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6
Changes in Reproductive Patterns
Previous chapters of this report focused on the consequences of different
aspects of reproductive patterns for the health of women and children as individu-
als. We examined the relationships between maternal age, birth spacing, and birth
order and the health of individual women and children. The health of women, we
concluded, can be improved by reducing the number of births and especially by
reducing high-risk births, specifically those of high-parity and to very young and
older women. The health of individual children can also be improved by reducing
high-risk births, specifically births to very young women and births occurring less
than 24 months after a previous birth. In this chapter we change the focus of our
attention and examine the degree to which reproductive patterns vary among
developing countries and the extent to which these patterns have changed as
societies move through demographic transition.
This chapter reviews evidence of changes in the proportions of high-risk births
occurring in countries as their levels of fertility decline. As fertility in a society
declines, other aspects of the society's pattern of reproduction may also change.
For example, women may be more likely to compress their childbearing by
delaying their first birth, having births closer together, and having their last birth
at a younger age. This was what happened in South Korea (Donaldson and
Nichols, 1978~. Such changes in the timing, spacing, and numbers of births in a
society change the proportion of high-risk births and thus affect the health of the
women and children in that society.
Our review of reproductive patterns in the developing world begins with an
examination of changes in birth order distributions that have occurred in countries
in which fertility has declined. We then examine evidence of changes in ages
76
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CHANGES IN ~PRODUCTWE PATTERNS 77
when mothers begin and when they complete childbearing as fertility declines in a
society. We then examine patterns and trends in birth spacing and the relationship
between contraceptive use and abortion. Finally, we examine how changes In
reproductive patterns affect mortality rates.
Most of the evidence presented in this chapter comes from three large-scale
survey research projects supported by the Agency for International Development:
the World Fertility Survey (WFS), the Contraceptive Prevalence Surveys (CPS),
and the Demographic and Health Surveys (DHS). Additional information comes
from other cross-sectional surveys and from national vital registration systems.
Unfortunately, comparable data from the same set of countries are not always
available, and the countries for which data are available are not necessarily
representative of the experiences of the developing world. However, the avail-
able data show considerable variation among societies in reproductive patterns
and allow us to illustrate the experience of many developing countries as their
reproductive patterns change. The increasing availability of more than one
national sample survey of fertility in many developing countries will make it
easier for future studies to examine changes in reproductive patterns. At the same
time, it should be recognized that one of the factors that can contribute to a
fertility decline and changing reproductive patterns is the level of infant mortality,
so that there are reciprocal effects.
The rates for a given event in a population depend on the rates for that event in
each subgroup and the relative size of that subgroup in the population. For
example, the overall infant mortality rate may be thought of as resulting from the
infant mortality rates applying to each birth order and the proportion of births by
birth order. The emphasis in this chapter, however, is on the distribution of births
by birth order, mother's age, and birth interval, and how these are likely to change
as fertility declines.
In order to gauge how the infant mortality rate will change with changing
reproductive patterns, it is necessary to know the level of infant mortality associ-
ated with each subgroup. At the same time, it should be recognized that these
subgroup rates may themselves change as reproductive patterns vary. The vari-
ations in infant morality rates associated with different levels of subgroup char-
acteristics provide some indication of the changes that might result from changing
reproductive patterns. At the same time, it should be noted that the exact amount
of change will also depend on the trends in the group-specific infant mortality
rates.
The emphasis in this chapter is on the distributions of births in populations, and
not on the probability of births to individuals or subgroups or how these distnbu-
tions are likely to change as fertility declines. For example, a decline in births to
older women may mean that an increased proportion of all births will occur to
younger women, even if birth rates decline for both young and older women. It is
virtually certain, for example, that lower fertility will result in a decrease in the
proportion of higher-order births and a corresponding increase in the proportion
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78 CO=~CE~ION AND REPRODUCTION
of first births. Lower fertility probably will lead to a decrease in the proportion of
births to older women, but it is not clear what effect lower fertility will have on the
proportion of births to very young women. There are limited grounds on which a
prediction can be made about possible changes in the distribution of birth inter-
vals. Several scenarios are possible. For example, if there is a reduction in
breastfeeding without a corresponding increase in contraceptive use as fertility
declines, birth intervals will become shorter. Average interval length could also
decrease as a result of changes in the birth order distribution. Intervals between
higher-order births are often longer than between lower-order births, so fertility
declines that reduce higher-order births and concentrate births among lower
orders could result in shorter average interval lengths. However, if contraceptive
use for spacing births increases without a corresponding decrease in breastfeed-
ing, the length of intervals may increase as fertility declines. These changes may
occur simultaneously, adding to the difficulty of predicting the effect of changing
fertility on the length of birth intervals. However, since potential changes in the
distributions of high-risk births may significantly affect the health of women and
children in a society, these changes need to be understood.
