Family Planning Improves
Child Survival and Health

Babies who survive and children who enjoy good health are universal humanitarian goals. Strategies to advance these goals in developing countries include both direct investments in health and nutrition programs and the increased availability of family planning services. These two strategies complement each other, and should be viewed together. Especially in times of fiscal austerity and reduced international assistance, they should not be pitted against each other in competition for scarce funds.

The basic conditions necessary for newborns to survive and for children to flourish are no secret. The ideal would be for all babies to be born to mothers who are in good health, who have obtained adequate prenatal care and who have access to the health facilities necessary for a safe delivery. Also needed are sufficient breastfeeding, good nutrition after weaning, hygienic living conditions—especially clean water and modern sanitation—and medical care that includes immunization against childhood diseases.

But two other, related factors also contribute to improved child health and survival in developing countries. These are smaller families and the use of methods of contraception that allow couples to plan their families. When women can plan when and how many children to have, the number of "high-risk" pregnancies and births is reduced, and infant and child health and survival improve.

Because the conditions that enhance babies' health and chances of survival can be found in most of the developed world, the high infant mortality rates of the past have largely disappeared in the West. In France, Japan and the United States, for example, fewer than 10 babies die for every 1,000 live births. Thus, for most Americans, the death of a baby is a rare event.

Yet some older Americans can remember when infant deaths were as common in the United States as they are currently in many parts of the developing world (Chart A). In 1920, the U.S. infant mortality rate was as high as Nigeria's is today (87 infant deaths for every 1,000 live births; Table 1, column 1). In 1965, it still equaled the current rate of 25 deaths per 1,000 in Sri Lanka, and in inner-city communities particularly, the rate remains close to that level.

Source: National Center for Health Statistics, Vital Statistics of the United States, 1991: Vol. II—Mortality, Part A, U.S. Government Printing Office, Washington, D.C., 1996

Country and year	Infant mortality rate	% of births less than 24 months apart	% of births unplanned	If want no more births, % not using effective method
Sub-Saharan Africa
Botswana, 1988	38	6	53	65
Burkina Faso, 1992–1993	94	9	24	92
Burundi, 1987	74	9	24	97
Cameroon, 1991	64	6	20	84
Cen. Afr. Rep., 1994–1995	97	11	23	92
Cote d'Ivoire, 1994	89	7	28	93
Ghana, 1993	66	5	43	86
Kenya, 1993	62	13	51	62
Liberia, 1986	144	10	u	86
Madagascar, 1992	93	16	23	90
Malawi, 1992	135	11	41	85
Mali, 1987	105	9	14	98
Namibia, 1992	57	7	33	49
Niger, 1992	123	15	13	95
Nigeria, 1990	87	8	11	89
Rwanda, 1992	85	13	49	81
Senegal, 1992–1993	68	11	28	90
Tanzania, 1991–1992	92	6	22	85
Togo, 1988	77	6	39	95
Uganda, 1996	81	8	28	87
Zambia, 1992	107	6	32	83
Zimbabwe, 1994	53	5	42	57
North Africa, Middle East
Egypt, 1992	62	12	34	45
Morocco, 1992	57	10	33	56
Sudan, 1989–1990	70	10	23	90
Tunisia, 1988	48	16	32	49
Asia
Bangladesh, 1993–1994	87	6	32	51
India, 1992–1993	79	10	23	61
Indonesia, 1994	57	6	17	41
Pakistan, 1990–1991	86	20	21	81
Philippines, 1993	34	14	44	68
Sri Lanka, 1987	25	14	36	45
Thailand, 1987	35	12	31	26
Turkey, 1993	53	11	31	61
Latin America & the Caribbean
Bolivia, 1993–1994	75	11	54	84
Brazil, 1996	39	10	47	27
Colombia, 1995	28	11	45	42
Dominican Republic, 1991	43	16	38	33
Ecuador, 1987	57	14	35	58
El Salvador, 1985	67	7	49	40
Guatemala, 1987	73	12	26	67
Mexico, 1987	47	14	51	45
Paraguay, 1990	34	12	23	58
Peru, 1991–1992	55	11	56	66
Trinidad & Tobago, 1987	28	16	35	53
Notes: u=unavailable. Most data for columns 1–3 refer to all births in the five years before the survey. However, data on birthspacing for about one-third of countries are for 10 years before the survey. In addition, data on unplanned births for Burundi, Namibia, Uganda, Sudan and Mexico refer only to the last birth in the previous five years. Source: All data are from the Demographic and Health Surveys.

