[Impact of family planning on maternal-child health. The future of humanity depends on our children]. / Impacto de la planificacion familiar en la salud materno-infantil. El futuro de la humanidad depende de nuestros hijos.

PIP: Better hygiene, nutrition, housing, health care and education are needed to prevent some of the estimated 15 million deaths in children under 5 and 500,000 maternal deaths that occur each year in the developing countries. The World Fertility Surveys and other studies beginning in the 1970s in Africa, Asia, the Middle East, and Latin America demonstrated the direct relationship between family planning and maternal and child mortality and morbidity. A child born in a high mortality country of Asia or Africa has a 20 times greater risk of dying before age 5 than a child in the US, Japan, or Sweden. Methods for reducing this mortality are known, including spacing of pregnancies, limiting family size, and avoiding pregnancy at unfavorable ages. During 1986, approximately 2 million children under 5 died from causes associated with rapid procreation and short birth intervals. It is estimated that 1 in 5 of these deaths would have been avoided if the interval between births had been longer. The high mortality rate is partly due to maternal exhaustion; mothers have insufficient time to recuperate between births, especially if they practice prolonged breast feeding, are undernourished, or engage in arduous physical labor. Inability to give high quality care to several children at a time may be another factor. From the 3rd birth on, women run 4 times greater risks of abortion or fetal death than in the 1st or 2nd pregnancy. The proportion of low birth weight babies increases significantly after the 4th child, explaining their vulnerability to health problems or death. Large family size may also prejudice the nutritional status of children. Infant mortality in the entire world in mothers under 20 is estimated at 126/1000 live births. The 1st child of an adolescent mother has an 80% greater probability of death than the 2nd or 3rd child of a mother aged 25-34 years. Lack of access to contraception and lack of motivation to use it are factors preventing tremendous infant mortality gains in the developing world. Only about 6000 of the estimated half million maternal deaths each year occur in developed countries. The indirect causes of maternal mortality are related to the unfavorable status of women reflected in poverty, illiteracy, lack of access to health care, and procreation patterns. The World Fertility Surveys indicate that 200,000 maternal deaths would be avoided each year if women not wanting more children had access to contraception. Contraceptive use would also prevent most of the estimated 100,000-200,000 maternal deaths from complications of abortion each year. The 4 basic elements of a maternal health program are primary care, prenatal care, attendance at delivery by trained personnel, and rapid access to emergency medical care.^ieng

[Impact of family planning on maternal-child health]. / Impacto de la planificacion familiar en la salud materno-infantil.

PIP: An estimated 15 million children under 5 die each year, most of them in developing countries. Some 1/2 million women die of causes related to pregnancy, leaving at least 1 million children orphaned. The World Fertility Surveys of the 1970s demonstrated the direct relationship between family planning and maternal-child health. Between 1985-2000, some 2 billion children are expected to be born, 87% of them in developing countries. Some 240 million will die before 5 years. The main causes of death in small children are acute diarrheal disease, respiratory infections, transmissible diseases preventable with vaccination, malaria, malnutrition, and high fertility. 3 aspects of reproduction have significant effects on child survival: spacing, parity, and maternal age. In 1986, approximately 2 million children under 5 died because of risks associated with rapid procreation, and it is estimated that 1/5 of all child deaths could have been prevented with longer birth intervals. Maternal exhaustion and the inability to give adequate care to several small children at once are believed to be the main causes. The problem of abortion or fetal death increases significantly beginning at the 3rd birth, and the proportion of low birth weight babies increases at the 4th birth. The risk of malnutrition increases in large families with limited resources. The safest ages for childbearing are 20-34 years; the worldwide infant mortality rate for mothers under 20 is about 126/1000. Adolescent mothers are at increased risk of problems in the pregnancy and delivery. Family planning can reduce risks related to spacing, family size, and maternal age, and also risk of congenital defects that increase for older mothers. According to the World Health Organization, each year there are some 500,000 maternal deaths, only 6000 of which occur in developed countries. Immediate causes of maternal death in developing countries include hemorrhage, sepsis, eclampsia, dystocic delivery, and induced abortion, but the underlying causes are related to the poor situation of the woman: poverty, illiteracy, lack of adequate prenatal health care, and childbearing at extreme ages. Estimates based on the World Fertility Survey suggest that if all women stating they wanted no more children used contraception, 30% of maternal deaths would be avoided. It is estimated that some 15 million women undergo induced abortions each year, with 100,000-200,000 resulting deaths.^ieng

