Reproductive Health in Developing Countries Expanding Dimensions, Building Solutions (1997) / Chapter Skim
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Pages 85-115
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From page 85... ...
INTENDED BIRTHS 85 85 4 Intended Births The nations that signed the Programme of Action of the InternationalConference on Population and Development (ICPD) committed to try ".
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From page 86... ...
86 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES 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.
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From page 87... ...
INTENDED BIRTHS 87 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)
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88 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES 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)
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From page 89... ...
INTENDED BIRTHS 89 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.
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From page 90... ...
90 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES Sub-Saharan Africa North Africa and Middle East Latin America and Caribbean Asia 50 40 30 20 10 Un wa nt ed b irt hs (% ) FIGURE 4-1 Percentage of most recent births or current pregnancies unwanted in countries with recent DHS surveys, by region.
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From page 91... ...
INTENDED BIRTHS 91 <20% 20–39% 50+%40–49% 50 40 30 20 10 Un wa nt ed b irt hs (% ) FIGURE 4-2 Percentage of most recent births or current pregnancies unwanted in countries with recent DHS surveys, by contraceptive prevalence.
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From page 92... ...
92 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES <20% 20–39% 50+%40–49% 50 40 30 20 10 Un wa nt ed b irt hs p er 1 ,0 00 w om en p er y ea r ( %) FIGURE 4-3 Unwanted births per 1,000 women aged 15-49 per year in countries with recent DHS surveys, by contraceptive prevalence.
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From page 93... ...
INTENDED BIRTHS 93 Indirect Measures The indirect approaches to measurement also produces high aggregate estimates of the extent of unwanted fertility. Cochrane and Sai (1993)
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From page 94... ...
94 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES <20% 20–39% 50+%40–49% 50 40 30 20 10 M is tim ed b irt hs (% ) FIGURE 4-4 Percentage of most recent births or current pregnancies mistimed in countries with recent DHS surveys, by contraceptive prevalence.
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From page 95... ...
INTENDED BIRTHS 95 ing 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.
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From page 96... ...
96 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES These 20 million unsafe abortions are estimated to have resulted in 70,000 deaths of women, of which 69,000 are in developing countries, one-third of them in Africa (World Health Organization, 1994:Table 3)
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From page 97... ...
INTENDED BIRTHS 97 plications of abortion; ensuring medically adequate abortions and postabortion care are secondary and tertiary prevention. Unintended births are disproportionately risky for the infant.
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98 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES TABLE 4-2 Most Recent Birth or Current Pregnancy Unintended in Selected Countries, by Birth Order: in percent Birth Order Country (Year) 1 2-4 5+ Bolivia (1993)
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From page 99... ...
INTENDED BIRTHS 99 dren (e.g., Frenzen and Hogan, 1982, for Thailand) , especially for unwanted girls (Muhuri and Preston, 1991, for Bangladesh)
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100 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES ter and Roy, 1996) -- showing that the associations are partly causal.
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INTENDED BIRTHS 101 high contraceptive prevalence) to more than 35 percent of women in 4 of 14 sub-Saharan African countries (Westoff and Bankole, 1995)
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From page 102... ...
102 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES will not be met solely by an expansion of services. Rather, they point to a need for better counseling, informed choice, and higher quality services that will build trust and create effective demand for family planning.
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From page 103... ...
INTENDED BIRTHS 103 The main reason that emergency contraception is not more widely used in developing countries is a lack of knowledge on the part of both health care providers and women at risk of unwanted pregnancies (International Planned Parenthood Federation, 1995)
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104 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES world have not fully profited from the "first contraceptive revolution" (Harrison and Rosenfield, 1996)
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INTENDED BIRTHS 105 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)
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From page 106... ...
106 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES mum, 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.
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INTENDED BIRTHS 107 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.
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From page 108... ...
108 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES 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)
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From page 109... ...
INTENDED BIRTHS 109 determinant. In many countries where abortions are legal, large numbers of women have little access to safe services.
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From page 110... ...
110 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES 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.
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From page 111... ...
INTENDED BIRTHS 111 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.
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From page 112... ...
112 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES health. But there are also examples of family planning programs serving (as opposed to coercing)
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From page 113... ...
INTENDED BIRTHS 113 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)
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From page 114... ...
114 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES 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.
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From page 115... ...
INTENDED BIRTHS 115 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)
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