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The impact of unregulated fertility on maternal and child survival
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International Journal of Gynecology & Obstetrics 50 Suppl, 2 (1995) 511-817
The impact of unregulated fertility on maternal and child survival P. Senanayake lntemational Planned Parenthood Federation, Regent's College, Regem's Park, London NWl 4NS, England, UK
Abstract Almost all maternal and child deaths represent merely the endpoint of the 'road to death' - a combination of factors that include high-risk pregnancy, socioeconomic disadvantage and inadequate health care. Unregulated fertility is the underlying cause of most high-risk pregnancies. They are: unwanted; in mothers younger than 20 or older than 35; closely spaced; and in women who already have several children. The resulting morbidity and mortality create a cycle of further disadvantage, further increases in child mortality and further high-risk pregnancies. Family planning is the single most important exit from the 'road to death.' Over the past 40 years it has contributed to the worldwide reduction in child mortality, and for every 100 women provided with family planning, a woman's life is saved.
Keywords: Family planning; Women at risk; Child deaths
The most striking aspect of maternal and child deaths is the sheer scale cf the problem: 1400 young women and 39000 children die every day worldwide, and almost all these deaths are preventable [1]. A closer look reveals something equally striking, and of huge importance to public health strategy: the underlying causes of maternal and child deaths are essentially the same. They should no longer be regarded in isolation, but together in terms of high-risk pregnancies, socioeconomic disadvantage and lack of access to health care.
... Corresponding author, Fax: 071 487 7865/7950.
Perhaps both the tragedy and hope lie in the fact that the majority of maternal deaths and disability are preventable. Time and time again, we find that unregulated fertility is the most important contributing factor, and it becomes increasingly obvious that universal access to reproductive health services including family planning is the key to safe mctherhood and child welfare. 1. Maternal mortality
The scale of maternal deaths was vividly described in Geneva at the first World Health Organization (WHO) inter-regional meeting on prevention of maternal mortality [2].
0020.7292/95/$09.50 © 1995 International Federation of Gynecology and Obstetrics SSDl 0020-7292(95)02480-Z
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P. Senanayake / lntemational Journal of Gynecology & Obstetrics 50 Suppl. 2 (/995) S 1I-S J7
"Every four hours, day-in, day-out, a jumbo-jet crashes and all on board are killed. The 250 passengers are women, most in the prime of life, some still in their teens."
More than 99% of these deaths are in developing countries [I]; in Northern Europe, the lifetime risk of death due to pregnancy is only I in 10 000; in Africa, it is 1 in 21 [3]. Overall maternal mortality . is 100-200-times greater in developing than in industrialized countries: a greater disparity than any other health measure [1]. Women a.re t~e creators of new life, the caretakers of dally life and the custodians and transmitters of community norms and social values and yet their work and lives are given little value. In a typical setting, with a maternal mortality ratio of 650 per 100 000 live births, and a total fertility rate of six births per woman, about 50000 out of every million families will be motherless because of pregnancy-related deaths. If each mother who dies has on average three to four children at the time of her death, it means that in every million families there are some 175 000 motherless children. These are orphans, not of an epidemic, but of a natural cause, pregnancy and childbirth. 2. Child mortality Worldwide, one in eight children die before their fifth birthday at a rate of 39000 every day [I]. Deaths in children under five represent a massive 30% of all human deaths (more than 50% in Africa versus 3% in industrialized countries) [4]. One third of child deaths occur during the first few weeks of life, a further third before the first birthday and the rest before the age of five. As with maternal deaths, more than 99% of these deaths are in developing countries. 3. The road to death What are the causes of all these deaths? Maternal and child mortality are usually classified according to medical causes and these are well recognized. For the mother: post-abortal sepsis (responsible for up to 40% of all maternal deaths);
postpartum sepsis; hemorrhage; eclampsia; obstructed labor. Perinatal deaths are associated with: birth asphyxia/trauma (usually due to prolonged/difficult labor); prematurity; congenital malformations; underlying maternal disease; antepartum hemorrhage; eclampsia; and intrauterine growth retardation. In/am/child deaths are caused annually by: diarrhea (5 million); respiratory infections (3 million); measles (1.9 million); malaria (I million); and tetanus (0.8 million). Malnutrition contributes to one third of all child deaths; human immunodeficiency virus (HIV) and pertussis are also responsible for this tragic loss of young lives. However, these events merely represent the last few meters of what has aptly been described as the 'road to death.' Almost all maternal and child deaths result from a lifetime of experiences and. circumstances that lead, step by step, to their fatal conclusion. A closer look at the underlying causes of this mortality reveals striking similarities, which may be considered in terms of: high-risk pregnancies; socioeconomic disadvantage; and lack of access to health care services. Unregulated fertility is the major cause of high-risk pregnancies and contributes, both directly and indirectly, to socioeconomic disadvantage and lack of access to health care, profoundly affecting not only the mother and unborn child, but the family as a whole. Almost all maternal and child deaths are preventable. There are many potential exits from the road to death, and family planning is the single most important escape route. All too often, however, it is barred or simply not signposted. 4. High-risk pregnancies More than 300 million women of reproductive age (about one third of the world's total): want no more children; want to space the next birth; or did not want their current pregnancy but do not have access to family planning services [5]. Until their needs can be met, such women will continue to have a disproportionately high number of highrisk pregnancies. They are unwanted (the main danger being unsafe abortion); or in a woman younger than 20 or older than 35; or closely spaced. Mothers who already have several chil-
P. Senanayake / Intemational JOIIl'l101 of Gynecology & Obstetrics 50 Suppl. 2 (1995) SIl-SJ7
dren or a poor obstetric history or underlying maternal disease are also very vulnerable. Most women in these categories would have avoided pregnancy - if only they had the means to do so. All high-risk pregnancies are associated with an increased rate of obstetric complications - the last slippery meters of the 'road to death.' The risks extend not only to the mother and her unborn child, but also, as we shall see, to the family as a whole.
