Published by the Global Health Council with support from the David and Lucile Packard Foundation
Authors: Nils Daulaire, M.D., M.P.H. 1701 K Street Suite 600 Washington, DC 20006 (202) 833-5900
Pat Leidl, M.A. Laurel Mackin, M.A. Colleen Murphy Laura Stark, M.Sc. Ph.D.
20 Palmer Court White River Junction, VT 05001 (802) 649-1340
Cover photo: Paul Harrison/Panos Pictures
www.globalhealth.org Š Copyright 2002 by the Global Health Council. All rights reserved.
N
early 200 million women become pregnant around the world each year. The United Nations estimates that one-third of these 1
pregnancies are unintended and unwanted. Of these, many
result in the death of the mother. How many women would be alive today if contraceptives and family planning services had been available to prevent these pregnancies? Thanks to a grant from the David and Lucile Packard Foundation, the Global Health Council has compiled a statistical analysis designed to detail the cost in women’s lives and health as a result of unintended pregnancy. At the 1994 International Conference on Population and Development (ICPD) in Cairo, 179 nations pledged to improve the health of the world’s women. How well has the world done in meeting this commitment? While the goal of this analysis is to provide an accurate metric for assessing the consequences of unintended pregnancy, it should not be forgotten that every statistic included represents the life of a woman or girl, a wife, a mother, a daughter or a sister. These statistics, and the lives they represent, shed light on a hidden and intransigent epidemic of premature death and disability that plays itself out in thousands of communities every minute of every day. The women, whose lives are represented in the analysis detailed in this report, and whose stories appear throughout this document, were victims of a twofold tragedy: they wanted to avoid pregnancy and they wanted to live. It is
1
N. Sadik, The State of World Population 1997, UNFPA, New York, 1997.
©Giacomo Pirozzi/Panos Pictures
a somber reflection of the world’s priorities that they were unable to do either.
"I had been working in a rural clinic in Bangladesh for just a few weeks when they brought her to us. She had been carried for hours on an oxcart from her village, and it was obvious that she was in very serious condition. We learned that she was 19, married at 15, already had two children, and had started active labor six days earlier. She had been attended at home by a traditional birth attendant, but had become exhausted from pushing and the baby had stopped moving. For the last two days she had developed an increasingly high fever. It was only when she seemed close to death that her husband decided to bring her to the clinic. When I examined her, it was immediately obvious that the fetus had died and started to putrefy inside her. She was unconscious and had a raging fever. We whisked her into the operating theater for an emergency delivery but we no sooner had her on the table than she had a seizure, started frothing at the mouth, and stopped breathing. Our efforts to resuscitate her were fruitless. She was the first woman I had ever seen die in childbirth. I went outside to talk to her husband and her sister. Her husband said he could not take her body for burial with the child inside it, so I returned to do a postmortem delivery. I discovered that the decomposing baby was in her abdominal cavity – her uterus, weakened from early and successive pregnancies, had obviously ruptured during labor. When I went back out to tell the husband I had completed this task he asked me if it had been a boy child; both the previous children were girls and he had wanted her to bear him a son. When I said that as best I could tell it was not, he said that in that case it was probably just as well – his wife could only have given him more girl children. With the husband busy with preparing his wife’s body for transportation back to the village, I turned to the sister and asked why the woman had chosen to have so many children so closely spaced and why she hadn’t considered family planning. Her sister, shyly, said that she knew her sister did not want to be pregnant again, but that these things were in the hands of God and of her husband. There was nothing she could have done to prevent it.” — Source: Dr. Nils Daulaire, report from Gonoshasthaya Kendra, Bangladesh, 1976
CHAPTER ONE
The widening gap
T
his story is not an isolated event. Every minute, somewhere in the world, a woman is either dying from, or suffering the effects of a pregnancy that was unplanned and, in many instances, unwanted. These deaths and the accompanying social and
economic costs are almost entirely avoidable; they are the result of poverty, ignorance, social and economic marginalization, entrenched gender bias, and inadequate access to effective family planning services.
THE
PROMISE
In September of 1994, the United Nations International Conference on Population and Development (ICPD) met in Cairo to address issues of population growth and sustainable development. Twenty thousand government delegates, UN representatives, NGOs and members of the media attended the nine-day conference to address a number of critical (and often controversial) issues, including immigration policy, reproductive health, reproductive rights, the empowerment of women, urbanization and access to health care. During the conference, delegates negotiated a 16-chapter Programme of Action that set out a series of recommended actions targeting population and development. Included was a pledge from 179 nations to transform and fund reproductive health services around the world. From what had previously been characterized as a narrow emphasis on population control through
5
ŠAndrew Petkun
Impoverished horizons: The inability of women to adequately time and space their pregnancies leads to high mortality rates in both mothers and their children
contraception – in effect, the rich telling the poor how to control their fertility – delegates expanded the conventional definition of "reproductive health" to include: A state of complete physical, mental and social well-being and not merely the absence of 2
infirmity, in all matters related to the reproductive system and to its functions and processes.
They went on to state: Reproductive health, therefore, implies that people are able to have a satisfying and safe sex life and they have the capability to reproduce and they have the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods for the regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.
At the ICPD, delegate nations made a commitment to generate the estimated U.S. $17 billion per year required to meet the reproductive health needs of the world’s women, with one-third to be provided by donor nations. Also contained in the commitment were assurances that everyone who wished to limit or space their children could do so with appropriate access to family planning services.
WHAT
IS MATERNAL MORTALITY?
The World Health Organization defines maternal mortality as: …death of a woman while pregnant or within 42 days of termination of pregnancy, regardless of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management. Maternal deaths are subdivided into direct and indirect obstetric deaths. Direct obstetric deaths result from obstetric complications of pregnancy, 2
ICPD Programme of Action, 1994.
6
labour, or the postpartum period. They are usually due to five major causes – hemorrhage (usually occurring postpartum), sepsis, eclampsia, obstructed labour and the complications of unsafe abortion – as well as interventions, omissions, incorrect treatment or events resulting from these. Indirect obstetric deaths result from previously existing diseases or from diseases arising during pregnancy (but without direct obstetric causes), which are aggravated by the physiological effects of pregnancy; examples of such diseases include 3
malaria, anemia, HIV/AIDS and cardiovascular disease.
A recent study undertaken by Save the Children points to an indisputable correlation between maternal mortality and inadequate access to quality reproductive health services. This finding has 4
been confirmed by similar studies around the globe, which clearly demonstrate that maternal mortality is highest in countries where women are least likely to have access to modern contraceptive methods. In Burkina Faso, for example, where only 4 percent of women use modern family planning methods, one in 14 will die of maternal causes over the course of her lifetime. In Brazil the opposite is true: nearly three-quarters of the female population regularly use family planning services and their lifetime risk of maternal mortality sinks to one in 130.
THE
CURRENT REALITY
With support from the David and Lucile Packard Foundation, the Global Health Council has undertaken a statistical analysis designed to produce a measure for assessing progress made toward the achievement of 1994 ICPD goals – particularly as they pertain to the health and survival of women. The study was designed to determine whether the further extension of family planning services might play a significant role in reducing deaths of women due to pregnancy and childbirth. The analysis revealed that in the six years following the Cairo ICPD (1995-2000), the world’s 1.3 billion women of childbearing age experienced a total of more than 1.2 billion pregnancies. Of these, more than 300 million – or more than one-quarter – were unintended. During this six-year time period, nearly 700,000 women lost their lives as a result of these 3 4
WHO, Maternal Mortality, 1993. Save the Children, State of the World’s Mothers, 2000, p. 16.
7
unintended and unwanted pregnancies. More than one-third died from the myriad problems associated with pregnancy, labor and delivery. The majority – more than 400,000 – died as a result of complications resulting from abortions carried out in unsafe,
unsanitary
and
often
illegal
conditions. Furthermore, while the Global Health Council’s figures show the number of live births has stabilized at around 131 million per year worldwide, they also reveal that the number of women dying each year as a result
of
unintended
pregnancy
has
increased. The
reasons
for
this
continued
prevalence of maternal mortality are manifold, including social and political upheaval in regions throughout the world, flagging funding for essential services, and the widening HIV/AIDS epidemic. The ©Peter Barker/Panos Pictures
Pre- and post-natal care saves lives: Family planning NGO workers collect information about slum dwellers in Calcutta, India.
figures also reflect the failure of the international community to live up to the ICPD commitments made to the world’s women assuring access to the reproductive health and family planning services that could readily reverse these terrible facts. The figures cited in this report are evidence of a serious health crisis, one that will only deepen as more women move into their prime reproductive years. Over the next decade, 600 million girls will become adolescents, the largest cohort of young women in human history. The worsening condition of women’s health could be slowed or even halted if their survival became a global priority in action, as well as words.
