Women and Societies Benefit When Childbearing Is Planned

amily planning has far- Africa have a one in 13 lifetime Poverty accounts for much of reaching benefits for risk of dying from pregnancy- the lack of adequate prenatal Fwomen and their fami- related causes; in other regions, and delivery services. Despite lies. Women who can plan the women have a considerably the 20-year international cam- number and timing of their lower lifetime risk: one in 50 in paign on behalf of safe mother- births enjoy improved health, South Asia and the Middle East hood, many developing country experience fewer unwanted and North Africa, and one in governments lack the resources pregnancies and births, and 160 in Latin America.1 to provide the maternal health services that can save women’s in Brief have lower rates of induced, The World Health Organization lives and protect their health. and often unsafe, abortion. In (WHO) estimates that for every addition, women who have con- maternal death that occurs trol over their fertility have a worldwide, an additional 30 High-Risk Pregnancies chance to get more schooling women—some 15 million Improving maternal health ser- and find paid employment— women annually—experience vices is clearly a critical com- achievements that enhance pregnancy-related health prob- ponent of any effort to reduce their social and economic sta- lems that often are serious and maternal mortality and morbid- tus and improve the well-being result in long-term disability. ity in developing countries. of their families. The most common problems Another is enabling women to This Issues in Brief presents the include uterine rupture, uterine avoid pregnancies that often most recent information on the prolapse (a displacement from lead to these events—those pregnancy-related health risks the normal position), pelvic that occur too soon or too late faced by women in developing inflammatory disease (which in a woman’s life and those that countries and documents the can lead to permanent sterility) occur in quick succession.

