HEO77 FAMILY PLANNING: Its Impact On The Health of Women And Children aU ~ ‘S. DEPOSITORY ot ree Center for Population and Family Health Reprinted By: PEACE CORPS Information Collection and Exchange September 1983 September 1984 ''The Center for Population and Family Health gratefully acknowledges the support of the United States Agency for International Devel- opment (AID/SPE-CA-0043), which made possible the research, preparation and distribution of this publication. ''Family Planning: Its Impact on the Health of Women and Children Researched and written by Deborah Maine The Center for Population and Family Health, College of Physicians and Surgeons, Columbia University © 1981 by the Center for Population and Family Health, Colum- bia University. All parts of this publication may be reproduced without permission, provided that the material is distributed free of charge and the publisher is acknowledged. ''I oO?! /™ = > ms g ee >) rh on ''Contents HALE M3} 14s PUBL Introduction 5 Chapter 1 9 Child Health and Family Planning Chapter 2 25 Women’s Health and Family Planning Chapter 3 39 Family Planning in Developing Countries Conclusion 49 Allan Rosenfield, M.D., Director, Joe Wray, M.D., M.P.H., Deputy Director, Center for Population and Family Health Notes 51 References 52 Acknowledgements 56 Credits 56 '' ''Introduction The future of a country, and of humankind, de- pends on its children. For children to grow into healthy, able adults, they need good food, clean water, education, and medical care. But first of all, they need a good start in life. They need to be born healthy, to live through the perilous first few days of life, and the first few years, when they are espe- cially vulnerable. They need mothers who are healthy and families that can give them care and attention. If they are born sickly, if their mothers are overburdened and ill, children’s chances to survive and prosper are diminished. As the direc- tor of the World Health Organization (WHO) says: “Each stage of development builds on the one before and influences the next.’’'»° Children younger than 15 and women in their childbearing years make up two-thirds of the peo- ple in the Third World.’ Therefore, the health of women and children is an important part of na- tional health. Developing countries have made great progress during the last few decades in pro- tecting the health of infants and mothers. Millions of children have been immunized against deadly diseases. Millions of women have received better care during pregnancy and delivery. These ad- vances have helped reduce infant and maternal deaths. But there is still much to be done. On aver- age, people in developing countries still live 15 years less than people in industrialized nations.” A large proportion of deaths in the Third World are among children. An estimated 15 million chil- dren younger than five die each year—the vast majority of them in developing countries.? Every year, about 500,000 women in the Third World die during pregnancy or childbirth, leaving at least one million children without mothers.’ As large as these numbers are, for every child or woman who dies, many more barely survive and live on in poor health, often permanently weakened or handi- capped.‘ What can be done to reduce disease and pre- vent deaths? Clearly, better food, housing, sanita- tion, and education are essential. Medical serv- ices need to be extended to rural areas and urban slums. Preventing illness is more efficient, and less costly, than curing people once they are sick. However, in most developed and developing countries, preventive care has only recently begun to receive the attention it deserves.® Preventive health care for mothers and chil- dren includes prenatal care, vitamin supple- ments, well-baby check ups and immunizations. It also includes family planning. As the WHO Expert Committee on Maternal and Child Health found, family planning can ‘‘favorably influence the health, development and wellbeing of the family and has a striking impact on mothers and chil- dren.’’6 P36 Family planning improves the health of women by enabling them to have children when they are best prepared to have them. Women who become pregnant while they are still very young have a much higher risk of complications during preg- nancy and childbirth than do women in their 20s. These complications can injure their health, even cost them their lives. The same is true of women who become pregnant near the end of their repro- ductive years. Having a large number of children increases the mother’s risk of illness or death. The spacing of pregnancies—the time interval be- tween pregnancies—is also very important. Hav- ing births too close together does not allow the woman’s body to recover from the strain of preg- nancy, childbirth, and breastfeeding. Further- more, a short interval between births means that the woman will have to care for several young children at the same time—a difficult task under the best of circumstances. Children, too, suffer when they are born close together in time, when the family is too large, when their mothers are too young or too old. Under these circumstances, they are more likely 5 ''to die in the womb or during the first few years of life, or to have their health and growth impaired. Women all over the world know the dangers of ill-timed pregnancies and having many children. In India, lran, Lebanon, the Philippines, and Tur- key, 21,000 women were interviewed in a WHO study.’ More than nine in 10 women said the health of the child and the mother are better if the child is born three years after the previous birth, rather than after an interval of only one year. About nine in 10 said that they believe that the health of mother and child are better if the family is small. More than nine in 10 know that contracep- tion improves the health of women and children. However, until very recently, women have not had convenient, effective ways of putting this knowledge into practice. When women do have access to modern methods of contraception, they generally choose not to have high-risk pregnan- cies. Most women do not want to have a birth every year, to begin childbearing when they are 15 or 16 years old, or still to be having children when they are over 35. An example of what can happen when women have access to family planning can be seen in Chile. Contraceptives have been provided by the government and private agencies since 1965. Since that time, the proportion of women in their childbearing years using contraceptives has in- creased from only three percent to more than 20 percent, as Figure 1a shows. Between 1964 and 1979, the birth rate fell from 36 births to 22 births per 1,000 population per year (Figure 1b). Most of the decline in births has been among women hav- ing their third or later birth and among women younger than 15 or older than 30 (not shown here). These changes in childbearing patterns have played an important part in the dramatic reduction of both infant and maternal mortality in Chile in the past 15 years.®'° Figure 1c shows that between 1964 and 1979, infant mortality declined from 6 more than 100 deaths per 1,000 live births to less than 40 deaths. During the same period, maternal mortality declined even more steeply, from more than 280 deaths per 100,000 live births to less than 80 (Figure 1d). Changes similar to those in Chile are taking place in other developing countries, although such complete data are usually not available. Furthermore, although our interest is in health, we often need to rely upon mortality data, because they are the only ones available for large popula- tions, across time, and in a variety of countries. This chartbook will explore the many risks to the health and lives of women and children that can be avoided or reduced through the use of fam- ily planning. It will show that large numbers of women in developing countries have already begun to use contraception to space their preg- nancies and limit the size of their families. How- ever, it will also show that much more needs to be done. Millions of women in developing countries still do not have easy access to family planning services—a fact that has serious health conse- quences. '' Figure 1a. Percent of women using contraception, Chile, 1964- 1978 Percent of women aged 15-44 Figure 1b. Birth rates, Chile, 1964-1979 Births per 1,000 population 27.0 48 ; 25.5 ~ 46 7 24.0 / 44 22.5 f 42 21.0 [ 40_ seni 19.5 J 38 18.0 / 36 QC 16.5 T 34 \ 15.0 / 32 \ 13.5 J 30° \ _ 12.0 / 28 CLUOUN - 10.5 T 26 90 24 ™N\ 75 ff 22 N 60 Ff 20 45 [ 18 7 30 7 16 1.5 ; 0 x 0 sacbieaaiaat 1965 1970 1975 1980 1965 1970 1975 1980 Year Year Figure 1c. Figure 1d. Infant deaths, Chile, 1964-1979 Maternal deaths, Chile, 1964-1979 Deaths per 1,000 live births Deaths per 100,000 live births 133 ; 310 126 - ; 295 ; 119 280 , 112 265 4 105 250 98 \. 