Although the proportion of Indian women who receive maternal health care is increasing, poor women remain far less likely to receive care than their better-off counterparts. Moreover, recent research suggests that “poverty” is not simply economic, but consists of multiple dimensions that have differing effects on receipt of health care. In the lead article in this issue, Sanjay Mohanty uses data from the 2005–2006 Indian National Family and Health Survey to examine how deprivation in three dimensions of poverty—education, wealth and health—is linked to women’s receipt of prenatal care, medical assistance at delivery and postpartum care [see article]. Overall, 32% of ever-married women reported deprivation in one of the three dimensions, 18% in two and 7% in all three. Women deprived in all three dimensions were less likely than those deprived in none to have obtained prenatal care, medical assistance at delivery or postnatal care. This pattern held true across all of India’s larger states, although the deprivation-related inequities tended to be lower in states where service coverage is high. At the national level, education was the most important dimension of deprivation; after controlling for confounders, women deprived in education alone were less likely to have received prenatal care and medical assistance at delivery than women deprived in both wealth and health.
In many developing countries, fertility has declined steadily in recent decades, in concert with increases in the strength of family planning programs and in social conditions. In analyses using Demographic and Health Survey data, Anrudh Jain and John Ross seek to determine the relationship of program efforts and social settings to fertility levels in 40 countries [see article]. On average, they found, fertility levels were lower in countries with better social conditions or stronger family planning programs than in those with poorer social conditions or weaker programs; they were strongest in the presence of both strong programs and good social settings. Moreover, fertility was positively associated with infant mortality and negatively associated with female education, but was not associated with poverty. The authors estimate that about half of the 2.3-birth difference between Sub-Saharan African countries and those in other regions can be attributed to differences in program effort and social conditions.
It is generally believed that women’s lack of decision-making power in developing countries restricts their use of modern contraceptives, but few studies have explored the importance of decision making among other aspects of women’s empowerment. Mai Do and Nami Kurimoto use Demographic and Health Survey data to explore the relationships between six measures of empowerment and use of female-only methods or couple methods in Namibia, Zambia, Ghana and Uganda [see article]. In all four countries, the overall empowerment score was positively associated with contraceptive method use. In multivariate analyses, household economic decision making was associated with use of female-only methods and use of couple methods, as were agreement on fertility preferences and women’s ability to negotiate sexual activity. In Namibia only, women’s level of disagreement with justifications for domestic violence was positively associated with the use of couple methods.
Changes in fertility preferences have generally been examined in the aggregate, which may mask the level and direction of change among individuals, especially in the short term. Using five waves of data collected between June 2009 and December 2010 from a random sample of women aged 15–25 in southern Malawi, Christie Sennott and Sara Yeatman look for associations between four categories of life events—reproductive, relationship, health and economic—and shifts in fertility timing preferences. Over the course of the study, 83% of the women reported at least one change in the desired timing of their next birth, although women with higher socioeconomic status had more stable preferences than poorer women. In each four-month period between interviews, more than half of the women reported changes in desired timing, and both delays and accelerations in desired timing were common. Several life events, including having a child, entering a serious relationship and experiencing changes in household finances, were associated with the level and direction of changes in fertility preferences.
Also in This Issue
In countries where temporary labor migration is common, the frequently used indicators of contraceptive prevalence and unmet need may be poor measures of family planning program performance. To test this hypothesis, Bharat Ban and colleagues used data from the 2006 Nepal Demographic and Health Survey (NDHS) and from a 2009 household survey based on the 2006 NDHS sample [page 43]. Their analysis, which looked at contraceptive use and unmet need by spousal residence status, focused on rural areas of the country, which account for the largest share of Nepal’s 26% migration rate. Among all married women, contraceptive use stabilized and unmet need increased significantly between 2006 and 2009. These statistics indicate poor family planning program performance, although district program managers reported that most couples in need of family planning were being reached. However, among women whose husbands were living at home, contraceptive use rose significantly and unmet need stabilized between 2006 and 2009, while among those whose husbands were away for three months or more, contraceptive use declined nonsignificantly and “unmet need” rose significantly.