chorionic villi sampling, amnioscentesis, and ultrasound imaging. Ultrasound imaging is very unreliable before the second trimester of a pregnancy, but it is the safest and cheapest of the methods and the most widely available in Asia, so there is some concern that the number of difficult late abortions may increase as a result of increased use of ultrasound imaging. Ultrasound equipment is available in hundreds of clinics and hospitals in India, no longer confined to the large, modern cities where the problem was first described.

Much of the evidence for widespread prenatal screening followed by sex-selective abortion is indirect, based on sex ratios of reported births. In South Korea, China, and Taiwan, the ratio of male births to female births has been steadily increasing since about 1980. In China, the ratio of male births to female births increases steeply with parity, up to parity four, and this difference increased over time during the 1980s (Westley, 1995). Sex-selective abortion illustrates the problems entailed in adopting a simple policy of goal maximization of individual reproductive choice. The definitions agreed at the ICPD lead to a salutary presumption that individual choices are paramount, but they do not solve all potential disputes about exactly which services are part of "reproductive health." India, Korea, and China have all adopted measures prohibiting fetal screening for sex and sex-selective abortion, but enforcement is likely to be difficult.

The Policy Environment

Fulfilling the goal of "every child wanted" will require changes of behavior on the part of public-sector bureaucracies (national and international), private-sector service providers, and current and potential users of services. In studying family planning programs it has sometimes proven useful to classify the needed changes as supply-side or demandside factors, but the distinction between the two is artificial (Koenig and Simmons, 1992). New services are provided, or their quality and accessibility increased, or policies made more supportive, in part because political leaders and bureaucratic officials decide that these changes are beneficial for the country and conducive to their own continued rule, and in part because an educated and informed public pressures for changes. Organizations in both public and private sectors create their microenvironment, but are also creatures of the larger policy environment.

As we discuss in Chapters 6 and 7, family planning programs in developing countries are typically subsidized: contraceptive supplies, counseling, and clinical services are distributed either free of charge or at prices well below full cost recovery by government agencies and nongovernmental organizations (NGOs). Because of the large numbers of couples now entering peak ages for childbearing and the increasing reliance on



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