Click for next page ( 6


The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 5
1 Introduction This report examines the scientific evidence regarding the consequences of reproductive patterns for the health of women and children in developing coun- tries. Reproductive patterns refer to the ages at which women give birth, the lengths of time between births, and the total number of births a woman has. Because reproductive patterns in developing countries have been influenced greatly by use of modern contraceptives, the risks and benefits of different contraceptive methods are also evaluated. Although some of the data on which our analysis is based have been drawn from research in developed countries, the focus of the report is the developing world. The chapters that follow address three fundamental questions: 1. What are the relationships between contraceptive use and reproductive patterns, on one hand, and women's and children's health, on the other? 2. What have been the effects of differences and changes in reproductive patterns on differentials and changes in women's and children's health? 3. What is the potential for family planning to bring about (further) improve- ments in women's and children's health? Answers to these three questions have important implications for health and family planning programs throughout the developing world because they help determine appropriate levels of resources to allocate to these programs. Ques- tions about the relationships among fertility, contraceptive use, and health are also of considerable interest to population scientists, independent of their policy implications. The relationship between fertility and mortality is a fundamental aspect of the transition from a pattern of high mortality -and high fertility charac- s

OCR for page 5
6 CONTRACEPTION AND REPRODUCTION tenstic of traditional agrarian societies to the pattern of low mortality and low fertility found in contemporary industrial societies. This report examines how the health of women and children changes as a society moves from a situation in which no effort is made to control fertility to one In which women are concerned about the number and spacing of their pregnancies and use modern contraceptives to regulate both. It is during this transition that some of the most important health effects of changing fertility may be found. THE DEMOGRAPHIC CONTEXT This report examines aspects of the remarkable demographic changes that have occurred throughout the developing world over the last several decades. Mortality in developing countries, particularly among infants and children, is substantially lower today than it was three decades ago. Major declines in fertility have also taken place in many, although by no means all, developing countries. Increased availability and use of modern contraceptives and later ages at marriage and first birth are among the most important factors in contributing to these fertility declines. But, despite the declines in fertility and mortality that have occurred, large differences in the levels of fertility and mortality remain between the developing and the- more developed world. On average, women in developing countries have more than twice as many children as women in developed countries. The average life expectancy at birth (see the glossary for a definition) in the developing world is 14 years less than life expectancy at birth in developed countries. During the first half of the 1980s, the average rate of infant mortality in the developing world was almost six times the level found in the more developed countries. More than 13 percent of the children born in the developing world die before age 5, compared with less than 2 percent of the children in more developed countries. About 15 million children, 98 percent of them in developing countries, are estimated to have died each year from 1980 to 1985 United Nations, 1988b). Precise data on maternal mortality, that is, on deaths during pregnancy and childbirth, are more difficult to obtain, but it is clear that maternal mortality is also much higher in developing than in developed countries. Figure 1.1 is a map of maternal mortality around the world. It shows that a woman's lifetime risk of maternal death ranges from greater than 1 in 25 in parts of Africa to considerably less than 1 in 1,000 in the United States, Canada, and Western and Northern Europe. Despite the trend toward overall lower mortality and fertility in developing countries, there is a substantial diversity in levels of mortality and fertility. Trends in infant mortality from 1955 through 1985 by geographic region are shown in Figure 1.2, and trends in child mortality (that is, deaths before age 5) are shown in Figure 1.3. According to the United Nations (1988b), the average probability of dying before age 1 declined by over 50 percent during this period in

OCR for page 5
in A' ~ ~ i_ ~ ~ - l ~ l ~- ~ l ~ ~ In cO -I In a, -= c) to lo to to Ads i ~ lo to l In 0 0 0 a) J ~ - ~ Go Go on - 4) . 4, At .~ 9-D D w w - w I_ lo U) .e U' E - _ ~ Ct _ ~ ~ 3 a' a: CO a) Cal

OCR for page 5
CONCEPTION AND REPRODUCTION 200 In Ir 1 50 m to 0 1 00 cr: lo AL ~ 50 ~ frica _ ~ America ~veloped Regions - O i I 1955 1960 1965 1970 1975 1980 1985 YEAR FIGURE 1.2 Infant mortality rates, by region, 1955-1985. Source: United Nations (1988b: Table A.2, pp. 36-41). 350 CD I 300 CC Am llJ o 250 cr 0 ~ 0 A _ ~ I ~ 200 IL ~ Om 150 I ,3 At In 1 00 lo Z 50 o 1955 1960 1965 1970 1975 1980 1985 YEAR FIGURE 1.3 Child mortality rates, by region, 1955-1985. Source: United Nations (1988b: Table A.1, pp. 30-33). More Developed Regions 1 1 1 Africa atin America

