4
Intended Births

The nations that signed the Programme of Action of the International Conference on Population and Development (ICPD) committed to try "… by the year 2015, … to provide universal access to a full range of safe and reliable family-planning methods and to related reproductive health services which are not against the law" (United Nations, 1994:sect 9.1). Family planning programs contribute to reproductive health in two main ways: by allowing women and men to exercise the "freedom to decide if, when and how often" to have children (as included in the ICPD definition of reproductive health) and by reducing the number of times that a woman is exposed to the risks of unsafe pregnancy and delivery. In addition to these direct effects, there is evidence for a long-term impact as well: families that are not burdened by excess fertility can and do invest more in the nutrition, schooling, and health care of their wanted children. This investment, in turn, can be expected to improve the reproductive health of the next generation, among other benefits.

In this chapter we first discuss the evidence that unintended pregnancies and births are common. We next summarize the evidence that unintended pregnancies are harmful for the health and well-being women and their families. The bulk of this chapter then deals with some of the main problems confronting family planning programs and provision of safe abortions, which are the primary means through which public policy facilitates achievement of the goal of intended births. The final section deals with the broader policy environment.



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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 4 Intended Births The nations that signed the Programme of Action of the International Conference on Population and Development (ICPD) committed to try "… by the year 2015, … to provide universal access to a full range of safe and reliable family-planning methods and to related reproductive health services which are not against the law" (United Nations, 1994:sect 9.1). Family planning programs contribute to reproductive health in two main ways: by allowing women and men to exercise the "freedom to decide if, when and how often" to have children (as included in the ICPD definition of reproductive health) and by reducing the number of times that a woman is exposed to the risks of unsafe pregnancy and delivery. In addition to these direct effects, there is evidence for a long-term impact as well: families that are not burdened by excess fertility can and do invest more in the nutrition, schooling, and health care of their wanted children. This investment, in turn, can be expected to improve the reproductive health of the next generation, among other benefits. In this chapter we first discuss the evidence that unintended pregnancies and births are common. We next summarize the evidence that unintended pregnancies are harmful for the health and well-being women and their families. The bulk of this chapter then deals with some of the main problems confronting family planning programs and provision of safe abortions, which are the primary means through which public policy facilitates achievement of the goal of intended births. The final section deals with the broader policy environment.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions DEFINING AND MEASURING INTENDED FERTILITY There is no unambiguous definition of ''intended birth" that would apply to the different societies covered by this report, nor to all families within any society. "Intentions" fit actual decisions and behavior only imperfectly: the answers to standardized questions used in household surveys cannot fully capture the complexity of the process by which intentions are formed or their intensity. However, some measures, even imprecise ones, are needed to gauge the extent of the problem of unintended pregnancy, and survey data on fertility intentions have been found to predict subsequent fertility behavior well, at least at a population level (Westoff, 1990).1 The best recent source of comparable data for large populations in developing countries is the Demographic and Health Surveys (DHS). Using different items in the standard DHS questionnaires, there are two broad approaches to measuring intentions. One approach relies on answers to direct questions about the last birth or current pregnancy. In most DHS surveys, women are asked, for each live birth that occurred less than 5 years before the interview: "At the time you became pregnant with [Name], did you want to become pregnant then, did you want to wait until later, or did you want no more children at all?" Women who are pregnant at the time of the interview are asked analogous questions about their current pregnancy. We use the term "unwanted" to refer to a pregnancy or birth to a woman who reports that she did not want any more children; "mistimed" for a pregnancy or birth to woman who wants more children, but not in the near future, and "unintended" to cover both.2 The second approach relies on hypothetical questions about all children. Most DHS surveys include this question: "If you could go back to the time when you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?" The answers can be averaged for a population, or a desired total 1   The Technical Note at the end of this chapter discusses some of the problems of existing measures of the prevalence of unintended pregnancies and abortions. 2   Other researchers use different terms. Some use "unplanned" to describe pregnancies that were not wanted at the time of conception or recognition of pregnancy, distinct from "unwanted," referring to the woman's wishes at the time of birth or interview. Asif and his colleagues (1994), analyzing data collected from pregnant women in Uttar Pradesh, India, distinguish between "unwanted," "unwanted but accepted," and "wanted" pregnancies; nearly half the pregnancies in his sample were classified unwanted but accepted. Brown and Eisenberg (1995) discuss the implications of various definitions of intention and wantedness.