FERTILITY DECLINES AND BIRTH ORDER DISTRIBUTION
Total fertility rates in the developing world have declined from an estimated
average of 6.1 during the first half of the 1950s to an estimated average of 4.1
during the first half of the 1980s (United Nations, 1988c). Significant declines in
total fertility rates have occurred throughout Latin America and Asia, as is well
known. However, declines in total fertility rates have not taken place throughout
the entire developing world: for example, although the fertility decline in China
has been extraordinary, the total fertility rates in su~Saharan African countries
are estimated by the United Nations (1988c) to have increased slightly.
As the total fertility rate of a population declines, the proportion of all births
that are first births increases and the proportion of higher-order births (fifth and
higher births) decreases. This is illustrated in Table 6.1, which shows changes in
the distribution of first and higher-order births for 11 countries that have experi-
enced significant fertility declines and that the United Nations judges to have
reasonably complete vital registration data.
In each case, the proportion of all births that are of order 1 increased substan-
tially, more than doubling in some countries, and the proportion of higher-order
births decreased. For example, in Malaysia the proportion of first births increased
from 12 to 26 percent, and the proportion of fifth- and higher-order births
decreased from 41 to 22 percent. These changes decrease the number of high-
risk, higher-order births and increase the proportion of high-risk first births. We
will return to the effects such distributional changes have on measures of health
and mortality at the end of the chapter.
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CHANGES IN REPRODUCTrVE PATTERNS 79
TABLE 6.1 Change in the Order Distnbunon of Births in Selected Countnes Over the Course
of Fertility Declines by Percentage Decline in Total Fertility Rates.
Proportion of All Proportion of all
Births of Order 1 Bits of Order 5+ Percent
1960s 1970s- 1960s 1970s- decline
Country 1980 1980 in TO
Singapore .23 .44 .33 .02 65
Hong Kong .25 .43 .23 .04 64
Barbados .22 .40 .35 .10 54
Mauritius .18 .36 .36 .11 52
Costa Rica .18 .32 .45 .17 50
Chile .25 .41 .31 .09 49
Trinidad
and Tobago .19 .32 .37 .19 43
Pueno Rico .27 .32 .27 .10 42
Panama .21 .29 .35 .22 42
Malaysia .12 .26 .41 .22 42
Fiji .23 .35 .36 .13 41
Source: United Nations Demographic Yearbook, venous years.
MATERNAL AGES AT CHILDBEARING
Because very young and older maternal ages are associated with increased risk
for both women and children, we are interested in the changes that are likely to
take place as fertility declines in the ages at which women begin and end child-
beanng. There is considerable information on the age at which women begin
childbearing. Information on age at completion of childbearing is more limited,
because measuring this requires that cohorts have completed childbearing. How-
ever, we can show changes in the proportion of births to women over age 35 in
some developing countries that have experienced declines in fertility.