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or during early childhood. Consider, for example, the estimated 15 million abandoned children on the streets of Latin American cities, constantly threatened by gunmen hired by local businessmen to 'clean up' the neighborhood. At best, unwanted children receive suboptimal parenting and are at high risk of disturbed physical and emotional development. Every child has the right to be born wanted.
6. Maternal age 5. Unwanted pregnancy 6. J. Teenage pregnancies
The obvious result of unregulated fertility is unwanted pregnancy. Half of all pregnancies are unplanned and a quarter are definitely not wanted, resulting in 150000 abortions every day. Up to half of these are unsafe abortions which are by far the most important cause of maternal death killing 500 women every day [1].
5. J. Abortions "There is no other condition in medicine where legal denial of safe technology has such dire consequences for so many couples" [6]. In Latin America, illegal abortion is the leading cause of death in young women [7]. In developing countries as a whole most of the casualties are older married women, and each death leaves several children without a mother. About 50 million abortions (200 per 1000 live births) are performed worldwide every year [1]. Up to half of these are performed illegally and in unsafe conditions because many governments continue to prohibit abortion except to save the woman's life or (in some places) for exceptional genetic reasons or cases of rape. Such laws affect more than one third of the world's population [1]. Ironically, however, they have been totally ineffective in reducing abortion rates. In contrast, liberal countries such as The Netherlands, which have universal access to family planning and safe abortion services, have not only eliminated deaths due to unsafe abortion, but have achieved the lowest total rates of abortion worldwide [4]. Unwanted pregnancies that do not end in abortion are likely to result in abandonment at birth
Teenage pregnancies are a massive global problem. More than 15 million teenage mothers give birth every year, and a further 5 million have abortions [5]. In many developing countries, early marriage and childbearing is the cultural norm, despite the considerable risks of pregnancy in women who may still have the body of a child. In industrialized societies (and increasingly in urban areas of developing countries) marriage and childbearing usually come later, but premarital sexual activity commonly results in unwanted pregnancy and abortion. Teenage mothers have a high mortality compared with those 20-29 years old, mainly because of an increased risk of obstructed labor: the immature narrow pelvis of the teenage mother leads to prolonged. difficult labor which all too often results in maternal and/or fetal death. Women who survive such labors commonly develop a vaginal fistula with long-term incontinence of urine and/or feces; they then face rejection by their husbands and their community, and a lifetime of social isolation. Teenage mothers are also at increased risk from anemia, hemorrhage, and preeclampsia. Bangladesh has the highest maternal mortality ratio outside Africa, largely because of its high proportion of very young mothers: 20% of young women are mothers by age IS, and 80% by age 20 [5]. A recent study found a five-fold increased mortality among pregnant IO-14-year-olds compared with women aged 20-24 [8]. Children of teenage mothers are also at risk, because of: consequences of obstetric complications, particularly obstructed labor, which may cause death or lifelong handicap with cerebral
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P. Senanayake / Intemattonal Journal of Gynecology & Obstetrics 50 Suppl. 2 (/995) 511-S/7
palsy and/or blindness; and 70% ir.creased risk of low birthweight (less than 2.5 kg) due to intrauterine growth retardation and/or premature birth [4J. Studies from Indonesia and EI Salvador have shown a 30% increase in perinatal mortality and a two-fold increase in infant mortality, respectively, among children of teenage mothers [4]. Furthermore, the EI Salvador study found that infant mortality in second/third children of teenage mothers was even higher than that of first-born children (350/1000 vs 100/1000). The World Fertility Survey found that children of teenagers have a 24% increase in child mortality [1].