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions fertility rate can be estimated by deleting recent births to women who report an ideal family size lower than their actual number of living children (Cochrane and Sai, 1993; Bongaarts, 1990). An alternative is to construct a "synthetic estimate" of desired total fertility rates, summarizing estimates of proportions of women at each parity who report that they want no more children. These indirect methods do not allow estimation of mistimed (as opposed to entirely unwanted) pregnancies, and they require a hypothetical recasting of respondents' lives that may not be especially meaningful. But they avoid one weakness of the direct questions about specific pregnancies: "[U]nderreporting is apparently common and is presumably caused by a reluctance of women to classify their offspring as unwanted" (Bongaarts, 1991:223). Since desired family size has fallen in almost all developing countries for which it has been measured, it has been conventional to focus on only one aspect of failure to achieve reproductive goals, namely, unwanted childbearing. Yet as Kingsley Davis (1967) noted three decades ago, "family planning" literally construed should include the notion of couples planning to have a family. Infertility can lead to loss of social status, divorce, and other negative consequences, as well as being a cause of tremendous unhappiness. Larsen and Menken (1989) provide useful evidence on the prevalence of infertility from a combination of demographic surveys and microsimulation of populations with varying amounts of deliberate fertility control. Larsen (1994) estimates that the proportion of women sterile by age 34 in 17 sub-Saharan African countries varied from a low of 11 percent in Burundi to a high of 31 percent in Cameroon. She concluded that "the true prevalence of sterility in sub-Saharan Africa is so substantial that it ceases to be a merely individual problem and has become a public health issue" (Larsen, 1994:469). As in previous reviews, Larsen found great geographic variation in apparent infertility, which she plausibly ascribes to geographic variation in the incidence of reproductive tract infections. In Chapter 3 we discuss the needs for programs to control sexually transmitted diseases (STDs), which is the most effective way to prevent infertility in the countries most affected. Whose Intentions? A crucial question in all societies is whose fertility intentions count in deciding if a birth is "intended." The potential mother is obviously most directly affected, and any definition of intention that did not include her wishes and interests would be unacceptable. Potential fathers also have, or are expected to have, a lot at stake in fertility decisions. A widely shared ideal would call for good spousal communication and socially

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions approved methods of reconciling disagreements that respect the rights of all involved. A recent review of published studies, based on both surveys and qualitative research, showed (Mason and Taj, 1987:632;631) "more often than not … women's and men's fertility goals are very similar. When gender differences do occur … they usually are small and are of both types (men more pronatalist than women and vice versa)." These are population averages, which could be consistent with some degree of offsetting disagreement between spouses. More importantly, general agreement on preferences for the number of children does not imply agreement among spouses about the desirability of particular behaviors (modern contraception, periodic abstinence, or induced abortion) to implement those goals. Husbands' disapproval is one of the most common reasons for women's not using contraception reported in surveys by women at risk of an unwanted pregnancy. As Bongaarts and Bruce (1995) point out, more than one-half of such women in most African countries also report that they have never discussed contraception with their husbands, suggesting that they may feel powerless to influence the decision or even raise the topic. Casterline, Perez, and Biddlecom (1996) report similar results from more intensive interviews in the Philippines. Intergenerational differences in family size goals may be more pronounced than interspousal differences. It is commonly believed by family planning program managers in South Asia, for example, that the chief opponents of small families are domineering mothers-in-law. Caldwell (1986) has argued that the patriarchs in West African lineage systems have a strong interest in seeing their sons have many children who can perform economic and religious services and generate prestige for their grandfathers. We know of no studies directly comparing the stated preferences of older people for grandchildren with the fertility goals of their adult children. The notion of a couple as the only decision makers whose preferences should count is probably a minority view in the world as a whole, and a recent development even where it is now the dominant view. Marriage and fertility decisions are widely regarded as too important to leave solely to prospective spouses and parents, particularly young ones. In practice, methods for estimating the extent of unwanted fertility and unmet needs for family planning implicitly take the woman's (potential mother's) stated intentions as paramount. The justification is that a woman is the person whose physical health is directly at risk in pregnancy and delivery; in all societies women, on average, bear the major share of responsibilities for child care.