Age at first birth has been rising in many developing countries. Trussell and
Reinis (1989) have estimated mean ages at first birth by age groups for the 40
developing countries participating in the WFS. It is difficult to be certain that
these data reflect change over time because of the tendency for women, especially
older women, not to report their first birth if it did not survive. The Trussell and
Reinis estimates, which are presented in Table 6.2, show increases in age at first
birth in most of the countries that have experienced declines in total fertility. By
comparing the average at first birth of the youngest with that of the oldest groups,
we can estimate the extent to which change has taken place. For example, in
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80 CO=~CE~ION AD REPRODUCTION
TABLE 6.2 Mean Age at First Birth, by Age
Country
Age at Time of Survey
20-24 25-29 30-34 35-39 40-44 4549
Africa
Benin 21.0 20.5 20.4 20.4 21.1 21.6
Cameroon 19.6 20.1 19.9 20.6 20.7 -- 22.0
Egypt 21.7 22.2 20.5 20.0 20.0 19.9
Ghana 20.4 20.7 20.6 20.5 21.2 21.2
Ivory Coast 19.0 19.4 19.2 19.9 20.1 20.4
Kenya 19.9 19.6 19.2 19.7 20.0 21.3
Lesotho 20.9 21.2 21.4 21.6 21.9 21.5
Mauritania 20.9 19.6 18.8 20.0 20.7 21.1
Morocco 22.5 21.4 20.4 19.5 19.9 19.5
Nigeria 20.0 20.2 20.2 20.9 22.5 22.9
Senegal 19.4 19.4 18.3 18.5 18.7 19.4
Sudan Worth) 20.7 20.1 19.4 20.7 20.4 21.8
Tunisia 24.8 24.2 22.3 22.0 22.1 22.7
Asia and the Pacific
Bangladesh 17.5 17.1 17.1 17.4 17.9 18.1
Fiji 23.2 22.4 20.9 20.6 20.4 20.7
Indonesia 21.0 20.5 19.8 19.6 20.1 20.7
Jordan 20.2 20.5 20.1 20.2 20.1 19.7
Korea 25.1 24.1 24.2 22.7 21.8 20.7
Malaysia 24.1 23.5 22.0 20.9 20.8 20.4
Nepal 21.0 20.8 20.8 21.5 21.7 22.0
Pakistan 20.1 20.6 19.9 19.8 19.1 19.4
Philippines 23.4 23.1 23.1 22.5 22.4 23.0
Sri Lanka 25.8 25.6 22.9 22.8 21.6 21.6
Syria 22.6 21.8 21.1 22.0 22.0 22.0
Thailand 22.9 23.0 22.2 22.7 22.4 22.4
Turkey 21.8 20.9 20.6 19.9 20.4 20.8
Yemen Arabic Republic 19.9 19.9 20.9 21.4 22.3 24.1
Caribbean and Latin America
Colombia 22.6 22.4 21.6 21.7 22.0 22.5
Costa Rica 22.4 22.9 21.9 21.7 21.9 22.B
Dominican Republic 21.2 20.3 20.7 20.2 20.3 21.3
Ecuador 22.7 22.4 21.5 21.3 21.3 22.4
Guyana 21.6 21.1 20.4 20.4 20.1 20.7
Haiti 24.9 23.8 23.5 23.4 22.0 24.1
Jamaica 19.5 20.5 19.8 20.3 21.5 21.7
Mexico 21.8 21.8 21.3 21.2 21.1 21.5
Panama 22.7 22.1 21.2 21.2 21.1 21.2
Paraguay 23.1 22.5 22.3 22.4 21.4 22.0
Peru 22.8 22.1- 22.0 21.4 21.5 21.9
Trinidad and Tobago 22.6 23.1 22.3 21.6 20.7 20.8
Venezuela 22.4 22.2 21.8 21.3 21.4 n.a.
Source: Trussell and Reinis (1989). Mean ages are based on data derived from the World Fertility
Surveys and are estimated based on statistical models developed by Coale and McNeil (1972) and
Rodriguez and Trussell (1980).
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CHANGES iN PRODUCTS PA=E~S ~ ~
Malaysia women ages 4549 were on average 20.4 when they had their first birth.
Trussell and Reinis's estimates show than in Africa, only Egypt, Morocco, and
Tunisia experienced a rise in the mean age at first birth. In Asia and the Pacific,
one sees more increases in the estimated mean age at fast birth, especially in
countries with significant fertility declines, such as Korea and Malaysia. In the
Caribbean and Latin America, however, the mean age at first birth has changed
relatively little, even though many of the countries in this region have experienced
notable declines in fertility. ~~
Data on changes in age at last birth are more difficult to obtain because cohorts
of women must have completed their fertility in order for age at Be last birth to be
measured accurately. McDonald (1984) estimated the mean age at last birth for
30 countries for women who were ages 4049 at the time the data were collected.