2002 Series, No. 3 and obstetric fistula (a muscle

Issues potentially beneficial impact of Many women in developing family planning on women’s tear that allows urine to seep countries have children in their lives. into the vagina and results in teenage years, when they are permanent incontinence if left physically immature and often Scope of the Problem untreated). malnourished, conditions that Every year, an estimated increase their risk of experi- 515,000 women—98% of them Maternity Care Lacking encing a difficult delivery and in developing countries—die Many of the conditions that obstetric complications. In as a result of pregnancy or result in maternal death or ill addition, adolescent women are childbirth. The major causes of health can be treated or man- less likely than older women to death are hemorrhage, preexist- aged safely with proper care. have access to prenatal and ing conditions that are compli- However, women in developing obstetric care. Early childbear- cated by pregnancy, acute countries often give birth with- ing is especially common in infection, complications from out any skilled medical care, Sub-Saharan Africa: In unsafe abortion, eclampsia, and emergency obstetric ser- Burkina Faso, Central African obstructed or prolonged labor vices are virtually nonexistent. Republic, Chad, Côte d’Ivoire, and ectopic pregnancy. Fewer than half of births are Guinea, Malawi, Mali, attended by a trained doctor or Mozambique, Niger, Uganda Maternal deaths are especially nurse in 20 of the 26 Sub- and Zambia, 60–70% of common in Sub-Saharan Africa: Saharan African countries list- women in their early 20s gave More than 1,000 women die for ed in Table 1 (column 2), five birth as teenagers, as did about every 100,000 births in Central of the Asian countries and two half of women in Benin, African Republic, Eritrea, countries each in Latin Cameroon, Gabon, Madagascar, Ethiopia, Mozambique and America and in the Middle Tanzania and Zimbabwe (Table Rwanda; in many other coun- East and North Africa. In 10 of 1, column 3). High levels of tries in the region more than these countries, fewer than one- adolescent childbearing are 500 women die for every quarter of births are attended also found in Bangladesh, 100,000 births (Table 1, col- by a trained professional. Nicaragua and Nepal. umn 1). Women in Sub-Saharan table 1 The risks associated with Maternal Health and Reproductive Behavior adolescent childbearing are apparent when the maternal Country and year Maternal % of births % of women Wanted Total % of married % of married mortality ratios (which repre- deaths per attended by 20–24 who fertility fertility women using women with 100,000 a trained gave birth rate rate a modern unmet need for sent the number of women live births provider before age 20 method family planning who die from pregnancy- related causes for every Sub-Saharan Africa Benin Rep., 1996 500 60 50 5.0 6.3 3 26 100,000 live births) of differ- Burkina Faso, 1998–1999 939 31 62 6.0 6.8 5 26 ent age-groups are compared. Cameroon, 1998 430 55 54 4.6 5.2 7 20 In Nepal, for example, the Central African Rep., maternal mortality ratio 1994–1995 1,100 46 61 4.7 5.1 3 16 among teenage mothers is Chad Rep., 1996–1997 830 15 71 6.3 6.6 1 u almost double that of women Côte d'Ivoire, 1994 600 45 63 4.7 5.7 4 28 Eritrea, 1995 1,000 21 47 5.7 6.1 4 28 giving birth in their early 20s. Ethiopia, 2000 1,528 6 44 4.9 5.9 6 23 Childbearing is even more Gabon, 2000 600 43 58 3.5 4.3 12 28 dangerous for women in their Ghana, 1998 210 44 41 3.7 4.6 13 23 Guinea, 1999 670 35 66 5.0 5.5 4 24 late 30s and 40s, many of Kenya, 1998 590 44 46 3.5 4.7 32 24 whom suffer from obstetric Madagascar, 1997 490 47 57 5.2 6.0 10 26 problems associated with ear- Malawi, 2000 620 56 62 5.2 6.3 26 30 lier births or from having had Mali, 1996 580 24 70 6.0 6.7 5 26 several children at closely Mozambique, 1997 1,100 44 65 4.7 5.2 5 7 Namibia, 1992 230 87 42 4.8 5.4 26 22 spaced intervals. In Nepal, Niger, 1998 590 18 70 7.2 7.5 5 17 the maternal mortality ratio Nigeria, 1999 700 42 43 4.8 5.2 9 18 among 35–39-year-old Rwanda, 1992 1,512 26 25 4.2 6.2 13 36 women is about three times Senegal, 1997 560 47 43 4.6 5.7 8 35 that for women in their 20s Tanzania, 1999 530 36 56 4.8 5.6 17 22 and early 30s. In Malawi and Togo, 1998 480 51 38 4.2 5.2 7 32 Uganda, 1995 510 38 66 5.6 6.9 8 35 Zimbabwe, the ratio for Zambia, 1996 650 47 63 5.2 6.1 14 27 women 30–39 is about twice Zimbabwe, 1999 400 73 48 3.4 4.0 50 13 as high as the ratio among women under 30.2 Latin America & Caribbean Bolivia, 1998 390 57 36 2.5 4.2 25 26 As these statistics make clear, Brazil, 1996 160 88 32 1.8 2.5 70 7 maternal mortality would drop Colombia, 2000 80 86 36 1.8 2.6 64 6 substantially if women in Dominican Republic, 1996 230 96 39 2.5 3.2 59 12 developing countries were Guatemala, 1995 190 35 47 4.1 5.0 27 23 able to limit childbearing to Haiti, 2000 600 24 31 2.7 4.7 22 40 Nicaragua, 1998 150 65 52 2.5 3.6 57 15 their 20s and early 30s. Peru, 2000 270 59 30 1.8 2.9 50 10 The risk of maternal death Asia and illness also increases Bangladesh, 2000 440 12 61 2.2 3.3 43 15 when women have births India, 1998–1999 410 42 u 2.1 2.9 43 16 spaced close together; insuf- Indonesia, 1997 450 43 31 2.4 2.8 55 9 ficient time to regain their Kazakhstan, 1999 70 99 22 1.9 2.0 53 9 strength affects women’s Kyrgyz Rep., 1997 65 98 37 3.1 3.4 49 12 health and survival, as well Nepal, 1996 540 9 52 2.9 4.6 26 31 Pakistan, 1990–1991 340 19 31 4.7 5.4 9 32 as their infants’. Yet 20% or Philippines, 1998 170 56 21 2.7 3.7 28 19 more of all births in 34 of the Uzbekistan, 1996 21 98 25 3.1 3.3 51 14 49 countries included in Vietnam, 1997 160 77 19 1.9 2.3 56 7 Table 1 occur less than two years after a previous birth.3 Middle East & North Africa Egypt, 2000 170 61 24 2.9 3.5 54 11 Prolonged breastfeeding and Jordan, 1997 41 97 17 2.9 4.4 38 14 postpartum sexual absti- Morocco, 1995 230 40 17 2.2 3.3 42 16 nence, the traditional means Turkey, 1998 130 81 26 1.9 2.6 38 10 Yemen, 1997 350 22 45 4.6 6.5 10 39 of achieving longer intervals between pregnancies, are Notes: u=unavailable. Unmet need refers to the proportion of married women aged 15-49 who do not want a child soon or do not becoming less viable as want any more children but are not using a contraceptive method. Source: All data are from the Demographic and Health Surveys. urbanization and moderniza-