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CHAPTER TWO
ANALYSIS AND RESULTS
T
here are a number of methodological challenges when it comes to compiling data on the relationship between unintended pregnancy and maternal mortality. Countries burdened with the highest mortality rates often have inadequate medical, census and
survey data. Intention is always difficult to establish, particularly when it pertains to something as personal and intimate as pregnancy. Induced abortion in many countries and societies is considered both shameful and illegal, and is, therefore, not readily reported. Our aim in conducting this analysis was to calculate the number of women who died during the six-year period between Jan. 1, 1995, and Dec. 31, 2000, as a result of pregnancies that were unintended and unwanted. This time period was selected because it marked the first full year after the ICPD highlighted maternal deaths as an important social and public health issue, and because a six-year time frame should be sufficient for researchers to detect demographic trends. Based on the best available statistics from the U.S. Census Bureau, UN agencies, reports from the countries themselves, and specialized surveys carried out by a variety of respected research organizations, the Global Health Council compiled a country-by-country profile of all 227 countries for the calendar years 1995 through 2000. For each country and each year, data were generated on the number of pregnancies, the number that ended in miscarriage and abortion, and the number carried to term. For each of these, the Council relied on data sources to calculate the numbers that resulted from unintended pregnancies, those that resulted in the death of the woman, and those
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Š Philip Wolmuth/Panos Pictures
Waiting: A tearful woman waits for pregnancy test results in a government-run health center served by a mobile family planning clinic in the northern village of Kfur Abil, Jordan.
carried to term. Detailed data and its sources are found in the appendix to this report. It is important to note however, that "pregnancy" and "birth" are not synonymous. Pregnancies included those that were miscarried, aborted or carried to term. Ultimately, we calculated estimates of the births that were the consequence of unintended and unwanted pregnancies and that resulted in a mother’s death. Our figures reflect the following constraints: • In compiling the data, we used only the rates on unintended pregnancies, excluding those that are mistimed, even though the mistimed pregnancies could be characterized as unintended; had we included the latter, the number of associated maternal deaths would have been considerably higher. • We did not estimate the number of maternal deaths from unintended pregnancies that ended in miscarriage. Reporting problems and uncertain diagnostics make miscarriage data particularly hard to verify. • The fact that abortion is widely illegal and, therefore, under-reported for fear of legal consequences contributes to mis-reporting and to under-reporting of abortion complications. Reported abortion rates by country is the starting point for this analysis (the data itself assumes that all abortions are the result of unintended pregnancies). To this figure was added the number of mothers’ deaths from unwanted births, gleaned through a country-by-country review of data from the Demographic and Health Surveys. It was assumed that women who carried unintended 5
pregnancies to term had the same mortality risk as the population of mothers at large. Thus, the overall maternal mortality ratio – subtracting the proportion of that mortality associated with abortions – was applied to the proportion of unwanted births. The number of mothers’ deaths from unwanted births added to women’s deaths from abortions was totaled to derive a conservative estimate of the number of maternal deaths from unintended pregnancies. Data for this project were calculated from numerous primary and secondary sources. Some data (such as the population and birth rates) were available by calendar year. Other data (such
5
Ross, Stover, Willard, Profiles for Family Planning and Reproductive Health Programs, Table A.16., 1996.
10
as the maternal mortality ratio, percentage of births that were unwanted, and abortion rates) were available only as a constant figure for the entire time period involved because the surveys upon which they were based were not conducted annually. In a few cases, national data were not available to account for some variables. In these instances, projections were based on regional averages or from rates from neighboring countries and those with comparable profiles. Based on primary data, separate tables were developed for each of the six calendar years included in the study. Countries were arrayed according to seven geographic regions: Africa, Latin America/Caribbean, North America, Near East, Europe, Asia, and the Developed Pacific. Based on the primary data, figures were calculated according to the number of live births, abortions (wherever primary country data were not available), fetal wastage, total number of pregnancies, total maternal deaths, abortion-related maternal deaths, non-abortion-related maternal deaths, unintended pregnancies, unwanted births, deaths resulting from unintended pregnancies excluding abortions, and total deaths resulting from unintended pregnancies. Data for each country and region were then compiled for the entire sixyear period.
RESULTS SUMMARY Unintended pregnancies The analysis reveals that, in the six years from January 1995 through December 2000, the world’s nearly 1.4 billion women between the ages of 15 and 45 experienced a total of more than 1.2 billion pregnancies. Of these, at least 338 million pregnancies (28 percent) were unintended or unwanted. The proportion of unintended pregnancies in each geographic region is shown in Table One. Demographers note that, as countries move through the transition from highly traditional and economically underdeveloped societies to those more economically developed and socially integrated with the rest of the world, an upward curve in the middle stages of this process typically appears in both the proportion and the number of unintended pregnancies. In
11
12
countries where societal norms favor large families, the early development stage is generally characterized by continued desire for many children and a reluctance to consider any births as "unwanted." In Africa, for example, a relatively small proportion of pregnancies (see Table One) are considered "unintended" despite the continent’s high fertility rate. As social conditions and attitudes change, often a lag time occurs between the desire for fewer children and the achievement of those aims. The "mid-development" nations of Latin America and the former Soviet Union characterize this with considerably higher levels of "unwantedness" despite increased access to family planning. As a result of widespread access to quality family planning, more economically developed nations such as those in Western Europe, the Developed Pacific and North America show a decline in “unwantedness” in a direct relationship with a high level of family planning.
Women’s deaths as a result of unintended pregnancies: The analysis shows that during this six-year period, almost 700,000 women died because of an inability to appropriately space, plan for, and prevent their pregnancies. These deaths comprised more than onefifth of all maternal mortality during this period. Furthermore, the number of women dying as a result of unintended pregnancies was shown to have in fact increased somewhat during the course of the six years evaluated. Although the numbers have remained fairly stable on a global scale, marked increases occurred in certain regions of the world, particularly in Africa, as seen in Figure One.
The toll of unsafe abortion Where women have little or no access to simple and reliable methods of contraception, an unintended pregnancy often leads to the decision to have an abortion. Our data confirm that during this period nearly three-quarters of unintended pregnancies worldwide were terminated, resulting in more than a quarter of a billion abortions.
13
14
In no region of the world were even half of unintended pregnancies carried to term (see Table Three). The Near East came closest, with 55 percent of unintended pregnancies resulting in abortions and 45 percent carried to term. Equally striking is the clear indication that prevailing legal and religious strictures apparently had relatively little – if any – effect on recourse to abortion. Latin America, which has some of the strictest abortion laws in the world, nonetheless, saw nearly a quarter of all pregnancies terminated by abortion. Even higher levels in the former Soviet states would indicate that family planning services have, as yet, made only limited inroads there. Globally, the data confirm that nearly 14 percent of all maternal deaths – one out of seven – are the result of abortion complications. National data analyzed herein clearly demonstrate that in countries where women desire to limit their families, and have access to adequate family planning services, the number of women both seeking abortions and dying as a result of them remains relatively low. In contrast, where women do not wish to have additional children but are unable to access quality health care and family planning services, both the number of abortions and the likelihood of dying from complications stemming from the procedure rise sharply. Even where women favor large families – but still have only limited access to reproductive services – mortality rates resulting from abortion remain extremely high. Maternal mortality as a consequence of abortion is directly associated with conditions of poor reproductive health services. The data show that women living in countries with the most limited services – notably in sub-Saharan Africa and South Asia – are those who suffer the highest risk of abortion-related death, despite their relatively lower level of unintended pregnancies (See Figure Two, p. 14 ). Clearly, regardless of whether or not these women wished to be pregnant, it is they who pay the price for a failure to meet the commitments of the ICPD.
15
UNINTENDED PREGNANCY AND MATERNAL MORTALITY “Seven years ago Mili’s sister Sundari became pregnant for the twelfth time. Sundari’s pregnancy – unexpected and unwanted – was uneventful up until the eighth month. One night she awoke bleeding profusely and in great pain. Sundari’s family called in a traditional birth attendant, who undertook a cursory examination only to announce that the 35-year-old woman should be taken to the hospital immediately. Unfortunately, by this time it was one o’clock in the morning; no transport was available. Bleeding and by now in great anguish, Sundari paced restlessly all night until morning. Sometime early in the morning a "compounder" was brought in who pronounced Sundari to be "beyond treatment." He overruled the traditional birth attendant, instructed the family to forgo an expensive hospital stay and persuaded the family that as a medical doctor, his decision should take precedence. While the family argued and agonized, Sundari continued to bleed. By mid-afternoon she was dead. To this date, Sundari’s sister Mili blames herself for failing to bring her sister to the hospital. She cannot bear to look at the seven children (four had died in infancy) left behind.” — Source: Mili Begum, UNICEF Bangladesh
According to the data presented in this report, more than one out of every four pregnancies that take place around the world each year is unintended. While more than two-thirds of these end in abortion, often at the cost of the woman’s life, a very large number are carried to term. Over the course of this study nearly 88 million children were born as the result of unintended pregnancy. While this does not necessarily mean that these children will not be loved or cared for, there is clear evidence that children resulting from such births face considerably higher disease and premature death rates. It is noteworthy that this number is more than twice the figure of 40 million AIDS orphans predicted by the year 2015, with the enormous social consequences this portends.
6
These children, and their families, face another hazard; namely, nearly a quarter of a million of their mothers did not survive childbirth. Again, women living in the most underprivileged 6
UNAIDS, 2000.