235 \ a2 6OUY™NN 220 \ 84 \ 205 \ ‘77 Ne 190 \ 70 Aw 175 \ 63 X\ 160 \ 56 \ 145 WV 49 N‘N 130 \. 42 \ 115 v\ 35 NX 110 \ 28 85 \ 21 70 \ Z 7 0 0 1965 1970 1975 1980 1965 1970 1975 1980 Year Year Source: ref. 8 '' ''Chapter | Child Health and Family Planning A child’s chances of being born healthy, of surviving the first few years Of life and of growing well are reduced if: Children in the family are born very close together in time. There are already three or more chil- dren in the family. The mother is younger than 20 or older than 35 when the child is born. Family planning improves children’s health by helping women to space their births, have smaller families, and avoid pregnancies at unfavor- able ages. In countries where large proportions of women have already adopted family planning, the result- ing changes in childbearing patterns have contributed substantially to re- cent declines in infant mortality. ''Birth Spacing When a woman has pregnancies close together, the likelihood increases that the pregnancy will end in miscarriage or that an infant born alive will die. As one expert on child health in developing countries says: ‘‘Medical workers, when caring for a mother and her young child, will come to real- ize that delaying the next conception and extend- ing the birth interval are quite as important a part of health care as seeing that the latest child is ade- quately immunized.’’":»:° Studies in Hawaii and Bangladesh found that the highest rates of fetal death are among preg- nancies that began less than one year after the end of the previous pregnancy. '*:'3 Data collected, in many countries by the World Health Organiza- tion and the Pan American Health Organization have documented an increase in deaths among infants born after short intervals.’:'* Figure 2 shows this effect using information from India and Turkey. Whether they were Hindu or Muslim, urban or rural, infants born less than one year after the end of their mothers’ last pregnancy were much more likely to die than were infants born after a longer interval.” The risk to infant health posed by short birth intervals continues even after the first year of life. Figure 3 shows deaths among children aged 1-4 years in the Philippines and Lebanon.’ Again, while death rates among children in rural and urban settings and among various religious and ethnic groups differ, the higher mortality among infants born after short birth intervals remains. The higher rate of fetal and infant deaths may be due, in part, to the lack of time for the mother’s body to fully recover after the last pregnancy — sometimes called the ‘“‘maternal depletion syn- drome.’’'S This may be especially important among women who breastfeed their children for long periods and among women who are malnour- ished and perform heavy physical work, as many Third World women do.'* However, some of the ill 10 effects of close birth spacing are probably due to the inability of families to care for several young children at the same time. When two children are separated by only a short birth interval, not only the younger of the pair suffers. The health of the older child may be harmed as well. People in some countries have long understood this. For example, the word ‘“‘kwashiorkor’’ is used in Ghana to describe the kind of malnutrition often seen when a child is weaned from the breast too early because the mother is pregnant again.'’ Breastfeeding is now known to be one of the most important factors in infant health in developing countries. Anything which cuts short the period of breastfeeding may endanger the health of the infant.'® Children who are weaned too early are much more susceptible to malnutrition and infection. The risk to the health of the older of a closely- spaced pair of children was demonstrated in a study in the town of Candelaria, Colombia.'® Nearly three-quarters of all children had a brother or sister less than two years younger than them- selves. Such children were much more likely to be malnourished than were children who were fol- lowed by a birth interval of at least three years. '' Figure 2. Infant deaths, by number of years between births, India and Turkey, 1971-1975 Deaths per 1,000 live births India— Hindu 300 250 <1 1 2-3 4> Interval in years India— Muslim <1 1 2-3 4> Interval in years Turkey—rural 300 250 200 150 100 50 O <1 1 2-3 4> Interval in years Turkey—urban 300 250 200 150 100 50 0 <1 1 2-3 4> Interval in years Source: ref. 7 See notes Figure 3. Child deaths, by number of years between births, the Philippines and Lebanon, 1970-1975 Deaths per 1,000 live births Philippines—rural <1 1 2-3 4> Interval in years Philippines—urban <1 1 2-3 4> Interval in years Lebanon—Muslim 200 150 100 50 0 <1 1 2-3 4> Interval in years Lebanon—Christian 200 150 100 50 Sr oo ft = — <1 1 2-3 4> Interval in years Source: ref. 7 See notes 11 ''Family Size The number of children a woman has already had affects her chances of having a successful preg- nancy and a child who survives. Fetal death rates increase with birth order.'*” Figure 4 shows deaths in the last two months of pregnancy and the first week of life in Tientsin, China. Women who were having their third or later delivery had more than four times as many mis- carriages and early infant deaths as women who were having their first or second birth. Other stud- ies on developing countries have found that fetal death rates increase after the second and third pregnancies.” Even infants who survive the first few days appear to be at a disadvantage if their mothers Figure 4. Fetal deaths during the last two months of pregnancy and deaths during the first week of life, by birth order, Tient- sin, China, 1978 Deaths per 1,000 deliveries 120 110 100 90 80 70 60 50 40 30 20 10 || a O 1&2 3> Birth order Source: ref. 21 12 already have had many births. Figure 5 shows deaths in the first year of life in El Salvador, Chile, and England and Wales. In these countries (and in many more not shown), after the third or fourth birth rates of infant death rise steeply (even though the proportion of children who died in their first year is several times higher in El Salvador and Chile than in England and Wales). In fact, in England and Wales this pattern has remained stable over decades, although infant deaths are much less frequent now than they were 30 years ago.” Thus, although improved living conditions and medical care greatly reduce the overall level of infant mortality, the effects of birth order remain. In England and Wales today, deaths dur- ing infancy are more than twice as common among poor families as among families at the top of the social scale, yet in each social class the effect of birth order can be clearly seen.” Figure 5 also shows the high rates of infant death that prevail in many parts of the Third World. While conditions have improved in many areas since 1970, the experience of El Salvador and Chile shown here is still representative of many parts of the developing world. While we do not know all the reasons for this strong and consistent relationship between birth order and child health, part of the explanation may lie in the birthweight of the infant. Low birth- weight infants are known to have a much higher risk of dying during the first year; they may also have more health problems than other children, if they survive.’ Beginning with the fourth child the proportion of babies of low birthweight increases steadily.”>° In developing countries, where so many chil- dren are malnourished, part of the effect of birth order on child health probably operates through nutrition. For example, the Candelaria, Colombia study shows that birth order (as well as birth spac- ing) affects the nutritional status of children. The '' Figure 5. Infant deaths, by birth order, El Salvador and Chile, 1968-1970, and England and Wales, 1977 El Salvador Chile Deaths per 1,000 live births Deaths per 1,000 live births 170 102 160 96 150 / 90 140 / 84 f 130 / 78 120 / 72 110 / 66 100 / 60 90 / 54 80 ceaaeell 48 oO”. 70 —— 42 Sa 60 360 50 30 40 24 30 18 20 12 10 6 0 0 1 2 3 4 5> 1 2 5> Birth order Birth order England & Wales Deaths per 1,000 live births 20 19 18 17 16 . 15 f/f 14 f/f 13 f 12 Zs Wo 10 4 0 1 2 io 4> Birth order Source: refs. 14, 23 See notes 13 ''more children in the family, the larger the propor- tion of the family income spent on food, but the less food per person."