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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 6
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 7
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OCR for page 8
CONCEPTION AND REPRODUCTION
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FIGURE 1.2 Infant mortality rates, by region, 1955-1985. Source: United Nations (1988b:
Table A.2, pp. 36-41).
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FIGURE 1.3 Child mortality rates, by region, 1955-1985. Source: United Nations (1988b:
Table A.1, pp. 30-33).
More Developed Regions
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atin America
OCR for page 9
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 10
|0 CONTRACEPTION AND REPRODUCTION
100 _
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1970 1975 1980
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1970 1975 1980 1985 1987
YEAR
EAST ASIA
, _
Rep. of Koreab
SOUTHEAST ASIA
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1985 1987
YEAR
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1985 1987 1970 1975 1980 1985 1988
YEAR
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WEST ASIA AND NORTH AFRICA
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YEAR
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LATIN AMERICA
_t
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~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 11
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.
Representative terms from entire chapter:
developing world