16
circumstances bore the highest risk. The reasons for this epidemic of unintended pregnancies are as diverse as the human condition. Poverty, ill health, fear of social ostracism, displacement, rape, incest, maternal depletion/exhaustion and mothers who are either too young or too old to carry a child safely to term are just a very few of the reasons why women seek to limit the number of children born to them. Indeed, the greatest burden on a woman’s health during her young adult years is reproductive in origin. Whether she dies or suffers serious disability as a result of pregnancy is directly correlated to whether she is able to access quality health care and family planning services. While the high levels of unintended and unwanted pregnancies cited in this report have been recognized by the public health community for some time, this analysis presents country-by-country data that, for the first time, highlights this issue from a global perspective. This analysis demonstrates that family planning can save lives and improve health. Failure to provide women with the means to prevent unintended pregnancy poses an extraordinary public health threat, one that could readily be addressed with modest resources.
17
ŠJosef Hadar
CHAPTER THREE
beyond mortality “My dear friend Rina has given birth to eight children, but only three of them survived childhood. On her third delivery her uterus prolapsed but she could not afford the surgery to correct the problem. During the next five years she gave birth to five babies and with each birth the pain got increasingly worse. After her eighth delivery, a part of her uterus fell out and could not be pushed back in. My friend is a hard-working person. She used to be able to do heavy household jobs but can now no longer lift anything heavy. Because of her slowness around the house and sexual problems with her husband, her marriage has become increasingly strained and difficult. At the age of 38, Rina has become seriously disabled.” — Source: Shuchitra Mallik, UNICEF Bangladesh
A
ccording to the World Health Organization, for every maternal death an estimated 30 additional women suffer pregnancy-related health problems that are frequently 7
permanently debilitating. Each year an estimated 17 million women suffer uterine
rupture, prolapse, hemorrhage, vaginal tearing, urinary incontinence, pelvic inflammatory disease and obstetric fistula, a muscle tear that allows urine or feces to seep into the vagina. These and other chronic conditions are more likely to occur in women who are on the cusp of childbearing years – either very young or very old – are suffering poor health, malnutrition or have given birth to a number of children already. Not only do these and other disabilities lead to social and economic isolation, they also increase the risk of maternal mortality during and after subsequent pregnancies. The costs to family and community, while beyond the scope of this analysis, are correspondingly severe. 7
©Karen Robinson/Panos Pictures
Healthy women, healthy world: A mother and her malnourished baby at the Al-Wiwha hospital in Iraq. Opposite: Mothers bring their children to the local NGO hospital for consultation.
WHO, Unsafe Abortion, 1997, p. 3.
19
SOCIAL
COSTS
Statistics related to maternal death, of course, are only indicators of the profoundly disruptive social, economic and emotional cost levied on families and communities owing to the loss of a mother. A mother’s death can in many instances have a far greater impact on the family and community than the death of a child, a septuagenarian or even a father. The death of the mother is very often the death of the household. In developing nations, where an estimated 98 percent of adult deaths relating to poor reproductive health services take place , the loss of a mother translates 8
into the increased likelihood that surviving family will not be able to properly care for existing children. As a result, children of deceased mothers are frequently farmed out to relatives or are forced out on the street. In addition, young children whose mothers have died run a much greater risk of dying themselves.
9
Because the women whose lives are lost are typically between the ages of 15 and 45, elevated levels of maternal mortality represent a significant threat to the broader socio-economic systems in which these deaths occur. Women not only serve as the primary educators of their families, they are also typically the primary caregivers of both young and old. It is women, moreover, who are often the main, if not the sole, breadwinners in their families.
PREVENTING UNINTENDED PREGNANCIES: COSTS AND BENEFITS The World Health Organization and the World Bank estimate that US $3 per person per year would provide basic family planning, maternal and neonatal health care to women in developing countries. This package would include prenatal, delivery and post-natal care in addition to postpartum family planning and the promotion of condoms to prevent sexually transmitted infections.
10
Investment benefits can be measured in a number of ways. The simplest metric is in the number of women’s lives saved as a result of access to appropriate health-care services. What is not ©Marc Schlossman/Panos Pictures.
Women and children, Kinshasa, Democratic Republic of Congo (formerly Zaire).
immediately apparent, however, is the benefit extended to her family, her community and society at large. By the very fact of her preserved life and health, a woman who has the means to regulate 8
Population Action International, A World of Difference, 2000, p. 3.
9
Taylor ME, Analysis of Systems: The Jumla Community Health Program, 2000.
10
WHO/UNFPA/UNICEF/World Bank Statement, Reduction of Maternal Mortality, 1999.
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her own fertility has a greater likelihood of obtaining an education and is more likely to contribute to the social and economic well-being of her family. If already a mother, she will continue to devote time and energy to existing children or other dependents. Finally, she is much more likely to space subsequent births accordingly. This ability to plan for additional children is something that benefits both mother and child. Studies show births too closely spaced not only endanger the mother’s life, but children born to such mothers face higher rates of malnutrition and an increased rate of childhood mortality.
11
What is a boon for the family is also of benefit to the economy as a whole. Studies undertaken by anthropologist Sidney Schuler suggest that new strategies for promoting reproductive health services in Bangladesh are helping to loosen the traditional social strictures that kept women isolated within their homes and, therefore, limited their opportunities and their potential contributions to the economy and society. Indeed, female productivity generates economic activity 12
that has the potential to benefit all. The obverse constitutes a serious hindrance to development that undermines local, regional and national economic aspirations.
REGIONAL DISPARITIES Many regions of the world have witnessed distinct progress in the provision to women of comprehensive reproductive health and family planning services. Contraceptive use has increased tenfold in developing countries, and other regions have undertaken reforms designed to increase access to quality prenatal and antenatal care. Despite this progress, there is a growing disparity between the health care available in industrialized nations and that which is available in the developing world. At present, women in some developing nations run several hundred times the risk of dying in pregnancy and childbirth compared to their counterparts in wealthier nations. In North America and Europe, one woman in 4,000 is likely to die from maternal causes. In Africa, one of every 15 women will die of these causes.
11
UNICEF, State of the World’s Children, 2000.
12
Schuler, SR, Bates, L, Khairul Islam, M; Reconciling Cost Recovery with Health Equity Concerns in a Context of Gender Inequality and
Poverty; International Family Planning Perspectives, vol. 28, no. 4, forthcoming, 2002.
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Tim Dirven/Panos Pictures
CHAPTER FOUR
RISK FACTORS
I
t is most often the poor and illiterate who pay the highest price for inadequate reproductive services; they do so with their lives, broken families, poverty, social isolation and chronic ill health. The human toll exacted from unintended and unwanted pregnancies is typically
a hidden one, buried under often age-old social norms governing the roles of women in society. Economic marginalization, poor education, and geographical isolation contribute further to inconsistent reportage, but are by no means the only indicators of high maternal mortality rates. Indeed, wealth alone does not ensure adequate reproductive health care for women.
LACK
OF
COMMITMENT
FROM
GOVERNMENTS
According to Save The Children’s "Mother’s Index," Kuwait’s annual GDP ranks third in the world. Yet the wealthy Gulf kingdom ranks 50th in the world with respect to overall maternal health. In striking contrast, Costa Rica – with its modest average income of U.S. $6,650 – ranked in 13
12th place for mothers and 8th for children. UNICEF speculates that strong government support for equitable health care and education, as well as emphasis on modern and affordable contraception, has much to do with Costa Rica’s standing. Since the 1970s, the government has invested 7 to 8 14
percent of its GDP in the public health sector. Fully 65 percent of women choose to use modern contraception, while an additional 10 percent rely on other forms of family planning such as the rhythm method. 13
Save the Children, State of the World’s Mothers, 2000, p.19.
14
Population Reference Bureau, Population Today, Washington, D.C., March 1998.
23
©Martin Adler/Panos Pictures
The price of vulnerability: Rwandan Hutu refugee and teenage rape victim mourns her child who died of starvation while both hid from warring Congolese factions in the jungle of Bunyakiri, Democratic Republic of Congo.
Donor governments also enter into this equation. For instance, the United States has been for many years the largest donor to international family planning and reproductive health programs. In the federal budget passed in 1994 (the same year as the ICPD), the total U.S. contribution to these programs reached $585 million. The federal budget enacted by Congress six years later provided $415 million for the same purposes. The inevitable result has been cutbacks at a time when the world seemed prepared to move forward.
YOUTH “Hamida’s parents married her off at the age of 13. Within two months, she became pregnant but almost immediately began experiencing violent bouts of morning sickness that made it impossible for her to keep anything down. After finally seeing a doctor, Hamida’s condition improved somewhat and she was able to resume work in the fields. Her eighth month of pregnancy, however, proved difficult and she again fell ill and was hospitalized for two weeks. In due time, Hamida went into labor. Her family called for a nurse who in turn advised them that Hamida’s condition was critical and that they must move her to a hospital right away. Once there, the attending doctor performed a quick examination and informed the family that, owing to Hamida’s youth and small size, she must undergo a Caesarean section and would require blood for a transfusion. While Hamida’s husband went in search of blood, the attending physician realized he could no longer put off surgery and went ahead. Hamida’s husband returned with blood but it was too late. Both his wife and child were dead.” — Source: UNICEF, Bangladesh
The story of Hamida is not an unusual one in areas of the world where marriage at the age of 12 or 13 is common practice. At this stage of a girl's life, her growth is usually incomplete and her body not sufficiently mature to allow for easy delivery. Pregnancy, therefore, is often very dangerous. Studies undertaken in Jamaica and Nigeria found girls younger than 15 are four to eight times more likely to die during pregnancy or delivery than women aged 15 to 19. Those who survive are more 15
likely to suffer serious bodily harm leading to chronic conditions such as obstetric fistula, vaginal tearing and incontinence. Their offspring are more likely to be born underweight and are, therefore, more vulnerable to increased rates of childhood disease and mortality. © Giacomo Pirozzi/Panos Pictures
Stolen childhood: Tanzania, 13-year-old Rwandan refugee with twins she has borne following a gang rape.
