Support for Family Planning Improves Women's Lives

Like the use of the telephone, the practice of family planning is so widespread and so routine in the United States that we almost take for granted its far-reaching benefits. Because American women using effective modern contraceptives can decide when to have their children and are able to bear only the number they want, they can plan their educational careers and their work, family and personal lives with an assurance that would have been impossible for their grandmothers.

In the developing world, family planning can bring these same benefits to women and do even more: By helping women prevent ill-timed or unwanted pregnancies, it can also save their lives and protect their health.

And for couples everywhere, the use of the condom and some other contraceptives helps protect against the spread of sexually transmitted diseases (STDs), which threaten the well-being and sometimes the survival of men and women worldwide.

Despite the many ways in which family planning benefits women and their families throughout the world, the support of developed countries—an essential component of financing and improving access to these necessary services in developing countries—is often under threat of being reduced or even eliminated. This Issues in Brief examines the advantages for women and society that family planning services bring, and that would be compromised if these services were curtailed.

High-Risk Childbearing
Every year, 585,000 women—99% of them in developing regions—die from causes related to pregnancy. These causes include the direct health consequences of high-risk pregnancies, unsafe abortions and difficult deliveries, as well as problems that arise soon after delivery. Maternal mortality ratios (representing the number of women who die every year from pregnancy-related causes per 100,000 live births) in Africa, Asia and Latin America are 10–100 times the ratios in the industrialized world (Table 1, column 1). UNICEF points out that "no public health problem shows greater disparity between rich and poor countries than maternal mortality."

table 1 Maternal Health Risks
Country and survey year 100,000 live	Maternal deaths per births	% of women 20–24 with at least 1 birth by age 18	% of women 30–34 with at least 4 live births
Sub-Saharan Africa
Botswana, 1988	250	26	53
Burkina Faso, 1992–1993	930	32	80
Burundi, 1987	1,300	8	69
Cameroon, 1991	550	46	68
Central Afr. Rep., 1994–1995	700	38	58
Côte d'Ivoire, 1994	810	44	69
Ghana, 1993	740	25	59
Kenya, 1993	650	28	68
Liberia, 1986	560	44	59
Madagascar, 1992	490	31	67
Malawi, 1992	560	38	74
Mali, 1995–1996	1,200	46	75
Namibia, 1992	370	18	45
Niger, 1992	1,200	53	81
Nigeria, 1990	1,000	35	68
Rwanda, 1992	1,300	8	67
Senegal, 1992–1993	1,200	34	70
Tanzania, 1996	770	25	64
Togo, 1988	640	30	74
Uganda, 1996	1,200	39	77
Zambia, 1992	940	34	72
Zimbabwe, 1994	570	23	58
North Africa & Middle East
Egypt, 1995	170	15	46
Morocco, 1992	610	7	46
Sudan, 1989–1990	660	17	59
Tunisia, 1988	170	3	56
Asia
Bangladesh, 1993–1994	850	47	60
India, 1992–1993	570	28	50
Indonesia, 1994	650	16	31
Pakistan, 1990–1991	340	17	62
Philippines, 1993	280	8	40
Sri Lanka, 1987	140	5	28
Thailand, 1987	200	9	18
Turkey, 1993	180	11	30
Latin America & Caribbean
Bolivia, 1993–1994	650	19	48
Brazil, 1996	220	16	18
Colombia, 1995	100	18	21
Dominican Republic, 1996	110	22	30
Ecuador, 1987	150	16	44
El Salvador, 1985	300	u	47
Guatemala, 1995	200	26	56
Mexico, 1987	110	19	45
Paraguay, 1990	160	16	37
Peru, 1991–1992	280	12	36
Trinidad & Tobago, 1987	90	13	30
Developed Countries
France, 1994	13*	2	6
Japan, 1992	16*	1	2
United States, 1995	13*	9	7
*Adjusted for underreporting; ratio based on national vital statistics would be lower. Note: u=unavailable. Sources: Mortality—United Nations Development Programme, Human Development Report, 1996, New York: Oxford University Press, 1996, pp. 154–155; births by age 18—The Alan Guttmacher Institute (AGI), Into a New World: Young Women's Sexual and Reproductive Lives, New York: AGI, 1998, Appendix Table 4, col. 3, p. 52; at least four births—for developing countries, special analysis of data from Demographic and Health Surveys; for France, Lavertu J, Fécondité et calendrier de constitution des familles: Enquête Famille de 1990, INSEE Résultats 579, Paris: Institut National de la Statistique et des Etudes Economiques, 1997; for Japan, special tabulations of the 1992 National Fertility Survey; for the United States, special tabulations of the 1995 National Survey of Family Growth.