6.2. 'Elderly' mothers In all societies, women over 35 years have a much higher maternal mortality than younger women, mainly because of an increased risk of preeclampsia and hemorrhage. For example Jamaican women over 40 years old have a five-fold increased maternal mortality ratio as compared with those aged 20- 24 [3]. Children also have an increased risk because of obstetric complications and an increased incidence of congenital malformations, especially Down's syndrome (20-times more common in mothers aged 40-44 than aged 20-24), congenital heart disease and cleft lip/palate. The stillbirth rate is two- to three-times higher in older mothers [9]. Infant mortality is also increased, for example, one study found it was 140/1000 in Peruvian 40-year-olds [8J. 7. Closely spaced Having children in quick succession (less than two years between each birth) is physically and emotionally exhausting. Associated malnutrition, physical work and repeated breastfeeding combine to make the mother less able to care for and feed her family. Further pregnancies are usually unwanted and frequently end in abortion. The perinatal mortality of closely spaced pregnancies is increased, largely due to an increase in the stillbirth rate: a study from Indonesia found that spacing less than 18 months was associated with a 2.8-times increased risk [4]. There is also a 60-
70% increase in the infant mortality rate [1]. An Indian study found that infant mortality with births spaced less than one year was 200/1000 (vs 80/1000 with spacing of 3-4 years). If an infant dies, yet another pregnancy is likely to follow soon afterwards because of loss of the natural contraceptive effect of breastfeeding. One of the most important effects of closely spaced births is premature discontinuation of breastfeeding of the previous child, which puts the health of that child at risk due to protein malnutrition (kwashiorkor) and increased susceptibility to infection. Close spacing increases the overall child mortality by 50%. Studies from Nigeria, Turkey, Lebanon, India and the Philippines found that spacing of less than one year doubled the infant and child mortality [9J. 8. High parity In many countries women continue to be judged by the number of children they have. They themselves may seek to havemore because of lack of confidence that existing children will survive. In Nigeria, for example, 80% of women will have experienced at least one infant/child death within their lifetime. Nevertheless, many women with three or more children are crying out for contraception. Surveys in Colombia, Indonesia and Thailand have shown that about three quarters of such women want no more children [10]. Apart from the risks of abortion (prevalent in women who already have several children), pregnancy in grand multiparas poses considerable threats to the mother's Jif~, including: preeclampsia; hemorrhage; anemia; cord prolapse; uterine rupture; sepsis; malpresentation; and pulmonary embolus. In most countries, parity shows a f-sbaped relation with maternal mortality; there is an increased risk in the first pregnancy, lowest risk in the second and a continually increasing risk in the third and subsequent pregnancies [9]. A Bangladeshi study found that maternal mortality was twice as high in fourth/fifth pregnancies than in second/third pregnancies, and three-times higher in eighth-plus pregnancies [11].
P. Senanayake [lntemational Joumal of Gynecology & Obstetrics 50 Suppl. 2 (/995) S11-817
Children born into large families are also at risk. Parity usually shows a If-curve relation with infant mortality, with the lowest risk in the second-born, followed by an increasing risk thereafter [9]. High risks are seen particularly after the fourth child, and become very high after the seventh. Much of the increased mortality is related to the obstetric complications cited above, but multiple factors contribute to a 'sick family' with decreased survival throughout early childhood: reduced quality of child care; less food per capita (in many societies, mothers and daughters are the first to go without); malnutrition, resulting in increased susceptibility to infections; and overcrowding, leading to increased exposure to infections, especially diarrhea and respiratory infections. There is a direct relation between the number of children and child mortality. Families with seven or more children have a 21% increase in child mortality [12]. Children born into large families also have a lower average IQ (intelligence quotient) than other children, and the youngest in the family do worst [II]. 9. Socioeconomic effects Unregulated fertility and its consequences have multiple adverse effects on the physical and emotional health of women and their children. The socioeconomic implications include: effects of maternal death/disability; and effects on the status of women in society. The result is almost always the same: further socioeconomic disadvantage, further increases in child mortality and a continued predisposition to further high-risk pregnancies. 10. Effects of maternal death/disability On average, each mother who dies leaves behind two bereaved children. In other words, each year one million children lose their mother as a result of pregnancy or childbirth. Some attempts have been made to quantify the impact on infant and child mortality - e.g., 95% of motherless infants in Bangladesh die before their first birth-
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day [3] - but the scale of suffering to the bereaved children and the partner is incalculable. For each mother who dies, many more are chronically disabled by vaginal fistula, uterine prolapse, obstetric palsy, pelvic inflammatory disease, or Sheehan syndrome. Women with vaginal fistula, in particular, are often rejected by their partners and by their community, and without treatment face a miserable, isolated life with urinary and/or fecal incontinence. In most societies, women are mainly responsible for everyday tasks such as food production. Disabled women are less able to carry out these activities leading to loss of family income and malnutrition. Women with chronic disability are less able to care for their children and .other dependents such as elderly or sick relatives. H. Effects on status of women in society Many cultures continue to judge women by the number of children they have. Young girls are not seen to require formal education. Those who do have schooling are likely to have their basic education curtailed by early marriage and childbearing. Illiteracy rates are consequently far higher in women than in men. Such lack of education is associated with social disadvantage, reduced earning potential and failure to use health sen ices. Uneducated women are far less likely to have the opportunity to make important decisions about their own lives and health, let alone contribute to the affairs of their local community. Often, such women face a life of fear, low self-esteem and inadequacy. The education of women is closely associated with reduced maternal and child mortality, increased contraceptive prevalence, and reduced total fertility rate (average number of children per completed family) [13]. Increased literacy reduces feelings of inadequacy and low self-esteem, and gives women the opportunity to step outside their traditional domestic role and participate in decision-making at all levels of society: family community, and government. The state of Kerala (India) is a good example of the positive effects of literacy on family size and infant mortality.