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions Unwanted Pregnancies and Births Direct Measures Figure 4-1 shows the proportions of recent births and current pregnancies reported as unwanted in the most recent DHS survey in 34 countries, grouped by region.3 The proportion varies widely among countries within regions, but it is clearly lowest in sub-Saharan Africa, where large desired family sizes are still reported, and generally highest in Latin America, the Middle East, and North Africa. Outside Africa, the proportion of births unwanted ranges in most countries from 12 to 34 percent. Figure 4-2 shows the proportion of unwanted births in the same countries, grouped by the percentages of married women aged 15-49 currently using any form of contraception (the contraceptive prevalence rate). The countries with the lowest contraceptive prevalence (most of which are in sub-Saharan Africa) have low proportions of unwanted births. The median is 18 percent among the nine countries with contraceptive prevalence of more than 50 percent, considerably higher than the median of 5 percent among the ten countries with contraceptive prevalence of less than 20 percent. This difference does not necessarily mean that women in the highest contraceptive prevalence countries are more likely to have an unwanted birth in a particular year. Precisely because they use contraception more, they are less likely to have a baby than are women in countries where contraceptive use is uncommon. This can be seen in Figure 4-3, showing the range of values for the unwanted birth rate (unwanted births per 1,000 women per year) for countries in the same contraceptive prevalence categories as in Figure 4-2.4 Countries with contraceptive prevalence above 50 percent tend to have lower unwanted birth rates than countries with contraceptive prevalence between 20 and 30 percent, despite having higher proportions of unwanted births, because they have much lower overall birth rates. Women are most at risk of unwanted births in countries where contraceptive use is in the range 20-40 percent, presumably because contraceptive behavior and fertility are lagging behind the more rapid change in fertility preferences. The proportion of unwanted births is the appropriate measure for discussing the consequences of unwantedness for children. It highlights 3   Countries chosen for DHS do not represent a random sample of all countries in a region, but they do cover a wide variety of conditions in developing countries outside China. 4   The unwanted birth rate was calculated as the product of the proportion of most recent births or current pregnancies reported as unwanted multiplied by the general fertility rate (births per 1,000 women aged 15-49 per year) as estimated by the United Nations.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions FIGURE 4-1 Percentage of most recent births or current pregnancies unwanted in countries with recent DHS surveys, by region. Wide bars show 25th centile, median, and 75th centile for countries in each category; narrow bars show lowest and highest values. SOURCE: Demographic and Health Surveys. the situation in many low-fertility societies where contraception and safe abortions are already widely available and well known. The second measure, the unwanted birth rate, is appropriate for gauging the effects of unwanted fertility on women's lives. It shows that women in low-fertility societies are less likely than those in societies with higher fertility rates to be affected by the consequences of unintended pregnancies and births.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions FIGURE 4-2 Percentage of most recent births or current pregnancies unwanted in countries with recent DHS surveys, by contraceptive prevalence. Data are for married women aged 15-49. Wide bars show 25th centile, median, and 75th centile for countries in each category; narrow bars show lowest and highest values. SOURCE: Demographic and Health Surveys.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions FIGURE 4-3 Unwanted births per 1,000 women aged 15-49 per year in countries with recent DHS surveys, by contraceptive prevalence. Wide bars show 25th centile, median, and 75th centile for countries in each category; narrow bars show lowest and highest values. SOURCE: Demographic and Health Surveys.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions Indirect Measures The indirect approaches to measurement also produces high aggregate estimates of the extent of unwanted fertility. Cochrane and Sai (1993) estimate that in developing countries outside China, 30 percent of fertility is unwanted. Bongaarts' aggregate estimates (also based on comparison of ideal with actual family size) show that in countries with high fertility (total fertility rates [TFR] above six births per women), only 16 percent of births appear unwanted. The highest percentages of unwanted births are found in countries in the middle range of fertility rates (between four and six births per woman), where nearly one-third of births are inferred to be unwanted. In low-fertility countries (TFRs below four births per woman), 25 percent of births appear unwanted. Figure 4-4 shows the proportion of recent births or current pregnancies reported as mistimed in DHS surveys, with countries grouped according to contraceptive prevalence rates.5 These data show no consistent association: the median proportion of mistimed births is just above one-fifth for all countries, across the range of contraceptive prevalence rates. This evidence suggests that the potential demand for family planning for purposes of spacing births can be high even when desired fertility is high. Country-level analyses of DHS data by Westoff and Bankole (1995) confirm that much of the unmet need for contraception inferred from women's replies, especially in sub-Saharan Africa, is motivated by the desire to delay first pregnancies or to space pregnancies, rather than by a desire to stop childbearing. Determinants The determinants of unintended fertility are complex, not easily reduced to factors such as lack of education, unfamiliarity with contraception and abortion, or unavailability of services. In Indonesia, for example, Weller et al. (1991) found no significant association between women's education and the wantedness of their most recent child born within the last 5 years. The researchers ascribed this lack of an association to the offsetting effects of education on preferences for lower fertility and on ability to control fertility. Data for the United States—a country where nearly all adults are literate, publicly funded family planning clinics have existed across the 5   The percentages shown in Figure 4-4 do not include the births and current pregnancies reported as unwanted (shown in Figure 4-2).