We have known for some time that better timing and spacing of pregnancies improves child health and survival. Large-scale studies in Western Europe and North America, published in the late 1970s and early 1980s, confirmed the beneficial effects that planned and timely childbearing have on child survival.¹ More recent evidence from developing countries also compellingly links improved child survival with smaller family size and well-timed pregnancies.²

This Issues in Brief will show how family planning can lead to significant improvements in the survival of newborns and the health of small children. Because women who use contraceptive methods can choose when to become pregnant, they are better prepared than women whose pregnancies are unexpected to seek care for themselves during pregnancy, and able to time their pregnancies to achieve the best situation for the infant.

High-Risk Pregnancies
Pregnancies may have a high risk of a poor or tragic outcome if they occur shortly after a birth, are among very young mothers or women past their childbearing prime, or are among women who have already had many births.³ In addition, high-risk pregnancies increase the mother's risk of dying in childbirth, and when the mother dies, her newborn's risk of dying during its first year of life is also increased.

The ways in which ill-timed pregnancies raise the mortality risks for babies are not fully understood. Most experts agree that the causes are primarily biological, even though social factors also play a role. A mother's age, the number of births she has already had and the spacing of those births all affect her health and her ability to carry a subsequent pregnancy safely to term.

Many high-risk pregnancies end in the birth of premature or very low birth weight babies, and such infants often fail to thrive, or lack the resilience needed to overcome the many threats to survival they may face during the first days and months of life. The early weaning that occurs if a mother quickly becomes pregnant again exposes the still-fragile infant to a number of infectious organisms through its intake of water and food rather than breastmilk.

In some instances, newborns face more than one risk-enhancing situation: Some older women giving birth have already had several children; some women with large families have had many pregnancies in rapid succession; and some adolescent mothers not only are physically immature, but are giving birth for the second or third time.

In addition, many women in the developing world whose pregnancies are high-risk for biological reasons also are at risk for social and economic reasons. They often are impoverished, and many live in unsanitary housing, are malnourished and have little education. And many women receive little or no medical care during pregnancy or when they give birth. For these reasons, disentangling the complex web of biological, social, economic and demographic factors that influence rates of child survival is difficult.

Closely Spaced Births
Babies born less than two years apart are much more likely to die than those born after a longer interval, as Chart B shows. This is a serious problem in developing countries where a substantial minority of births occur within less than 24 months of a previous one. Column 2 of Table 1 indicates that closely spaced births account for one in five of all births in Pakistan; one in six in the Dominican Republic, Madagascar, Niger, Tunisia, and Trinidad and Tobago; one in seven in Ecuador, Kenya, Mexico, the Philippines, Rwanda and Sri Lanka; and around one in 10 in another 16 of the 45 developing countries listed.

Source: see reference 2; averages are based on 45 Demographic and Health Surveys..

Closely spaced births present a risk to the health of all three family members involved: the mother herself, who does not have sufficient time to regain her strength after delivery; the initial child, who often has to be weaned early; and the baby born subsequently, who is likely to be premature or low-birth-weight. If all births occurring within less than two years of each other could be more widely spaced, one in four infant deaths in developing countries might be prevented.⁴

Some traditional childbearing practices have helped to ensure lengthy intervals between births. In a number of societies, for example, women have breastfed for long durations. At the same time, cultural taboos often require a lactating woman to abstain from sexual relations. Both sexual abstinence and the lengthy duration of breastfeeding have served to lengthen the interval between successive pregnancies. But as these practices become less common than in the past, the incidence of closely spaced births is likely to increase.