15
Alan Guttmacher Institute, Support for Family Planning Improves Women’s Lives, 1998.
24
Many women living in developing countries give birth to their first child before they reach the age of 18. Throughout most of sub-Saharan Africa, Bangladesh, India and in impoverished Guatemala, 25 to 43 percent of women now aged 20 to 24 delivered their first child before their 18th birthday. If a pregnant teenager is unmarried, she will face even greater risks – family 16
shame and societal disapproval prevent many such girls from seeking any kind of care during pregnancy. For these and other reasons, both social and economic, very young women are less likely to access quality prenatal care than are older mothers and, therefore, are more likely to seek unsafe abortions. The risk factor further increases among this population due to nutritional deficiencies, widespread in most developing countries. These and other factors exacerbate the problem of stunted growth, predispose girls to chronic anemia and increase their risk of maternal hemorrhage.
WOMEN
OVER
35
“Maleka was 45 years old when she became pregnant with her seventh child. She considered the possibility of having an abortion, but discarded the idea for fear her husband would find out. Such was her shame and despair that she didn’t inform anyone – not even her daughters – until she was quite far along. Her pregnancy was a difficult one. Her hands and legs swelled with edema and in her eighth month, Maleka’s entire body ballooned. Minara, her daughter, was beside herself with anxiety and called in the services of a dai – the Bengali term for traditional birth attendant. She wanted to take her mother to the hospital but the dai reassured Minara that her mother was fine and the situation under control. Minara was not convinced and ran to the nearest phone booth to call an ambulance. When she returned the dai informed her that her mother had delivered and that all was well – despite the fact that Maleka continued to bloat and appeared weaker than ever. Ten days following her delivery, Maleka was still ailing. After many entreaties and tears the family finally agreed to take their delirious daughter-in-law to the hospital, where she was promptly put on saline. By then Maleka was so ill she could not speak. When the convulsions started, Minara screamed for the nurse who, not realizing the seriousness of the situation, scolded the distraught girl for being noisy. As night fell Maleka slid into a troubled coma. She never woke up.” — Source: Minara Begum, UNICEF
For older women, age coupled with other factors – such as the number of preceding births and how
16
Liz Gilbert/ courtesy of the David and Lucile Packard Foundation
Heightened risk: Girls under age 18, women over age 35, women who have four or more children, and those who already have health problems are at the greatest risk of pregnancy related complications and maternal mortality.
Ibid.
25
closely they are spaced – drives mortality rates even higher than those experienced by younger women.
17
CLOSELY SPACED PREGNANCIES “Ahila Bala lived in Kamar Para in Chirirbandar of Dinajpur district with her day laborer husband, her only living child and her husband’s parents. Because her husband earned less than U.S. $20 per month the family had to scramble for food and were forced to subsist on a woefully inadequate ration of one meal per day. Ahila Bala’s life had always been hard. Given into marriage at the age of 14, her low caste Hindu parents were too poor to send her to school and considered her a burden. A local religious leader suggested that they marry her off. A grown-up daughter living at home was considered not only a financial liability but also a black mark against the family honor. At the age of 18, she had already given birth three times. Owing to Ahila’s young age, ill health and chronic malnutrition, each child was born underweight and proved too weak to survive – with the exception of one. When she again found herself pregnant, Ahila decided to heed the urging of a local community volunteer, defied her in-laws and sought prenatal counseling at a local clinic. Health care workers found Ahila to be extremely anemic and referred her to a nearby hospital. She did not go.
©Dieter Telemans/Panos Pictures
Anemia causes high mortality rates: Aral Sea, Uzbekistan. Gynecologist Kalbike Jiyemuratovna holds a newborn baby in the town's maternity clinic. “I haven’t seen any healthy babies since the 1980s,” says Kalbike. “All the babies are weak because of the anemia they get from their mothers.”
On March 6, attended by a traditional birth attendant and her paternal aunt, Ahila delivered yet another baby. Passing the placenta however was quite another matter. After more than one and a half hours, the anxious birth 17
Walsh JA, Feifer CN, Measham AR, Gertler PJ, Maternal and Perinatal Health; In Jamieson DT, Mosely WH, Measham AR, Bobadilla
JL, Disease Control Priorities in Developing Countries, Oxford University Press, New York, 1993, pp. 363-390.
26
attendant entreated Ahila’s husband to take her to the hospital, whereupon Ahila looked up pleadingly and told them she was afraid she would not make it. She died a few moments later.”
— Source: Dr. Shehlina Ahmed, Health Advisor, PLAN International Bangladesh Pregnancy and childbirth are hard on the body. For any woman, the chances of serious injury, illness or even death increases exponentially after the birth of her third child. This is because frequent pregnancy, childbirth and breastfeeding deplete women’s physical resources and stamina, making it more difficult for them to fight the effects of blood loss, infection or trauma during or after childbirth. WHO maintains that women who have given birth to five or more children are two to three times more likely to die during pregnancy or childbirth than those who have been able to limit their families to two or three children.
18
WOMEN WHO ARE ALREADY
ILL
Another primary indicator of maternal mortality is poor health on the part of the mother. Malaria, tuberculosis, iron-deficient anemia and the ever-widening threat posed by HIV/AIDS are just a few of the conditions that predispose mothers to problems during pregnancy and birth. According to medical experts, women who are HIV-positive during pregnancy are more likely to suffer severe antenatal and postnatal complications with a higher mortality rate from puerperal sepsis and other complications. In Africa today, women make up more than half of those newly infected with HIV. 19
There is little indication that these numbers will decline anytime soon.
20
Although female-controlled methods of preventing infection are now available, their cost is prohibitive and their use still involves negotiation with a male partner. Vaginal microbicides – gels or creams that kill the virus on contact – are still in the development phase and have not been approved for widespread use.
18
WHO, Unsafe Abortion, 1997, p. 3.
19
JE Wiebenga, Maternal Mortality at Queen Elizabeth Central Hospital, Malawi Medical Journal, 1989-1990.
20
UNAIDS, 2001.
27
©Liba Taylor/Panos Pictures
Already ill: Women in a Salvation Army hospital, which treats many HIV and AIDS patients, Chikankata, Zambia.
UNSAFE ABORTION “She was semi-conscious. Some children playing near her house saw blood coming from her room and ran to alert the neighbors. When they opened the door, they found her lying in a pool of her own blood – so much of it – and she was brought to our clinic by the neighbors. Her name was not known. We at once began resuscitating her. We gave her hydrocortisone, oxygen and dextrose because she was bleeding, bleeding, bleeding. We gave her intravenous fluids. We removed a lot of clots and gave her ergometrine, raised the foot of her bed and sent for the ambulance, which took 40 minutes to arrive. By this time our patient had improved a little and told us her name was Muthoni and that she was the mother of three children. We prayed with the patient. She asked for water – ‘maji’. This is a bad sign, a sign of danger. I did not know whether to insert a speculum – there were so many clots. When the ambulance arrived, a nurse from the facility accompanied her to Kenyatta Memorial Hospital. Her last words were ‘mama yangu’ (my mother), ‘watoto wangu’ (my children) and ‘mungu nisamehe’ (God forgive me). Instead of being taken to the hospital, she was taken to the mortuary.” — Source: Midwife Evelyn Mutio describes the death of a 23-year-old mother of three following a botched abortion
The World Health Organization defines unsafe abortion as follows: Unsafe abortions are characterized by the lack or inadequacy of skills of the provider, hazardous techniques or unsanitary facilities. Although the legality or illegality of the services may not be a defining factor of their safety, for the purpose of these tabulations, unsafe abortion has been defined as an "abortion not provided through approved facilities and/or persons." What constitutes approved facilities and persons will vary according to the legal and medical standards of each country. The definition does not take into consideration the differences in quality, services available or the other substantial differences between health systems.
21
According to the data analyzed in this report, deaths as a result of unsafe abortions account for 64 percent of the 687,000 women who have died as a result of unintended pregnancies since 1995. Contrary to popular stereotypes, the vast majority of women seeking abortions are married and caring for a number of children already. They may seek out abortion services to limit their family, space births, and address contraceptive failure. Most often they undergo abortion because they are unable to access 21
WHO, Unsafe Abortion, 1997, p. 3.