Mean ages at last birth for these women ranged from 31.5 for Indians in Guyana
to 38.4 in Kenya. Unfortunately, there are no later cohorts for comparison.
Another way to see if changes have occurred in the age pattern of childbearing
is to examine the proportion of all births occurring to young and older women at
two different times. Table 6.3 shows proportions of births to younger women
(under 20) and older women (over 35) at To time periods in 11 developing
countries that have experienced significant declines in fertility. The proportion of
births to women ages 35 and older declined in all these counmes. Declines were
substantial in some cases from 20 to 6 percent in Hong Kong and marginal in
TABLE 63 Changes in the Distribution of Births by Matemal Age in Selected Countries Over
the Course of Fertility Decline by Percent Decline in Total Fertility Rates Between 1960 and 1980
Proportion of All Births Proportion of All
to Women Under 20 Births to Women 35+ Percent
1960s 1970s- 1960s 1970s- Decline
Country 1980 1980 in TFR
Singapore .08 .04 .14 .05 65
Hong Kong .05 .()4 .20 .06 64
Barbados .21 .25 .15 .06 54
Mauritius .13 .14 .15 .07 52
Costa Rica .13 .20 .18 .09 50
Chile .12 .17 .17 .09 49
Trinidad
and Tobago .17 .19 .1 1 .08 43
Puerto Rico .18 .18 .11 .07 42
Panama .18 .20 .11 .09 42
Malaysia .1 1 .07 .14 .13 42
Fiji .13 .11 .12 .08 41
Source: United Nations Demographic Yearbook, various years.
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82 CO=RACE=ION ED REPRODUCTION
others, especially in those countries with a relatively low proportion of births to
older women in the earlier time period, such as Panama Those countries with the
greatest fertility declines all experienced a substantial drop in the proportions of
births to women ages 35 and older. The proportion of births to women younger
than age 20 increased in 6 of the 11 populations as their fertility declined.
Delaying age at first birth can benefit the health of women and their children,
particularly for women who might begin childbearing at very young ages. The
data on ages at which women begin childbearing reviewed above indicate that, in
a number of countries, fertility declines have also been accompanied by increas-
ing ages at first birth. A decrease in the proportion of births to older women is
also related to declines in fertility. This change in reproductive pattern has
probably benefited the health of women and children in these populations.
SPACING OF BIRTHS
As shown in Chapter 5, births following a previous birth by less than 24
months are associated with increased risk in many developing countries, in
developed countries, and in high-mortality historical populations. Although
scientists have not yet specified the precise mechanisms involved in these rela-
tionships, the association is so widespread that it is prudent to be concerned about
the potential effects on infant health of short birth intervals.
There is limited evidence regarding the relationship between changes in the
proportion of short birth intervals (less than two years) in a population and
changes in levels of fertility. Table 6.4 presents Hobcraft's (1987) estimates for
18 countries of the proportion of second- and higher-order births that followed the
previous birth by less than 2 years during the 10 years preceding the WFS survey.
This table presents a cross-sectional view of countries at different stages in the
demographic transition. Kenya and Jordan, the counmes with the highest total
fertility rates, have a high proportion of short birth intervals. However, among the
other countries, those with lower levels of fertility tend to have higher proportions
of short birth intervals than those with higher levels of fertility. Over half the
births in Costa Rica occurred less than two years after the previous birth, and their
total fertility rate of 3.8 is relatively low. In comparison, 37 percent of births in
Bangladesh followed within two years of a previous birth, while the total fertility
rate was 6.1.
If an increase in short intervals occurs when fertility declines, then there are
reasons to be concerned about the increased risk to infants associated with
increases in the proportion of short birth intervals. However, this cross-sectional
perspective may be an incomplete or inaccurate view of the relationship between
changes in birth spacing and fertility declines.
