UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)
|
| UN Population Division, Department of Economic and Social Affairs, with support from the UN Population Fund (UNFPA) |
|
Population Network News
No. 5, Fall 1993
Part IV
Demographic and Health Survey Results -Malawi
---------------------------------------------
Rich with details, the First Report of the Malawi Demographic and Health
Survey 1992 provides new estimates of fertility, contraceptive use,
infant mortality, and maternal care. The results of the additional module
on AIDS point to a need for continued educational efforts in this area.
The survey indicates that fertility is still high (a total fertility rate
of 6.7 children per woman among currently married and cohabiting women),
while contraceptive use is correspondingly low (7.4 percent for modem
methods and 13.0 percent for any method). Interestingly, a larger, but
still low, percentage of the married or cohabiting men surveyed reported
using contraceptives, generally condoms (12.5 percent for modem methods
and 25.1 percent for any method). Considering this low use rate,
knowledge of methods and sources is quite high: 95 percent of women know
of at least one method, while 85 percent know of a source. As might be
expected, education and urban residence are associated with higher
contraceptive use.
Questions on maternal health offer some grounds for optimism, reporting
that 86 percent of women giving birth received tetanus toxoid injections,
while 90 percent received some ante natal care, generally from nurses or
trained midwives. In addition, more than half of the births in the five
years preceding the survey had been attended by trained medical
personnel.
The section on AIDS reveals high levels of awareness of AIDS as a disease
that can be sexually transmitted. However, means of protecting oneself
from AIDS were less well-known, as can be seen in the figure below.
Limiting the number of partners to avoid the disease was the most
well-known preventive strategy, followed by avoidance of prostitutes and
sterilization of needles and syringes. Use of condoms, however, was not
well-known. Only 11.8 percent of women recognized the protective benefits
of condoms. Men were much more aware, although fewer than one third of
them thought that condoms could prevent the transmission of AIDS.
Continued efforts at education and service provision are clearly needed.
Publications of Note
---------------------
* World Population Prospects: The 1992 Revision, United Nations. The
latest annual revision of the United Nations population projections is
now available. In addition to the usual country-specific, regional, and
global projections, the volume provides special sections on population
estimates for the Commonwealth of Independent States and Georgia, as well
as a set of projections of the demographic impact of AIDS for fifteen
countries in Africa were HIV infection rates were over 1 percent in the
adult population. Starting from a base year of 1980, the projections
indicate that among these 15 countries, the AIDS crisis will result in a
population 4 percent small in the year 2025 than it would be expected to
be were there no AIDS in the country. For a subset of four very high
prevalence countries (Malawi, Rwanda, Uganda, and Zambia, where the adult
HIV prevalence rate is over 5 percent), the population is expected to be
7.5 percent smaller in 2025 than would be projected without AIDS. These
figures are, of course, subject to the usual cautionary statements
regarding assumptions and interpretation that accompany all projections.
Contact: United Nations.
* Global Population Assistance Report, 1982-1991, United Nations
Population Fund (UNFPA). UNFPA has just come out with its annual report
on donor contributions for population assistance, which estimates that in
'991 commitments for loans and grants for international population
assistance reached $ 1,306 million, an increase of 34 percent over 1990.
Of that, $952 million dollars took the form of grants, representing an
increase of 19 percent over the preceding year. The report offers various
breakdowns of assistance by type of organization and commitments versus
expenditures. In 1991, the United States was the largest donor,
committing approximately $352 million. The World Bank, the largest
multilateral donor, was right behind, with estimated commitments of $351
million.
Contact: UNFPA.
* Reproductive Health Matters. A new journal has been established,
devoted to analysis of reproductive health matters from a women-centered
perspective. Marge Berer, editor, explains in the introduction to the
first issue that "a women-centered perspective is one that looks at
experiences, values, issues, and information from the point of view of
the women whose lives are affected." Taking as it theme population and
family planning policies, the first volume offers articles on population
and the environment, country and case studies of population policy in
India, Malaysia, and South Africa, and other issues such as abortion and
sexuality.
* Unsafe Abortion and Sexual Health in the Arab World, International
Planned Parenthood Federation, Arab World Region. IPPF/AWR organized a
conference on unsafe abortion in the Middle East in December 1992. The
report of the conference summarizes discussion on the situation in these
countries, where legal abortion is very restricted, except in the case of
Tunisia. The speakers at the conference covered many topics, including
the status of national laws, the role of religion in shaping public
feelings about abortion, the attitudes of providers, and the impact of
cultural values . Case studies from Turkey, Bangladesh, Kenya, and India
were also presented for Comparison.