28
dependable family planning services. In regions of the world where access to affordable and effective contraception remains limited or nonexistent, women often undergo self-induced or unsafe abortions. Abortion – whether medical or surgical – when carried out under careful clinical guidelines and with trained personnel, carries the lowest physical risks for women of any significant medical intervention. A procedure that is low risk in the developed world, however, is often fraught with dangers in the frequently unsanitary conditions endemic in the developing world. Current studies show that women living in sub-Saharan Africa still face the greatest risk of mortality owing to unsafe abortion. One of every 150 abortions ends in the death of the woman – as opposed to one in 85,000 procedures undertaken in the developed world. The Global Health Council’s statistical 22
analysis corroborates these figures (see Table Four, p. 16). Despite this stark scenario, many women continue to opt for abortion out of sheer desperation. Women may attempt to induce abortion themselves, or may rely on the services of untrained nonmedical personnel or health workers operating in unhygienic conditions. Methods range from the insertion of sharp objects into the uterus, ingestion of noxious substances, to incomplete dilatation and curettage or external force, such as deep and prolonged abdominal massage. This analysis has revealed yet another reason why women may continue to subject themselves to the risks associated with abortion. In every geographic region of the world the risk of maternal death from abortion was found to be lower than the risk of maternal death from a pregnancy carried to term (see Table Six, p. 30). From a global perspective risk of death was more than twice as great for a woman delivering a child than for abortion. While this discrepancy was hardly surprising in the clinical conditions of economically developed countries, it is particularly striking that it was also evident in Africa and Asia. It is the very women traditionally deprived of effective preventive family planning methods who are most likely to risk abortion in the absence of any other alternative. Theirs is a multiple bind: they can neither prevent their pregnancies nor terminate them safely – but neither can they be confident of surviving childbirth, delivering healthy babies or supporting their children once they are born.
22
Population Action International, A World of Difference, 2000, p. 7.
29
Liz Gilbert/ courtesy of the David and Lucile Packard Foundation
No recourse: A teenage girl is hospitalized for pregnancyrelated complications. The maternal mortality rate in Nigeria is among the highest in the world. A Nigerian woman faces a one in 13 lifetime risk of maternal mortality.
“Shafikun was 35 years old and very poor when she realized she was pregnant with her seventh child. Her previous six children were all grown and she felt so ashamed and embarrassed she decided to risk an abortion. During her fourth month, Shafikun quietly inserted a herbal root into her uterus in the hopes that it would trigger a miscarriage. Soon after the bleeding began, she suddenly collapsed into convulsions and died soon after.” — Source: Taslima Begum, UNICEF Bangladesh
The risk of maternal mortality during abortion depends largely on the skill of the practitioner, the method used, the risks of infection and the general health of the woman involved. The presence of sexually transmitted diseases, anemia, malaria, HIV/AIDS, the woman’s age and the phase at which the abortion is performed all contribute to potential complications. These include sepsis, hemorrhage, genital and abdominal trauma, perforated uterus, poisoning and secondary complications such as gangrene or acute renal failure. Researchers estimate that for every woman who dies as a result of unsafe abortion, 30 more will suffer chronic disability.
23
Chronic pelvic pain, pelvic inflammatory disease (PID), tubal occlusion and secondary infertility are just a few of the long-term chronic conditions that may afflict women who survive unsafe abortion. Typical multiple complications from illegally induced abortion are reported in a 1989 study of 840 patients in Ibadan, Nigeria. These are: sepsis (86 percent), 24
hemorrhage (35 percent), uterine perforations (16 percent), lower genital tract injury (10 percent), renal failure (0.4 percent), embolism (0.2 percent). Of the 840 patients admitted for complications, 59 died. Access to safe and reliable contraception would go a long way towards preventing these women from risking their lives at the hands of unsafe, unskilled practitioners working in unsanitary conditions. By providing women with the means to avoid unintended pregnancy, family planning services prevent abortions and save lives.
23
Ibid.
24
WHO, Unsafe Abortion, Global and Regional Estimates of Incidence of and Mortality Due to Unsafe Abortion, 1997, p. 3
30
“One morning during a visit to one of my weaving groups, I noticed the absence of one of the best weavers. I asked where she was. The government worker assigned to the group replied that she had died two days earlier from a massive hemorrhage resulting from an attempted abortion. She was in her early twenties and already had five children. Abortion in Togo, at this time and also currently, was illegal and safe procedures were unavailable.” — Source: Suzanne Marks, former Peace Corps volunteer
GENDER-BASED VIOLENCE “I punished her by beating with a cane and like, three or four slaps. It is a must that I remain firm as father of the family. I am head of the household.” — Male (45-years old) Tanzania — Source: Population Council, Horizons, HIV and Partner Violence, 2001
Systematized gender bias leads to exploitation on many fronts, but by far the most destructive manifestation is sexual and physical abuse. Gender-based violence is strongly associated with high maternal mortality rates. According to WHO, between 10 and 50 percent of women are violently abused by an intimate partner at least once during their lifetime. “Shahida is the mother of seven children. Within days of giving birth to her third child, she and her husband got into an argument during which he kicked her in the abdomen, knocked her down and then jumped up and down on her stomach. Because she did not want to alarm her children, Shahida bit her lip and kept silent while he kicked her over and over again. That night, while urinating she felt the ligaments holding her uterus give way and the organ slip out. She could even touch it. From that point onward, Shahida has suffered from what is known as prolapsed uterus. Shahida has given birth to four more children since that time. Each pregnancy and delivery has been characterized by an almost inconceivable agony. Her life has become a thing of continued misery. She can neither lift anything heavy – including her children – nor sit down comfortably because her uterus is likely to slip out and she must suffer the humiliation of trying to press it back with her fingers. When clothing sticks to the organ, attempts to pull it off invariably trigger yet another round of bleeding. Sex with her husband is likewise fraught with pain and accompanied by the dread that she will again get pregnant and perhaps die as a result.” — Source: Suchitra Mallik, CARE Bangladesh
©Andrew Petkun
Culturally sanctioned violence: A young girl stands vigil by her ailing sister following a ritual genital mutilation.
31
ŠTim Dirven/Panos Pictures
Population Action International defines gender-based violence as female infanticide, incest, rape, child abuse, prostitution and harmful traditional practices such as forced early marriage, and genital mutilation. The latter – a painful, dangerous and disabling procedure visited on an estimated two 25
million African girls every year – is an important cause of maternal mortality, as well as a major factor in the spread of HIV/AIDS. Physical abuse, moreover, is frequently accompanied by sexual abuse, which in turn contributes to increased rates of unwanted pregnancy. In addition, it increases the likelihood that the victim will be exposed to sexually transmitted diseases, including HIV, hepatitis B and a host of other infectious diseases. A 1999 study in Uttar Pradesh, India, found that women married to abusive husbands were more likely to have unplanned pregnancies and suffer from higher rates of sexually transmitted infections. Researchers 26
determined that fear of violence prevented these women from negotiating sex or demanding that their abusive spouses wear condoms. Along the same lines, a Population Council study undertaken in Dar es Salaam, Tanzania, revealed that 39 percent of HIV-positive female respondents had been the victims of physical abuse, while 17 percent had had at least one partner who had been sexually abusive. Without adjusting for other variables, researchers concluded that HIV-positive women were more than 2.8 times more likely than HIV-negative women to have experienced a violent episode with a current partner.
27
Despite the extreme forms gender-based abuse can take, as with every other indicator of maternal mortality, violence against women speaks to a wider and more deeply entrenched problem relating to the subordinate status of women in many societies.
25
Population Action International, A World of Difference, 2000.
26
Ibid.
27
Population Council, Horizons, HIV and Partner Violence: vol. 7, 2000.
Š Shezad Noorani/Panos Pictures
Bangladesh: An exhausted young prostitute rests before receiving her next customer at the Tanbazar brothel in Nariyan. Left, A Northern Alliance soldier manning a checkpoint. Regressive attitudes towards women extend to the seating arrangements in cars - these women have to sit in the trunk.