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions FIGURE 4-4 Percentage of most recent births or current pregnancies mistimed in countries with recent DHS surveys, by contraceptive prevalence. Wide bars show 25th centile, median, and 75th centile for countries in each category; narrow bars show lowest and highest values. SOURCE: Demographic and Health Surveys. country since the late 1960s, private outlets for contraceptive supplies and advice are widespread and costs of contraception are very low in relation to incomes (by international standards), and abortion is safe and common (about 30 percent of all pregnancies not ending in miscarriage are terminated by induced abortion)—are revealing. In the United States, nearly one-half of all births in 1988 were unintended (Kost and Forrest, 1995): more than one-quarter of births to women with 16 or more years of schooling

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions were unintended, and births to women with three or more previous births were more likely to be unintended than were first births. The evidence demonstrates that making contraception and abortion safe and widely available and ensuring that women have high levels of education do not, by themselves, reduce the proportions of unintended pregnancies and births. Thus, despite the increased use of effective contraception, the proportion of births that are unwanted or mistimed may rise in the early stages of the fertility transition before leveling off or falling. Changes in fertility preferences that accompany the fertility transition make the goal of eliminating unintended births a moving target. There is good evidence that fertility intentions change during the course of the transition to low fertility. Desired family size has fallen in almost every country where trend data are available from DHS and the World Fertility Survey, and the decline has sometimes been dramatic: in Kenya, the average fell by more than three children per woman in 20 years (Rutstein, 1995). Desired family size has fallen quite consistently for almost all birth cohorts of women, and for both educated and uneducated women, in 28 countries for which two or three comparable surveys are available (Rutstein, 1995). Lloyd (1994:191) argues that "the emergence of 'unwanted fertility' is symptomatic of parents' rising aspirations and their increasing awareness of alternatives to their own and their children's current condition." This gap between intentions and experience appears to grow in the early stages of the demographic transition, when declining mortality, particularly for infants and children, results in larger numbers of children growing up for given numbers of live births. As actual fertility declines, wanted fertility may decline even faster, so that the proportion of births that are unintended may actually grow even while fertility control is becoming more prevalent. Induced Abortions The evidence about the prevalence of unintended pregnancy discussed so far is based on women's reports about their intentions and contraceptive behavior. Further evidence that large proportions of pregnancies are unintended comes from the limited available data on the prevalence of induced abortion. The most authoritative estimates are that in 1987, worldwide, there were between 26 and 31 million legal abortions and 10 to 22 million illegal abortions (Henshaw and Morrow, 1990). By combining direct reports with incomplete data on treatment of abortion complications, Henshaw estimated that in 1990, there were total of 20 million "unsafe abortions," that is, those "not provided through approved facilities and/or persons" (World Health Organization, 1994:2).

