child survival programs—a distinction that runs counter to the way they operate on the ground. Indeed, both programs are housed within the agency's Center for Population, Health and Nutrition in an attempt to integrate their activities, just as the health needs of mothers and children are intertwined.

In FY 1999, Congress appropriated $385 million for population assistance. In addition to voluntary family planning services and the purchase and distribution of contraceptive supplies (including condoms for the prevention of HIV/AIDS and other sexually transmitted diseases [STDs]), population assistance funding supports training in the delivery of high quality reproductive health care services; research on contraceptive technologies, especially in a developing country context; and information, education and communications programs related to reproductive health.

Child survival activities, meanwhile, received $245 million in FY 1999 (not including the $100 million U.S. contribution to the United Nations Children's Fund [UNICEF]). AID uses child survival funds to support immunization efforts and good nutrition; the treatment of diarrheal disease, acute respiratory infection and polio; the promotion of breastfeeding; the prevention and treatment of malaria; the prevention of blindness among children; and assistance for displaced children and orphans. Maternal health interventions, such as prenatal and emergency obstetric care, are also included.

In recognition of the essential contributions of birthspacing to child survival (see box), AID regards pregnancy timing and spacing as a legitimate component of its child survival strategy. Under pressure from congressional conservatives to fund only "traditional" child survival activities, however, AID has stated that it will continue to support birth-spacing efforts under the child survival program, but it will not use child survival funds to purchase contraceptives. Funds for the actual purchase of contraceptives must come from the population account. The bottom line, then, is that the population and child survival programs are not in competition with each other; they are interdependent.

Attacking Family Planning

In 1997, 147 members of the House, Pitts and Tiahrt among them, supported an unsuccessful effort to eliminate funding for the population program entirely. Having failed to kill the program frontally, Pitts and like-minded colleagues adopted a new approach toward the same end: Rather than zero out the program, they would seek to transfer more than one-quarter of its budget to the child survival account.

Certainly, there is real need for more funds for child survival efforts, although this area is no different from reproductive health, HIV/AIDS, basic education and other development efforts in that the need will always outstrip available resources. Rather than seeking to increase development assistance funding overall in order to allow for increases in the programs that work together to promote economic and social development, however, Pitts's proposal would single out family planning for deep cuts. As a result, it is clear that his effort is aimed as much at undermining the international family planning program as at strengthening child survival efforts.

"Our first priority must be to save the lives of children already placed in this world," says Pitts in his press release accompanying introduction of this year's Save the Children Act. A popular sentiment indeed. But the rest of his statement concentrates more on what he is against than what he is for. "It is a documented fact," claims Pitts—who chairs the congressional Values Action Team, the purpose of which is to coordinate legislative strategy with groups such as the Christian Coalition and Family Research Council—"that appropriating more funding for condoms, IUDs, Depo-Provera, and fertility experiments takes away from our opportunity to focus our extraordinary resources towards the tangible result of saving children's lives." Amplifying on his point in a Washington Times opinion column, Pitts calls support for contraceptive services "shortsighted" and "dubious," and alleges that the reason women in poor countries die in childbirth is not that they lack access to contraception but that they are in poor health. In doing so, however, he blatantly refuses to recognize the vital role that pregnancy timing and spacing play in improving women's health and, as a result, their pregnancy outcomes.

Pitting Women Against Children

That connection, however, is not lost on key organizations working on the front lines to provide basic health care to children and their families in the world's poorest countries. Last fall, when Pitts threatened to force a vote on his proposal in the form of an amendment to the pending foreign assistance appropriations bill, the international nongovernmental organizations Save the Children and CARE protested. "Instead of supporting children's health," they wrote in a joint letter to Congress, the Pitts proposal "ignores the fact that family planning and child survival are inextricably linked."