33
“Nadzua Kache belongs to the Duruma tribe of coastal Kenya where she lives with her husband and two children. The region she calls home is arid, harsh and the people who live there eke out a meager existence, harvesting maize and whatever else they can scratch from the hostile soil. Because the area is so poor, literacy is low and the resultant traditional culture is bound by ignorance, taboos and strictures that virtually guarantee ill health, particularly for women. For the average Duruma male, family planning is considered an invitation for female promiscuity. In order to maintain the respect of family and community, proprietorial mothers-in-law and unskilled traditional birth attendants further propagate this deep-rooted belief with the result that women are expected to bear as many children as there are "eggs" in her belly. In keeping with this uncompromising attitude, delivering in a hospital is considered "cowardly," and a man whose wife requires such services is sneered at and ridiculed. Angry and humiliated, the husband in question will frequently withhold postnatal support to punish his "weak" wife. Instead of having a goat or a chicken slaughtered in celebration, the new mother must forage for vegetables in the family plot for herself and her newborn child. Community disapproval and censure compel most expectant mothers to risk a home birth despite the obvious dangers. It was in this uncompromising environment that Nadzua began her third labor. Relying on the advice of her local midwife, Nadzua had forfeited all high-protein foods including milk, eggs and meat, so that the baby, "would not become so big and cause problems during delivery." As was typical among her people, Nadzua was still expected to till the fields under the supervision of her husband in order to provide food for both him and "her children." Because she did not have a daughter and field work is not among the "listed" tasks for men, Nadzua toiled alone in the fields, fetched firewood, cooked and provided all means of support for her family. She was the first to rise and the last to go to bed at night. As with her other pregnancies, Nadzua was determined to prove her courage to her husband and quietly acquiesced to a home birth. After hours of agonizing labor, orders from her traditional birth attendant and a gaggle of local female elders to "push harder," coupled with threats by her husband that he would discipline her if she continued "withholding delivery," Nadzua brought forth her baby. The child however, was dead – most likely the casualty of seven hours of futile pushing. Little did anyone know that Nadzua was pregnant with twins – this time the second baby was presenting elbows first. A TBA, trained by the Agha Khan Health services, was sent for and upon arrival immediately declared that Nadzua should never have been forced into a home birth and that she should be sent to the dispensary immediately. She also warned that Nadzua was in great danger of losing the second child and indeed, her own life because she was exhausted from the pointless suffering of the first delivery. Upon arrival at the dispensary, the on-duty nurse quickly examined Nadzua and announced that she needed a Caesarean section – something that could only be undertaken at the nearest hospital fully 60 kilometers away. With no public transport available at that hour of the day, and too poor to afford it in any case, the husband had no means to transport his anguished wife to the hospital. Fortunately a team from the Kenya chapter of the Agha Khan Health Services showed up to deliver a message on their way to the city. Their truck was converted into a makeshift ambulance and Nadzua was successfully transported to the district hospital where she underwent lifesaving surgery. Sadly however, the second baby was also stillborn and to this day her husband condemns her for "wasting his babies." If the same thing happens again, he swears he will divorce her and marry another.” For Nadzua, her double loss has been compounded by a deep sense of powerlessness and despair. Despite the well-intentioned advice of family planning counselors warning of the dangers of conceiving so soon after her last traumatic pregnancy, the odds are stacked against her. With no authority to defy her husband and go on birth control, nor to refuse him, Nadzua will likely conceive soon and continue to do so until all the "eggs in her are exhausted." Chances are she will not survive her next pregnancy. — Source: Fred M. K’ung, Information Office, Agha Khan Health Services, Kenya
34
WOMEN
IN SOCIETY
Although the causes of maternal mortality are complex, they are clearly linked to the continued low status of women in many regions of the world. Deprived of adequate food, medical care, education and the corresponding means to acquire economic independence, many women in the highest risk nations are unable to demand quality healthcare and access to contraception. For the hundreds of thousands of women who die of maternal causes each year, premature death is the final step in a long continuum of deprivation, discrimination and pain. For the many more women damaged and disabled by inadequate care, ignorance and poverty, physical trauma is compounded by an inability – through no fault of their own – to meet the often harsh and unrelenting expectations of family and community. This marginalization is manifested in a variety of ways according to region, custom and socio28
economic status. Seventy percent of the world’s most impoverished people are women. In studies undertaken in Asia, researchers found that most parents routinely fed their female children 16 percent less than male siblings – predisposing them to infectious diseases, malnutrition and greater maternal risk once they reach their childbearing years. Girls are frequently last to receive both medical attention and education. In most developing countries, female literacy lags well behind male literacy; 80 percent of women in sub-Saharan Africa, for example, are deprived of even the most basic education. Illiterate women marry younger, have babies earlier and are often unable to fend for themselves economically nor can they participate in public life. A joint statement on safe motherhood, released in 1999 by WHO, the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF) and the World Bank, acknowledges that: The low social status of women in developing countries is an important factor underlying maternal mortality. Low social status limits women’s access to economic resources and basic education, impeding their ability to make important decisions on childbearing, health and nutrition.
29
©Didier Lefevre/Panos Pictures 28
World Bank Annual Report, 1995.
29
Joint WHO/UNFPA/UNICEF/World Bank Statement, 1999.
Veiled threat: A woman hides her face from a Taliban guard just outside a village mosque, Afghanistan.
35
Without knowledge of reproductive alternatives, women cannot demand what has become a recognized right for women and men living in industrialized nations: namely, to be informed and to have access to safe, effective, affordable and effective methods of family planning of their own 30
choosing. 30
ICPD Programme of Action, 1994.
Paul Harrison/Panos Pictures
Deserted: Pregnant Brazilian mother with her eight children. The father has left his wife and family for another woman.
36
CHAPTER FIVE
CONCLUSION
I
n 1994, the nations of the world met in Cairo and pledged to improve the reproductive health of the world’s women. Yet during the six years that followed, nearly 700,000 women died simply because they could not obtain basic services required to prevent
pregnancies they did not wish to bear. Had their wishes been honored – had they not become pregnant – they would have lived. Tens of millions more did live, but were forced to bear the consequences of pregnancies that were too much for their bodies. Access to family planning and reproductive health services would not have taken away their poverty nor the conditions of life in which they must daily struggle – but it would have given them a chance. Family planning is about preventing needless deaths. It is also about empowering women, their partners and their families to make choices about how many children to have, when to have them, and when to stop. Family planning is not a political term but a medical one: it is a means of identifying and addressing concerns – including health concerns – related to pregnancy and maternity. Countries that fail to provide adequate resources in this area risk provoking the very thing we all seek to avoid – pointless deaths, shattered families and unnecessary suffering. Today, at the start of a new century and a new era of medical breakthroughs, too many women are still dying from causes that were all but vanquished from the industrialized world half a century ago. The divide stretches not only between rich and poor, industrialized and developing, but also between social and cultural expectations and the painful realities that most women live
37
©Mark Hakansson/Panos Pictires
New life, new hope: A newborn baby girl tests her lungs while her mother looks on in a maternity ward in Elbason, Albania.
and die with every day, every hour, and every minute, all over the world. The freedom to choose how many children to bring into the world and when to do so is a right that many take for granted. The same is not true for the vast majority of women living in impoverished and socially disadvantaged circumstances around the world. Theirs remains a grim choice between the lesser of two evils: to carry an unwanted child to term and face ill health, economic want, truncated opportunities for their other children, and even death, or to risk almost exactly the same disastrous consequences through unsafe abortion. The purpose of this analysis was to examine to what degree the global community has lived up to commitments made to the world's women in Cairo in 1994. The results detailed here – of steady or even rising death rates owing to unintended and unwanted pregnancies – speak to the responsibility of governments to furnish services pledged to their citizens. It also calls for governments of affluent countries to assure that means be made available to support those essential services. As the world’s wealthiest and most powerful country, it is also fair to ask why the United States provided nearly 30 percent less support for these efforts in 2000 than it did in 1994. No woman should die trying to become a mother. Nor should any woman die for want of decent reproductive health care that is effective and should be cheaply available around the world. The International Conference on Population and Development represented an important rhetorical step forward in the achievement of women’s reproductive health. This analysis, however, indicates that the world’s rhetoric has yet to translate into reality: women and their families are still suffering from the effects of pregnancies that they can neither physically nor economically support, and many are paying for that fact with their lives. If we are to keep the promises made to the world’s women, we have miles to go before we sleep.
38
Chip Thomas
APPENDIX METHODOLOGY AND DATA SOURCES
40
1
I. Raw Input: Constants Variables input as constants from 1995 to 2000:
II. Raw Input: Yearly Variables input from other sources and available as yearly estimates.
Maternal Mortality Ratio (MMR): maternal deaths per 100,000 live births. Maternal Mortality in 1995: Estimates Developed by WHO, UNICEF, UNFPA 2001. WHO/RHR01.9.2
Number of women aged 15-44 U.S. Census Bureau International Database, Table 94 (1995 Midyear Population by Age and Sexadjusted for population growth)
Percentage of Unintended Pregnancies: Percentage of women answering “no” to DHS survey question, “Was your last birth wanted?” (Does not include mistimed births.) Ross, Stover, and Willard. 1996. Profiles for Family Planning and Reproductive Health Programs. Table A.16. McMillan and Moss consultants estimated unintended pregnancies for countries not included in Profiles for Family Planning and Reproductive Health Programs.
Births Rate: Number of live births per 1000 people. U.S. Census Bureau International Database, Summary Demographic Data.
Abortion Rate: Abortions per 1000 women age 15-44. Henshaw, Singh, and Haas. 1999. The Incidence of Abortion Worldwide. Family Planning Perspectives, vol 25, supplement. January 1999. Abortions, % Unsafe/Illegal: Henshaw, Singh, and Haas. 1999. The Incidence of Abortion Worldwide. Family Planning Perspectives, vol 25, supplement. Table 1. January 1999. Proportion of Maternal Deaths due to Unsafe Abortion (%): Percentage of maternal deaths due to unsafe abortion. WHO, Unsafe Abortion: Global and Regional Estimates of Incidence of a Mortality due to Unsafe Abortion with a Listing of Available Country Data - Third Edition 1997 - Ref. WHO/RHT/MSM/97.16. Unsafe Abortion Mortality Ratio: Deaths due to unsafe abortion per 100,000 live births. WHO, Unsafe Abortion: Global and Regional Estimates of Incidence of a Mortality due to Unsafe Abortion with a Listing of Available Country Data - Third Edition 1997 - Ref. WHO/RHT/MSM/97.16. II.
1
When country data were not available, estimates from the region that includes the country were applied. Regional groupings as defined by the United Nations. In countries where estimate is less than 1% or is negligible, the figure is presented as zero. 2 GHC estimated MMR for countries not included in Maternal Mortality in 1995.