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions contraceptive method. But if large numbers of contraceptive users are discontinuing use of any method, rather than switching to one that better meets their needs, it probably indicates that the program is not meeting their needs (Jain and Bruce, 1994). Lastly, the measures taken to improve quality of services provided by existing providers in existing facilities may result in great efficiency—more output for a given level of resources—than would the deployment of new workers or building of new facilities. The argument that improved quality will lead to greater demand for services and operation at more efficient scales is still largely untested. In a situation analyses of clinics and other family planning service sites in the same clusters included in the 1991-1992 DHS in Peru, Mensch, Arends-Kuenning, and Jain (1994) found that the quality of local services affected the likelihood of contraceptive use more in the rural than in the urban areas (because, the authors suggest, urban residents had access to a choice of clinics). Extreme differences in the quality index they constructed were associated with a predicted increase in contraceptive use from 33 percent to 38 percent of women; in this sample, that difference is comparable to the differences between uneducated women and women with postsecondary education (although less than the estimated effects of exposure to mass media). Quality control in health care in most developing countries is typically achieved through routine monitoring or periodic assessments. There is a great need for simple and replicable monitoring techniques, including self-assessments and peer review. The client-oriented program evaluation devised by the Association for Voluntary Surgical Contraception is a form of self-assessment that has proved useful in several countries. Peer review has been tried with some success, for example, by midwives in Indonesia (MacDonald et al., 1995). Quality assurance should be considered primarily as a management responsibility in current programs, rather than simply as a topic for research and pilot programs. But there is a need for more operations research and dissemination of experience on replicable methods of quality improvement. The type of programmatic linkages between family planning and other reproductive health services, especially infectious disease control and antenatal and delivery care, will vary among settings depending on such factors as whether free-standing services are already developed and patterns of utilization. Family planning programs in many countries reach large numbers of young women and thus are particularly well suited as sources of information about sources of prenatal care and emergency care for obstetric complications (see Chapter 5). As discussed in Chapter 3, family planning programs have an important role in controlling reproductive tract infections (RTIs). At a minimum,

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions clinical contraceptive services, like other clinical services, should be included in measures to prevent iatrogenic infections. Both clinical and community-based programs need to incorporate into guidelines for counseling some realistic assessment, and discussion, of clients' exposure to STDs, including HIV. Latex condoms and nonoxnynol-9 reduce the risk of STD transmission as well as unwanted pregnancy. As we argue in Chapter 3, family planning clinics providing insertion of IUDs should be able to supply standardized case management of symptomatic infections (using the World Health Organization algorithms) and selected screening efforts. Information, Education, and Communication The diffusion of information about modern contraception throughout the world in the last three decades has been a remarkable achievement. In 13 of the 22 countries where DHS surveys were conducted in 1990-1993, more than 90 percent of women said they had heard of one or more modern contraceptive methods. In all countries except Nigeria, more than one-half of the women had heard of one or more modern methods (Curtis and Neitzel, 1996). In every country except 4 of the 11 sub-Saharan African countries, more than one-half of the women had heard of the contraceptive pill, the best-known method worldwide. These survey questions have sometimes been criticized on the grounds that respondents claim knowledge out of politeness or so as not to appear ignorant (e.g., by Bongaarts and Bruce, 1995), but even without prompting, the majority of women in all but five countries could name at least one modern contraceptive method (Curtis and Neitzel, 1996). Men are even more likely than women to know at least one contraceptive method: in 15 countries where men were interviewed in DHS surveys, more than one-half of the men reported that they had heard of at least one modern contraceptive method (Ezeh, Seroussi, and Raggers, 1996). Of course, knowledge that an option exists is not enough. Informed choice and effective use of contraceptives require basic knowledge of how a method works, what noncontraceptive effects it might have, and how to use it. There is evidence both from standardized survey questions and from more intensive interviews and observations that many women and men do not know such things, even in countries where family planning programs are well established. For example, in the DHS in Egypt in 1992, women who reported using the contraceptive pill were asked to show their packet of pills. Interviewers inspected the packets for evidence that the pills had been taken out of sequence, and they asked the women whether they had missed days and what they would do if they did miss a day. Thirty-seven percent of the women had missed taking at least one