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P. Senanayake [Intematlonal Journal of Gynecology & Obstetrics 50 Suppl. 2 (1995) S11-S17
12. The impact of family planning As we have seen, the underlying causes of maternal and child deaths are: high-risk pregnancy, socioeconomic disadvantage and lack of health services. Consequently, the public health priorities for reducing such deaths are: family planning socioeconomic development and improved health services. The impact of family planning has to be viewed in the context of the development of the country as a whole. Nevertheless, universal access to family planning is probably the most cost-effective and feasible strategy to reduce maternal and child mortality. It reduces the total number of pregnancies especially those at high-risk, and abortions. The cumulative effect is a massive reduction in the maternal mortality rate which is particularly marked in societies with initially high total fertility rate (TFR). By contrast, improvements in antenatal/obstetric services reduce the maternal mortality ratio and are the main strategy to reduce maternal deaths in countries that already have a low TFR. Family planning leads to reduced child/infant mortality which increases maternal confidence and leads to reduced desired family size. Family planning is an integral part of primary health care, and offers exceptional opportunities for health education and case identification, e.g., sexually transmitted diseases. It has been estimated that if all women were able to limit their childbearing to no more than four children borne between the age of ]8 and 35, and spaced by at least 2 years this would prevent 5.6 million infant deaths and 0.2 million maternal deaths every year [14]. Family planning not only saves the life of a woman and her children directly, but also improves her socioeconomic status and that of her family; it enables her to feel a sense of control over her own body and destiny, often for the first time in her life. The simple experience of being able to control one's own fertility commonly leads to dramatic improvemen-t in quality of life as women assume greater responsibility for their own destiny and gain greater confidence to take positive action to improve other aspects of their existence, including health and social rights. "For
many women, the opportunity to control their own fertility is often the first form of empowerment in their experience" [6J. "It is women's knowledge that they can, if they wish, control the timing of their childbearing (and society's understanding that women can do so) that enlarges women's economic choices and enhances their status" [15]. 13. Conclusion Over the past 40 years, contraceptive prevalence has increased from less than IQll/o to more than 50%, and the total fertility rate has decreased from more than six to less than four [16]. Meanwhile, child deaths have fallen from 24 million per year in the 1950s to 14 million today, and infant mortality has fallen from lO3/1000 during the period from 1965 to 1970 to 71/1000 from 1985 to ]990 [I]. A conservative estimate would suggest that meeting the family planning demands of 100 million couples would prevent 200 million births and 900 000 maternal deaths [12]. "Providing family planning services to women who want to avoid unwanted pregnancies is probably saving the life of one woman out of every hundred" [12]. References [I] World Health Organization. Reproductive Health: A Key to a Brighter Future. Biennial Report 1990-1, p. 3. Geneva: WHO, 1992. [2] Report of the First Inter-regional Meeting on Prevention of Maternal Mortality, Geneva, November 1985. Geneva: WHO, 1985. [3] World Bank. Making motherhood safe. Washington DC: World Bank, 1993. [4] Wallace HM. Giri K, editors. HealthCare of Women and Children in Developing Countries. Oakland: Third Party, 1990. [5] International Planned Parenthood Federation. IPPF Annual Report 1991-92. London: IPPF, 1992. [6J Sai FT. Politics and ethics in family planning. In: Senanayake P, Kleinman RL, editors, Family Planning: Meeting Challenges and Promoting Choices. Carnforth: Parthenon, 1993; 365. [7} Sai F, Nassim J. The need for a reproductive health approach. Int J Gynecol Obstet 1989; (Suppl 3): 103. [8] International Planned Parenthood Federation. Unmet sexual health needs of adolescents. lPPF Med Bul 1994; 28: 2.
P. Senanayake [ Intemattonal Journal of Gynecology & Obstetrics 50 Suppl. 2 (/995) S II-S17 [9] Omran AR. Interrelations between maternal and neonatal health and family planning: conceptualization of the theme. In: Del Mundo F, lnes-Cuyegkeng E, Aviado OM, editors, Primary Maternal and Neonatal Health. New York: Plenum Press, 1983; 23. [10] Senanayake P, Kleinman RL, editors. Family Planning: Meeting Challenges and Promoting Choices. A Report on the 40th Anniversary IPPF Family Planning Congress, New Delhi, India. Carnforth: Parthenon, 1993. [II] Center for Population and Family Health. Family Planning: Its Impact on the Health of Women and Children. New York: Columbia University Press, 1991. [12J Fathalla MF. Impact of family planning on health. In: Senanayake P, Kleinman RL, editors, Family Planning:
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Meeting Challenges and Promoting Choices, Camforth: Parthenon, 1993; 15. [13] Sinding SW. Getting to replacement: bridging the gap between individual rights and demographic goals. In: Senanayake P, Kleinman RL, editors, Family Planning: Meeting Challenges and Promoting Choices. Carnforth: Parthenon, 1993; 23. [14] Johns Hopkins University Population Information Program. Healthier mothers and children through family planning. Popul Rep Ser 1 1984; N27. [15] Birdsall N, Chester LA. Contraception and the status of women: what is the link? Fam Plann Perspect 1987; 19: 14. [16] Sadik N. The State of World Population 1991. New York: UNFPA, 1991.