Population: Total mid-year population. U.S. Census Bureau International Database, Table 001 (1995 Total Midyear Population) III. Calculated Data Data calculated from raw input. These variables were calculated either because they were independently important to the analysis or because they were needed as an intermediate step to calculate additional variables. Pregnancies: abortions + fetal wastage + births. Births: calculated from population and birth rate. Abortions: calculated from abortion rate and number of women aged 15-44. Fetal Wastage (miscarriage): abortions + births * 0.17647. Approximately 15 percent of all pregnancies end in miscarriage, so this figure estimates miscarriage via abortions and births. Maternal Abortion Deaths: calculated from births and unsafe abortion mortality ratio per 100,000 live births. Maternal Deaths: calculated from births and maternal mortality ratio (MMR). Maternal Deaths (excluding Maternal Abort. Deaths): maternal deaths - maternal abortion deaths. In some years and countries, this calculation resulted in a negative number, which was adjusted to zero. Unintended Pregnancies: unintended births + abortions. Unintended Births: births * percentage of unintended births. Deaths due to Unintended Pregnancies (not aborted): maternal deaths from pregnancy (excluding maternal abortion deaths) * percentage of unintended pregnancies. Deaths due to Unintended Pregnancies (total): maternal deaths from unintended pregnancies not aborted + number of maternal abortion deaths.
Totals By Region – year 1995–2000 Number of Women Aged 15-44
*Average number of women aged 15-44 for 1995-2000
Pregnancies
Births
Abortions
Maternal Abortion Deaths
Maternal Deaths
Unintended Pregnancies
Unintended Births
Deaths Due to Unintended Pregnancies
1995 Totals AFRICA LATIN AM/CARIBBEAN N. AMERICA NEAR EAST EUROPE ASIA DEVEL PACIFIC
1,312,008,489 130,380,416 116,044,054 66,450,279 58,590,762 189,836,621 708,307,511 42,398,846
201,471,148 34,659,860 19,012,170 6,761,542 10,447,037 20,210,362 106,661,989 3,718,188
130,866,900 25,212,139 11,697,435 4,276,316 7,380,743 10,668,516 69,407,163 2,224,589
40,383,661 4,248,757 4,462,917 1,470,998 1,499,243 6,510,301 21,255,573 935,872
72,583 29,715 4,650 18 2,276 1,817 34,093 13
526,592 276,454 21,966 490 17,717 4,134 205,520 311
55,140,405 6,095,088 6,813,262 1,855,160 2,740,835 8,296,711 28,242,847 1,096,502
14,756,744 1,846,331 2,350,345 384,162 1,241,591 1,786,410 6,987,274 160,630
112,883 45,184 8,726 61 4,789 2,387 51,699 37
1996 Totals AFRICA LATIN AM/CARIBBEAN N. AMERICA NEAR EAST EUROPE ASIA DEVEL PACIFIC
1,327,356,405 133,959,626 118,339,129 66,671,009 57,174,882 190,154,382 718,801,837 42,255,540
201,695,532 35,272,916 19,066,214 6,769,177 10,543,869 20,042,052 106,266,497 3,734,807
130,560,751 25,617,838 11,659,183 4,277,994 7,508,234 10,517,687 68,738,987 2,240,829
40,880,537 4,364,155 4,547,107 1,475,810 1,454,059 6,518,066 21,587,581 933,758
73,123 30,258 4,628 18 2,331 1,777 34,097 13
532,539 282,268 21,855 491 18,032 4,035 205,545 313
55,564,290 6,240,374 6,885,680 1,860,223 2,715,692 8,259,673 28,507,815 1,094,832
14,683,753 1,876,219 2,338,573 384,413 1,261,633 1,741,608 6,920,234 161,074
113,967 46,248 8,678 61 4,884 2,328 51,731 37
1997 Totals AFRICA LATIN AM/CARIBBEAN N. AMERICA NEAR EAST EUROPE ASIA DEVEL PACIFIC
1,347,769,821 137,847,941 120,592,021 66,883,569 59,616,143 190,507,479 730,166,219 42,156,449
202,795,653 35,864,036 19,082,097 6,739,403 10,641,708 19,950,054 106,780,546 3,737,809
130,850,927 25,993,001 11,588,992 4,247,974 7,523,667 10,433,650 68,818,980 2,244,662
41,525,464 4,491,445 4,630,799 1,480,522 1,521,789 6,523,904 21,944,529 932,477
73,532 30,760 4,595 18 2,311 1,765 34,070 13
537,902 287,464 21,708 488 18,217 3,991 205,719 314
56,184,574 6,388,958 6,952,274 1,862,383 2,785,346 8,240,453 28,861,585 1,093,574
14,659,109 1,897,513 2,321,475 381,862 1,263,557 1,716,549 6,917,056 161,097
114,762 47,106 8,615 61 4,894 2,306 51,744 37
1998 Totals AFRICA LATIN AM/CARIBBEAN N. AMERICA NEAR EAST EUROPE ASIA DEVEL PACIFIC
1,366,417,193 141,700,968 122,698,901 67,070,970 61,523,543 190,880,695 740,451,446 42,090,669
203,772,020 36,384,598 19,064,342 6,752,626 10,713,274 19,908,853 107,189,337 3,758,989
131,052,351 26,277,192 11,495,719 4,255,049 7,533,987 10,388,333 68,838,671 2,263,400
42,153,952 4,649,732 4,708,979 1,484,686 1,572,301 6,534,201 22,272,311 931,742
73,782 31,112 4,552 18 2,287 1,760 34,040 13
541,525 291,031 21,525 489 18,402 3,986 205,775 316
56,786,499 6,544,492 7,008,704 1,867,229 2,836,458 8,242,529 29,193,593 1,093,493
14,632,546 1,894,760 2,299,725 382,543 1,264,157 1,708,328 6,921,282 161,751
115,003 47,419 8,535 61 4,899 2,302 51,749 37
1999 Totals AFRICA LATIN AM/CARIBBEAN N. AMERICA NEAR EAST EUROPE ASIA DEVEL PACIFIC
1,383,778,749 145,625,418 124,631,617 67,151,561 63,408,305 191,215,576 749,697,187 42,049,085
204,804,034 36,896,599 19,018,443 6,763,327 10,774,591 19,821,135 107,755,224 3,774,714
131,365,591 26,580,683 11,385,569 4,262,401 7,535,976 10,305,202 69,018,535 2,277,225
42,717,925 4,781,442 4,780,116 1,486,430 1,622,431 6,542,771 22,573,451 931,284
74,033 31,499 4,503 19 2,258 1,758 33,984 13
545,594 295,092 21,306 490 18,577 3,958 205,853 318
57,361,352 6,678,155 7,054,409 1,869,672 2,885,614 8,233,704 29,546,387 1,093,411
14,643,427 1,896,712 2,274,293 383,242 1,263,183 1,690,933 6,972,936 162,127
115,362 47,883 8,443 61 4,898 2,294 51,745 37
2000 Totals AFRICA LATIN AM/CARIBBEAN N. AMERICA NEAR EAST EUROPE ASIA DEVEL PACIFIC
1,401,011,470 149,565,947 126,464,236 67,223,576 65,278,384 191,428,074 759,084,053 41,967,200
205,480,927 37,386,658 18,955,767 6,771,404 10,824,158 19,746,754 108,017,572 3,778,613
131,389,620 26,863,278 11,265,173 4,267,684 7,528,121 10,240,355 68,942,932 2,282,077
43,269,255 4,915,397 4,847,238 1,488,013 1,672,417 6,544,394 22,872,050 929,746
74,228 31,859 4,450 19 2,222 1,759 33,907 13
549,202 298,887 21,074 491 18,738 3,941 205,753 318
57,861,210 6,811,653 7,093,855 1,871,761 2,932,667 8,223,403 29,836,174 1,091,696
14,591,954 1,896,255 2,246,618 383,748 1,260,250 1,679,009 6,964,124 161,950
115,619 48,299 8,346 61 4,888 2,291 51,695 37
Totals 1995-2000 AFRICA LATIN AM/CARIBBEAN N. AMERICA NEAR EAST EUROPE ASIA DEVEL PACIFIC
1,356,390,355* 139,846,719 121,461,660 66,908,494 60,932,003 190,670,47 734,418,042 42,152,965
1,220,019,313 216,464,667 114,199,032 40,557,480 63,944,637 119,679,210 642,671,167 22,503,120
786,086,140 156,544,131 69,092,070 25,587,417 45,010,727 62,553,743 413,765,269 13,532,782
250,930,795 27,450,928 27,977,156 8,886,458 9,342,242 39,173,636 132,505,496 5,594,879
441,282 185,204 27,379 111 13,685 10,636 204,190 77
3,233,354 1,731,195 129,435 2,939 109,684 24,045 1,234,165 1,890
338,898,329 38,758,719 41,808,185 11,186,429 16,896,613 49,496,473 174,188,402 6,563,509
87,967,534 11,307,791 13,831,029 2,299,971 7,554,371 10,322,837 41,682,906 968,629
687,595 282,138 51,344 366 29,251 13,910 310,363 223
41
Totals By Country for the period 1995–2000 Number of Women Aged 15-44
Pregnancies
Births
Abortions
Maternal Abortion Deaths
Maternal Mortality Ratio
Maternal Deaths
