A young mother lies with her newborn child. Photo Credit: UNFPA
by Mary Ellen Stanton, CNM, USAID Senior Maternal Health Advisor
When I started midwifery training decades ago in the United States, in the hospital where I worked, I first saw evidence of disrespect and abuse of women in labor. Women were separated from families and visitors from admission to discharge four days later and, in the second and third stages of labor, their legs were secured by stirrups and their wrists put in leather restraints. Soon after, I worked in West Africa in a government maternity and witnessed women being verbally abused — “if you don’t push and your baby is born dead, it will be your fault” – and physically abused by slapping and massive fundal pressure to force delivery. Women were ridiculed for making too much noise in labor — and then were chastised if they were silent and delivered alone.
Fast forward decades later. As I visit maternity services in a number of countries, I don’t need to look far to see and hear evidence of disrespect and abuse of women in childbirth. A convulsing woman in labor on the steps of an urban referral hospital turned away from because she cannot pay. A doctor who derides poor women for not using family planning to control their fertility. A nurse who tells me that postpartum mothers “sneak in” to see their hospitalized newborns at night, while the families seek to find funds to pay the bills in order to get their newborns discharged. Unclothed women laboring and giving birth as visitors walk by. A researcher who tells of a postpartum mother being detained for months because she could not pay her bill. The human rights worker who tells me that refugee women are discriminated against in childbirth and that one refugee was forced to keep her stillborn in her bed with her for 24 hours against her will.
Navrongo, a rural district in northern Ghana that faced high infant and under-5 mortality and where women averaged over 5 children each 20 years ago, was the focus of an innovative and influential public health project from the early 1990s to 2002. Based on the network and infrastructure of an existing vitamin A supplementation program that had started in 1989, the project was ambitious and wide-ranging. It included providing bed nets for malaria prevention, treating and preventing anemia in pregnancy, restructuring the way health services were delivered, combating Female Genital Mutilation, providing family planning services, and more. In a few years, quality health services were available for the first time and the fertility rate and under-5 and infant mortality rates had declined sharply.
Dr. Fred Binka, the former director of the Navrongo Health Research Centre and current professor at the School of Public Health at the University of Ghana joined a panel of Ghanian Ministry of Health officials and researchers at the PopPov conference to discuss the Navrongo project and its wide-ranging effects. Three points struck me from the panel presentation and discussion:
The Cameroon 2011 Demographic and Health Survey – Multiple Indicator Cluster Survey is the fourth DHS in a series that began in 1991. As so often observed in sub-Saharan countries, the birth rate decline has “stalled” at a high level and, in Cameroon’s case, for quite some time. The survey interviewed 15,426 women ages 15 to 49 and 7,191 men ages 15 to 59 from January to August, 2011. The total fertility rate (TFR — the average number of children would bear in her lifetime if the birth rate of a particular year were to remain constant) obtained in the survey was 5.1 for the three-year period preceding the survey. For urban women, the TFR was 4.0 and, for rural women, who were a 46.1 percent of the sample, 6.4. The TFR in the 2010 DHS was actually slightly higher than that obtained in the 2004 survey, when it was 5.0 nationally, and 6.1 for rural women while that of urban women remained unchanged. TFR decline came to an end in Cameroon from 1998 onwards as can easily be seen in the figure below. In the survey, 49.3 percent of women with five living children said they did not wish to have any additional children and 64.9 percent of those with six or more children also said that they wished to cease childbearing. Of those two groups, the percentage who declared themselves to be sterile or who were sterilized was 5.1 percent and 5.9 percent, respectively.
In the survey, 23.4 percent of currently married women said that they were using some form of family planning, with 14.4 percent using a modern method. Use of the male condom accounted for more than half of modern use at 7.6 percent, followed by 3 percent using injectables, and 1.9 percent using the contraceptive pill. Reported contraceptive use was similar to that in the 2004 DHS, which was 26 percent for all methods and 12.5 percent for modern methods. (In the 2007 MICS, contraceptive use was reported as 39.7 percent for all methods and 17.6 for modern methods. TFR data were not collected.)
The 2010-2011 Demographic and Health Survey (DHS) interviewed 15,688 women and 4,929 men ages 15 to 49. The total fertility rate (TFR — the average number of children would bear in her lifetime if the birth rate of a particular year were to remain constant) obtained in the survey was 5.0 for the three-year period preceding the survey. For urban women, the TFR was 3.9 and for rural women, who were 51 percent of the sample, 6.0. There has been slow annual decline in survey TFRs in the country of about 0.7 children per woman since 1986 when it was 6.6, although the pace of decline has slowed recently. The TFR obtained in Senegal’s 2008-2009 Malaria Indicator Survey was 4.9, suggesting a potential stall in TFR decline. When asked about their future childbearing desires, 35.7 percent of married women with five living children said that they wanted no more and, among women with six or more living children, 63.8 percent said that they wanted no more. The desire to cease childbearing only comes after one has quite a large family.