The major causes of maternal deaths are similar throughout the developing world, although the relative importance of each varies from one region to another. Overall, the leading causes are hemorrhage, or excessive bleeding (accounting for 24% of all maternal deaths); preexisting conditions that are complicated by pregnancy (20%); sepsis, or acute infection with fever (15%); complications of unsafe induced abortions (13%); eclampsia (12%); obstructed or prolonged labor (8%); and ectopic pregnancy and other conditions (8%).

According to the World Health Organization (WHO), for every maternal death that occurs worldwide, an estimated 30 additional women suffer pregnancy-related health problems that can be permanently debilitating. Each year, approximately 17 million women are affected with such conditions as uterine rupture, uterine prolapse (a displacement from the normal position), hemorrhage, vaginal damage, urinary incontinence, obstetric fistula (a muscle tear that allows urine to seep into the vagina) and pelvic inflammatory disease (which can lead to permanent sterility).

The vast majority of pregnancy-related complications that lead to health problems or death can be prevented in the first place, or successfully treated, if the right medical care is available. High-quality and accessible prenatal and maternity care services are the major reasons for the low levels of death and disability associated with pregnancy and childbearing in developed countries. In the developing world, unfortunately, services are often of poor quality, and coverage is inadequate or, in some areas, completely lacking.

Most women in developing countries still give birth at home, helped by a close family member or traditional birth attendant. Fewer than one in five women obtain assistance from a trained doctor or nurse when they give birth in Burundi, Niger, Yemen, Bangladesh and Pakistan; fewer than one-half receive professional medical assistance in Ghana, Kenya, Mali, Nigeria, Senegal, Uganda, Egypt, Morocco, India, Indonesia, Bolivia and Guatemala. Even when women deliver in a hospital, the equipment, supplies, drugs, or operating rooms and trained staff needed to do cesarean sections or manage emergencies may be lacking.

Who Is Most at Risk?
Young Women and Mothers over 35. The risks of dying during pregnancy or childbirth are higher for women younger than 20 and for women 35 and older than for other women (Chart A). Teenagers' physical growth is usually incomplete, and their bodies have not developed sufficiently for pregnancy and delivery to proceed easily. Chronic malnutrition—which is widespread in poor countries—exacerbates the problem of insufficient or stunted physical growth. In addition, very young women are even less likely than older women to obtain prenatal or delivery care—especially if they are unmarried.

chart a Maternal Mortality

Both younger and older women face an elevated risk of dying during pregnancy or childbirth.

Sources: Bolivia and Uganda—Demographic and Health Surveys, 1993–1994 and 1996, respectively. Bangladesh—Koenig MA et al., Maternal mortality in Matlab, Bangladesh, 1976–1985, Studies in Family Planning, 1988, 19(2):69–80.

The younger the adolescent, the greater her maternal risk. In Jamaica and Nigeria, for example, women younger than 15 are 4–8 times as likely to die during pregnancy or delivery as are women aged 15–19. Although pregnancies at such early ages are common only in certain parts of the world, many women in all developing regions have their first child by age 18. In most of Sub-Saharan Africa, in Bangladesh and India, and in one of the poorest countries of Latin America—Guatemala—25–53% of women aged 20–24 had their first child before their 18th birthday (Table 1, column 2).

Maternal risk is elevated for older women in part because they frequently have had many births and have spaced births closely, risk factors discussed next.