GfNDLOGY
&OBSTETRlfJ
International Journal of Gynecology & Obstetrics 50 Suppl, 2 (1995) 511-817
The impact of unregulated fertility on maternal and child survival P. Senanayake lntemational Planned Parenthood Federation, Regent's College, Regem's Park, London NWl 4NS, England, UK
Abstract Almost all maternal and child deaths represent merely the endpoint of the 'road to death' - a combination of factors that include high-risk pregnancy, socioeconomic disadvantage and inadequate health care. Unregulated fertility is the underlying cause of most high-risk pregnancies. They are: unwanted; in mothers younger than 20 or older than 35; closely spaced; and in women who already have several children. The resulting morbidity and mortality create a cycle of further disadvantage, further increases in child mortality and further high-risk pregnancies. Family planning is the single most important exit from the 'road to death.' Over the past 40 years it has contributed to the worldwide reduction in child mortality, and for every 100 women provided with family planning, a woman's life is saved.
Keywords: Family planning; Women at risk; Child deaths
The most striking aspect of maternal and child deaths is the sheer scale cf the problem: 1400 young women and 39000 children die every day worldwide, and almost all these deaths are preventable [1]. A closer look reveals something equally striking, and of huge importance to public health strategy: the underlying causes of maternal and child deaths are essentially the same. They should no longer be regarded in isolation, but together in terms of high-risk pregnancies, socioeconomic disadvantage and lack of access to health care.
... Corresponding author, Fax: 071 487 7865/7950.
Perhaps both the tragedy and hope lie in the fact that the majority of maternal deaths and disability are preventable. Time and time again, we find that unregulated fertility is the most important contributing factor, and it becomes increasingly obvious that universal access to reproductive health services including family planning is the key to safe mctherhood and child welfare. 1. Maternal mortality
The scale of maternal deaths was vividly described in Geneva at the first World Health Organization (WHO) inter-regional meeting on prevention of maternal mortality [2].
0020.7292/95/$09.50 © 1995 International Federation of Gynecology and Obstetrics SSDl 0020-7292(95)02480-Z
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P. Senanayake / lntemational Journal of Gynecology & Obstetrics 50 Suppl. 2 (/995) S 1I-S J7
"Every four hours, day-in, day-out, a jumbo-jet crashes and all on board are killed. The 250 passengers are women, most in the prime of life, some still in their teens."
More than 99% of these deaths are in developing countries [I]; in Northern Europe, the lifetime risk of death due to pregnancy is only I in 10 000; in Africa, it is 1 in 21 [3]. Overall maternal mortality . is 100-200-times greater in developing than in industrialized countries: a greater disparity than any other health measure [1]. Women a.re t~e creators of new life, the caretakers of dally life and the custodians and transmitters of community norms and social values and yet their work and lives are given little value. In a typical setting, with a maternal mortality ratio of 650 per 100 000 live births, and a total fertility rate of six births per woman, about 50000 out of every million families will be motherless because of pregnancy-related deaths. If each mother who dies has on average three to four children at the time of her death, it means that in every million families there are some 175 000 motherless children. These are orphans, not of an epidemic, but of a natural cause, pregnancy and childbirth. 2. Child mortality Worldwide, one in eight children die before their fifth birthday at a rate of 39000 every day [I]. Deaths in children under five represent a massive 30% of all human deaths (more than 50% in Africa versus 3% in industrialized countries) [4]. One third of child deaths occur during the first few weeks of life, a further third before the first birthday and the rest before the age of five. As with maternal deaths, more than 99% of these deaths are in developing countries. 3. The road to death What are the causes of all these deaths? Maternal and child mortality are usually classified according to medical causes and these are well recognized. For the mother: post-abortal sepsis (responsible for up to 40% of all maternal deaths);
postpartum sepsis; hemorrhage; eclampsia; obstructed labor. Perinatal deaths are associated with: birth asphyxia/trauma (usually due to prolonged/difficult labor); prematurity; congenital malformations; underlying maternal disease; antepartum hemorrhage; eclampsia; and intrauterine growth retardation. In/am/child deaths are caused annually by: diarrhea (5 million); respiratory infections (3 million); measles (1.9 million); malaria (I million); and tetanus (0.8 million). Malnutrition contributes to one third of all child deaths; human immunodeficiency virus (HIV) and pertussis are also responsible for this tragic loss of young lives. However, these events merely represent the last few meters of what has aptly been described as the 'road to death.' Almost all maternal and child deaths result from a lifetime of experiences and. circumstances that lead, step by step, to their fatal conclusion. A closer look at the underlying causes of this mortality reveals striking similarities, which may be considered in terms of: high-risk pregnancies; socioeconomic disadvantage; and lack of access to health care services. Unregulated fertility is the major cause of high-risk pregnancies and contributes, both directly and indirectly, to socioeconomic disadvantage and lack of access to health care, profoundly affecting not only the mother and unborn child, but the family as a whole. Almost all maternal and child deaths are preventable. There are many potential exits from the road to death, and family planning is the single most important escape route. All too often, however, it is barred or simply not signposted. 4. High-risk pregnancies More than 300 million women of reproductive age (about one third of the world's total): want no more children; want to space the next birth; or did not want their current pregnancy but do not have access to family planning services [5]. Until their needs can be met, such women will continue to have a disproportionately high number of highrisk pregnancies. They are unwanted (the main danger being unsafe abortion); or in a woman younger than 20 or older than 35; or closely spaced. Mothers who already have several chil-
P. Senanayake / Intemational JOIIl'l101 of Gynecology & Obstetrics 50 Suppl. 2 (1995) SIl-SJ7
dren or a poor obstetric history or underlying maternal disease are also very vulnerable. Most women in these categories would have avoided pregnancy - if only they had the means to do so. All high-risk pregnancies are associated with an increased rate of obstetric complications - the last slippery meters of the 'road to death.' The risks extend not only to the mother and her unborn child, but also, as we shall see, to the family as a whole.