Contact IPPF
* The Middle East Population Puzzle, by Abdel R. Omran and Farzaneh Roudi
(Population Bulletin, Vol. 48, No. 1), explores the implications of
demographic change in the Middle East for that region and for the world.
Special attention is paid to labor and refugee movements, as well
as ethnic groups and the role of the family. The report notes that while
improvements in women's education, population policies to slow fertility,
and political developments will help determine the future demography of
the Middle East, the momentum created by past fertility and the current
age structure suggests that the region will have close to 500 million
inhabitants by 2025, almost double its current size of 265 million.
Contact: Population Reference Bureau.
* Abortion and Health: A List of Selected Resources, International
Planned Parenthood Federation, Public Affairs Department. This
bibliography includes material published since 1980 on the impact of
induced abortion on women's lives and health; the extent of illegal and
unsafe abortion around the world; and what measures can be taken to
ensure that women have access to safe abortion.
Contact: IPPF
* The East Asian Miracle: Economic Growth and Public Policy, World Bank
Policy Research Report (August 1993). This volume attempts to understand
the factors underlying the remarkable economic growth of eight countries
in East Asia (Japan, Hong Kong, the Republic of Korea, Singapore, Taiwan,
Indonesia, Malaysia, and Thailand). As the subtitle suggestions, "sound
development policy was a major ingredient in achieving rapid growth"
through high levels of investment and substantial improvements in human
capital. Discrete government interventions, designed to subsidize
specific industries or protect domestic markets from imports, also had a
role to play. The report acknowledges the contribution of East Asia's
"rapid demographic transition" in freeing up resources for increased per
capita investments in children -- at home and at school. These
investments played a considerable role in deepening the human resource
base used for developing the economy.
---------------------------------------------------------------------
PNN is a quarterly round-up of news and information relevant to Bank
staff working in the population field. It is produced by the
Population, Policy and Advisory Service (PPAS) and edited by Chantal
Worzala.
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archive PHNFLASH PNN5B Population News
Population Network News
No. 5, Fall 1993
Part II
Demystifying Contraceptive Procurement
--------------------------------------
A recent publication by the inter-agency working group on Contraceptive
Requirements and logistics Management Needs outlines the contraceptive
procurement options for developing country governments. Written in
nontechnical language, Contraceptive Procurement-Options for Programme
Managers lays out the pluses and minuses of three basic mechanisms for
ensuring supply:
a) Procurement through a single source;
b) Procurement through an intermediate agency and
c) Competitive procurement.
In comparing these methods, the booklet examines differences in price,
delivery times, and requisite staffing on the part of the government. It
also notes the restrictions that various donors place on the need for
competitive bidding in the use of funds.
Female Education and Fertility -- New Research
Findings and Policy Questions
-----------------------------------------------
At the 1993 General Conference of the International Union for the
Scientific Study of Population (IUSSP), there was an excellent session on
education and fertility. The session was chaired by Helen Ware and
comments were provided by Zeba Sathar and Susan Cochrane (World Bank) .
The papers presented ranged from discussion of simple correlation
analysis between education and the intermediate determinants of
fertility, to focus group studies, to multiple country or multiple time
period analysis of nationally representative surveys.
A number of the papers shed new light on the education fertility
interaction. For example, a study of the effect on female autonomy on
contraceptive use in Gujarat showed that their was a significant
relationship between a variety of measures of autonomy and contraceptive
use. Based on 1983 and 1988 DHS results, a study of the Philippines
compared education's relationship to fertility in the 1980s to earlier
analyses for the 1970s. In the earlier decade, education had its
affect on fertility almost exclusively through the age at marriage. In
the 1980s, however, education affected contraceptive use as well. In this
case, education's effects on fertility varied by time period.
Two other studies came from Latin America. The first was a study of the
correlates of fertility in nine countries of Central and South America
where DHS surveys had taken place. The study found a significant
difference in education's effect in the Central and South American
countries. While actual fertility differed substantially across
educational groups in all countries, in South America there was not much
difference in desired fertility across educational groups. In Central
America, by contrast, there were differences in desired fertility,
although not as wide as the differences in actual fertility. The final
study was a small anthropological study of the relationship between
education and fertility of mothers and daughters.