[Family planning needs help to reduce the number of abortions]. / La planificacion familiar necesita ayuda para reducir el numero de abortos.

PIP: M. Peter McPherson, the administrator of the US Agency for International Development, believes that international assistance for family planning programs is necessary to reduce the number of abortions in the world. When couples desire fewer children and family planning services are unavailable, they frequently have recourse to abortion even when the practice is illegal. Data from some countries of Asia and Latin America indicate that 1 of every 3 women have had abortions, many of which would have been avoided if family planning services had been available. An estimated 360,000 abortions have been avoided in Mexico since the governmental family planning program began in 1972. The number of Chilean women seeking treatment for complications of illegal abortion has declined substantially since modern family planning methods became available in 1965. The health and survival of mothers and children is another important reason for supporting family planning. Studies in 26 countries confirm that children born within 2 years of the previous birth have a risk of death twice that of children born 2 or 3 years after the last birth. Mortality among children under 4 would be reduced by 21% if all births were spaced at least 2 years apart. At least 200,000 maternal deaths each year are attributable to too many pregnancies or to pregnancy at too young or old an age. The desire of many Third World families to have fewer children is not merely a product of western speculation, but is confirmed in surveys which demonstrate that couples are unable to limit or space their children because of lack of family planning services. Even though careful study has not yet clarified the exact relationship between population and economic growth, the impact of population growth on the economy is unquestionable. It is rarely argued that rapid population growth contributes to economic development. Family planning would contribute to economic growth by reducing population pressure.^ieng

The effects of birth spacing on child and maternal health.

Child and maternal mortality and morbidity are examined in relation to the interval between pregnancies. Most data available pertain to child mortality. Very little reliable information links child morbidity or maternal health detriments to short birth spacing. The evidence on child mortality suggests that very short intervals (conceptions less than six months after a birth) are detrimental to survival of the second child, but these results must be viewed in light of the methodological difficulties of studies of this subject. Policy implications of the data are perhaps less clear than is sometimes assumed.

PIP: The health effects of birth spacing remain relatively obscure despite frequent exhortation to space pregnancies in order to improve maternal and child health. Most studies have not controlled for very important confounding factors. More needs to be known about the relationship of birth interval to child health apart from maternal age and parity. It is important to control for socioeconomic effects and prior child deaths because these factors are so closely associated with differentials in health risks. For example, the raw data of Fedrick and Adelstein's work suggested a birth interval effect on survival, with higher risks at the longest intervals; correction for age and socioeconomic class completely eliminated an effect except in the very shortest interval. We do not yet know which months of postneonatal mortality are most affected by short birth interval, nor understand whether the effects are more likely due to prematurity and/or low birth weight, or to nutritional status and child care at the commencement of weaning. More needs to be known about the mechanism of excess risk for siblings born into families with a prior early child death. Also in many societies where birth interval effects on mortality have been demonstrated, the distribution of births is already relatively favorable. A very small percentage of children are subject to the risks of the shortest intervals, and a great majority of births already occur with greater than 24-month spacing. Perhaps where traditional lactation practices help avoid the worst hazards of short intervals, emphasis on delaying the 1st birth and/or making available the means for women to limit their fertility may have as much impact on health as birth spacing alone. Birth intervals may be most measurable in situations where general infant and child mortality patterns are already high. Finally, we do not know how to measure the health effects of high fertility or short intervals on mothers or their effects on healthy women of low parity and their children.