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Executive Summary Family planning programs have been developed and supported to provide people with a means to achieve the number of children they desire and to reduce unwanted pregnancy, as a means of improving the health of women and children, and to contribute to slower population growth and more rapid economic develop- ment. In 1987 the National Research Council's Committee on Population ap- pointed the Working Group on the Health Consequences of Contraceptive Use and Controlled Fertility to assess what is known about the health risks and benefits of contraceptive methods, about the effects of reproductive patterns (numbers, timing, and spacing of births) on women's and children's health, and about the likely effects on the health of women and children of trends and differences in reproductive patterns in the developing world. The working group concluded that family planning programs contribute to the improvement of the health of women and children in developing countries by providing safe and effective means for women to reduce the number of births and high-risk pregnancies they have. Family planning may also improve the health of infants by increasing the spacing between births. Easy access to family planning services and improved provision of these services should be encouraged, particu- larly in conjunction with efforts to increase access to prenatal care, to encourage breastfeeding, and to advance other health services. In countries in which safe abortion is not available, family planning services are even more important from a health standpoint because they provide a medically sound way ~ reduce un- wanted pregnancies that could otherwise lead to maternal death or injury from dangerous abortion procedures. 1

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2 EXECUTIVE SUMMARY REPRODUCTIVE PATTERNS AND MATERNAL HEALTH Research conducted in developing countries demonstrates that maternal age and parity are associated with maternal health. In particular, maternal mortality may be reduced by: Reducing the total number of pregnancies each woman has; Reducing the number of high-parity births; -- Reducing the number of births to very young and older women; Reducing the use of abortion to terminate unwanted pregnancies in coun- tries in which safe abortion is unavailable; and Reducing the number of pregnancies to women with major health problems. CONTRACEPTIVE RISKS AND BENEFITS Modern contraceptives are an important means through which women in developing countries control their fertility. On the basis of our review of the scientific evidence concerning the risks and benefits of contraception, we con- clude that the risks associated with the use of currently available modern contra- ceptive methods are considerably lower than the risks associated with pregnancy, labor and delivery, particularly in developing countries. Moreover, research has increasingly demonstrated direct health benefits of contraceptive use. Although these results are based largely on studies conducted in the developed world, we regard the available research as a reasonable guide to the risks and benefits of contraceptive use in the developing world. REPRODUCTIVE PATTERNS AND CHILDREN'S HEALTH A large and growing number of studies in the developing world demonstrate that the spacing between births, maternal age, and birth order are associated with child health and survival. In some cases the causal mechanisms influencing these relationships are not fully understood Nevertheless, the weight of evidence suggests that infant and child mortality may be reduced by: Reducing the number of births that occur within approximately two years of a previous birth; Reducing the number of children born to very young mothers; Reducing the number of children born to women in poor health; and Reducing the number of higher-order births. Children born following unwanted pregnancies may also be at increased health risk, but the evidence is incomplete.

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EXECUTIVE SUMMARY 3 HEALTH CONSEQUENCES OF CHANGING REPRODUCTIVE PATTERNS FOR COUNTRIES Declining fertility will improve the health of women In a society by reducing the number of pregnancies and births and therefore the exposure to risk. Other changes in reproductive patterns will improve the health of women and children to the degree that high-risk pregnancies and births are reduced. Some of the changes Hat are likely to take place will reduce certain high-risk births while at the same time increasing others. For example, as a society's level of fertility drops, the proportion of high-risk, higher-order births will decrease, but the proportion of high-risk fast births will increase. The effect of an increase in the proportion of high-risk first births can be mitigated by an increase in the age at which women begin childbearing, especially in societies where a large proportion of women have their first birth at very young ages. Whether spacing between births will widen or narrow as fertility declines is not clear; both patterns are found in the few countries for which data for more than one point in time are available. Changes in fertility may be associated with an increase in the proportion of short birth intervals if declines in breastfeeding are not offset by increased contraceptive use. Although more research on the rela- tionship between contraceptive use and breastteeding is needed, programs de- signed to encourage both breastfeeding and contraceptive use for birth spacing are likely to have important health benefits for children.

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