® This results in a higher rate of malnourished children in large families, as a detailed study of the families of textile workers in India demonstrated. Since all of the families had similar income, the more children in the family, the less food each person received, as Figure 6 shows. The investigator noted that the difference in diet between families with three or fewer and families with four or more children was large enough to make the difference between an ade- quate and an inadequate diet. Consequently, the more children in the family, the higher the propor- tion diagnosed as malnourished. These studies indicate that large family size and short birth spacing interact with poor nutrition to create a group of children at very high risk of ill- ness and death. AWHO Scientific Group explains how this may work: “The incidence of diarrheal Figure 6. Amount of protein and calories consumed daily, per person, by number of children in the household, India, 1968 Grams of protein Calories 82.5 3060 81.0 30258 N 79.5 2990 ao ~, 78.0 2955 \ 765 ww 2920 \ 75.0 ™ 2885 \ 73.5 \ 2850 \ 72.0 \ 2815 \ 70.5 \ 2780 \ 69.0 \ 2745 \ 67.5 \ 2710 \ 66.0 \ 2675 \ 64.5 \ 2640 \ 63.0 \ 2605 \ 61.5 \ 2570 \ 60.0 \ 2535 \ 58.5 - 2500 Z GZ O Oo 1 2 3 4> 1 2 3 4> Number of children Source: ref. 27 See notes Number of children 14 ''disease, the principal cause of death in less devel- oped countries during the first two years Of life, is clearly associated with poor weaning practices, and early weaning often follows a short pregnancy interval. The ensuing malnutrition, which reaches its peak during the second year of life, is also related to the high incidence of other infectious diseases....The health impact of spacing is assuming increasing importance in developing countries, where [prohibitions against] the early resumption of cohabitation are losing their force in many communities. ’’28 p.'3 As might be expected, the same factors that af- fect children’s health also seem to affect their de- velopment. Children in large families and children born close together grow less well, both physically and intellectually, than other children. The decline in intelligence test scores as family size increases has been vividly demonstrated in studies of large numbers of children in Scotland, England, France, and the United States.2° One of the larg- est studies to document the effect of birth order on intelligence was done in the Netherlands; 400,000 19-year-old men registering for military service were compared by family size, birth order, and socioeconomic group. Figure 7 shows the signifi- cant decline in intelligence test scores with in- creasing birth order. Furthermore, although there are large differences in performance among dif- ferent socioeconomic groups (as is usually the case), the decline in scores with increasing birth order is apparent in all groups. Figure 7. Intelligence test scores among 19-year-old men, by birth Order and socioeconomic group, the Netherlands, 1953- 1956 eee NOnManual Manual ams == arm Average test scores 1.0 - 1.9 i i _ 20 — 2.1 22 23 | 2.4 25 26 —e 280 29 3.0 3.10 | 3.20 3.3 _ 3.4 _ 3.5 3.6 S37 3.8 1 2 3 4 5 6 t= Birth order Source: ref. 30 See notes ''Maternal Age The health of infants is affected by their mothers’ age when they are born. In general, the most fa- vorable age for a woman to have children is in her 20s. Fetal deaths are less common among women between the ages of 20 and 34 than among older or younger women.*'? Figure 8 shows deaths during the last two months of pregnancy and the first week of life, by mothers’ age, in China and in England and Wales. Information on women younger than 20 is not given separately in China, but in England and Wales it is clear that the risk is much higher for such women than for women only a few years older. The risk of death during the first year among children born to women of different ages is shown in Figure 9. These data are taken from a study of more than 35,000 child deaths in the Western Hemisphere. The researchers concluded that their results ‘definitely indicate the importance of the mother’s age and parity as determinants inthe survival and future health of the child.’’'*.°? Of the 15 areas studied, Chaco Province in Argentina had the highest rate of infant mortality and the Figure 8. Fetal deaths during the last two months of pregnancy and deaths during the first week of life, by age of mother, Tient- sin, China, 1978, and England and Wales, 1977 China England & Wales Deaths per 1,000 deliveries Deaths per 1,000 deliveries 68 26 64 25 60 , 24 56 I 23 52 [ 22 / 48 \ I 21 / 44 \ [ 20 \ / 40 \ [ 19 \ / 36 \ [ 18 \ [ 32 \ [ 17 \ / 28 \ / 16 \ / 24 Xv [ 15 ™~N L. 20 ee 14 NZ 4 Z 0 0 <25 25-29 30-34 35> Age of mother Source: refs. 21, 23 <20 20-24 25-29 30-34 35> Age of mother 16 ''State of California, United States, had the lowest. The infant mortality rate in Monterrey, Mexico was intermediate. Despite the differences in death rates, the pattern in relation to maternal age re- mained similar, with women in their late 20s having the lowest rates of infant loss. The very high rate of infant loss among women younger than 20 is probably partly due to their in- ability to care for their children. In the United States, for example, teenage mothers often find themselves in difficult economic circu mstances.3 In addition, very young women may not have the experience and maturity to cope with mother- hood, especially if they have several children. A United States study, which followed more than 5,000 infants through their first year, found that those born to women younger than 18 were most likely to have a serious illness and to be hospital- ized.% ee Figure 9. Infant deaths, by age of mother, Argentina, Mexico, and the United States, 1968-1970 =—_—_—_ Chaco, Argentina Monterrey, Mexico =—_—_—_ California, United States Deaths per 1,000 live births 150 i _ 13000. 1eO ees A a 90 80. ~<20 20-24 25-29 35> Age of mother Source: ref. 14 17 ''Children born to older women have a much greater risk of having birth defects than do those born to younger women. Figure 10 shows how the risk of malformations rises steeply among infants born to women in their late 30s. Defects that in- crease with maternal age include heart defects, cleft palate and lip, and Down’s Syndrome (a severe, lifelong mental and physical disability sometimes called ‘‘mongolism’’).%° The propor- tion of infants born with Down’s Syndrome rises geometrically among women older than 30. Figure 10. Infants born with malformations, by age of mother, United States, 1973-1974 Per 100,000 live births 1230 a 1195 1160 1125 1090 1055 1020 985 940 905 870, 835 800 __ Se Oe <20 20-24 25-29 30-34 35> Age of mother Source: ref. 35 18 infant Health: What Can Family Planning Do? Because of the risks to fetal and infant health linked with short intervals, high birth order, and maternal age, family planning can make a sub- stantial contribution to infant health in developing countries. When women have access to family planning information and contraceptive methods, large proportions of them choose not to have births close together, large families, and births when very young or old. Figure 11 illustrates how family size has de- clined in recent years, using total fertility rates* for the mid-1960s and 1970s. In nine of these 10 countries, the number of children an average woman would be expected to have has declined by at least one child. (In the Philippines, the de- cline was slightly less.) In several countries (Costa Rica, Colombia, and Mexico) the decrease was two or more children per woman. *The total fertility rate is the number of children an average woman would be expected to have if she went through life bearing children at the current rate for each age group at the time of the study. '' Figure 11. Total fertility rates, mid-1960s and mid-1 970s Mid-1960s wi Mid-1970s Country ; Costa Rica Jamaica ea Mexico Philippines Sri Lanka = Thailand Tunisia Venezuela 3 ee 0 1 2 8 4 5 6 7 8 9 Children per woman Source: ref. 37 See Notes 19 ''Figure 12 shows the decline in childbearing among women aged 15-19 for the same countries and the same period of time. In Colombia and Egypt, births among very young women fell by more than one-half in this decade. In four other countries, the declines were one-fifth to more than one-third. In the rest of the countries the declines were about one-tenth—still a substantial change for so short a time. Figure 13 shows the decrease in births among women 30-34. In half of the countries the declines were 20-40 percent. In Costa Rica, fertility among women of this age group