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions pill during the month preceding the interview. Only one-third of those who missed a day knew that they should take two pills on the following day or switch methods temporarily. The lack of information may well be due to inadequate services. Findings from multivariate analysis indicate that women whose source of supply was the government clinics were four times as likely as those with other sources to have taken pills out of sequence or missed days (Trottier et al., 1994). Bongaarts and Bruce (1995) created an index of contraceptive knowledge using data from 12 DHS surveys. It shows that the percentage of women who could name a contraceptive method spontaneously, knew where to get supplies or services, and had an opinion (either positive or negative) about side effects of the method was less than 50 percent, often well below, in 6 of the 12 countries. To explore reasons for not using contraception, Bongaarts and Bruce (1995) used the DHS data, supplemented by results from intensive studies from women respondents who reported that they did not want to get pregnant but were not currently using contraception. The researchers argue that most unmet need is associated with women's lack of knowledge, concerns about health, side effects, the behavior required to use contraception, and objections from their husbands. Bongaarts and Bruce (1995:64) conclude: As a combined consequence of poor community information levels, inadequate services, and low literacy, a large proportion of women may not be sufficiently knowledgeable about the health effects of methods to make an informed and comfortable decision about contraception. In such an environment, the impact of unknowns, unfounded rumors, or negative perceptions … will depend largely on the adequacy of the program communication strategies and client-provider exchanges. Such results show a continuing, important role for information, education, and communication campaigns and face-to-face counseling by providers, especially where nonprogram channels of information about contraception are weak. High rates of method failure likely indicate insufficient knowledge about contraceptive use (though the fact that failure rates are higher for couples who want more children some time in the future indicates that motivation also plays a part). Concerns for health effects can be based either on an accurate appraisal of the risks and benefits of a method, in which case the availability of alternatives is particularly important, or on inaccurate information, in which case family planning programs can be considered to have failed in their most fundamental role. Improving knowledge about the side effects of contraception can make an important contribution to women's health. As Casterline, Perez, and Biddlecom (1996) show, both contraceptive users and women with unmet need (as conventionally defined) in their Philippine samples reported a great deal of worry about health effects in in-depth interviews.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions Mass communication, social marketing7, and community-based distribution of contraceptive information and supplies are all strategies that have proved successful in spreading two basic messages—the existence of safe and effective contraceptive methods and the small family norm—even in countries like Bangladesh where the weight of tradition worked against them (Cleland et al., 1994; Lissance and Schellstede, 1993; Piotrow et al., 1994). Now, family planning programs face a new challenge in trying to convey subtler messages about the advantages and disadvantages of different methods and about effective use. There have been some successes in using proven strategies to convey information beyond the basic messages: for example, experiments with adapting the ''training and visit" system of agricultural extension to health and family planning in several Indian states. Abortions Access to Safe Abortion In the past three decades, more than 70 countries have changed their laws to remove criminal prohibitions of abortions or to expand the scope of provisions under which abortion had previously been legalized (Cook, 1989). More than 50 percent of all women in developing countries live in countries where induced abortion is legal under most circumstances, 27 percent live in countries where abortions are legal under various medical or social criteria, and 15 percent live in countries where induced abortion is either always illegal or legal only when a woman's life is threatened if she carries the pregnancy to term. These figures are heavily affected by China and India, however: excluding these countries, the figures are 19 percent (almost always legal), 52 percent (legal under specified criteria), and 28 percent (almost always illegal) (Population Reference Bureau, 1995; Henshaw and Morrow, 1990). The current legal status of induced abortion varies widely across regions: 174 million women live in developing countries where abortion is usually illegal, most of them in Central and West Africa, South Asia apart from India, the Middle East, and South America. The legal status of abortion is without doubt important in determining whether women have access to safe abortions, but it is not the only 7   Sheon, Schellstede, and Derr (1987:367) define contraceptive social marketing as the distribution of contraceptives through existing commercial and retail channels, and their sale at low prices, with subsidies from national governments or donors, with the primary aim of achieving high distribution among low-income groups. (See also Sherris, Ravenholt, and Blackburn, 1985, for a review of social marketing.)

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions determinant. In many countries where abortions are legal, large numbers of women have little access to safe services. In some countries where abortions are meant to be legal under specified criteria, there are in fact few provisions for referring women who meet those criteria to abortion providers, and abortions are treated by the health services as though they were illegal under most circumstances. Conversely, there are countries where most abortions are illegal, but where women can find clinics that provide services with relative impunity, as in Colombia. The problems of access, interpersonal relations, and technical quality of care may well be linked for abortion and emergency treatment of the sequelae of abortion. Even legal and mandated services can be abusive and accusatory (McLaurin, Hord, and Wolf, 1990). Studies in Brazil show poor technical quality of care—the wrong intravenous fluids used and wrong decisions about procedures (Costa and Vessey, 1993). In many countries, including India, induced abortion is legal under various circumstances, but many hospitals have no provisions for referrals or for performing the procedure: For many women in many countries, the right to a safe abortion exists only de jure, not de facto. In many developing countries, the most common technique used for abortions in hospitals is still uterine evacuation through dilatation and curettage, although the World Health Organization recommends vacuum aspiration in most cases (World Health Organization, 1986). Dilatation and curettage needlessly exposes women to risks of uterine perforation and the risks associated with general