813
or during early childhood. Consider, for example, the estimated 15 million abandoned children on the streets of Latin American cities, constantly threatened by gunmen hired by local businessmen to 'clean up' the neighborhood. At best, unwanted children receive suboptimal parenting and are at high risk of disturbed physical and emotional development. Every child has the right to be born wanted.
6. Maternal age 5. Unwanted pregnancy 6. J. Teenage pregnancies
The obvious result of unregulated fertility is unwanted pregnancy. Half of all pregnancies are unplanned and a quarter are definitely not wanted, resulting in 150000 abortions every day. Up to half of these are unsafe abortions which are by far the most important cause of maternal death killing 500 women every day [1].
5. J. Abortions "There is no other condition in medicine where legal denial of safe technology has such dire consequences for so many couples" [6]. In Latin America, illegal abortion is the leading cause of death in young women [7]. In developing countries as a whole most of the casualties are older married women, and each death leaves several children without a mother. About 50 million abortions (200 per 1000 live births) are performed worldwide every year [1]. Up to half of these are performed illegally and in unsafe conditions because many governments continue to prohibit abortion except to save the woman's life or (in some places) for exceptional genetic reasons or cases of rape. Such laws affect more than one third of the world's population [1]. Ironically, however, they have been totally ineffective in reducing abortion rates. In contrast, liberal countries such as The Netherlands, which have universal access to family planning and safe abortion services, have not only eliminated deaths due to unsafe abortion, but have achieved the lowest total rates of abortion worldwide [4]. Unwanted pregnancies that do not end in abortion are likely to result in abandonment at birth
Teenage pregnancies are a massive global problem. More than 15 million teenage mothers give birth every year, and a further 5 million have abortions [5]. In many developing countries, early marriage and childbearing is the cultural norm, despite the considerable risks of pregnancy in women who may still have the body of a child. In industrialized societies (and increasingly in urban areas of developing countries) marriage and childbearing usually come later, but premarital sexual activity commonly results in unwanted pregnancy and abortion. Teenage mothers have a high mortality compared with those 20-29 years old, mainly because of an increased risk of obstructed labor: the immature narrow pelvis of the teenage mother leads to prolonged. difficult labor which all too often results in maternal and/or fetal death. Women who survive such labors commonly develop a vaginal fistula with long-term incontinence of urine and/or feces; they then face rejection by their husbands and their community, and a lifetime of social isolation. Teenage mothers are also at increased risk from anemia, hemorrhage, and preeclampsia. Bangladesh has the highest maternal mortality ratio outside Africa, largely because of its high proportion of very young mothers: 20% of young women are mothers by age IS, and 80% by age 20 [5]. A recent study found a five-fold increased mortality among pregnant IO-14-year-olds compared with women aged 20-24 [8]. Children of teenage mothers are also at risk, because of: consequences of obstetric complications, particularly obstructed labor, which may cause death or lifelong handicap with cerebral
Sl4
P. Senanayake / Intemattonal Journal of Gynecology & Obstetrics 50 Suppl. 2 (/995) 511-S/7
palsy and/or blindness; and 70% ir.creased risk of low birthweight (less than 2.5 kg) due to intrauterine growth retardation and/or premature birth [4J. Studies from Indonesia and EI Salvador have shown a 30% increase in perinatal mortality and a two-fold increase in infant mortality, respectively, among children of teenage mothers [4]. Furthermore, the EI Salvador study found that infant mortality in second/third children of teenage mothers was even higher than that of first-born children (350/1000 vs 100/1000). The World Fertility Survey found that children of teenagers have a 24% increase in child mortality [1].