fell by more than one- half. In the other three countries shown, the de- Figure 12. _ Percent decline in births among women aged 15-19, mid- 1960s to mid-1970s Figure 13. Percent decline in births among women aged 30-34, mid- 1960s to mid-1970s Country a Country Costa Rica on Fi Colombia ec —— Jamaica Jamaica oo ne Mexico ye Sas Philippines eee Mexico RS Philippines Say unica Tunisia WR Venezuela rv. i 7 0 10 20 30 40 50 0 10 20 30 40 50 Percent Percent Source: ref. 37 See notes Source: ref. 37 See notes 20 '' clines were 10-15 percent during the decade. Women in developing countries use contracep- tion not only to prevent unwanted births; they are increasingly using it to Space wanted births, as data from the World Fertility Survey demonstrate. Figure 14 shows the proportions of women who say they want more children that are using contra- ception. In Colombia, more than four in 10 women who want future births are using some method of Figure 14. Percent of women who want more children that are using contraception, 1975-1978 Country Bangladesh Colombia Dominican Republic Jamaican Jordan Pakistan MO Pru Thailand 0 10 20 30 40 50 Percent Source: refs. 38-46 See notes '' ''contraception; in Jamaica, Peru, and Turkey, the proportion is more than three in 10; in the Dominican Republic, Jordan, and Thailand, more than two in 10. Only in Bangladesh and Pakistan Figure 15. Percent of women whose last two pregnancies were less than 24 months apart, by use of contraception during the pregnancy interval, 1974-1978 Did not use contraception x Used contraception Country Bangladesh Colombia — Jamaica Jordan ee a Malaysia — 3 ot Sri Lanka 2 7 0 10 20 30 40 50 Percent Source: refs. 38, 39, 41, 42,47, 48 See notes are few women using contraception to space their births. Women who use contraceptives are more suc- cessful than other women in spacing their births. Figure 15 shows the proportions of women in various countries whose last two pregnancies were less than two years apart. The greatest dif- ference between women who used contraception in the interval and those who did not is found in Jordan; 31 percent of contraceptors had a birth interval of less than two years, compared with 47 percent of noncontraceptors. The country in which use of contraception made the least dif- ference is Bangladesh, where 21 percent of con- traceptors and 25 percent of noncontraceptors had short birth intervals. Even so, this represents a decrease of one-sixth. Kenyais the first African cou ntry to complete its part of the World Fertility Survey. While the infor- mation presented in Figure 15 is not yet available for Kenya, preliminary data show that the average interval between births was almost five months longer for women who used contraception (18.2 months) than for women who did not (13.7 months).*9 The impact of declines in high-risk pregnancies on infant mortality has been analyzed in anumber of countries. In Costa Rica, for example, birth rates have declined rapidly in recent years (in large part due to the widespread availability of contraceptives). Between 1960 and 1977, births of fifth and higher order and births among older women decreased sharply.°° During the same period, the infant mortality rate fell by almost 60 percent. An estimated one-fifth of this decline is due to the changes in childbearing patterns. In the United States, one-half of the decline in infant mortality during 1960-1970 is attributed to the in- creasing concentration of births among women of more favorable age and family size.*" 23 '' 24 ''Chapter 2 Women’s Health and Family Planning Complications of pregnancy and childbirth are still a major cause of death among women in developing countries. Women’s chances of hav- ing such complications (and, there- fore, their chances of dying) are in- creased when: They have already had three or more children. They are younger than 20 or older than 30. Family planning improves the health of women by helping them to avoid high-risk pregnancies. In addition, when women have access to effec- tive methods of contraception they are less likely to resort to dangerous illegal abortions in order to control their fertility. Therefore, adoption of contraception can prevent many neediess deaths among women in the Third World. 25 ''Women’s Health and Family Planning Traditionally, poor women in developing coun- tries were either pregnant or breastfeeding during most of their reproductive years.?’ Their bodies did not have time to replenish stores of vital nutri- ents. This is still true of a great many women inthe Third World, and it has grave consequences for their health. In most developing countries in the mid-1970s, 40-180 women died due to pregnancy Figure 16. or childbirth for every 100,000 children born.52-53 In some areas, rates are even higher. By compari- son, during the same period there were fewer than 20 maternal deaths per 100,000 live births in most parts of Europe. Figure 16 shows death rates among women and men of various ages in Matlab, Bangladesh, and the proportion of deaths among women re- Deaths among women from pregnancy and childbirth, and from all other causes, and deaths among men from all causes, by age, Matlab, Bangladesh, 1968-1970 a Women—pregnancy and childbirth ee Women-—all other causes Deaths per 100,000 per year 800 750 00 700 Men-—all causes 40-4 ''lated to pregnancy and childbirth. Pregnancy and childbirth were the most important causes of death among women aged 15-19. Furthermore, high maternal mortality raised the overall death rate for women well above that for men in the age groups between 15 and 39. Another way to look at these data is to express maternal deaths as a pro- portion of all deaths among women (not shown). Among women aged 15-19, almost six in 10 of all deaths were related to pregnancy and childbirth; among women 20-29, more than four in 10; among women 30-34, more than three in 10. For women of all ages together, more than one in four deaths were related to pregnancy and childbirth. 27 ''Birth Order The effect of pregnancy and birth on a woman’s health is, in part, determined by the number of pregnancies she has had. Figure 17 shows this effect in more than 200 villages in Matlab, Bangla- desh. Among women having their fourth or fifth birth (not a very large number of births for developing countries), the risk of death was almost double that of women having their second or third birth. Women having their eighth or later birth had three times the risk of death as women having their second or third birth. Deaths were also very common among women having their Figure 17. Maternal deaths, by birth order, Matlab, Bangladesh, 1968-1970 Deaths per 100,000 live births 750 485 Birth Order Source: ref. 54 28 first birth (not shown), in part because many of them were very young. Maternal deaths increase with birth order because many complications of pregnancy and childbirth rise sharply among third and later births. An estimated 25 million women in de- veloped countries have such complications every year.® Figure 18 shows maternal deaths from three major complications of pregnancy in England and Wales during 1973-1975. Deaths from hemor- rhage (uncontrolled bleeding) and from pul- monary embolism (blood clots in the lungs) are especially common among fourth and higher order births. Toxemia (very high blood pressure during pregnancy that can lead to convulsions) is about equally high among first and fourth and later births, but much lower among second and third births. Figure 18 also shows deaths from all causes combined. Fourth and higher order births carry many times the risk of death of first or second births, even in a country where medical care is available and free to all people. Other complications that increase with birth order are problems with the placenta and um- bilical cord, collapse and tearing of the uterus, abnormal birth position of the fetus, and anemia. ?7:22:27.28.31.57 These complications kill many women, but weaken and injure many more. For example, anemia makes a person more vulnerable to many diseases and infections. All of these complica- tions are serious, even if they occur in a hospital. - However, they are much more serious when a woman is delivering her baby at home, with only relatives or an untrained midwife to help her, or when the nearest medical care is either too far away or too expensive—situations common in most developing countries. '' Figure 18. Maternal deaths, by cause and birth order, England and Wales, 1973-1975 Hemorrhage Toxemia Deaths per million births Deaths per million births 95 oo - 38 90 - 36 85 34 80 32 75 30 70 — 28 65__ 26 60 ee 55 _ ; _ 22 — 50 _ 20 450 _ 18 40 16 _ 35 _ oA 30 _ tC 25 : 10, 20 8 Wo fe — _6- __ a 10_ : ee. oo So ee eee _ OO OO _ - 1 2 3 4> 1 2 3 4> Birth order Birth order Pulmonary embolism All other causes Deaths per million births Deaths per million births MO : ee 720 oo — 720, 6B 680 640 640 yf 60 600 / oe / / 80 _ 40 0 4 2 3 4 5> Birth order Birth order Source: ref. 56 ''Maternal Age Studies from all over the world show that the risk of complications of pregnancy and delivery (and, consequently, the risk of death) are affected by a woman’s age.