anesthesia. Manual vacuum aspiration can be safely delivered in nonhospital settings (McLaurin, Hord, and Wolf, 1990). Abortions will likely become more common in developing countries in the next few decades. There is very little information about how the necessary medical or paramedical supervision for medical abortions can be assured in practice, and how these services would best be linked with family planning. When providers are properly trained, manual vacuum aspiration should make early abortion safer and less expensive than the dilation and curettage procedure. For both provision of abortions where legal and treatment of incomplete abortions, the equipment and training for manual vacuum aspiration should be made widely available. Sex-Selective Abortions Prenatal diagnostic techniques, even those using sophisticated equipment, have spread to some developing countries, so that deformed or unhealthy—or female—fetuses can be identified. There has been a good deal of speculation about the use of such techniques to identify and abort female fetuses. There are three ways of determining the sex of a fetus:

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions modern contraception for fertility control, the demand for subsidized services could rise rapidly. Countries with subsidized services that face increasing demand have a limited number of options: they can devote more public funds to subsidizing family planning; they can ration services; or they can reduce the average level of subsidy per contraceptive user. The latter can be done either by making services more efficient or by mobilizing private funds, for example, through user fees. In Chapter 7 we discuss the rationale for public-sector financing and some of the experience with user fees. Recent discussions of population policy have returned to an issue that dominated much of the debate during the early years of international assistance to family planning in developing countries: whether the provision of contraceptive supplies and information suffice or a wide range of other incentives for fertility control and disincentives for large families (measures "beyond family planning") would be required to create effective demand for contraception. In large measure, this debate was overtaken by events in the 1970s and 1980s as individual demand for contraception proved strong in most countries even without incentives and disincentives. Once fertility declines began in Asian and Latin American countries, they proceeded with such rapidity that they seemed to have their own momentum; few stalled because of a lack of continued efforts to stimulate demand (Cleland and Wilson, 1987; Knodel, Chamratrithirong, and Debavalya, 1987; for a counter example, see Hirschman, 1986). There is little information on which to base estimates of the likely effects on fertility intentions and behavior of policies in other sectors, such as education and social policies to improve women's status. Most current proposals are based on observations of associations (e.g., of women's education and fertility) rather than evaluations of actual interventions. Increasing girls' schooling is likely to produce a range of benefits for women, their families, and society at large. In the discussions surrounding the ICPD in 1994, the demand-side proponents were not arguing for top-down incentives and disincentives aimed solely at fertility reduction, but for measures to improve education and literacy of women and to raise women's economic and legal status more generally. The argument is that when women have more decision-making power in their households, communities, and society, they will use it in ways that promote reproductive health in the largest sense. Conversely, where women are powerless, efforts to introduce reproductive health programs as isolated interventions will not achieve much. When the client environment is supportive, programs are effective. Programs are forced to achieve more by a demanding public, as Nag (1983) has shown with useful comparisons of South Asian health services and Caldwell (1986) has argued with historical examples concerning child

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions health. But there are also examples of family planning programs serving (as opposed to coercing) large numbers of women even in unpropitious circumstances, as in Bangladesh (Cleland et al., 1994). Where women are illiterate, poor, and powerless, an ability to limit fertility may be an important (though not in itself sufficient) precondition for change in their status. This argument can be made not only with examples from what are now poor countries, but with historical examples from what are now rich countries, where improvements in the legal and political status of women typically followed by decades the onset of fertility declines. The education of girls and the improvement of the legal, economic, and political status of women have much broader effects on society than just their impact on fertility and reproductive health. But in the narrow sectoral perspective of a report on reproductive health, they might be seen as the long-term measures that would ensure the sustainability of all short-term programs targeted directly at improving reproductive health. These are complementary investments working on different time scales and through different organizations in society, rather than substitutes. In the short run, there are several relatively low-cost ways in which policy reforms can support the goal of intended births. Kenney (1993) provides a convenient "checklist" of laws and administrative regulations that limit the availability of safe contraception: health and safety regulations that restrict the choice of methods or of providers; taxes and barriers to trade; regulation of advertising; and restrictions affecting the private sector (both commercial and nonprofit institutions). Though it is likely that improved access and quality of family planning services would reduce high rates of abortion in many countries, even widespread and high-quality family planning services will not eliminate the demand for abortions. In practice, the effectiveness of reversible contraception is always well short of 100 percent, and coerced or simply unplanned sexual relations remain common. It is beyond the scope of this report to assess the arguments about whether abortion is morally justified, and under what circumstances, or whether public financing and provision of abortions is justified in a society where a significant minority believe induced abortion to be immoral. But there are many countries where early abortions, in particular, are completely legal, yet unsafe abortions are common, and complications are a major health problem (World Health Organization, 1994). Even where abortions are largely or entirely illegal, medical care for complications is still provided. Thus, regardless of the legal status of induced abortion, improved care for incomplete abortions and complications must be seen as a part of reproductive health services.