Published data on changes in the proportion of short birth intervals in popula-
tions experiencing declines in fertility are surprisingly limited. Table 6.5 presents
data from 10 countries in which both birth interval data and total fertility rates are
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CHANCES IN PRODUCTS PA=E~S 83
TABLE 6.4 Proportion of Births of Orders Two and Above Chat Occurred Less Than Two
Years After the Previous Birth and Total Fertility Rates for the Five-Year Penod Prior to the
Survey
Proportion with preceding
Country (Survey year) Interval < 2 Years Total Futility Rate
Kenya (1977-1978) .40 8.2
Jordan (1976) .54 7.8
Senegal (1978) .21 7.1
Camerom (1978) .32 6.3
Ivory Coast (1980-1981) .29 6.3
Bangladesh (1975-1976) .37 6.1
Morocco (1980) .42 5.9
Lesotho (1977) .20 5.6
Peru (1977-1978) .44 5.5
Jamaica (1975-1976) .48 5.0
Colombia (1976) .53 4.6
Malaysia (1974) .41 4.6
Thailand (1975) .37 4.5
Panama (1975-1976) .47 4.4
Korea (1974) .22 4.2
Costa Rica (1976) .53 3.8
Sn Lanlca (1975) .35 3.7
Trinidad and Tobago (1977) .49 3.2
Sources: For intervals, Hobcraft (1987); for fertility rates, Goldman, Rutstein, and Singh (1985).
available for some point in the 1970s and some point in He 1980s. For two of
these countries, Thailand and Taiwan, we also have data from the 1960s. In ~ of
these 10 populations, the proportion of birth intervals of less than two years
decreased as fertility levels dropped. These data are admittedly limited, but they
do present a picture opposite from that given by cross-sectional data showing that
the proportion of intervals that are short is negatively associated with total fertility
rates over time. If birth intervals do lengthen as fertility levels decline, improve-
ments in maternal and child health should occur. However, the increase in the
proportion of short intervals in Senegal should be of concern to health officials
and policy makers, particularly if this reflects emerging patterns in Africa. As
data collected at more than one time become available for a larger number of
countries, the relationship should become clearer.
Breastfeeding and postpartum abstinence are the primary traditional factors
contributing to long interbirth intervals. Intensive unsupplemented breastieeding
postpones the return of ovulation (McNeilly, 1977), thus extending the length of
birth intervals. Postpartum abstinence, which can have mean durations Heater
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84 CONTRACTION AND REPRODUCTION
TABLE 6.5 Changes in the Distribution of Births by Length of Preceding Interval and Total
Fertility Rates (I~FR) in Selected Countries
1960s
Proportion of
intervals less
than 24 months TF~
1970s
Proportion of
intervals less
than 24 maths TFR
1980s
Proportion of
intervals less
than 24 months TFR
Senegal 21 7.1 34 6.68
Ecuador 46 5.3 28 4.38
Peru 41 5.5 26 4.1d
Mexico 49 6.1 28 3.8c
Dominican Republic 54 5.7 25 3.7d
Colombia 53 4.6 21 3.38
Trinidad and Tobago 49 3.2 17 3.18
Sri Lanka 35 3.7 19 2.78
Taiwan 37a 5.1b 49a 3.4c 53a 2.6f
Thailand 3oa 6.1 25a S.la 19~ 2.48
a Closed intervals occurring within 12 months of survey. All other birth intervals are for the 10
years prior to the surveys.
b 1963-1965.
c 1971-1973.
d 3 years prior to survey.
c Year prior to survey.
f 1978-1980.
g 5 years preceding survey.
Sources: Senegal, Ecuador, Peru, Mexico, Dominican Republic, Colombia, Trinidad and Tobago,
Sri Lanka: 1980s data provided by the Demographic and Health Survey project; 1970s data from the
World Fertility Survey (A. Pebley). Taiwan: Data provided by A. HenT~alin. Thailand: John Knodel
and Kua Wongboonsin, "Birth Interval and Birth Order Distributions over Ihailand's Fertility Tran-
sinon." August, 1988. 1980 TI;Ks from DHS Newsletter except Taiwan.
than a year in some populations, is also an important influence on birth interval
lengths in some countries. Table 6.6 presents estimates of mean durations of
breastEeeding and postpartum abstinence by Singh and Ferry (1984) for 20 WFS
countries. Mean durations of full (unsupplemented) breastfeeding range from 2.2
months in Kenya to 7.9 months in Mauritania. Mean duration of total breastieed-
ing is as high as 26.5 months in Bangladesh. Countries with longer intervals
between births tend to be the countries in which durations of breastfeeding are
longer. There is a wide range in periods of postpartum abstinence, with mean
durations of more than a year in several countries.