*Malaria Indicator Survey
Note: TFRs are for the three years before the surveys except 1999, which is five years.
The Malawi 2010 Demographic and Health Survey (DHS) is the latest in a regular series of DHS surveys that began in 1992. The survey interviewed 23,020 women ages 15 to 49 and 7,175 men ages 15 to 54 from June to November 2010. The total fertility rate (TFR — the average number of children would bear in her lifetime if the birth rate of a particular year were to remain constant) obtained in the survey was 5.7 for the three-year period preceding the survey. For urban women, the TFR was 4.0 and, for rural women, who were a 81.3 percent of the sample, 6.1. This is a fairly typical difference between urban and rural fertility found in surveys. TFR decline has been quite consistent, although slow. The fastest annual decline in survey TFRs was between the 2000 and 2004 surveys at -0.8 while annual decline from 2004 to 2010 was a bit less. If the -0.05 annual change currently observed in the TFR continued, it would take Malawi over 70 years to reach the two-child family. Regarding possible future fertility trends, 51.4 percent of women with four living children said that they not wish to have any more as did 61.9 percent of those with six or more living children.
In the survey, 46.1 percent of currently married women said that they were using some form of family planning, 42.2 percent a modern method. As in much of sub-Saharan Africa, injectables were by far the most frequently used method, used by 25.8 percent of the women. This method was followed by the pill (2.5 percent) and the male condom (2.4). The use of injectables showed the largest increase, from 18 percent in the 2004 DHS.
Note: TFRs are for the three years before the surveys.
Source: National Statistical Office Zomba, Malawi, Malawi Demographic and Health Survey 2010 (Calverton, MD: ICF Macro, 2011).
The decline in infant and child mortality has been somewhat slower than in other African countries. The infant mortality rate in the five years before the 2010 DHS was 66 infant deaths below age 1 per 1,000 live births, down from 81 in the five to nine years before the survey and 92 in the 10 to 14 years before the survey. The decrease in the child death rate, ages 1-4, was more substantial, having declined to 50 deaths per 1,000 five years before the survey, from 79 five to nine years before the survey, and 97 10 to 14 years before it.
The Rwanda 2010 DHS is the latest in a regular series of DHS surveys that began in 1992, although hostilities had delayed the next survey until 2000. The 2010 survey interviewed 13,671 women ages 15 to 49 and 6,329 men ages 15 to 59 from September 2010 to March 2011. The total fertility rate (TFR — the average number of children would bear in her lifetime if the birth rate of a particular year were to remain constant) obtained in the survey was 4.6 for the three-year period preceding the survey. For urban women, the TFR was 3.4 and for rural women, who were a 85 percent of the sample, 4.8. The TFR saw its fastest decline in the 2010 DHS. From the 2007-08 Interim DHS to the 2010 survey, the TFR fell by 1.1 children nationwide — by 1.3 in urban areas and 0.9 in rural areas in a period of only four and a half years. This is sharpest drop in a sub-Saharan TFR I can ever remember seeing. As an indicator of future fertility plans, 56.2 percent of women with three living children said that they not wish to have any more children as did 76 percent of those with four living children. It is clear that the large family size of eight children per woman is truly a thing of the past.
Note: TFRs are for the three years before the surveys. 2007-2008 data from Interim DHS.
Source: National Institute of Statistics of Rwanda, Ministry of Finance and Economic Planning, Ministry of Health Rwanda, MEASURE DHS, ICF Macro, Demographic and Health Survey 2010, Preliminary Report.
The new Demographic and Health Survey (DHS) in Zimbabwe presents evidence that the country’s progress on reproductive and maternal and child health has stagnated in recent years.
The 2010-2011 Zimbabwe DHS interviewed 9,171 women ages 15 to 49 and 7,480 men ages 15 to 54. The total fertility rate (TFR — the average number of children would bear in her lifetime if the birth rate of a particular year were to remain constant) obtained in the survey was 4.1 for the three-year period preceding the survey and is an increase from the previous DHS in 2005-2006. For urban women, the TFR was 3.1 and, for rural women, who were 61.3 percent of the sample, 4.8. The TFR has been relatively stable since the 1994 DHS, particularly in rural areas. But there has been a noticeable resurgence in the TFR in urban areas in the past five years. The proportion of women who say that they do not wish to have any more children can be an indicator of childbearing intentions. When asked about their future childbearing desires, 49.5 percent of percent of married women with three living children said that they wanted no more and, among women with four living children, 65.2 percent said that they wanted no more. It would seem that the very large families of the past are no longer desired.