As populations everywhere become more urbanized, as commercial infant formulas become more accessible and as women of childbearing age work away from the home in increasing numbers, both the average length of time babies are breastfed and the once common practice of sexual abstinence after a recent birth are declining in many countries. If women who stop breastfeeding and resume sexual relations do not immediately start to practice some form of contraception, they will soon be at risk of becoming pregnant again.

Age of Mothers
Throughout the developing world, babies born to women younger than 20 are, on average, one-third more likely to die than infants born to women in their 20s and 30s (see Chart C). This is mostly because babies born to very young mothers are more likely to be premature, to be low-birth-weight and to suffer from complications at the time of delivery. And many adolescents do not know how to obtain or cannot afford good prenatal and delivery care. In addition, teenage births are likely to be first births, and first births always carry a higher risk than subsequent births.

Source: G.T. Bicego and O.B. Ahmad, 1996 (reference 2), Chart B; averages are based on 40 Demographic and Health Surveys.

The link between early childbearing and lower rates of infant survival in developing countries has serious implications. One in five women aged 20–24 report having had their first child before their 18th birthday, and two out of five report doing so before they were 20.⁵ This high incidence of teenage childbearing is partly because even when adolescents want to prevent pregnancy, they often face special problems in obtaining the contraceptive products or services that would enable them to do so.

In addition, babies born to women older than 40 are at somewhat greater risk of dying in infancy than those whose mothers are in their 20s and 30s. To compound the problem, older women often have several children already, and babies born after the mother has already had a number of children are also more likely to die in infancy than babies whose mother has had only one or two previous births. Further, in the developing world, many older women with large families are in poor health: They often suffer from such problems as anemia, poor nutrition, cardiovascular disease or uterine prolapse.

For these reasons, helping older women avoid unwanted pregnancy improves child survival. Indeed, high levels of contraceptive sterilization in Latin America (mostly among women in their 30s or older who have had all the children they want⁶) is likely to be one reason for the overall lower infant death rates in Latin America compared with those of Asia and Sub-Saharan Africa (Table 1).

Unplanned Pregnancies
Many women in developing countries acknowledge—even after a new baby is born and part of the family—that they did not plan to have that child. The proportion of births that are reported as unplanned ranges from one-quarter to one-half in most countries (Table 1, column 3). This is troubling because there is some evidence—although it is mostly based on the experience of developed countries—of a link between whether parents wanted a child and its survival and well-being.⁷

In developed countries, women who plan to become pregnant and want a child tend to recognize that they are pregnant soon after conception. Partly because of this earlier awareness, they visit a doctor sooner and generally take better care of themselves during pregnancy than women with unwanted pregnancies. Women with wanted pregnancies are also likely to receive more consideration, support and care from family members. A review by the U.S. Institute of Medicine of the research on this topic concluded that "the child of an unwanted conception is at greater risk of weighing less than 2,500 grams at birth, of dying in its first year of life, of being abused, and of not receiving sufficient resources for healthy development."⁸

In developing countries, there is less evidence that a baby's safe delivery and healthy growth is linked to whether the pregnancy was a wanted one. In addition, prenatal, maternal and child health services are often not widely available or are of poor quality, and poverty sharply limits how well a family can take care of infants and children who are in poor health.

Yet there is little reason to believe that the degree to which a baby is wanted would not have some effect on women's care of themselves during pregnancy and of their newborns subsequently. One study on Indonesia, Korea and the Philippines demonstrates that even after factors such as the parents' education and economic level and the availability of health clinics are taken into consideration, babies are more likely to suffer from acute respiratory infections and severe diarrhea if the pregnancy was unwanted than if it was wanted.⁹

Understanding the Danger
Most women understand the dangers of having children at closely spaced intervals, of having large numbers of children and of having children late in their reproductive years—the three major biological factors associated with high-risk pregnancies.

When married women in developing countries who already have four children are asked if they would like to have more, about eight out of 10 say no; so do half of women with fewer children.¹⁰

Even among women who say they want another child, the vast majority want to delay their next pregnancy. Their preferred interval between births is 3–5 years in all regions of the world.¹¹ If women were able to achieve the intervals they want between pregnancies, fewer babies would die in infancy.