In most developing countnes, more women have breastfed than have used
modem contraception; therefore declines in breastfeeding could greatly increase
the proportion of short birth intervals (DaVanzo and Starbird, 1989). Accord-
ingly, some experts have been concerned that breastfeeding in the developing
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CHANCES iN PRODUCTS PA"E~S 85
TABLE 6.6 BreastEeeding and Postpartum Abstinence in 20 Counties
Mean Duration (months)
% of Mothers
Unsupplemented Postpartum Who Ever
County Breas~eeding Breastteeding Abstinence Breastfeed
Bangladesh 26.5 n.a. 3.0 98
Benin 19.2 2.6 15.5 97
Lesotho 19.1 2.5 15.0 95
Ghana 17.9 4.5 10.0 92
Senegal 17.7 4.9 n.a. 98
Cameroon 17.5 5.1 13.9 98
Ivory Coast 17.5 5.0 13.1 98
Kenya 16.9 2.2 2.9 98
Egypt 16.3 7.4 n.a. 95
Sudan (North) 15.8 5.6 2.6 98
Mauntania 15.6 7.9 n.a. 98
Haih 15.3 n.a. 6.5 96
Morocco 14.2 5.5 n.a. 94
Tunisia 14.0 6.2 1.6 95
Philippines 12.6 3.3 2.8 86
Syria 11.2 5.5 1.2 95
Paraguay 10.9 2.9 1.5 93
Yemen A.R. 10.6 4.5 2.8 92
Fiji 9.4 n.a. 5.1 87
Costa Rica 5.0 n.a. 1.3 75
Source: Singh and Feny (1984:Table 5).
world has declined. Millman (1986), however, found variability in trends in
breastfeeding practices among the populations she examined, with decreases in
some populations, increases in some, and stability in patterns in others. She
concludes that there is no evidence of systematic declines in levels of breastfeed-
ing, although substantial declines have occurred in some countries, for example,
Taiwan. However, data concerning breastfeeding trends are limited, and it is
difficult to be certain that rapid changes in breastfeeding practice are not occur-
ring.
Survey data from many countries indicate Tat many women desire to space
their births. In Africa, spacing children has been a dominant reason for using
contraception, although prevalence of modern contraception remains extremely
low (London et al., 1985~. In 17 Latin American and Caribbean countries for
which WFS data are available, an average of 38 percent of women con~acepting
were doing so to delay their next birth, compared with 48 percent who were using
contraception to prevent further childbearing (Cleland and Rutstein, 1986~. Cross-
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86 CO=RACEPIION AND REPRODUCTION
national analyses of contraceptive use for spacing are difficult because no stan-
dard set of women has been asked questions about contraception for spacing, and
the form of the questions concerning contraception for spacing has varied.
While a significant proportion of women apparently wish to space their births,
there is a negative association between the two primary mechanisms affecting
spacing, breastfeeding, and contraceptive use. Women who breastfeed are less
likely than others to use contraception, and women who practice contraception are
less likely to breastfeed (Millman, 1985; DaVanzo and Starbird, 1989~. Pebley et
al. (1985) found that the proportion of breastfeeding women using oral contracep-
tives was generally low, but not inconsequential. Gomez de Leon and Potter
(1989) present evidence suggesting that many women may either perceive
breastfeeding and contraceptive use to be incompatible or they substitute one for
the other.
Births within 24 months of a previous birth are at increasing risk, but no clear
picture emerges on the association between declining fertility and changes in the
proportion of short birth intervals. The proportion of short intervals decreased as
fertility declined in the six Latin American countries in Table 6.5, as was also the
case in Sri Lanka and Thailand. However, the proportion of short intervals
increased in Senegal and Taiwan. Trends in breastfeeding and contraceptive use
for spacing are also not clear, but there is an inverse association between the two
behaviors that influence spacing.