Note: TFRs are for the three years before the surveys, except the 1988 survey, which is for five years.
The Burkina Faso 2010 DHS interviewed 17,087 women ages 15 to 49 and 7,307 men ages 15-to 59 from May 2010 to January 2011. The survey was a combined DHS-Multiple Indicator Cluster Survey (MICS), the latter a survey often undertaken by UNICEF to gather additional information, such as child health. The total fertility rate (TFR) obtained in the survey was 6.0 for the three-year period preceding the survey. For urban women, the TFR was 3.9 and, for rural women, who were a little over 72.9 percent of the sample, 6.7. In the capital, Ouagadougou, the TFR was 3.4, but this was higher than in the 2003 DHS, when it was 3.1. Successive surveys indicate that there has been a very slow decline in the TFR over the years and that the pace of decline between the last two surveys slowed. To put these rates into a longer perspective, the TFR was estimated from the 1985 Census at 7.2 and, from a 1991 government survey, at 7.3. As mentioned in previousblog posts on recent DHS, the desire to continue or ceasechildbearing can provide insight into possible future fertility trends. Of the women with 5 living children, 40.2 percent said that they did not wish to have any more children; among women with 6 or more living children, 61.4 percent said that they also wished to ceased childbearing. An additional 5 percent in both groups declared themselves infertile.
In the 2010 survey, 16 percent of currently married women said that they were using some form of family planning, 14.9 percent a modern method. The three most common modern methods were injectables (6.2 percent), implants (3.4 percent), and the pill (3.2 percent). Family planning has increased from the 2003 DHS, when it was 13.8 percent for all methods, modern and traditional, and 8.6 percent for modern methods.
Note: TFRs are for the five years before the surveys except 2010, which is three years.
Source: Ministère de l’Economie et des Finances, Institut National de la Statistique et de la Démographie, MEASURE DHS ICF Macro Enquête Démographique et de Santé (EDS-IV) et à Indicateurs Multiples (MICS) EDSBF-MICS IV.
For New Yorkers, the High-Level meetings at the United Nations often mark a period of blocked traffic, increased security, and general inconvenience. However, this week’s High-Level Meeting on Non-Communicable Diseases marked an important opportunity for the Population Reference Bureau. At the Extended SUN Workshop on Sept. 21, 2011, PRB launched its very first ENGAGE presentation under the RENEW Project. RENEW is a global initiative funded by The Gates Foundation to raise the visibility of malnutrition, mobilize commitment and resources, and accelerate the implementation of proven and promising new approaches.
The objective of the Extended Workshop was to bring leaders and stakeholders together to discuss the first year of progress of the SUN movement, to highlight the links between malnutrition, during the 1000 day window of opportunity, and challenges later in life (including noncommunicable diseases), and to strengthen action in taking the movement forward. Country representatives from Uganda, Benin, Burkina Faso, Ethiopia, Ghana, Guatemala, Lao PDR, Mali, Malawi, Mauritania, Mozambique, Nepal, Niger, Peru, Senegal, the Gambia, Tanzania, Zambia, Zimbabwe, and Bangladesh were recognized for their commitment to scaling-up nutrition interventions, raising expectations about nutrition outcomes, and delivering important policy and programmatic results in a short period of time.
Continuing my recent practice of posting a quick summary of results from new demographic surveys in developing countries, here is another new Demographic and Health Survey (DHS) preliminary report, this time from a sub-Saharan African country. This will help readers of this blog to stay right up-to-date with the latest developments.
The Ethiopia 2011 DHS interviewed 16,515 women ages 15 to 49 and 14,110 men ages 15 to 59 from September 2010 to June 2011. The total fertility rate (TFR — the average number of children would bear in her lifetime if the birth rate of a particular year were to remain constant) obtained in the survey was 4.8 for the three-year period preceding the survey. For urban women, the TFR was 2.6 and for rural women, who were a little over 75 percent of the sample, 5.5. There appears to have been an acceleration of TFR decline from the 2005 to the 2011 survey compared with the 2000 DHS, which had a three-year TFR of 5.5.* In 1990, a government survey had shown the TFR as 6.4. The desire to continue or cease childbearing provides one insight into possible future fertility trends. Of the women with 5 living children, 55.8 percent said that they did not wish to have any more children; among women with 6 or more living children, 68.6 percent said that they also wished to ceased childbearing.
Note: TFRs are for the three years before the surveys, except five years before the 2000 survey
Source: Ethiopian Central Statistics Agency (CSA) and ICF Macro, Ethiopia Demographic and Health Survey (EDHS) 2011, Preliminary Report.
by Eric Zuehlke, web communications manager
Note: TFRs are for the three years before the surveys.
Note: TFRs are for the three years before the surveys. 2007-2008 data from Interim DHS.