*' This is true regardless of the level of maternal mortality in the country. Figure 19 shows maternal deaths in Venezuela in 1966-1968 and in England and Wales in 1973-1975. Despite the fact that rates in England and Wales are so much lower than those in Vene- zuela, the lowest risk of death in both countries is among women in their 20s. In both countries, women 40 or older had at least five times the risk of death of women aged 20-24. This shows that the increased risk of death linked to older maternal age is not confined to women in poor countries. Even though maternal death rates are falling in many developing countries, women over 30 still run a considerably greater risk of death from pregnancy than do younger women. Where data are available, this pattern can be seen within a single country. Figure 20 shows that maternal death rates fell considerably in Sri Lanka between 1956-1958 and 1966-1968. How- ever, the pattern of deaths by age remained. In both time periods, women 30-34 were more than one-third more likely than women aged 20-24 to die giving birth. Women 40 or older were more than three and one-half times as likely to die as were women in their early 20s. Figure 21 shows how deaths from major com- plications of pregnancy vary with age. For hemor- rhage and toxemia (as for all causes combined), women in their 20s have the lowest rates, while rates among women 30 and over rise sharply. Al- though these charts look quite similar to those showing deaths from complications of pregnancy by birth order, maternal age and birth order have independent effects. For women in each age group, those having their second birth are least likely to die. For women in each birth order group, women in their 20s are less likely than other 30 women to die during pregnancy or delivery.° While maternal deaths from infection (sepsis) are no longer common in the developed coun- tries, they are still a major problem in the Third World. The risk of infection is much higher among older women than among women in their 20s.°" '' Figure 19. Maternal deaths, by age, Venezuela, 1966-1968, and England and Wales, 1973-1975 Venezuela amas ENgland & Wales Deaths per million births Figure 20. Maternal deaths, by age, Sri Lanka, 1956-1958 and 1966- 1968 ——«—_ 1956-1958 ummm 1966-1968 Deaths per 100,000 live births 2430, 945 2340 ee 910 2250 885 / 2160_ 840 ] 2070 805 ] 1980 a 770 ] 1890 735 ] 1800 700 7 W100 665 T 1620 _ 630 ] 1530 _ 595 7 1440 0 560 7 1950 0 525 7 1260 490 7 1170 ; 455 / 7 1080 420 7 / 990 385 7 / 200 _ 350 PA / 810, / 315 _ A 7 720 / 280 Ne J 630 4 / 245 / 540 fF 210 WA 450 JS 175 Sf 360 Ta 140 a 270 7 Sf 16 = 180 a. 70 20 35 Oo - / 0 <20 20-24 25-29 30-34 35-39 40> <20 20-24 25-29 30-34 35-39 40> Age Age Source: refs. 52, 56 See notes Source: ref. 52 See notes 31. '' Figure 21. Maternal deaths, by cause and age, England and Wales, 1973-1975 Hemorrhage Toxemia Deaths per million births Deaths per million births 290 116 280 112 270 108 260 104 250 100 240 96 230 92 220 88 210 , 84 200 | _80 190 I 76 180 I 72 . 170 I 68 | 160 | 64 | 150 | 60 | 140 fl 56 / 130 | 52 | 120 | 48 | 110 | 44 | 100 [ 40 | 90 / 36 / 80 } 32 i 70 VA 28 / 60 / 24 | 50 / 20 \ | 40 J 16 NX —————— 30 WA 12 eu" 20 WA 8 10 — S/S 4 0 0 16-19 20-24 25-29 30-34 35-39 40-44 Age Source: ref. 56 16-19 20-24 25-29 30-34 35-39 40-44 Age ''Induced Abortion Although many countries have adopted more liberal abortion laws during the last few years, in most developing countries induced abortion is still illegal or permitted only to save the life of the woman.*® Even where it is legal, access to abor- tion may be limited by bureaucratic restrictions, distance, or expense. Consequently, an esti- mated 15-25 million women resort to illegal abortion each year rather than have unwanted births.5° Many of these women do not have access to effective methods of contraception, which would have prevented most of their unwanted pregnancies. For a few affluent women in urban centers, having an illegal abortion may be relatively safe, because they are able to pay medical personnel to perform the abortion. However, for the vast major- ity of women in developing countries, having an illegal abortion means pain, fear, and a substan- tial risk of infection, hemorrhage, and death.* It is estimated that more than 68,000 women in de- veloping countries died from illegal abortions in 1977.© Since it is extremely difficult to obtain information about any illegal act, even these large numbers are probably underestimates. It is especially troubling that health experts believe that illegal abortion is becoming increas- ingly widespread. For example, in Africa, where illegal abortion had been less common than in some other parts of the Third World, anincreasing number of young, urban women are having illegal abortions.°® These women are the unfortunate victims of cultures in transition: They are marrying later than earlier generations did and having pre- marital sex. But they still do not have easy access to effective contraception. Furthermore, they are subject to dismissal from schools and jobs if they are known to be pregnant. Special studies give some idea of the size and seriousness of this problem: In Malaysia one out of 10 married women ad- mitted that they had had at least one illegal abor- tion.®' In Turkey about one out of seven women in 1975 said that they had had an illegal abortion, com- pared with only one out of 14 in 1963. A 1978 survey of illegal abortion practitioners in rural Thailand found that each one of them per- formed an average of 350 abortions per year. This means that there were 37 abortions per 1,000 women of reproductive age in the region each year. Most of the practitioners used dangerous traditional methods, including ‘‘massage’’ of the abdomen, insertion of herbs or sharp sticks into the uterus, and toxic herb teas. In El Salvador Maternity Hospital, one-quarter of obstetric deaths were due to illegal abortion.” In Bolivia, 60 percent of the cost of running the obstetric/gynecological services is devoted to treating women who come to the hospital with complications of an illegal abortion.” ''Reported deaths from illegal abortion in a vari- ety of countries are shown in Figure 22. These numbers do not necessarily show which countries have the highest rates (they may just have a more accurate reporting system), and all of these rates are probably underestimates. However, Figure 22 does give some picture of illegal abortion as a Figure 22. Annual deaths from illegal abortion, 1970s public health problem. In countries where abor- tion is legali—for example, Canada, the United States, the United Kingdom, Japan, and several Scandinavian nations—deaths from illegal abor- tion are almost unknown now (less than one death per million women aged 15-44).°° Country, ee Barbados 2 Chile a Colombia ee ee carica Dominican Republic MMM car OE saver —_ _ Te __ | aia Mauritius Te ££ NN Phiippines Thailand Vinidad & Tobago i — Uruguay Venezuela _ 0 10 20 30 40 50 60 70 80 90 Deaths per million women aged 15-44 Source: ref. 58 See notes ''Women’s Health: What Can Family Planning Do? In developed and developing countries, as con- traceptive use increases, women have smaller families and fewer births at unfavorable ages. For example, in Chile, between 1962 and 1978, the proportion of all births that were third or later births declined sharply, as Figure 23 shows. Figure 24 demonstrates that while births declined among women of all ages, the largest declines were among girls younger than 15 and among women 30 and older. Given a choice, women can Figure 23. Births in 1978 as a percent of births in 1962, by birth order, Chile 1962 cd 1978 Percent 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 7 1 2 3 Birth order Source: ref. 8 and do avoid high-risk pregnancies. By making it possible for women to avoid high- risk pregnancies, family planning makes a sub- stantial contribution to maternal health. It is esti- mated that if only women aged 20-34 had births, maternal mortality would be reduced by one-fifth in Mexico, Thailand, and Venezuela, and by about one-quarter in Colombia and the Philippines. Researchers in Bangladesh estimate that if women there had no more than three children, 35 ''maternal deaths would be reduced by fully 30 percent.” The potential for preventing deaths from illegal abortion through family planning is clearly very great, since these pregnancies are unwanted. This has been demonstrated in a number of coun- tries, including the United States, Great Britain, Yugoslavia, and Chile.59*5°* Data from Eastern Europe show that placing restrictions on legal abortions has the opposite effect. In Romania, for example, legal abortions had been available on request until 1966, when restrictions on access were imposed. As a result, deaths due to abortion rose from one to eight deaths per 100,000 women between 1965 and 1972.