CONTRACEPTIVE USE AND INDUCED ABORTION
Abortion may be used when women wish to control fertility but do not practice
contraception or when they experience a contraceptive failure. However, because
of lack of data, it is impossible to estimate the incidence of abortion or the
relationship between changes in contraceptive use and abortion in developing
countries.
Three patterns of abortion and contraceptive use can be identified from the
limited data available for countries moving from high to lower levels of fertility
(Rogers, 1988~. Abortion rates may increase during the early stages of the
fertility transition, as women began to control their fertility and contraceptive use
increases. This has been the experience in China, Singapore, and Taiwan, al-
though a different pattern may take place in different cultural contexts. The
second pattern was found in many countries of Western Europe and Japan, as the
progression from high to low fertility combined with the assimilation of effective
contraception was accompanied by a decline in abortion. A third pattern is
characteristic of low-fertility countries in which the use of effective contraception
is widespread, abortion is legal and available, and its use appears to be low. This
is the current situation in England and Wales and the Netherlands. Overall then,
the evidence suggests that the increased use of effective contraception can reduce
the incidence of induced abortion, unless it is already low.
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CHANGES IN REPRODUCTIVE PATTERNS 87
EFFECTS OF CHANGES IN REPRODUCTIVE PATTERNS
ON MORTALITY RATES
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88 CO=RACE~ION ^D REPRODUCTION
A related issue concerns the potential for change in mortality rates caused by a
change in fertility. The amount of change in mortality rates will depend on how
common potentially detrimental reproductive patterns are in a population. For
example, birth spacing patterns and the frequency of pregnancy at very young
ages vary considerably in developing countries. The proportion of intervals that
are very short is small in most countries in sub-Saharan Africa and South Asia. In
these regions there is not much room to reduce this proportion further, as there is,
for example, in Latin America. Rather, as fertility declines, the concern of policy
makers should be to prevent an increase in the proportion of birth intervals that are
detrimentally short by respecting traditional practices and by promoting breastfeed-
ing and contraceptive use for spacing. Childbearing at very young ages is more
common in some South Asian countries than elsewhere in the world, and there-
fore the scope for improving women's and children's health through delays in the
age at first birth is greater in these countries.
CONCLUSION
As levels of fertility decline in developing countries, their patterns of repro-
duction also change. In particular, women may begin bearing children at later
ages and complete childbearing at earlier ages, and the spacing between births
may change. These changes in timing and spacing are likely to directly affect the
health of women and children in these countries in addition to the direct benefits
of having fewer children.
In many developing countries in which fertility has declined, age at marriage
and age at first both have increased. Delaying age at first birth is likely to benefit
women and children, especially in societies in which childbearing begins at very
young ages. Although published evidence on changes in birth spacing is surpris-
ingly scarce, cross-sectional relationships between the proportion of short birth
intervals and the total fertility rates of countries indicate that spacing tends to be
closer in societies with lower fertility. However, in ~ of the 10 countries in which
data on spacing are available for two or more times, the proportion of short
intervals declined as fertility declined. While the available data indicate that
changes in birth spacing are likely to occur as fertility declines, the direction of
change remains unclear. Analysis of spacing using data from the Demographic
and Health Surveys currently under way will give further indication of relation-
ships between birth spacing and fertility declines.
Declining fertility does lead to changes in the distribution of births by birth
order; most notably, the proportion of births that are first births, which are
typically higher-risk births, increases. Because of the change in the birth order
distribution and the different level of risk associated with different birth orders,
the paradoxical situation can en se whereby aggregate measures of mortality, such
as the infant mortality rate, can increase, although the mortality rate for each birth
OCR for page 89
CHANCES IN REPRODUC.T~E PANELS 89
order may decrease. In addition, as fertility declines, the number of infant deaths
will decline, even if the infant mortality rate does not change.
The overall health of a population may improve as fertility declines, both
because of the direct and indirect effects discussed in this report, and because of
factors such as improved nutrition and improved delivery of health care. Thus,
the level of risk associated with first births or close birth spacing may decrease
over time. As health and demographic data continue to be collected and com-
pared with information from earlier surveys, the complex associations among the
numerous factors influencing the health of women and children should be better
understood.
Representative terms from entire chapter:
birth intervals