6.2. 'Elderly' mothers In all societies, women over 35 years have a much higher maternal mortality than younger women, mainly because of an increased risk of preeclampsia and hemorrhage. For example Jamaican women over 40 years old have a five-fold increased maternal mortality ratio as compared with those aged 20- 24 [3]. Children also have an increased risk because of obstetric complications and an increased incidence of congenital malformations, especially Down's syndrome (20-times more common in mothers aged 40-44 than aged 20-24), congenital heart disease and cleft lip/palate. The stillbirth rate is two- to three-times higher in older mothers [9]. Infant mortality is also increased, for example, one study found it was 140/1000 in Peruvian 40-year-olds [8J. 7. Closely spaced Having children in quick succession (less than two years between each birth) is physically and emotionally exhausting. Associated malnutrition, physical work and repeated breastfeeding combine to make the mother less able to care for and feed her family. Further pregnancies are usually unwanted and frequently end in abortion. The perinatal mortality of closely spaced pregnancies is increased, largely due to an increase in the stillbirth rate: a study from Indonesia found that spacing less than 18 months was associated with a 2.8-times increased risk [4]. There is also a 60-
70% increase in the infant mortality rate [1]. An Indian study found that infant mortality with births spaced less than one year was 200/1000 (vs 80/1000 with spacing of 3-4 years). If an infant dies, yet another pregnancy is likely to follow soon afterwards because of loss of the natural contraceptive effect of breastfeeding. One of the most important effects of closely spaced births is premature discontinuation of breastfeeding of the previous child, which puts the health of that child at risk due to protein malnutrition (kwashiorkor) and increased susceptibility to infection. Close spacing increases the overall child mortality by 50%. Studies from Nigeria, Turkey, Lebanon, India and the Philippines found that spacing of less than one year doubled the infant and child mortality [9J. 8. High parity In many countries women continue to be judged by the number of children they have. They themselves may seek to havemore because of lack of confidence that existing children will survive. In Nigeria, for example, 80% of women will have experienced at least one infant/child death within their lifetime. Nevertheless, many women with three or more children are crying out for contraception. Surveys in Colombia, Indonesia and Thailand have shown that about three quarters of such women want no more children [10]. Apart from the risks of abortion (prevalent in women who already have several children), pregnancy in grand multiparas poses considerable threats to the mother's Jif~, including: preeclampsia; hemorrhage; anemia; cord prolapse; uterine rupture; sepsis; malpresentation; and pulmonary embolus. In most countries, parity shows a f-sbaped relation with maternal mortality; there is an increased risk in the first pregnancy, lowest risk in the second and a continually increasing risk in the third and subsequent pregnancies [9]. A Bangladeshi study found that maternal mortality was twice as high in fourth/fifth pregnancies than in second/third pregnancies, and three-times higher in eighth-plus pregnancies [11].
P. Senanayake [lntemational Joumal of Gynecology & Obstetrics 50 Suppl. 2 (/995) S11-817
Children born into large families are also at risk. Parity usually shows a If-curve relation with infant mortality, with the lowest risk in the second-born, followed by an increasing risk thereafter [9]. High risks are seen particularly after the fourth child, and become very high after the seventh. Much of the increased mortality is related to the obstetric complications cited above, but multiple factors contribute to a 'sick family' with decreased survival throughout early childhood: reduced quality of child care; less food per capita (in many societies, mothers and daughters are the first to go without); malnutrition, resulting in increased susceptibility to infections; and overcrowding, leading to increased exposure to infections, especially diarrhea and respiratory infections. There is a direct relation between the number of children and child mortality. Families with seven or more children have a 21% increase in child mortality [12]. Children born into large families also have a lower average IQ (intelligence quotient) than other children, and the youngest in the family do worst [II]. 9. Socioeconomic effects Unregulated fertility and its consequences have multiple adverse effects on the physical and emotional health of women and their children. The socioeconomic implications include: effects of maternal death/disability; and effects on the status of women in society. The result is almost always the same: further socioeconomic disadvantage, further increases in child mortality and a continued predisposition to further high-risk pregnancies. 10. Effects of maternal death/disability On average, each mother who dies leaves behind two bereaved children. In other words, each year one million children lose their mother as a result of pregnancy or childbirth. Some attempts have been made to quantify the impact on infant and child mortality - e.g., 95% of motherless infants in Bangladesh die before their first birth-
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day [3] - but the scale of suffering to the bereaved children and the partner is incalculable. For each mother who dies, many more are chronically disabled by vaginal fistula, uterine prolapse, obstetric palsy, pelvic inflammatory disease, or Sheehan syndrome. Women with vaginal fistula, in particular, are often rejected by their partners and by their community, and without treatment face a miserable, isolated life with urinary and/or fecal incontinence. In most societies, women are mainly responsible for everyday tasks such as food production. Disabled women are less able to carry out these activities leading to loss of family income and malnutrition. Women with chronic disability are less able to care for their children and .other dependents such as elderly or sick relatives. H. Effects on status of women in society Many cultures continue to judge women by the number of children they have. Young girls are not seen to require formal education. Those who do have schooling are likely to have their basic education curtailed by early marriage and childbearing. Illiteracy rates are consequently far higher in women than in men. Such lack of education is associated with social disadvantage, reduced earning potential and failure to use health sen ices. Uneducated women are far less likely to have the opportunity to make important decisions about their own lives and health, let alone contribute to the affairs of their local community. Often, such women face a life of fear, low self-esteem and inadequacy. The education of women is closely associated with reduced maternal and child mortality, increased contraceptive prevalence, and reduced total fertility rate (average number of children per completed family) [13]. Increased literacy reduces feelings of inadequacy and low self-esteem, and gives women the opportunity to step outside their traditional domestic role and participate in decision-making at all levels of society: family community, and government. The state of Kerala (India) is a good example of the positive effects of literacy on family size and infant mortality.
