“I never wanted to have four children. I had planned for only two,” said 39-year-old Shaimaa in a frustrated tone. Not that Shaimaa did not like children, but she explained that the financial burden of having to raise four children had itself been “hard labour”. Shaimaa had two unwanted pregnancies because she had probably received “bad medical advice on contraception”, she said.
“My husband has had to stop work, and I’ve been grappling with different jobs since to make ends meet,” she said. “I had to accept jobs that involved difficult tasks like cleaning and looking after elderly people to be able to educate my children,” she added.
As the only breadwinner of her family, Shaimaa has to work 12 hours a day as a care-assistant in a home for the elderly.
Her oldest two children have recently gone to university, adding to the financial pressure. “I want them to receive a university education so that they can get good jobs and have a better life than mine,” she said. “I just hope I can pursue that dream under the present financial pressure.”
Similar financial pressures seem not to have dissuaded Mahmoud, a doorman from Aswan, from having more children. His wife has given birth to their third child despite the fact that Mahmoud can hardly support his family since he also has to provide for his parents and siblings back home.
“We love having children, and we trust that God will provide for them,” Mahmoud explained. “I’m trying to get an extra job beside door-keeping to be able to feed my family. It’s hard, of course, but children are the only support we have in life when we grow old.”
While family planning programmes may have proved inadequate in Shaimaa’s case, Mahmoud’s logic may equally epitomise the many challenges hindering decades of state efforts to curb Egypt’s growing population.
Having children is, of course, a very personal choice, and many parents like Mahmoud hardly think twice about how their family planning decisions could affect the larger society.
As a result, many governments worldwide may feel compelled to intrude into the lives of the people, either meddling with birth-control policies to help the floundering economy or providing incentives to couples to have more children in cases of low fertility rates.
Sometimes such policies fail to yield the expected results or end up causing a demographic imbalance that forces a reversal of government policies, as is currently the case in China and Singapore.
Egypt falls into the first category, as overpopulation has been widely seen as a time-bomb stifling attempts at economic development.
The government has adopted national birth-control policies over recent decades, but these were temporarily pushed down the list of priorities in the aftermath of the 25 January Revolution that ended the rule of former president Hosni Mubarak.
Today, however, family planning is back on track, since the birthrate has surged and the political will to curb it been revived after President Abdel-Fattah Al-Sisi said flatly at a youth conference last year that “terrorism and overpopulation” were “the two biggest dangers that Egypt faces”.
Head of statistics agency the Central Agency for Population and Mobilisation Statistics (CAPMAS) Abu Bakr Al-Guindi has similarly warned that the country could be facing a “catastrophe if population growth continues unabated”.
According to Egypt’s 2017 census, the country’s population has more than doubled over the last 35 years, currently hitting 104 million people.
If the current birthrate continues, being the world’s 13th highest at a newborn every 15 seconds, Egypt’s population is estimated to grow almost 50 per cent by 2038.
For even the casual observer, these alarming figures immediately translate into daily hardships. Car-drivers now have to cope with round-the-clock traffic deadlock, especially in highly congested cities like Cairo and Alexandria.
Public hospitals can hardly accommodate the number of patients they receive, while children are crammed into classrooms in state schools and expanding housing has encroached on arable land to meet population growth rates in rural areas.
In the meantime, according to official figures poverty rates have increased to 28 per cent of the population, a figure that unofficial sources say could in reality be much higher, perhaps to the tune of 34 per cent or even extending to half the population.
Although government figures indicated a drop in unemployment rates to 10.6 per cent of the population for the first quarter of this year, compared to 11.3 at the same time last year, Egypt still needs to create jobs for at least one million people entering the labour market every year.
More alarmingly, perhaps, is the fact that Egypt is about to face what the UN terms “water poverty” and problems in feeding its population unless action is taken now.
Economists explain that overpopulation becomes a threat when the rate of consumption exceeds savings and imports are larger than exports, the case in Egypt and many other developing countries. When the population is overblown, more imports are needed and consumption accelerates to cause problems that can stymie any attempts at development.
Economic development is also often gauged by a country’s per capita income and the public services the government provides, and both seem to have been crumbling under rapid population growth in recent years.
Egypt has been adopting family planning policies to rein in population growth since the 1960s, but it was in the 1970s that the US aid agency USAID stepped in with financial support for family planning programmes among other health services in Egypt.
It was under former president Mubarak that Egypt intensified its efforts to rein in population growth rates, especially following Egypt’s hosting of an international population conference in 1994.