% In Chile, between 1965 (when modern methods of contraception started to become widely avail- able) and 1978, the number of women seeking help at hospitals for complications of illegal abor- tions declined dramatically. Figure 25 shows the proportion of all obstetric hospitalizations due to abortion in Chile during those years. This decline not only saved many women from suffering and death, it also allowed such valuable hospital re- sources as blood supplies, antibiotics, bed space, and staff time to be used to care for other people in need. This is important in developing countries, where medical resources are scarce. As hospitalization due to complications of illegal abortion has declined in Chile, so have Figure 24. Births in 1978 as a percent of births in 1960, by age of mother Chile ® 1960 i978 Percent 100 90 80 70 60 50 40 30 10 O <15 15-19 25-29 Age of mother Source: ref. 8 i 40-44 45-49 30-34 35-39 ''deaths from these complications, as Figure 26 shows. However, because abortion is still illegal in Chile, more than 20 women died from abortions for every 100,000 live births that took place in 1979. By comparison, in the United States, where induced abortion has been legal since 1973, there now is less than one death from abortion per 100,000 live births.® Figure 25. Percent of all obstetric hospitalizations that were due to abortion, Chile, 1964-1978 Figure 26. Maternal deaths due to abortion, Chile, 1964-1979 Deaths per 100,000 live births Percent 125 22.0 120 21.5 115 21.0 y 110 205 \ 105 20.0 100 195 \W 95 19.0 \ 90 18.5 \ 85 18.0 \ 80 17.5 \ 75 17.0 \ 70 16.5 \ 65 16.0 \. 60 15.5 \A 55 15.0 v\ 50 14.5 L 45 14.0 \ 40 13.5 \ 35 13.0 lL 30 12.5 25 12.0 20 11.5 15 11.0 10 J 5 0 0 1965 1970 1975 1980 1965 1970 1975 1980 Year Year Source: ref. 8 Source: ref.8 37 '' ''Chapter 3 Family Planning in Developing Countries As modern methods of contracep- tion have become available in many parts of the Third World, millions of women have begun to use them to plan their families. Yet there is still a great unmet need for family planning services: Many women still have pregnancies too close together. Many women who want no more children are not using an effective method of contraception. Large proportions of women in some countries do not know of any place to get family planning services or supplies. Even though some modern methods of contraception have rare but serious side effects, they pose less threat to the health of most women than do pregnancy and childbirth. This is true in developed countries, where maternal mortality rates are low. The saving of lives due to use of effective contraceptives is probably much greater in developing coun- tries, where maternal mortality rates are so much higher. 39 ''Contraceptive Practice Today Since the mid-1960s, when the oral contraceptive and IUD began to be widely used and organized family planning programs were begun in many countries, there has been what can truly be described as a ‘‘contraceptive revolution’ in many parts of the world. This revolution has pro- gressed farthest in developed countries, but there is no doubt that it is also well under way in many developing countries. In 1976, 34 percent of women at risk of unwanted pregnancy worldwide were estimated to be using some form of contra- ception.®” In many developing countries, birth- rates have begun to fall.°” Nevertheless, many millions of couples still have no way to exercise their right “‘to determine in a free, informed and responsible manner the number and spacing of their children’’—a right affirmed by the World Population Conference in 1974.8. 159 Of the 34 percent of women who were using some method of contraception in 1976, nearly half were using an inefficient method. Furthermore, 66 percent of women at risk of un- wanted pregnancy were using no method of any kind. Data from the World Fertility Survey make it possible to measure unmet need in other ways. Figure 27. Percent of women whose last two pregnancies were less than 24 months apart, 1974-1976 Country Bangladesh = Conia Jamin tel i Site 7 0 10 Percent 20 30 40 50 Source: refs. 38-41, 47, 69, 48 See notes ''For example, Figure 27 shows the proportions of Many people assume that women in poor coun- women in various countries whose last two preg- _ tries have large families simply because they want nancies were closer together than is good for to. However, this is generally not true. Figure 28 maternal and child health. In all seven countries, shows that in many developing countries large more than two in 10 women with at least two chil- proportions of women with three living children dren had short birth intervals. In Colombia and want no more children. The smallest proportion is Jamaica, this was true of four in 10; and in the in Jordan, where one-quarter of women with three Dominican Republic, nearly five in 10. children say they want no more. In seven of these Figure 28. Percent of women with three living children who want no more children, 1974-1977 Country Berghoe! PERO eS ol ae =a | — Dominican Heouh + aE Se ee ane oa _ Fj IRIE nee — Mexico Neval MMBC — Percent Source: refs. 38, 70, 40, 71, 42, 72, 69, 44, 48, 45 See notes 41 ''10 countries, more than one-half of women do not want a fourth child. Figure 29 shows the proportions of women aged 30-34 who want to stop having children. They range from 49 percent in Jamaica to 79 percent in Bangladesh. If these women were able to put their wishes into practice and prevent un- wanted births, many unnecessary infant and ma- Figure 29. ternal deaths could be avoided. Even though they want no more children, many women in developing countries are not using con- traceptives. Figure 30 shows women who say they want no more children by whether they are using any method and whether they are using an effi- cient method of contraception. There is great variation among the countries. The lowest propor- Percent of women aged 30-34 who want no more children, 1974-1977 Country Bangladesh Costa Rica Dominican Republic rr 40 #450 °}°+&60 70 80 90 Jamaica Jordan Bee ee Mexico _ SE a a IRS [2 ir He RC a a a TELE a a aR SAT 2). Oo 10 £20 °}& 30 Percent Source: refs. 38, 70, 40, 71, 41, 42, 72, 43, 48, 45 See notes 42 ''tion of women not using any method is in Costa Rica, where only 16 percent of women who want no more children are completely unprotected against unwanted pregnancy. At the other ex- treme is Nepal, where 91 percent of women who want no more children are not using any method. Figure 30 also shows that in some countries a great many women are using such inefficient methods of contraception as withdrawal, rhythm, and douches. Such women are likely to have an unwanted pregnancy and be faced with choosing between an unwanted birth or a dangerous illegal abortion. At first it seems puzzling that women who want Figure 30. Percent of women who want no more children that are using an efficient, inefficient, or no method of contraception, 1974-1977 i Efficient method Ed No method Inefficient method Country Colombia si 4 £Pieee et ioe Percent Source: ref. 73 See notes & '' no more children are not taking steps to prevent pregnancy. However, it is important to remember that many of these women do not have easy access to contraceptive supplies or information. Figure 31 shows the proportion of women who say that they do not know where to get contraceptive advice or supplies. In general, countries where large proportions of women do not know where to get contraception are the same countries in which large proportions of women who want no more children are not using any method. This shows that information about family planning and access to supplies is an important factor in preventing unwanted and high-risk pregnancies.’