The panel discussion of the papers gave rise to a number of
policy-relevant questions, outlined below:
1. What are the channels through which various levels of schooling
have their effect? There is a tendency in the field to treat education's
effects as if they were linear. If this is true, it does not matter
if all girls are given some education or half the girls are given
twice the education. If, however, a small amount of schooling is
associated with an increase in fertility, then, ceteris paribus, these
two strategies will not have equal effects on fertility.
2. Does education affect fertility more through age at marriage or
contraceptive use? Existing evidence indicates that this pattern varies
by country, and, as the Philippines study indicates, the effect may well
change over time.
3. How do education and family planning programs interact? Can a strong
program substitute for the effects of education and short cut the time
lag between educating girls and affecting their fertility behavior years
later? Or are only women with more schooling willing and able to
avail themselves of the services offered by family planning programs?
Program accessibility may be a mitigating factor. The small educational
differential in fertility in Asia suggests that the well-established
public family planning programs in these countries are accessible to
women of all educational groups. In Latin America, however, where there
is reliance on the private sector, less educated and poorer women do not
have an equal ability to make use of family planning. Thus, large
socio-economic differentials in fertility exist, even though differences
in desired family size are small.
4. What are the educational outputs that have the most effect on
fertility? Is it knowledge per se, patterns of discipline, organizational
skills learned in school, market opportunities, or self confidence and
autonomy? If these channels can be better understood, it may be
possible to find shorter, less expensive ways to achieve education's
effects through adult training, or IEC (Information, Education, and
Communication) campaigns . Further, longitudinal research is needed to
address this question.
5. Most of the research done to date has studied the effect of education
of women on their own fertility. Can the education of the current
generation of children affect the fertility of their parents? John
Caldwell has theorized that the process of schooling makes children more
demanding, causing wealth flows to shift from that of children giving net
wealth to parents over a lifetime, to parents giving more to children
than they receive. Again, more research into the causal relationships is
warranted.
6. The ultimate policy question arises: Given the large body of research
linking female education to reduced fertility, how much should
educational policy be guided by that relationship?
What to do about STDs?
----------------------
The latest Population Report offers a comprehensive look at "Controlling
Sexually Transmitted Diseases." Noting that STDs are nearly as common as
malaria, the report covers many facets of the issue, which is gaining
attention as family planning is broadened to address reproductive health
in a larger sense. STDs are of special concern because of their
prevalence (there are an estimated 250 million new cases per year,
world-wide) and their contribution to the spread of HIV/AIDS. STDs can
also lead to sterility, ectopic pregnancy, miscarriage, and injury to
children born to infected mothers.
In addition to outlining the reasons for addressing STDs, the Report
discusses the difficulty of diagnosis in developing country settings and
the complicated relationship between family planning and STD treatment
and prevention services. On the topic of diagnosis,the Report describes
an approach now promoted by the World Health Organization (WHO). Called
the "syndromic approach," it involves identification of a group of
symptoms related to STDs. Based on these symptoms, a patient is treated
immediately, without waiting for somewhat sophisticated laboratory test
results, which are often not available in developing countries. Thus, a
woman with genital ulcers, for example, would be treated for both
chancroid and syphilis, without further diagnosis of which disease she
actually has. WHO has produced guidelines and a flow chart outlining the
proper diagnosis and treatment under the syndromic approach for use by
practitioners.
As for the integration of STD treatment and prevention into family
planning programs, there are many factors to be considered. For one, the
contraceptive advice given for effective fertility regulation (e.g., IUDs
or the pill) do nothing to prevent the spread of STDs. Meanwhile,
condoms, which offer the most protection against STDs, do not offer
effective birth control. The only real solution is to counsel patients to
use two methods-- advice that many find hard to follow. In addition, STD
screening and treatment can take time and resources already in short
supply--posing a challenging resource allocation question. Nevertheless,
the report offers examples of clinics that have integrated the services
successfully.
In addition to discussing the issues above, the report offers practical
advise on how to recognize and treat STDs, counsel patients, and promote
prevention.
For more information, see Population Reports, Series L, Number 9. June
1993.