OCR for page 5
INTRODUCTION 9 less developed countries, with declines ranging from 29 percent in Eastern Africa to 80 percent in China. The average probability of dying before age 5 in less developed regions decreased by 52 percent, with Eastern Africa (29 percent) and China (79 percent) again being the regions of least and greatest improvement. Although comparable data are not available, maternal mortality also appears to have decreased substantially during the last three decades in some regions. Sivard (1985) estimates that maternal mortality in Latin America declined by almost half from 1960 to 1978. However, maternal mortality has remained high in Africa and South Asia. With the exception of sub-Saharan Africa, fertility declined in every region during the last two decades. Concomitantly, contraceptive use has increased significantly in areas experiencing declines in fertility. Figure 1.4 shows that substantial increases in contraceptive prevalence occurred both in countries where initial levels of use were high and in countries where use was low. The increase in contraceptive use has been rapid in some countries, such as Thailand, but much slower in others, such as Egypt and Pakistan. FAMILY PLANNING IN DEVELOPING COUNTRIES The increase in contraceptive use in developing countries is due in part to government support for family planning services, which has increased the availa- bility of contraceptives. In the early days of organized family planning in the developing world, the primary rationale for such support was that increasing contraceptive use would lower fertility, thereby slowing rapid population growth, which in turn would facilitate economic and social development. Government planners, policy makers, and many politicians accepted the argument that slowing aggregate rates of population growth would accelerate economic development. Public support has also been provided because the ability to determine the number and spacing of one's children has been increasingly recognized as a basic human right. In addition to -promoting contraceptive use for development and human rights reasons, many governments have also encouraged family planning as a means of improving the health of women and children. Health issues have long been the major concern in some areas, notably throughout Latin America. Over the years the health benefits of increased contraceptive use and lower fertility have become the most important policy objectives for a number of developing countries and for many of the international agencies that support family planning programs. This increased interest in the health consequences of changing fertility has been encouraged both by a growing awareness of the potential benefits that lower fertility and better spacing of pregnancies may have on maternal and child health and by an increasing eagerness by politicians to work to improve health. While the number and timing of pregnancies have long been regarded as factors affect- ing women's health, it was not until the early 1970s that a significant number of

OCR for page 5
|0 CONTRACEPTION AND REPRODUCTION 100 _ Z 80 60 o: z o z ct UJ 40 20 _ O I 1 1 1 1 1 1 1 1 1 1 1 1 1970 1975 1980 YEAR ~oor CD z IIJ j~ 60 (' 40 z C' ~ 20 80 100 C' cL UJ c:: 60 o '_ 40 c~ 20 _ Pakistan O 1 1 1 1 1 1 ~1 1 1 ~ I I ~ ~ I ~ 1970 1975 1980 1985 1987 YEAR EAST ASIA , _ Rep. of Koreab SOUTHEAST ASIA Malaysia / ~' O 1 1 ~ ~ 1 1 1 1 970 1 975 1 980 1 1 1 1 1 1 1 1 1 1 1985 1987 YEAR SOUTH ASIA - Bangladasha ~ Nepal 100 z Ch,na _ ~ <: o z LL o CD z E z o z c~ 80 60 40 20 SUB-SAHARAN AFRICA Zmb~wo Botswana - Kenya SenegalG ~ I 1 1 1 0 I 1 1 1 1 1 1, 1 1 1 1 1 1 1 1 1 1 1985 1987 1970 1975 1980 1985 1988 YEAR 100 _ WEST ASIA AND NORTH AFRICA 80 _ 60 40 20 _ - O I I 1 1 1 1 1 1 1 1 ~ 1 1 1 1 1 1 1 1 970 1 975 1 980 YEAR 100 Z 80 C: 0 40 u~ O 20 _ O I ~ ~ I ~ I ~ I 1 1 ~ I ~ I ~ I 1 1 1 970 1985 1 988 LATIN AMERICA _t Trinided and Tobsoo ~ ~olombia ~ _~~ 0Om. Rep.~~ Peru _. ~ Ecuador El Salvador~~' Guatemalab 1975 1980 1 985 1988 YEAR FIGURE 1.4 Trends in contraceptive prevalence: percentage of married wanen ages 15-49 (unless otherwise noted) using contraception, 1970-1988. aCurrently marmed less than age 50. iCurrently married ages 15-44. Source: United Nations (1989), Lcvels and Trends of Contraceptive Use as Assessed in 1988 and selected Contracentive Prevalence Sun~ev~ (CP5;) n~~hin ~nd ~P~]th Sur`reys (DHS), and Centers for Disease Control (CDC) Surveys. --r~ ~~~~~ ~~~~~~ ~ ~^r ~ ~ ^~^

OCR for page 5
INTRODUCTION 1 1 studies began to examine the relationship between different patterns of fertility and women's and children's health. The advances in contraceptive technology, in particular the widespread use of the birth control pill and the intrauterine device (IUD), that contributed to the diffusion of family planning also raised questions about the health effects associ- ated with prolonged use of some methods. The real and perceived health risks of different contraceptives are cited by some health professionals in developing countries as reasons to place restrictions on certain contraceptives, as well as by some couples in developing countries as their reason for being reluctant to control their fertility using modern contraceptives. Contraceptive methods have contin- ued to evolve as efforts are made to reduce health risks and improve efficacy, and research increasingly has demonstrated direct health benefits associated with the use of some contraceptive methods. ORGANIZATION OF THE REPORT Given the widespread changes that have taken place, it is important for both scientific and policy reasons to assess the scientific evidence available on the relationships among contraceptive use, reproductive pattems, and health. The remainder of the report is organized as follows. Chapter 2 provides an overview of the hypothesized relationships between reproductive patterns and the health of women and children. Chapter 3 examines the evidence on the effects of pregnancy and reproductive patterns on women's health and survival. Chapter 4 assesses the health risks and benefits of different contraceptive methods that may be used to control fertility. Chapter 5 evaluates the evidence on the effects of different reproductive patterns on children's health and survival. Chapter 6 describes the changes in reproductive patterns that have taken place across the developing world. Chapter 7 presents the implications of the working group's analysis for family planning policy and for future research. A glossary of technical terms related to reproduction and contraception completes the report.