> Of course, simply knowing a place to get contraceptives is a very rough measure of accessibility. Time and expense to travel to the family planning site, having services available at a time of day when women can get away from their family duties, and many other factors may influence utilization. In country after country, when contraceptives are made available, large proportions of women use them. Yet some women are afraid to use modern methods such as the pill and |UD. Fortu- nately, these methods have been studied inten- sively for many years, and much has been learned about their risks and benefits. The best studies of the pill and its effects on health have been done in England, where more than 60,000 women have been carefully followed for adozen years.’* The most serious health prob- lem associated with pill use is an increased risk of cardiovascular disease (strokes, blood clots and heart attacks) among pill users 35 and older who smoke cigarettes. Other health problems linked to pill use include an increased risk of gallbladder disease, and of liver tumors. Although benign and extremely rare, these liver tumors can be life- threatening. While studies of the effects of the pill have dis- covered these health problems, they have not ''confirmed other suspected complications of pill use. Most importantly, women who use the pill have not been found to have higher rates of cancer than other women.” In fact, it seems that pill use may be protective against cancer of the endometrium (lining of the uterus) and of the ovaries. Women who use IUDs have an increased risk of pelvic infection.”” This may be important in popu- lations where sexually transmitted diseases are common, since the IUD might aggravate un- detected or untreated infections. In the last decade a number of important im- provements have been made in sterilization tech- niques, notably the introduction of laparoscopy and minilaparotomy. Sterilization is a safe method of fertility control for couples who have completed their families.7*:79 Barrier methods of contraception (such as the diaphragm and condom) and traditional methods (such as rhythm and withdrawal) are also safe, in that they are not known to have harmful side ef- Figure 31. Percent of married women who do not know where to get contraceptive supplies or advice, 1974-1978 Country Colombia ET Costa Rica Indonesia Malaysia Mexico i 0 10 20 30 Percent Source: ref. 74 See notes ''fects. However, these methods are not as effec- tive as the pill and IUD, and unintended preg- nancies among couples using barrier and tradi- tional methods expose the woman to the dangers of pregnancy and childbirth. Figure 32 shows the risk of death posed by various methods of fertility control among women of different ages in the United States. These esti- mates combine the risk of death from complica- tions of contraceptive use with the risk of death from unintended pregnancy and childbirth. For example, among pill users there are few preg- nancies, so most of the deaths are from complica- tions of method use, whereas among women using barrier methods the deaths are due to com- plications of pregnancy. In all age groups, women using no method of fertility control have a greater risk of dying than do women using the pill (provided they do not smoke), IUD, or barrier methods and/or abortion to control their fertility. For women aged 30 and older who smoke, pill use is more dangerous than using no method of contraception. The estimates in Figure 32 are based on infor- mation for the United States, where deaths due to pregnancy and childbirth are infrequent. In de- veloping countries, where maternal mortality rates are many times higher, the reduction in deaths among women using contraception is be- lieved to be even greater than in developed coun- tries.2° Nevertheless, it is important that the effects of contraceptive methods on the health of Third World women be carefully investigated. A variety of such studies have been done or are now underway.®'®283 To date, there do not appear to be any special, serious side effects of modern meth- ods of contraception among women in developing countries. Furthermore, it may be that pill use poses less risk to women in developing countries, since cardiovascular disease is generally less common than in developed countries.® On the whole, the best data currently available indicate that use of effective methods of contra- ception substantially decreases, rather than in- creases, the risk of death for most women in both developed and developing countries. '' Figure 32. Estimated death rates associated with use of different methods of fertility control, by age of woman, United States, 1972-1978 No method oO Diaphragm and condom a Pill/nonsmokers x Diaphragm, condom, and legal abortion oO Pill/smokers Legal abortion M@ wp Deaths per 100,000 women per year 62 60 58 56 54 52 50 48 46 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 15-19 20-24 25-29 30-34 35-39 40-44 Age Source: ref. 58 See notes 47 '' ''Conclusion The maternal and child health problems that exist in many developing countries today are indeed enormous. Unfortunately, the sheer size and number of these problems can sometimes dis- courage action. However, programs which can make substantial improvements are possible right now. One of these is family planning. The evidence presented in this chartbook clearly shows that having many children, at short intervals, or at unfavorable maternal ages endan- gers the health and wellbeing of both the mother and the young child. Furthermore, the birth of another child too soon can have a negative impact on the next older child as well. The data demon- strate that these relationships hold across cultural and socioeconomic groups, although the impact is significantly greater among people without ac- cess to medical care. Consequently, as with so many other problems, the poor suffer most. Improvement of the delivery of medical care to pregnant women and young children is a high pri- ority in health ministries throughout the develop- ing world, but progress has generally been disap- pointingly slow. Providing family planning infor- mation and services can help improve the suc- cess of maternal and child health programs by enabling couples to avoid high-risk pregnancies and births. Simply stated, family planning can help prevent many unnecessary deaths among women and children. Few public health measures can have so great an effect in a relatively short time as the implementation of a family planning program providing easy access to effective methods of contraception. Family Planning was recognized as an essential component of primary health care at the WHO conference in Alma-Ata in 1979, which made a commitment to ‘‘health for all by the year 2000.’’* In addition to their health benefits, family plan- ning programs enable couples to exercise the basic human right to control their fertility—a right affirmed in major United Nations-sponsored meetings, including the World Population Confer- ence held in Bucharest in 1974, and more recently at the International Conference on Family Plan- ning in the 80s, held in Jakarta in April, 1981, and attended by delegates from more than 90 coun- tries.68.86 The latter conference issued the “Jakarta Statement’, which included the follow- ing points: “Family planning is an essential component of any broad-based development strategy that seeks to improve the quality of life for both individ- uals and communities.” “We believe that... [if these recommendations are followed] the lives of millions of mothers and children will be saved and the living conditions of individuals in a stabilized world population will be enhanced in the twenty-first century.”’ “Family planning is a basic human right. Gov- ernments should be encouraged to translate this right into realistic policies and programs which meet the needs of their people.”’ Few social programs in history have been im- plemented as widely and effectively in so short a time as family planning. Since the early 1960s, 118 countries have adopted policies which sup- port family planning programs, more than one- half of them citing health or human rights as rea- sons for doing so. These programs have proven to be relatively inexpensive to implement. In many instances, pilot programs have been expanded to provide national coverage surprisingly quickly. Furthermore, birth rates have begun to decline (in some cases quite sharply) in many developing countries.