But many women who say they want to stop having children altogether or to delay their next pregnancy are not using the contraceptive methods that would help them achieve these goals. In the countries of Sub-Saharan Africa, 57–98% of women who want no more children are not using an effective family planning method (Table 1, column 4). Nor are about half of women who want no more children in most countries of Asia and Latin America.

A Crucial Combination
Family planning services that help women avoid high-risk and unwanted pregnancies can contribute to improvements in infant and child health even in the poorest of countries. The impact of family planning is probably greatest when it helps women space births at healthy intervals, avoid having large numbers of children, and prevent unwanted pregnancies, especially in their later childbearing years.

Programs designed to encourage and enable women to avoid giving birth in their teenage years would also reduce infant mortality rates. However, this requires raising the average age at which most women marry or encouraging young women to postpone their first pregnancy—both difficult goals.

Nevertheless, the crucial contribution of social and economic development to better health should not be overlooked. The improved living conditions that contributed to a declining infant death rate in the United States have yet to reach many areas of the world. Millions of families in Africa, Asia and Latin America still lack clean water, decent housing, good medical services and sufficient food—basic elements needed to alleviate the causes from which most infants are dying: diarrhea, respiratory infections, malaria, measles and malnutrition.

If Americans want their tax dollars to go toward programs that would improve child health and survival in developing countries, such programs should focus on improving broad health services and economic conditions, as well as on making family planning services available to women who want and need them.

References
1. J. Fedrick and P. Adelstein, "Influence of Pregnancy Spacing on Outcome of Pregnancy," British Medical Journal, 4:753–756, 1973; M.R. Rosenzweig and T.P. Schultz, "Estimating a Household Production Function: Heterogeneity, the Demand for Health Inputs and Their Effects on Birth Weight," Journal of Political Economy, 91:723–746, 1983; and J. Knodel and A.I. Hermalin, "Effects of Birth Rank, Maternal Age, Birth Interval and Sibling Sizeship on Infant and Child Mortality: Evidence from 18th- and 19th-Century Reproductive Histories," American Journal of Public Health, 74:1098–1106, 1984.

2. J.M. Sullivan, S.O. Rutstein and G.T. Bicego, Infant and Child Mortality, Demographic and Health Surveys Comparative Studies, No. 15, Macro International, Calverton, Md., 1994, Table 3.4, pp. 21–23; and G.T. Bicego and O.B. Ahmad, Infant and Child Mortality, Demographic and Health Surveys Comparative Studies, No. 20, Macro International, Calverton, MD, 1996, Tables 3–5, pp. 25–26.

3. J. Haaga, "Mechanisms for the Association of Maternal Age, Parity and Birth Spacing with Infant Health," in A.M. Parnell, ed., Contraceptive Use and Controlled Fertility: Health Issues for Women and Children, National Academy Press, Washington, D.C., 1989.

4. Population Reference Bureau, Family Planning Saves Lives, Washington, D.C., 1997, Chart 2, p. 5.

5. The Alan Guttmacher Institute (AGI), Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, New York, 1995, Appendix Table 5, cols. 7 and 8, p. 48.

6. Ibid., Appendix Table 6, col. 7, p. 50.

7. Institute of Medicine, National Academy of Sciences, The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families, National Academy Press, Washington, D.C., 1995.

8. Ibid., p. 81.

9. E.R. Jensen and D.A. Ahlburg, "Within-Family Resource Pressures and Child Health in Indonesia, Korea and the Philippines," paper presented at the annual meeting of the Population Association of America, Washington, D.C., Mar. 26–29, 1997.

10. Special tabulations of data from the Demographic and Health Surveys.

11. A. Bankole and C.F. Westoff, Childbearing Attitudes and Intentions, Demographic and Health Surveys Comparative Studies, No. 17, Macro International, Calverton, MD, 1995, Table 5.2, p. 17.

Credits
Akinrinola Bankole and Susheela Singh oversaw data compilation and analyses used for this publication, which was written by Deidre Wulf. This Issues in Brief was made possible by support from the Andrew W. Mellon Foundation and the Rockefeller Foundation.

© copyright 1997, The Alan Guttmacher Institute.