Safe Motherhood Operations Research
-----------------------------------
PHN (Population, Health & Nutrition Dept.) has received a grant of
Canadian $3 million from CIDA to conduct operations research on
alternative safe motherhood approaches. The research will include some of
the largest-scale demonstration projects in maternal health. Three
prospective studies will be targeted toward answering key implementation
questions that build upon lessons learned in prior maternal health
research. Each study will include a control area for comparison. The
demonstration projects are aimed at strengthening Bank assistance and
increasing our knowledge of what strategies and specific interventions
are most cost-effective in reducing maternal morbidity and mortality.
The Population Council, which has extensive experience in operations
research in family planning and reproductive health and field offices in
many developing countries, will be the principal executor of the research
program. The research will be conducted in three representative
settings: Ecuador in Latin America, Ghana in Africa, and Vietnam,
Indonesia or India in Asia. A proposal from the Population Council is
currently being reviewed by relevant departments of the Bank to ensure a
strong link between the demonstration projects and current Bank efforts.
The research design focuses on strengthening a continuum of care for
women through enhanced prenatal, delivery and postpartum health services.
Each project is being devised to answer specific questions regarding the
timing, order, content and quality of health care services likely to
improve maternal health. Interventions will be sequenced or phased in, so
that the effects of each project component can be evaluated separately.
Research will be conducted in collaboration with communities, NGOs,
research institutions and government agencies to support local
institution building.
Nexus (Revised)
----------------
The Population, Agriculture and Environment Nexus in Sub-Saharan Africa
(Revised), by Kevin Cleaver and Gotz Schreiber, provides an analytic
framework for looking at cross-sectoral issues arising from the
interactions between natural and social systems. In observing the
challenges facing sub-Saharan Africa, this study tests the hypothesis
that there are significant linkages between rapid population growth,
stagnant agricultural production, and environmental degradation.
Through an examination of the evidence, the findings suggest that there
is indeed a nexus between these factors, which operates through
traditional crop and livestock production techniques, land tenure
systems, women's responsibilities, traditional family planning methods
(e.g., extended and near-universal breast feeding), and methods of forest
resource utilization.
On the population side, the study found that the Boserup hypothesis--that
population density leads to innovation and intensification of agriculture
-- does appear to hold in periods of low population growth. However,
these coping mechanisms cannot keep pace with the rapid population growth
experienced since the 1960s.
In addition to the health, economic, and cultural forces that lead to
high fertility in Sub-Saharan Africa, the report notes that some evidence
exists to link traditional land tenure systems to fertility decisions.
"Where the amount of land allocated is based on the ability to cultivate
it, this ability--under the low-resource farming conditions prevailing in
most of sub-Saharan Africa--is primarily determined by the ability to
mobilize labor. In most cases, this means family labor -- more
specifically, female and child labor."
The report acknowledges that actions to alleviate the burden of high
fertility must emphasize increasing the demand for smaller family size -
factors that also relate to agricultural production and environmental
degradation. Suggested activities include increased education,
reduction of women's work loads, improved agricultural development, and
improved food security. Access to family planning services is, of course,
also necessary.
While the report offers an excellent analysis of the interrelationships
between the three causes of concern, the next step is to devise programs
that will operationalize the findings -- a goal which may prove quite
difficult to achieve.
[This report, published as part of the Agriculture and Rural Development
Series, is available in the World Bank Bookstore. Country and area
studies are in process for Cote d'lvoire, Malawi, Nigeria, Ethiopia,
Rwanda, Kenya, Tanzania, and the Sahel.
---------------------------------------------------------------------
PNN is a quarterly round-up of news and information relevant to Bank
staff working in the population field. It is produced by the
Population, Policy and Advisory Service (PPAS) and edited by Chantal
Worzala.
--Boundary (ID TdCWf8TOI7Ipr62UzzBeVQ)
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archive PHNFLASH PNN5A Population-Related World Bank Work
Population Network News
No. 5, Fall, 1993
Part I
Projects Approved in FY94
-------------------------
* China - Rural Health Worker's Development Project.
As part of the Bank's over-riding objective of reducing poverty in China,
this project will seek to improve the quality of health services in rural
areas through upgrading and expanding the training of rural health
workers. The government of China has made rural health care a priority
because the Chinese countryside contains large pockets of poverty
(involving almost 100 million people). Moreover, less than 30 percent of
the health providers in these areas have received formal clinical
training. One of the objectives of the project is to increase the number
of female doctors working in the rural areas, based on the belief that
they will be better able than their male colleagues to provide maternal
and child health and family planning services. A complementary maternal
and child health project is under preparation.