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions TECHNICAL NOTE: Problems with Measurement of Fertility Intentions and Abortion Much of the available evidence about fertility intentions comes from verbal reports of respondents' mental states at some time in the past or about hypothetical chances to make decisions all over again in response to standardized questions. It is imprecise, at best, to summarize intentions formed more or less unclearly and desires felt more or less intensely into simple dichotomies (wanted or unwanted; correctly timed or mistimed). Verbal reports can be inconsistent over time or with the subsequent behavior, or they may be too consistent, as when people rationalize whatever they did or come to terms with whatever happened to them by claiming that what happened is what was intended. Estimates based on survey items like those used in the Demographic and Health Surveys (DHS) have been criticized by Pritchett (1994) and others on several grounds: preferences are unstable (though unstable individual preferences would not invalidate conclusions based on population averages; they are analogous to any type of measurement error in this respect), too hypothetical to be used as definitions of unmet need for contraception, and too much influenced by respondents' knowledge of what the interviewers would consider the "correct" answer. This last concern might diminish the usefulness of these survey items for predicting individual fertility without diminishing their usefulness for examining changes in norms or predicting fertility in a population. Westoff (1990) has argued that data on fertility intentions are meaningful because in the aggregate they predict behavior: the proportion of women who reported in early surveys of the World Fertility Survey (WFS) or DHS that they want no more children was a good predictor of subsequent contraceptive use. However, this work tests only one of the survey items needed to construct measures of unwanted fertility. It could be that the forward-looking survey item ("Do you now want more children?") is an accurate predictor of behavior, at least in the aggregate, but the recall items ("Did you want your last pregnancy?") or explicitly hypothetical items ("If you could start over, how many children would you have?") are not valid or reliable. For example, we know of no direct attempts to validate the recall data by comparing prospective data gathered around the time of conceptions with data gathered later in pregnancies or after the outcomes. Answers to different questions in the same DHS interview can appear inconsistent, as for example, when women report that their last pregnancy was entirely unwanted (rather than mistimed) yet that they now want another child. (However, Westoff and Bankole [1995]

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions report that removing such women does not much change aggregate estimates of unmet need for contraception.) For this report, we rely most on the direct measure, for two reasons: the direct items allow consideration of mistiming as well as a desire for complete cessation of childbearing; and the major objection to the direct measure of wantedness is that it produces underreporting. But if significant percentages of pregnancies appear unwanted using a measure that is probably biased then the argument that unwantedness is a big problem is strengthened. We need to distinguish between the wantedness of conceptions and of births. It is likely that many women change their minds about the impending birth during the course of the pregnancy, either becoming reconciled to the birth or regretting an initially wanted conception. Rosenzweig and Wolpin (1993), using data from a survey in the United States for which women were interviewed by random assignment either before or after a birth, found an 8 percent decrease in wantedness after the birth, which suggests that at least in this population regret may be more common than rationalization. In an extreme case, a woman may not have intended the sexual intercourse that produced the conception, or the conception, but report as pregnancy goes on that she wants the birth, perhaps not seeing any acceptable alternative. Such an "intended birth" would not be regarded as an indicator of good reproductive health. Conversely, a change of intentions about an initially wanted pregnancy could come about because of a change in circumstances during a pregnancy—abandonment or abuse by the father, for example. It has been argued that conceptions are intended even when births are not; this may be the case, for example, in cultures where a new or potential wife's proof of fecundity is highly valued. Data on abortions provide evidence both of the extent of unintended pregnancy and of one of its major potentially harmful consequences in developing countries. But existing data are very incomplete. Direct estimates based on household surveys produce implausibly low estimates of the prevalence of induced abortion. In the United States, for example, where most states had liberalized abortion laws even before laws against first-trimester abortions were ruled unconstitutional in 1973, confidential surveys of providers suggest that induced abortions are more than twice as common as is reported in household surveys (Jones and Forrest, 1992). There has been some recent experimentation with survey methods in both developed and developing countries, and survey researchers may have given up too easily on the prospect of measuring abortion with direct questions (see Huntington, Mensch, and Miller, 1996; Laumann et al., 1994:457). The estimates produced by the Alan Guttmacher Institute and the World Health Organization (which we use in the text) are based

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions on a combination of sources, including reports of abortion complications treated in hospitals and clinics which are then extrapolated to the community (see discussion in World Health Organization, 1994:5-9). The estimates, especially of clandestine abortions, should be considered approximate at best.