Women with Many Children. Women who have had five or more children are about 2–3 times as likely to die during pregnancy or childbirth as are those with two or three children. Millions of women worldwide face this increased risk, given the large family sizes that are typical in many regions. For example, the proportion of women aged 30–34 who have already had four or more children is especially high—ranging from about 40% to 80%—throughout Africa and the Middle East and in some Asian countries (Table 1, column 3).

For women who become pregnant many times, the problem is not just that they are more often exposed to obstetric risk, but also that frequent pregnancy, childbirth and breastfeeding deplete women's physical resources and stamina. This makes it more difficult for them to fight the effects of heavy blood loss, infection or trauma during childbirth and after a delivery or abortion.

Women with Closely Spaced Pregnancies. Maternal depletion also threatens safe childbearing among women who become pregnant again before they have had time to recover fully from an earlier birth. This problem, too, is common: Births spaced less than two years apart account for one in 10 of all births in developing countries as varied as Liberia, Malawi, Senegal, Morocco, Sudan, India, Turkey, Bolivia, Brazil and Peru. They represent more than one in seven births in Madagascar, Niger, Tunisia, Pakistan, the Dominican Republic, and Trinidad and Tobago.

Even in developed countries, a short interval between pregnancies is a risk factor, moderately raising levels of preterm delivery and intrauterine growth retardation.

Women with Unwanted Pregnancies. Every year, an estimated 190 million women throughout the world become pregnant, and many of them did not want to conceive. In Latin America, an average of 40% of women of reproductive age who do not want to become pregnant for at least a couple of years, or ever again, are not using an effective contraceptive method; in Sub-Saharan Africa, the proportion is 85% (Chart B). Such women often cannot avoid having an unplanned pregnancy. It should come as no surprise, therefore, that many women seek abortions, and each year approximately 20 million of them obtain abortions under conditions in which the procedure is illegal and therefore unsafe, greatly increasing their risk of maternal morbidity and mortality.

chart b Nonuse of Effective Methods

Many women who do not want to become pregnant are not using effective contraceptive methods.

Note: Percentages are regional averages, based on women aged 15–44, weighted by population size. Source: Special analysis of data from Demographic and Health Surveys.

Lowering Maternal Risk
Family planning reduces the total number of pregnancies among women of childbearing age. For this reason alone, it can substantially lower levels of maternal mortality and morbidity. Furthermore, by helping women—especially those at highest risk—to space and limit their pregnancies, it can do more.

Even in parts of the world where women customarily marry as adolescents, contraceptive use to postpone pregnancy until after the teenage years would reduce maternal mortality associated with very early childbearing. What is more, women who wait to begin childbearing are less likely to have a large number of children than those who first give birth at a young age. And those who start practicing family planning early in their married lives are less likely than those who delay to have closely spaced births.

Finally, the prevention of unwanted pregnancies would mean a reduction in the more than 76,000 maternal deaths that result from unsafe abortions each year in developing countries—almost 15% of the total number of maternal deaths in these countries. The associated reduction in maternal morbidity might be even more impressive, given that 30 women suffer pregnancy-related disabilities for every woman who dies.

Offering STD Protection
Millions of men and women throughout the world suffer from STDs. In addition to the discomfort and embarrassment these diseases cause, some STDs greatly increase the likelihood of HIV transmission during sexual intercourse, and can have other serious health consequences.

Worldwide, the most common bacterial STDs (which are curable) are gonorrhea, trichomoniasis, candidiasis, syphilis, genital ulcers resulting from chancroid, and chlamydia. The most common viral STDs (which are incurable, though not necessarily untreatable) are hepatitis, herpes, genital warts and HIV.

An estimated 333 million new infections with curable STDs—or 11 for every 100 adults—occur worldwide every year (Table 2). In absolute numbers, South and Southeast Asia is the worst affected region. But an individual's risk of contracting one of these STDs is highest (one in four) in Sub-Saharan Africa.

table 2 Curable STDs
Region	New yearly infections (millions)	Yearly rate per 100 adults
World	333	11
South & Southeast Asia	150	18
Sub-Saharan Africa	65	25
Latin America & Caribbean	36	15
East Asia & Pacific	23	3
Eastern Europe & Central Asia	18	11
Western Europe	16	8
North America	14	9
North Africa & Middle East	10	6
Australasia	1	9
Source: World Health Organization (WHO), An Overview of Selected Curable Sexually Transmitted Diseases, Geneva: WHO, 1995.