Decades of modest decreases in Egypt’s population growth, however, gave way to a sudden surge in the birthrate following the 25 January Revolution, and the 2012 birthrate was considered a setback, taking Egypt back to the records of the early 1990s.
As a result, the government entered the fray last year with more intensive efforts to curb the surge in the birthrate. New policies, including a campaign named “two is enough,” were adopted as part of the country’s population and development strategy for 2015-2030.
The “two [children] is enough” project was designed by the Ministry of Social Solidarity, and it has been widely adopted by local media.
It was clear at the outset that the project would not adopt a strict family planning policy that implied penalties and rewards akin to that of China but would rather aim to increase awareness and provide better reproductive health services.
Fighting illiteracy, unemployment and poverty were all announced by the government as part of its broader birth-control strategy.
The strategy soon received the support of USAID, which announced on its website that it would “provide technical assistance and training to the Ministry of Health and Population to strengthen its Family Planning and Reproductive Health Programme.”
“Contraception is the last thing we can rely on in the population strategy,” the then health minister Ahmed Emadeddin told the newspaper Al-Masry Al-Youm during the launch of the programme.
He explained that tackling issues of illiteracy, school dropout rates, early marriages, unemployment and religious misconceptions on the issue were also equally important when dealing with family planning.
However, more than a year after the campaign was launched there have been calls for adopting harsher policies, imposing penalties on those who do not stop at having two children.
Parliament has recently been discussing a family planning bill which suggests depriving the third child of any kind of government support and offering financial incentives to those who decide to stop at two.
“Parents who do not abide by the number of children stipulated in the bill should not expect the government to subsidise the food, medical treatment, or education of the extra children,” MP Mohamed Masoud explained.
Devil In The Details
The bill soon attracted criticism for being too harsh. Professor of gynaecology and family-planning expert Ahmed Rashed slammed it for being “catastrophic” as most of those who have large families belong to the poorer strata of society.
“It is totally illogical and against human rights to punish a third baby in this way,” Rashed said. After all, “20 per cent of pregnancies have been found to be the result of unmet needs. That is, 20 in every 100 women have an unwanted pregnancy as a result of not receiving the right or any reproductive health services, while those resulting from using the wrong contraceptive methods due to bad advice could reach 80 per cent of unplanned pregnancies,” he said.
A 2014 paper by Tarek Amin, professor of community medicine and public health at Cairo University’s Faculty of Medicine, corroborates the fact that “unmet needs” are prevalent among many “Egyptian women having more births than they consider ideal.”
“According to Ministry of Health statistics, around eight in 10 married women in Egypt want no additional children or to delay the next birth for at least two years, yet a sizeable proportion do not use contraception,” Amin wrote in his Trends and Patterns of Use and Barriers to Family Planning in Egypt.
“A recent survey has showed that the highest level of the use of family planning was observed in the 35-39 age group at some 92 per cent,” he added.
Total fertility would thus perhaps “fall to 2.4 births per woman” if unmet needs were efficiently tackled, according to Amin.
Imposing penalties would be a grave mistake, he said. “The problem with the current unclear family planning policies immediately show up in the mentality of those designing them,” he lamented.
He said that penalties were not just against a child’s right to education and healthcare, as stipulated in the constitution and human rights documents.
“They would also strip the country of having a healthy and well-educated generation in future,” he insisted, adding that having more uneducated and unhealthy children is “primarily the government’s problem, not a mother or child issue”.
Rashed is equally worried that any such campaign would stop at a local media campaign in the absence of any “transparent strategy or effective outreach campaign similar to the state project to fight the Hepatitis C virus, for example.” Contraceptives, he explained, are too expensive to be handed out for free, while healthcare providers may find few incentives to do an honest day’s work since the bulk of the project’s budget could be channeled to senior officials.
“Workers in family planning clinics sometimes produce papers showing that contraceptives were provided, while in fact they often get rid of them simply because of government inspections,” Rashed told Al-Ahram Weekly.
“Family planning programmes were most effective in the period between 1996 and 2000, when USAID-supported fieldworkers would go on outreach visits to women in their homes in rural areas and provide advice in pediatric clinics when mothers went for their children’s vaccinations or check-ups. This is not the case now,” he said.
In the absence of these outreach programmes, Rashed said that “media campaigns can hardly convince women to visit clinics or change their convictions regarding the number of children they would like to have.”
“The government has to recruit civil society to help in effective awareness campaigns, and it needs to recruit technical advisors who have the will to bring actual change on the ground,” he said.