Maternal Health 2 The Alan Guttmacher Institute tion increase, particularly in only 11 of the 49 countries; chart a Sub-Saharan Africa. For prevalence is highest, 64%– Impact of Education example, the period of pro- 70%, in Brazil and Colombia tection against pregnancy (Table 1, column 6). In most Countries with higher levels of female education provided by breastfeeding Sub-Saharan African coun- have higher rates of contraceptive use… and postpartum abstinence in tries, fewer than one in five Nigeria and Ghana shrank by women use a method, and in 50 about four months between 16 countries, fewer than one the late 1980s and the late in 10 do so. 40 1990s. If modern contracep- Low levels of contraceptive 30 tive methods are not used to use do not mean that women compensate for shorter dura- do not want to practice family 20 tions of these practices, planning. In general, closely spaced births are 10 10–30% of married women of likely to increase in these childbearing age throughout countries and elsewhere; using a modern% of women method 0 the developing world do not >50% death and ill health are likely <20% 20Ð50% want a child soon or do not % of women 20Ð24 with secondary education to increase as well. want any more children but …and lower fertility rates. Achieving Smaller Families are not using a contraceptive method; in other words, they 7 Increasingly, women want have an unmet need for fami- smaller families than their ly planning (Table 1, column 6 mothers and grandmothers 7). Unmet need is even high- 5 did; the vast majority have er in Haiti, Rwanda, Senegal 4 had all the children they and Yemen. Even in some 3 want by their mid-30s. In Sub-Saharan African coun- Latin America, Asia, and the 2

tries where large families are Births per woman Middle East and North wanted—for example, 1 Africa, women generally want Burkina Faso, Côte d’Ivoire, 0 2–3 children (Table 1, col- Ethiopia, Malawi, Mali and <20% 20Ð50% >50% umn 4). Wanted family size is Uganda, more than one in % of women 20Ð24 with secondary education higher in Sub-Saharan five married women do not Africa—typically 4–6 chil- want a child soon but are not Source: Demographic and Health Surveys; averages based on 49 countries. dren—although the smaller- using family planning to family norm is beginning to space their births. reproductive health status reduce the occurrence of take hold there as well. would improve. unintended pregnancy and However, many women in Reducing Unsafe Abortions abortion. However, an increase in con- Sub-Saharan Africa and else- Roughly one in four of the traceptive use would not nec- where are having more chil- world’s women live in coun- essarily result in an immedi- Enhancing Women’s Status dren than they want. In tries that severely restrict ate decline in unsafe abor- Worldwide, women who want Bangladesh, Benin, Bolivia, access to abortion.4 WHO tions. As smaller families children understand that the Ethiopia, Haiti, Jordan, estimates that 20 million become the norm, women freedom and ability to decide Kenya, Malawi, Morocco, unsafe clandestine abortions who do not have easy access when to have them and how Nepal, Nicaragua, Peru, the occur each year, resulting in to family planning services many to have are fundamen- Philippines, Rwanda, an estimated 78,000 mater- will continue to turn to abor- tal to achieving their goals in Senegal, Uganda and Yemen, nal deaths, the vast majority tion to avoid an unwanted other areas of their lives, women have, on average, 1–2 of which occur in developing birth. In some countries, such as schooling, paid more children than they countries. In addition, unsafe therefore, abortion levels may employment and reaching wanted. In fact, the average abortions have many of the increase in the short term, their full potential. total fertility rate is greater same negative health effects until the supply of contracep- than the wanted fertility rate as those resulting from giving In developed countries, most tive services is adequate to in all 49 countries listed birth without skilled medical women did not seek more meet the demand and women (Table 1, column 5). attention. If women were able education and equality with become more adept at using to avoid the unplanned preg- men until family planning Yet, contraceptive use is gen- contraceptive methods effec- nancies that end in unsafe became an accepted and rou- erally low. Half or more of tively. In the longer term, abortion, both their survival tine part of their lives. married women use a modern however, increased use of chances and their long-term Women in developing coun- family planning method in effective methods will help tries are likely to have the