The Global Health Council, the membership of which comprises professionals and organizations from around the world committed to promoting health and development, also protested to key members of Congress. In its letter, the Council stated that the effect of the Pitts proposal could be as many as 75,000 more infant and child deaths annually, and over two million more unintended pregnancies, resulting in thousands more maternal deaths and almost one million more abortions. The Council also noted that sharply cutting funding for population programs would mean reduced availability of condoms, which, in turn, would severely impede efforts to limit the spread of HIV/AIDS and other STDs.

Pitts never followed through on his threat last fall, but it appears likely that at some point during this year's legislative session he will. This year, however, by formally introducing his proposal in the form of a freestanding bill early in the session, he has afforded himself the opportunity to gather cosponsors and grassroots support well in advance of a likely vote during the annual appropriations process. With scarce funds available for development assistance overall, increases for any purpose would appear to be remote. That is no doubt part of the appeal of Pitts's proposal, since it might appear to be the only way to increase funding for children.

Still, whether in the form of an amendment to an appropriations bill or as the freestanding Save the Children Act, the same organizations—with Save the Children taking particular offense at the bill's title—remain staunchly opposed to raiding the population program, even for the cause of children. They view the proposed fund transfer fundamentally as an attack on family planning rather than a boost for child survival. And they stand by the central message that Save the Children and CARE sent to Congress last year: "If you truly want to improve the lives of children and their mothers, then you should vote to increase funding for both of these interventions."

Pregnancy Timing and Spacing Are Key to Child Survival

The benefits of family planning for both mothers and children are largely taken for granted in the United States and other developed countries, where rates of maternal and infant mortality are low. But in the developing world, the impact of pregnancy timing and spacing on maternal and infant survival and health is particularly stark.

Throughout the developing world, babies born to women younger than 20 or to women older than 40—who often have several children already and may be in poor health themselves—are at much greater risk of dying in infancy than those born to women in their 20s or 30s (see chart). And, as a 1997 report by the Population Reference Bureau concludes, "closely spaced pregnancies are more likely to result in low birth-weight babies who are more vulnerable to infection and thus less likely survive. Even if they survive the first year, these children are almost one and one-half times more likely to die before age five than children whose births were spaced at least two years apart." Indeed, if all births in developing countries were spaced at least two years apart, infant mortality could be reduced, on average, by one-quarter (see chart). This would be a significant accomplishment considering that an estimated 12 million children younger than five die every year, largely of preventable causes.

Equally important to enhancing the chances of a good pregnancy outcome is ensuring that the mother herself is healthy. According to a 1999 report by Save the Children, "research and decades of experience have shown...that improving the well-being of mothers—and increasing their status and ability to make choices—has a direct and powerful impact on the well-being and future of their children." Moreover, points out the report, when mothers die in childbirth, their infants are more likely to die as well, and their surviving children become vulnerable to serious health problems.

The report issues a call to action to governments, communities and families to give higher priority to the basic needs of women and adolescent girls—the world's future mothers—in the areas of health (especially reproductive health), education, economic opportunity and food security. The evidence that much remains to be done to improve women's reproductive health is clear and pervasive. According to the World Health Organization, at least 600,000 women die each year from complications of pregnancy or childbirth. Indeed, pregnancy-related complications are the leading cause of death among 15-19-year-old women worldwide. As a result, UNICEF estimates that simply meeting the existing demand for family planning in developing countries could bring a 20% reduction in the number of pregnancies and at least an equivalent reduction in maternal deaths and injuries.

Age of mothers
Infant deaths are fewest when women give birth in their 20s and 30s.
Infant deaths per 1,000 live births
< 20	20-29	30-39	40-49
Age of mother at birth of child
Source: Demographic and Health Surveys Comparative Studies, 1996.

Spacing babies
In developing countries, longer birth intervals reduce a baby's likelihood of dying...
Infant deaths per 1,000 live births
< 2	2-3	>= 4
Number of years since preceding birth
...and spacing births at least two years apart could prevent an average of one in four infant deaths.
% infant deaths preventable by spacing
Source: Top, Demographic and Health Surveys Comparative Studies, 1996. Above, Population Reference Bureau, 1997.