However, cultural, economic and social barriers also have to be tackled for any family planning policy to bear fruit.
“Most of those having large families belong to the poorer strata of society with no access to social or medical insurance programmes,” explained Karima Korayem, a professor of economics at Al-Azhar University and an economic consultant to a number of international organisations. “Many such families do not even have access to food ration cards.”
There is also a consensus among demographic experts that for many poor families a child costs little and soon becomes a financial asset to the family as they drop out of school to join the labour market early in their lives.
“Those people are not stupid. They do have a point,” Korayem said. “Family planning policies should study the demographic reality in order to be able to design concrete solutions because media campaigns cannot deal with such issues,” she insisted.
Since having more children is seen as a form of life insurance for the very poor when they get old or if the family breadwinner falls ill or dies, the real solution in Korayem’s view is to provide a stronger safety network to that segment of society.
“If poor families felt they received real government support in the form of a pension and health insurance, they would probably not feel the need to have more children or even employ those children when they are young,” Korayem insisted. “In the absence of such support, awareness campaigns will just fall on deaf ears.”
Middle-class families already tend to have fewer children because, as Rashed puts it, “they are encumbered with the expenses of private schooling, university education and high living costs. Most middle-class families who have more than two children would thus fall into the category of those having an unwanted pregnancy,” Rashed said.
But social workers also mention other family planning barriers like couples wanting a different sex of child, usually a boy in rural areas, or having religious misconceptions about contraception as being haram (sinful), the latter being tackled by Al-Azhar, the renowned religious institute.
“It is common that women have more children in attempts to have a boy,” said Fatma, a 65-year-old mother of six girls, of whom three are married. Fatma had six girls in her attempts to have a boy, but she never succeeded.
She does not seem to regret it despite the hardships she has had to bear in educating her girls and marrying them off. Instead, she feels rewarded that her girls do all the household chores for her since she is growing old.
They also help with expenses since they all work and contribute to the household budget. “Children are an asset in life,” Fatma said in a contented voice.
Yet, although her eldest daughter wanted to stop at two children, her husband threatened to remarry if she did not have more. “Now she has four, and her health has deteriorated,” Fatma lamented. “Life has changed. It is not easy to have many kids these days,” she said.
Changing the mindsets of people and cultural barriers is hard, and some pessimists could agree with a recent editorial in the UK Guardian newspaper suggesting that in many cases “crude attempts to raise and lower birthrates are unlikely to produce sustainable solutions.”
There are also those who view overpopulation as more of an asset than a threat. They argue than half of Egypt’s population is young, which means they can be productive and help in economic growth.
China and Singapore are mentioned as cases in point to corroborate this kind of argument. “China’s economic miracle has been fueled by its ‘demographic dividend’: an unusually high proportion of working age citizens,” wrote the Guardian. China, however, is currently facing a “time bomb of an ageing population” as a result of its harsh one-child family planning policy.
Today, it needs to reverse this as “the number of young adults is plummeting due to strict birth control policies,” while with increased life its population bulge is becoming a problem as it ages,” the newspaper said.
In the meantime, “tens of millions of workers have migrated to the cities, creating an even worse imbalance in rural areas which already suffer low incomes, poor public services and minimal social security.
Egypt’s slogan mimics Singapore’s ‘stop at two’ edict in the 1970s,” the Guardian suggested. But Singapore is trying to reverse its policies, offering incentives for couples having more than two children.
“Egypt might want to proceed with care” because “as China and Singapore have found, an apparently desirable fall in the birthrate can have unanticipated consequences,” according to the newspaper.
But Korayem rules out any similarity between Egypt and China or Singapore since each country has “its own demographic character and culture”.
Those in the opposite camp who remain positive on overpopulation issues suggest investing in Egypt’s human assets via developing education in a way that would serve the labour market and providing young people with help in starting small and medium-sized enterprises.
They suggest this could mimic India in boosting productivity and exporting human expertise.
But, as Korayem argues, “there is no one solution that fits all, and the question of whether other countries’ experiences fit Egypt has to be carefully studied first.” After all, she said, “small and medium-sized enterprises have failed in many cases when people could not pay back loans.”
Rashed insists that curbing population growth should come first. “The bulk of the population falls into the school-age category, which costs a lot until it reaches the age of productivity,” he argued.
“So, you need to have a population size that meets your resources first, or otherwise you will be left with an unhealthy, poorly-educated generation that can hardly be productive.”
* A version of this article appears in print in the 8 November, 2018 edition of Al-Ahram Weekly under the headline: Debating birth control