Maternal Health 3 The Alan Guttmacher Institute same experience. Aspirations transmitted infections, which information and means to do MD: Macro International, 2001, to stay in school, to obtain can result in serious health so.” The ICPD report called Table 12.3, p. 181. paid work outside the home problems and make people on governments and interna- 3. Donovan P and Wulf D, Family planning can reduce high infant and to help improve their more susceptible to contract- tional donors to take steps to mortality levels, Issues in Brief, New family’s welfare are depen- ing HIV. “prevent unwanted pregnan- York: Alan Guttmacher Institute dent on women’s confidence cies and reduce the inci- (AGI), 2002, No.2. Convincing people to use that these goals are compati- dence of high-risk pregnan- condoms is difficult in soci- 4. AGI, Sharing Responsibility: ble with their equally strong cies and mortality and mor- Women, Society and Abortion eties, including those found aspirations to be married and bidity” and “make quality Worldwide, New York: AGI, 1999, in many developing coun- Chart 3.1, p. 21. to have children. family planning services tries, that are unwilling to affordable, acceptable and 5. Jejeebhoy SJ, Women’s In a mutually reinforcing talk openly about men’s sexu- Education, Autonomy and accessible to all who need process, being able to plan al relationships outside of Reproductive Behavior, Oxford, UK: and want them.” Eight years Oxford University Press, 1995. their families opens new marriage or sexual activity later, however, contributions opportunities for women, and among young unmarried peo- from developed countries Sources of Data women who take advantage ple. Information and counsel- have not met the funding tar- Demographic and Health Surveys of those opportunities have ing can help sexually active gets set at ICPD, levels of (DHS) for 49 developing countries an increased need for family individuals and couples are the main source of data for this contraceptive use are still planning. For example, in assess their level of risk and report. These are nationally repre- low in most developing coun- sentative surveys with sample sizes many developing countries, act to protect themselves and tries, and millions of women typically ranging between 5,000 the increase in women’s edu- their partners against infec- and 15,000 women of reproductive who want and need family cation over the last two tion. Increasingly, health care age; they are carried out with tech- planning services are unable decades is believed to be providers and policymakers nical assistance from Macro to obtain them. International. strongly associated with are promoting the use of dual women’s increased ability to methods—the condom to As the report acknowledged, postpone childbearing and protect against HIV and the right to plan the timing Susheela Singh and Akinrinola have smaller families.5 other STIs and another and spacing of their children Bankole oversaw data compilation Similarly, educated women method, such as the pill, for will remain inaccessible to and analyses and Rubina Hussain and April Fehling provided are more motivated to prac- better protection against many women and couples research assistance for this publica- tice family planning so that unintended pregnancy. unless adequate resources tion, which was written by Deirdre they can achieve the smaller are available to make high- Wulf and Patricia Donovan. This families they want and devel- A Basic Right quality and affordable family Issues in Brief was made possible by op their broader life goals planning services a reality. support from The Bill and Melinda The Convention on the Gates Foundation. (Chart A). Furthermore, Elimination of All Forms of Achievement of this goal will women who are accepted as Discrimination Against require that support for fami- ©2002, The Alan Guttmacher Institute equals by their sexual part- Women (CEDAW) adopted ly planning remain a high ners are also more likely to by the United Nations in priority for international be able to negotiate contra- 1979 recognizes the right of donors as well as developing ceptive use, particularly use all women to “specific educa- country governments. of the condom, than women tional information to help to who are not. ensure the health and well- References being of families, including 1. Ransom EI and Yinger NV, Protection Against HIV information and advice on Making Motherhood Safer: A Not-for-Profit Corporation for Overcoming Obstacles on the Sexual and Reproductive Health In addition to the beneficial family planning,” as well as Pathway to Care, Washington, DC: Research, Policy Analysis and effects of modern contracep- to “access to adequate health Population Reference Bureau, Public Education 2002, Table 1, p. 6. tive methods on women’s care facilities, including 120 Wall Street ability to achieve safer preg- information, counseling and 2. Calculations based on data for New York, NY 10005 nancies and births, one services on family planning.” Nepal: Pradhan A, Aryal RH, Phone: 212.248.1111 method—the condom—offers Regmi G, Ban B and Govindasamy Fax: 212.248.1951 Fifteen years later, 180 coun- P, Nepal Family Health Survey [email protected] protection against infection tries attending the 1996, Calverton, MD: Macro with HIV and other STIs. International Inc., 1997, Table 10.2, 1120 Connecticut Avenue, N.W. International Conference on Suite 460 Throughout the world, but p. 157; Zimbabwe: Zimbabwe Population and Development Washington, DC 20036 especially in countries with Central Statistical Office and Macro Phone: 202.296.4012 (ICPD) affirmed the “basic International, Zimbabwe high rates of AIDS and HIV Fax: 202.223.5756 right of all couples and indi- Demographic and Health Survey [email protected] infection, wider use of the 1999. Calverton, MD: Macro viduals to decide freely and condom is crucial to control- International, 2000; Table 12.3, p. Web site: www.guttmacher.org responsibly the number, 199; Malawi: Malawi National ling the spread of the epi- Additional copies may be pur- spacing and timing of their Statistical Office and Macro demic, as well as to reducing chased for $1.00 each. Volume children and to have the International, Malawi Demographic discounts are available. 4/2002 high levels of other sexually and Health Survey 2000, Calverton:

Maternal Health 4 The Alan Guttmacher Institute