* Argentina - Maternal and Child Health and Nutrition Project.
This project integrates family planning and reproductive health
activities into larger health and nutrition programs. Designed to ensure
the provision of primary health care, child development, and adequate
nutrition to poor families in urban areas, this project will fund
municipal sub projects in six provinces. The sub projects will be chosen
based on criteria concerning the number of poor to be served, the
administrative and financial capacity of the areas, their commitment to
change, and agreement with the basic package of services set out by the
project. This basic package covers most elements of essential maternal
and child health and nutrition activities, with one focus being women's
reproductive health. Among the interventions listed as priorities for
this element are family planning information and services, prenatal and
postpartum care breast feeding promotion, control of STDs and cervical
cancer screening.
Projects Under Preparation
---------------------------
Ukraine Health Project Ukraine, with a population of 52 million,
separated from the former USSR in 1991. The new nation inherited a health
care system in decay that was over staffed, hospital-centered, and
lacking adequate emphasis on basic health services. There was, moreover,
widespread distrust of Western innovations in fertility regulation
techniques, especially oral contraceptives . These provider attitudes
also influenced public opinion and knowledge: Surveys indicate that
up to two-thirds of the reproductive-age population is uninformed about
the means and methods of modern family planning, despite clear desires to
limit fertility. As a result, there is a great reliance on abortion for
fertility control. The abortion ratio was 155 per 100 live births in
1990, or about 83 abortions per thousand women of reproductive age (a
comparable ratio for the United States is about 25 abortions per 100 live
births).
Heavy reliance on abortion has had serious implications for women's
health. Reports indicate that a third of women who have had abortions
suffer from subsequent inflammatory genital diseases, while many others
experience miscarriages and complications during later pregnancies.
Secondary sterility is also considered a serious consequence of abortion
as performed in Ukraine.
Through the use of withdrawal and other traditional methods of family
planning, coupled with reliance on abortions Ukraine has had very low
fertility for several decades. Data based on the 1989 census indicate a
total fertility rate of 1.9 which, even with demographic momentum, is
below replacement. Fertility has fallen further since independence,
partly in response to economic uncertainty. In 1992, the number of deaths
exceeded the number of births, prompting many Ukrainians to consider
demographic decline as a problem of national security. Given this low
fertility, there is no interest in family planning as a means of reducing
the number of births; there is, however, a strong and growing interest in
reducing dependence on abortion and its negative side-effects through
provision of contraceptives and related services.
To reduce dependency on abortion yet achieve women's fertility
objectives, the Ministry of Health estimated that in 1991 it would have
needed to import about US $72 million in contraceptives, including IUDs,
orals, and condoms. The costs of such imports was then estimated to be
about one quarter of the 4 billion ruble cost of the hospital services
dealing with abortions that could have been avoided had contraceptives
been available. They cannot, however, be purchased without foreign
exchange, which is now a binding constraint on Ukraine's development.
The World Bank, in cooperation with trust fund resources provided by the
Governments of Canada and Japan, is helping Ukraine's Ministry of Health
design a project to strengthen maternal and child health care while
looking towards reforming the health care system. Providing essential
inputs for family planning services and better management of abortion is
expected to be a central part of the project. These services will not
reduce fertility; they will improve reproductive health and cut into the
nearly one million abortions now being performed each year.
This project is a good example of the Bank's broader focus in the
population arena on women's reproductive choice and reproductive health
that expands earlier efforts by some borrower countries to promote family
planning principally as a means to slow population growth.
Projects Under Supervision
---------------------------
Kenya - Population III and Population IV Projects.
Recent, dramatic declines in fertility in Kenya make the recent midterm
review of these projects especially appropriate. Three fertility surveys
show the marked downward trend of fertility in Kenya, the first
Sub-Saharan country where fertility has begun to fall. The total
fertility rate dropped from 7.9 in the late 1970s to 6.7 in the late
1980s, accompanied by an increase in contraceptive prevalence from 6
percent to 27 percent. The midterm review found that the two
projects had made some contributions to the fertility decline through
enhancing contraceptive distribution. However, some restructuring of the
projects will be recommended to better respond to an increased demand
for contraception that is greater than that anticipated during project
preparation.
---------------------------------------------------------------------
PNN is a quarterly round-up of news and information relevant to Bank
staff working in the population field. It is produced by the
Population, Policy and Advisory Service (PPAS) and edited by Chantal
Worzala.