In the cramped office of New Cairo hospital’s family planning clinic, Safah Hosny sets a box overflowing with contraceptives next to the visitors’ ledger on a small desk.
There are eight condoms for one Egyptian pound, about 4p, or ampoules of injectable birth control, for just under 9p. A contraceptive implant lasting three years costs 22p, while copper IEDs – the most popular form of birth control on offer according to Dr Hosny – cost 17p.
The low prices, far less than in any Egyptian pharmacy, are due to subsidies provided by Egypt’s health ministry, as clinics like Dr Hosny’s are on the frontline of Egypt’s battle against an exploding birthrate. A government programme called “two is enough” has been launched to encourage people to limit family size. From this month, the prime minister, Mostafa Madbouly recently announced, the government will cease to provide financial support to a family after their second child.
The five-year, $19m (£15m) programme comprises a poster campaign as well as growing a network of mobile and fixed family planning clinics across Egypt. Posters covering the walls of Egypt’s metro show an Egyptian 50-pound note, worth about £2.20, torn into five. “Would you rather divide this into five, or into two?” it asks.
But the price and availability of contraceptives at clinics like that in New Cairo hospital belie a wider issue: that Egypt has a long way to go in persuading its people.
“Sometimes patients arrive here knowing absolutely nothing about contraception, so I have to explain all the different methods,” says Hosny. “Then [the woman] chooses, with her husband’s permission. Her husband is normally here for the first visit, and witnesses her signing a consent form which shows she understands, but then she is alone for the follow-up appointments.”
Hosny says the clinic is happy to serve unmarried women. “For unmarried women I suggest the pill or injections,” she says, pulling out a slide of contraceptive pills.
Population size is now regarded as such a crisis by the government that President Abdel-Fatah al-Sisi declared at a 2017 conference: “We have two real challenges facing our country: terrorism and overpopulation.”
Egypt now has more than 104 million people, including 94.8 million inside the country. A baby is born every 15 seconds in the country, meaning it ranks 13th in terms of global population. This has placed strain on already scarce resources such as water, and could amplify existing problems for families already struggling to put food on the table following a 2016 financial crisis that led Egypt to devalue its currency and sparked rising inflation. According to Egypt’s official statistics agency, the Central Agency for Public Mobilisation and Statistics, 27.8% of Egyptians live below the poverty line.
Yet “two is enough” risks failing to target the things that could make a real difference when families, particularly those from Egypt’s working class, are deciding to have children. The campaign will increase sex education for some medical professionals, but will not begin a programme of sex education in schools, currently non-existent. It also ignores options for women with unwanted pregnancies, with abortion seen as a legal grey area in Egypt.
“I think it has to be multi-disciplinary thing,” says Dr Hussein S Gohar, an obstetrician and gynaecologist at the Yosri Gohar hospital in Cairo. “You have to start in schools to educate young kids about sex education, contraception and the hazards for themselves, as well as the future of the population explosion. Then they have to target people about to get married, and married people. But if you’re going to make legislation punishing them for a third child, then you have to provide an exit route for them, by allowing medical termination or even abortion clinics.”
The heart of the problem, according to Gohar, means thinking about what motivates people to have large families in Egypt. “You need to change the mentality of the people and how they see things rather than just telling them what to do,” he said. “You can’t just go to people once every few months and say the population is too large and there’s not enough water so you need to have a smaller family.”
Dr Ahmed Fathy, an obstetrician and gynaecologist at New Cairo hospital, agrees. “For poorer families, it’s not about whether a child is a gift from God, but rather [that] extra children are a method of income,” he explains. “If you’re a family with a farm, extra workers cost more money. But if you have more children, one can look after the animals, another can look after the machines, and another can tend to the plants.”
The Egyptian government’s best efforts may also fail to reach more conservative doctors in rural areas, who are more likely to convey the message to patients that every child is a blessing, or to limit information about contraception. “The fact is that in every country, the government can’t cover the entire spectrum,” says Dr Natalia Kanem, head of the UN Population Fund, which has partnered with Egyptian ministries for the “two is enough” campaign. “Private providers can misinform, or even perform so-called medical female genital mutilation. Our job is to flood real information here to counter the myths.”
A mushrooming and overwhelmingly young population disadvantages young women according to Kanem, who cites the fact that 62% of the Egyptian population is aged 29 or younger. “If you have a young population, those young people tend to have children young as their mothers were young, so you see an acceleration,” she says. “Unless women are able to make a conscious decision to have a child later, to marry later.
“When girls are left behind, half the population is left behind.”