°*” One characteristic common to many of the most successful family planning programs is that they have adapted to local needs and involved 49 ''people from the communities they serve in planning and implementation. For example, on the island of Bali in Indonesia, the traditional village governing councils, ihe “oanjars’’, nave taken on the management of the family planning activities in the villages, at times comoining famiiy planning activities with other deve;opment pro- grams such as crafts cooperatives. One of the most outstanding family planning programs in the world is found in the People’s Republic of China, where policy is determined by the central govern- ment, but neighborhood groups have a consider- able amount of autonomy in deciding how to carry out government policy. In countries as diverse as Colombia, Thailand, Brazil and Egypi, comrnunity groups have had substantial involvement in their family planning programs, often suppiementing government or private sector clinic-based pro- grams with more flexible and responsive modes of service delivery. At present, community-based programs are operating in at least 57 developing countries.® ‘‘Social marketing’ programs, in which contraceptives are sold at iow cost through local shops and vendors, are operating in at least 38 countries. These innovative programs have done much to extend access to contraceptives into areas where people would not be served by conventional, clinic-based programs. In most community-based programs, local peo- ple are involved not only in educational and moti- vational activities, but in the distribution of contra- ceptives as well. Such programs were initiated in the late 1960s, after a careful assessment oi the health risks and benefits of modern methods of contraception.®” As the data presented in this book show, according to the best available infor- mation, for the vast majority of women use of ef- fective methods of contraception (including the pill) poses much less risk to health than do preg- nancy and childbirth. Data from the World Fertility Survey (WFS) 50 show that the success of family planning pro- grams in many developing countries has been truly remarkable.’ Where contraceptives have been made available, sizable proportions of women have adopted their use. However, while much has been accomplished, much remains to be done. The WFS also shows that considerable unmet desire for contraception continues to exist in most developing countries. in order to provide the best possible future for the world’s children, couples must have the ability to plan their families—to have the number of chil- dren they want, and to space and time their births. Great progress toward this goal has been made in only 15 years, and with continued and increased effort, it can be reached. Together with other development efforts, family planning programs can help provide a better life for people the world over. ''Notes Infant mortality is deaths under one year of age. Child mortality is deaths at 1-4 years of age. Figure 2: The interval is the number of years between the end of the previous pregnancy and the birth of the index child. Hindus shown do not include the ‘‘scheduled”’ castes. Figure 3: The interval is the number of years between the end of the previous pregnancy and the birth of the index child. Muslims included are Shiites; Christians are Maronites. Figure 5: The rates for England and Wales are for legitimate births only. Figure 6: Families with more than two adults are excluded. Figure 7: Intelligence test used was the Raven Progressive Matrices (Dutch Modification), in which the highest score is 1 and the lowest score is 6. Socioeconomic group data are the subjects’ fathers’ occupations at the time of the test. Figures 11-13: Data are for the following years: Costa Rica 1965, 1977; Colombia 1965-1966, 1977-1978; Egypt 1966, 1970-1974; Jamaica 1964, 1976; Mexico 1967-1969, 1977-1978; Philippines 1963-1967, 1975; Sri Lanka 1965, 1974; Thailand 1965-1969, 1974-1976; Tunisia 1965, 1976; Venezuela 1966, 1976. Figure 14: Includes only women who are currently married, fecund, and not pregnant. World Fertility Survey (WFS) Table 5.2.1 for Bangladesh, Jamaica, Jordan, and Thailand; 5.2.3 for Colombia, the Dominican Republic, and Pakistan; Sum- mary Reports for Peru and Turkey. (See references.) Figure 15: Includes only women who are currently married, fecund, and not pregnant. Only women with at least one live birth included in Bangladesh and Jordan; only women with at least two live births included in Colombia and Sri Lanka; only women with at least two live births, or one live birth and a current pregnancy, included in Jamaica and Malaysia. WFS Table 4.6.2. (See references.) Figures 19 and 20: Deaths due to abortion are excluded. All births included in England and Wales; live births only in Vene- zuela. Figure 22: Data are for 1973-1977, except in Colombia, Ecuador, El Salvador, Guatemala, Jamaica, and Mexico, for which the data are for 1968-1972. Figure 27: Includes only women with at least two live births, or one live birth and a current pregnancy. Women who are not currently married or in union are excluded in the Dominican Republic; women who are not currently married and fecund, or who are currently pregnant, are excluded in Bangladesh, Nepal, and Sri Lanka. WFS Table 4.6.2. (See references.) Figures 28 and 29: Includes only women who are currently married and fecund; in Costa Rica and the Dominican Republic, women who are currently married or in union, and fecund. WFS Table 3.1.1; Fiji, Table G1; Peru, Summary Report. (See references.) Figure 30: Includes only women who are currently married, fecund, and not pregnant. Efficient methods of contraception are the pill and IUD, sterilization, injection, condom, and female barrier methods (diaphragm, creams, jellies, foaming tablets). Inefficient methods include douches, withdrawal, rhythm, and folk methods. Figure 31: Includes only currently married women. Figure 32: Includes only nonsterile, sexually active women. 51 ''References 1. 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Primary Health Care: Report of the International Confer- ence on Primary Health Care, Alma-Ata, USSR, 6-12 Sep- tember 1978, World Health Organization, Geneva, 1978. 86. “Jakarta Statement,” Issued by the International Con- ference on Family Planning in the 1980’s, Jakarta, Indonesia, April 26-30, 1981, Popline 3(5):1, May 1981. 87. A. Rosenfield, D. Maine and M.E. Gorosh, ‘‘Nonclinical Distribution of the Pill in the Developing World,”’ /nternational Family Planning Perspectives, 6(4):130-136, December 1980. ''Acknowledgements A great many people have generously assisted in the preparation of this chartbook. Lynn Landman and Richard Lincoln of The Alan Guttmacher Insti- tute read several drafts and gave them the benefit of their editorial expertise. The manuscript was reviewed and commented upon by Martin Gorosh, Stephen Isaacs, Judith Jones, Donald Lauro, Susan Philliber, Joanne Revson, Allan Rosenfield, John Ross, William van Wie, Walter Watson and Joe Wray of the Center for Population and Family Health, Columbia University; William Bair, Duff Gillespie, Elizabeth Maguire, James Shelton and Samuel Taylor of the Agency for In- ternational Development; John Benditt and Joy Dryfoos of The Alan Guttmacher Institute; Anibal Faundes and Dorothy Nortman of the Population Council; Ronald Gray of Johns Hopkins Univer- sity; David Morley of the Institute of Child Health, University of London; and Peter Donaldson of the International Fertility Research Program. Special thanks are also owed to Christopher Tietze of the Population Council; and to the staff of the CPFH Library, in particular Judith Wilkinson who tracked down invaluable materials. Credits Design Rudolph de Harak and Janice Bergen of Rudolph de Harak & Associates, Inc. Copyediting Beatrice Jacoby and Lois Morgan Typing and proofreading Lori Rutman Printing Lincoln Graphic Arts, Inc. Photographs P. 2:K. Heyman P. 4:M. Beebe, Photo Researchers P. 8: K. Heyman P. 17: D. Sheehan, Black Star P. 21: K. Heyman P, 22: K. Heyman P. 24: B. P. Wolff, Photo Researchers P. 27: United Nations, Photo Researchers P. 30: M. Gorosh P. 35: C. Armstrong, Rapho/Photo Researchers P. 38: J. Wray P. 40: K. Heyman P. 44. 8. P. Wolff, Photo Researchers P. 48: K. Heyman ''The Center for Population and Family Health is a division of the School of Public Health and part of the International Institute for the Study of Human Reproduction, Faculty of Medicine, Colunbia University. '' Wes ast, * = acannon 5S Bid ie tilts ‘ The Center for Population and Family Health 60 Haven Avenue B-3 New York, New York 10032 USA f, sit sate. tase ae 1s ai linda Dest Bhs ele Sd rie ite ee ''GENERAL LIBRARY - U.C. BERKELEY EAN aN 8000500057 ''''