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P. Senanayake [Intematlonal Journal of Gynecology & Obstetrics 50 Suppl. 2 (1995) S11-S17
12. The impact of family planning As we have seen, the underlying causes of maternal and child deaths are: high-risk pregnancy, socioeconomic disadvantage and lack of health services. Consequently, the public health priorities for reducing such deaths are: family planning socioeconomic development and improved health services. The impact of family planning has to be viewed in the context of the development of the country as a whole. Nevertheless, universal access to family planning is probably the most cost-effective and feasible strategy to reduce maternal and child mortality. It reduces the total number of pregnancies especially those at high-risk, and abortions. The cumulative effect is a massive reduction in the maternal mortality rate which is particularly marked in societies with initially high total fertility rate (TFR). By contrast, improvements in antenatal/obstetric services reduce the maternal mortality ratio and are the main strategy to reduce maternal deaths in countries that already have a low TFR. Family planning leads to reduced child/infant mortality which increases maternal confidence and leads to reduced desired family size. Family planning is an integral part of primary health care, and offers exceptional opportunities for health education and case identification, e.g., sexually transmitted diseases. It has been estimated that if all women were able to limit their childbearing to no more than four children borne between the age of ]8 and 35, and spaced by at least 2 years this would prevent 5.6 million infant deaths and 0.2 million maternal deaths every year [14]. Family planning not only saves the life of a woman and her children directly, but also improves her socioeconomic status and that of her family; it enables her to feel a sense of control over her own body and destiny, often for the first time in her life. The simple experience of being able to control one's own fertility commonly leads to dramatic improvemen-t in quality of life as women assume greater responsibility for their own destiny and gain greater confidence to take positive action to improve other aspects of their existence, including health and social rights. "For
many women, the opportunity to control their own fertility is often the first form of empowerment in their experience" [6J. "It is women's knowledge that they can, if they wish, control the timing of their childbearing (and society's understanding that women can do so) that enlarges women's economic choices and enhances their status" [15]. 13. Conclusion Over the past 40 years, contraceptive prevalence has increased from less than IQll/o to more than 50%, and the total fertility rate has decreased from more than six to less than four [16]. Meanwhile, child deaths have fallen from 24 million per year in the 1950s to 14 million today, and infant mortality has fallen from lO3/1000 during the period from 1965 to 1970 to 71/1000 from 1985 to ]990 [I]. A conservative estimate would suggest that meeting the family planning demands of 100 million couples would prevent 200 million births and 900 000 maternal deaths [12]. "Providing family planning services to women who want to avoid unwanted pregnancies is probably saving the life of one woman out of every hundred" [12]. References [I] World Health Organization. Reproductive Health: A Key to a Brighter Future. Biennial Report 1990-1, p. 3. Geneva: WHO, 1992. [2] Report of the First Inter-regional Meeting on Prevention of Maternal Mortality, Geneva, November 1985. Geneva: WHO, 1985. [3] World Bank. Making motherhood safe. Washington DC: World Bank, 1993. [4] Wallace HM. Giri K, editors. HealthCare of Women and Children in Developing Countries. Oakland: Third Party, 1990. [5] International Planned Parenthood Federation. IPPF Annual Report 1991-92. London: IPPF, 1992. [6J Sai FT. Politics and ethics in family planning. In: Senanayake P, Kleinman RL, editors, Family Planning: Meeting Challenges and Promoting Choices. Carnforth: Parthenon, 1993; 365. [7} Sai F, Nassim J. The need for a reproductive health approach. Int J Gynecol Obstet 1989; (Suppl 3): 103. [8] International Planned Parenthood Federation. Unmet sexual health needs of adolescents. lPPF Med Bul 1994; 28: 2.
P. Senanayake [ Intemattonal Journal of Gynecology & Obstetrics 50 Suppl. 2 (/995) S II-S17 [9] Omran AR. Interrelations between maternal and neonatal health and family planning: conceptualization of the theme. In: Del Mundo F, lnes-Cuyegkeng E, Aviado OM, editors, Primary Maternal and Neonatal Health. New York: Plenum Press, 1983; 23. [10] Senanayake P, Kleinman RL, editors. Family Planning: Meeting Challenges and Promoting Choices. A Report on the 40th Anniversary IPPF Family Planning Congress, New Delhi, India. Carnforth: Parthenon, 1993. [II] Center for Population and Family Health. Family Planning: Its Impact on the Health of Women and Children. New York: Columbia University Press, 1991. [12J Fathalla MF. Impact of family planning on health. In: Senanayake P, Kleinman RL, editors, Family Planning:
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Meeting Challenges and Promoting Choices, Camforth: Parthenon, 1993; 15. [13] Sinding SW. Getting to replacement: bridging the gap between individual rights and demographic goals. In: Senanayake P, Kleinman RL, editors, Family Planning: Meeting Challenges and Promoting Choices. Carnforth: Parthenon, 1993; 23. [14] Johns Hopkins University Population Information Program. Healthier mothers and children through family planning. Popul Rep Ser 1 1984; N27. [15] Birdsall N, Chester LA. Contraception and the status of women: what is the link? Fam Plann Perspect 1987; 19: 14. [16] Sadik N. The State of World Population 1991. New York: UNFPA, 1991.