Sound information is the prerequisite for health action: without data on the dimensions, impact and significance of a health problem it is neither possible to create an advocacy case nor to establish strong programmes for addressing it. The absence of good information on the extent of the burden of maternal ill-health resulted in its relative neglect by the international health community for many years. Maternal deaths are too often solitary and hidden events that go uncounted. The difficulty arises not because of lack of clarity regarding the definition of a maternal death, but because of the weakness of health information systems and consequent absence of the systematic identification and recording of maternal deaths. In recent years, innovative approaches to measuring maternal mortality have been developed, resulting in a stronger information base. WHO, UNICEF and UNFPA estimates for the year 2000 indicate that most of the total 529,000 maternal deaths globally occur in just 13 countries. By contrast, information on the global burden of non-fatal health outcomes associated with pregnancy and childbearing remains patchy and incomplete. Nonetheless, initial estimates based on systematic reviews of available information and confined to the five major direct pregnancy-related complications indicate a problem of considerable magnitude.

Global burden of maternal death and disability

Unsafe abortion: worldwide estimates for 2000.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(01)06182-7.pdf

Do Better Family Planning Services Reduce Abortion in Bangladesh

Although fertility decline often correlates with improvements in socioeconomic conditions, many demographers have found flaws in demographic transition theories that depend on changes in distal factors such as increased wealth or education. Human beings worldwide engage in sexual intercourse much more frequently than is needed to conceive the number of children they want, and for women who do not have access to the information and means they need to separate sex from childbearing, the default position is a large family. In many societies, male patriarchal drives to control female reproduction give rise to unnecessary medical rules constraining family planning (including safe abortion) or justifying child marriage. Widespread misinformation about contraception makes women afraid to adopt modern family planning. The barriers to family planning can be so deeply infused that for many women the idea of managing their fertility is not considered an option. Conversely, there is evidence that once family planning is introduced into a society, then it is normal consumer behaviour for individuals to welcome a new technology they had not wanted until it became realistically available. We contend that in societies free from child marriage, wherever women have access to a range of contraceptive methods, along with correct information and backed up by safe abortion, family size will always fall. Education and wealth can make the adoption of family planning easier, but they are not prerequisites for fertility decline. By contrast, access to family planning itself can accelerate economic development and the spread of education.

https://mahb.stanford.edu/wp-content/uploads/2014/02/2013_CampbellPrataandPotts_TheImpactofFreedomonFertilityDecline_JFPRHC.pdf

The impact of freedom on fertility decline

This paper reviews the determinants of fertility and attempts to extract conclusions that are relevant for fertility reduction policies in developing countries. In the first tier of fertility determinants, socioeconomic development has a decisive effect in lowering fertility in the long run. In the short run, however, and for specific households, the effects are much more tangled. Higher income, for instance, allows households to afford more children, but nevertheless often reduces fertility because of its links to other factors like education. Education, especially for women, fairly reliably reduces fertility, though its effect may take years to appear. Improved health and lower mortality also contribute to lower fertility, through both biological and behavioral channels. The effect of female employment, in contrast, is uncertain and undependable. Urban residence has a pervasive effect in reducing fertility, though much of this is attributable to education and better health. Particular improvements in welfare can therefore be expected to lead to lower fertility, but the effects are neither uniform nor immediate. Development is essential for fertility transition to run its full course.

Jean Van der Tak

Papers

Abortion, fertility, and changing legislation: An international review