According to the WHO's most recent global estimate, every year, 5.9 million individuals become infected with HIV—an increase over previous estimates. The vast majority of new infections are in Sub-Saharan Africa (four million) and South and Southeast Asia (1.3 million)—the regions with the highest STD rates.

Next to complete sexual abstinence—an impractical goal for most people—the most effective protection against the spread of both bacterial and viral STDs is the latex condom. If used correctly, this method—while offering contraceptive protection—can dramatically reduce the likelihood that an infected man or woman will pass the disease to a sexual partner.

The female condom, the sponge, and the diaphragm or cervical cap used with a spermicide also have the potential to reduce STD transmission. What is more, by reducing genital wart infections, all barrier and spermicidal methods offer some protection against the development of cervical cancer. However, while the effects of spermicidal methods on reducing the risk of certain STDs is clear, the evidence on their effects on HIV transmission remains inconclusive.

Other modern contraceptive methods also confer some health protection. The pill helps reduce a woman's chance of developing endometrial or ovarian cancer, and the longer it is used, the lower the risk. What is more, among women with chlamydia and gonorrhea, hormonal contraceptives reduce the chance of pelvic infection, ectopic pregnancy and infertility.

Family planning and reproductive health service providers help improve and even save the lives of both women and men by educating couples about healthy sexual behavior, the benefits of condom use, and STD prevention and treatment, and by linking clients and their families to other preventive and curative health services.

Empowering Women
Access to family planning services is affirmed as a universal human right in many United Nations documents. More concretely, it contributes to the advancement of women and to the fuller development of society.

Women who are able to defer childbearing until their 20s improve their chances of having time to obtain adequate schooling, develop work skills and acquire broad life experience. And women who bear only the number of children they want have increased opportunity and time to be in the labor market and to build competence and achieve personal fulfillment. Such participation in society enhances women's sense of self-worth and improves the well-being of their families.

The relationship between women's empowerment and family planning is often mutually reinforcing: As women obtain more education and gain the skills and confidence they need to go out into the world and earn money of their own, their desire and ability to plan their childbearing also grows. Moreover, women who practice family planning are more likely than those who do not to seek other types of health care services for their children and themselves.

Taking Effective Action
Helping women avoid high-risk and unwanted pregnancies remains an urgent health priority—especially where access to prenatal and emergency obstetric care is inadequate, and nutrition and overall health are poor. And the use of the latex condom is the only effective way known to prevent the transmission of STDs—including HIV—among sexually active couples. What is more, in many parts of the developing world, a woman's first referral to other important health services is often made through her initial contacts with a family planning provider, be it a clinic, community-based distributor or outreach worker.

In many developing countries, it will be difficult—and will take decades—to improve overall health and living conditions, and to change deeply entrenched, discriminatory cultural practices and attitudes that harm women and jeopardize their health. While these broad goals should continue to be pursued, the more widespread provision of family planning services is an achievable (and highly cost-effective) way of improving both women's lives and the well-being of couples and families everywhere.

Sources of Data
The Alan Guttmacher Institute (AGI), Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, New York: AGI, 1995.

AGI, Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States, New York: AGI, 1991.

National Academy of Sciences, Contraception and Reproduction: Health Consequences for Women and Children in the Developing World, Washington, DC: National Academy Press, 1989.

Safe Motherhood Initiative, Causes of maternal deaths, , accessed Apr. 9, 1998.

United Nations Children's Fund (UNICEF), The Progress of Nations, 1996, New York: UNICEF, 1996.

World Health Organization (WHO), Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion, Geneva: WHO, 1994.

Credits
Akinrinola Bankole and Susheela Singh oversaw data compilation and analyses used for this publication, which was written by Deirdre Wulf. This Issues in Brief was made possible by support from the Andrew W. Mellon Foundation and the Rockefeller Foundation.

© copyright 1998, The Alan Guttmacher Institute.