Unintended Pregnancies
Unintended Births
Deaths Due to Unintended Pregnancies
AFRICA
42
Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Congo Congo, Democratic Repub. Cote d'Ivoire Djibouti Equatorial Guinea Eritrea Ethiopia Gabon Gambia, The Ghana Guinea Guinea-Bissau Kenya Lesotho Liberia Madagascar Malawi Mali Mauritania Mauritius Mayotte Mozambique Namibia Niger Nigeria RĂŠunion Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa Sudan Swaziland Tanzania, United Republic of Togo Uganda Western Sahara Zambia Zimbabwe
Total
7,045,784 2,043,435 1,239,229 359,900 2,310,869 1,169,249 3,094,613 82,323 717,219 1,624,512 120,401 599,476 9,949,079
6,118,556 3,748,693 2,248,554 390,205 4,255,044 2,001,205 4,575,039 110,732 1,094,500 3,086,538 188,623 894,703 18,702,401
4,482,105 2,757,269 1,636,163 290,646 3,103,776 1,413,390 3,238,916 75,847 779,710 2,282,411 130,711 634,608 13,807,742
718,670 429,121 275,109 41,029 513,013 287,635 649,869 18,276 150,616 341,147 29,619 125,890 2,089,307
1,076 2,702 1,980 142 3,756 2,162 3,174 92 764 2,237 200 622 13,532
150 1,300 880 480 1,400 1,900 720 190 1,200 1,500 570 1,100 940
6,723 35,844 14,398 1,395 43,453 26,854 23,320 144 9,357 34,236 745 6,981 129,793
1,794,375 594,557 368,370 59,049 612,334 365,372 805,337 33,445 160,752 361,689 41,383 144,928 2,779,694
1,075,705 165,436 93,261 18,020 99,321 77,736 155,468 15,169 10,136 20,542 11,764 19,038 690,387
2,431 4,691 2,688 220 5,026 3,521 4,141 102 876 2,525 249 813 19,345
3,090,202 85,811 96,813 810,125 12,100,683 240,809 265,876 4,120,553 1,585,672 270,911 6,356,858 465,223 554,146 3,033,564 2,107,197 2,048,597 523,403 292,084 27,554 4,018,367 371,031 1,977,107 24,133,931 167,710 1,479,827 30,136 2,049,924 21,001 1,023,642 1,453,183 10,733,703 6,884,788 224,362 7,065,196 977,112
5,270,419 153,632 147,141 1,366,510 22,701,894 291,827 456,482 5,340,873 2,574,783 416,527 8,799,264 539,596 990,387 5,293,756 3,436,369 4,043,548 915,544 226,125 53,944 6,329,432 482,834 4,041,983 37,742,218 162,152 2,200,353 53,214 3,101,036 16,747 1,871,599 2,623,749 8,521,797 10,105,145 331,658 11,701,813 1,575,862
3,793,834 109,478 104,739 962,243 16,319,852 197,483 328,986 3,624,982 1,836,548 293,906 5,915,592 405,622 718,809 3,753,438 2,402,545 2,982,229 662,017 120,354 39,074 4,391,502 368,111 2,996,769 28,402,890 96,573 1,506,264 38,541 2,180,799 9,069 1,363,612 1,872,705 5,908,017 7,887,129 256,332 8,208,507 1,122,564
686,025 21,110 20,331 199,291 2,976,768 50,570 59,024 914,763 352,019 60,142 1,563,787 53,035 123,020 746,257 518,370 454,789 116,196 71,853 6,778 988,518 42,297 438,918 3,678,011 41,257 364,037 6,690 455,083 5,166 227,249 357,483 1,335,513 702,248 25,577 1,738,038 216,919
4,591 168 103 1,472 24,969 194 398 4,386 2,222 356 9,051 199 870 5,743 3,676 3,608 801 184 60 6,719 180 3,626 34,367 148 2,305 38 2,639 14 1,650 2,865 2,895 1,893 126 12,559 1,358
1,200 520 1,400 1,100 1,800 620 1,100 590 1,200 910 1,300 530 1,000 580 580 630 870 45 400 980 370 920 1,100 39 2,300 800 1,200 100 2,100 1,600 340 1,500 370 1,100 980
45,526 569 1,466 10,585 293,757 1,224 3,619 21,387 22,039 2,675 76,903 2,150 7,188 21,770 13,935 18,788 5,760 54 156 43,037 1,362 27,570 312,432 38 34,644 308 26,170 9 28,636 29,963 20,087 118,307 948 90,294 11,001
981,944 51,763 28,710 246,441 3,955,959 64,394 72,184 1,241,011 443,847 77,777 2,551,691 156,875 144,585 1,196,669 854,727 568,113 142,676 85,934 10,295 1,151,004 87,575 498,853 4,331,278 49,948 748,135 10,159 603,378 6,436 281,793 451,118 2,694,357 1,001,959 47,365 2,493,221 295,498
295,919 30,654 8,379 47,150 979,191 13,824 13,159 326,248 91,827 17,634 987,904 103,839 21,564 450,413 336,356 113,325 26,481 14,081 3,517 162,486 45,278 59,935 653,266 8,692 384,097 3,469 148,294 1,270 54,544 93,635 1,358,844 299,711 21,788 755,183 78,580
7,784 280 212 1,919 41,097 266 527 5,916 3,213 495 20,382 698 1,059 7,666 5,112 4,185 999 184 68 8,063 326 4,105 40,763 148 10,551 62 4,239 14 2,729 4,220 6,849 6,317 196 19,711 2,033
4,297,124 48,920 1,915,574 2,541,917
8,892,312 87,692 3,329,998 2,859,656
6,501,377 63,678 2,359,268 1,805,397
1,057,093 10,860 471,231 625,311
9,947 15 3,610 2,762
1,100 850 870 610
71,515 541 20,526 11,013
1,570,701 14,044 624,584 800,435
513,609 3,184 153,352 175,124
14,811 42 4,709 3,563
139,846,719
216,464,667
156,544,131
27,450,928 185,204
1,106
1,731,195
38,758,719
11,307,791
282,138
Totals By Country for the period 1995–2000 Number of Women Aged 15-44
Pregnancies
Births
Abortions
Maternal Abortion Deaths
Maternal Mortality Ratio
Maternal Deaths
Unintended Pregnancies
Unintended Births
1,019 7,145 2,444,020 5,977 28,541 25,098 19,585 2,752 905,651 14,941,950 2,940 1,342,279 3,232,380 260,099 1,286,310 6,613 652,571 1,077,545 293,387 14,715 8,791 40,337 754,736 61,089 872,191 290,218 211,086 37,973 6,278,114 729 19,712 315,485 177,114 332,866 3,433,953 186,071 609 3,622 15,131 333 10,626 31,375 104,652 1,650 192,562 1,866,045 8,825 1,712
202 1,638 609,685 1,054 7,150 4,323 10,453 840 498,847 4,592,790 518 308,795 1,160,964 107,894 34,866 1,340 120,020 396,274 47,113 6,771 2,543 9,295 294,974 19,403 440,498 60,481 16,126 7,656 2,685,421 112 4,642 124,018 61,390 63,576 1,412,501 63,390 72 850 3,641 138 2,348 7,470 19,561 500 27,478 590,161 1,085 162
41,808,185
13,831,029
Deaths Due to Unintended Pregnancies
LATIN AMERICA/CARIBBEAN
Anguilla Antigua and Barbuda Argentina Aruba Bahamas Barbados Belize Bermuda Bolivia Brazil Cayman Islands Chile Colombia Costa Rica Cuba Dominica Dominican Republic Ecuador El Salvador French Guiana Grenada Guadeloupe Guatemala Guyana Haiti Honduras Jamaica Martinique Mexico Montserrat Netherlands Antilles Nicaragua Panama Paraguay Peru Puerto Rico Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent & the Gren. Suriname Trinidad and Tobago Turks and Caicos Islands Uruguay Venezuela Virgin Islands, US Virgin Islands, British
Total
2,724 18,355 7,839,035 16,410 71,305 69,251 50,732 14,491 1,738,479 42,275,982 8,072 3,444,948 9,510,636 845,581 2,684,349 17,577 1,888,478 2,911,415 1,368,193 33,949 20,828 103,473 2,554,230 178,143 1,438,977 1,276,319 649,866 101,057 23,855,860 2,056 50,234 1,063,703 642,907 1,150,814 6,005,502 900,746 1,790 9,241 38,301 1,484 27,592 102,158 283,637 3,834 705,489 5,452,495 25,798 5,167
121,461,660
2,212 16,361 6,939,883 12,678 67,224 51,206 66,643 8,060 2,141,139 36,405,429 6,437 3,127,905 8,910,129 730,953 2,497,761 16,057 2,128,663 3,217,061 1,521,434 35,901 22,307 88,592 3,558,535 140,351 2,045,656 1,693,363 608,801 83,071 20,854,681 1,606 43,735 1,197,945 537,388 1,504,029 7,153,365 583,015 1,335 8,818 38,714 1,082 25,988 95,727 222,516 4,450 598,305 5,155,285 23,291 3,944
114,199,032
1,063 8,400 4,064,570 5,853 35,749 22,750 47,515 4,938 1,413,165 20,595,470 3,050 1,625,236 5,502,197 469,106 871,655 8,376 1,276,814 2,053,232 1,046,945 22,572 12,713 44,261 2,564,995 77,613 1,307,115 1,209,622 322,521 40,293 14,133,796 748 22,104 826,787 341,057 1,009,135 4,058,911 372,882 598 4,723 21,417 724 13,812 57,463 104,048 2,632 343,475 3,106,111 12,058 1,802
817 5,507 1,834,334 4,923 21,391 20,775 9,132 1,913 406,804 10,349,160 2,422 1,033,485 2,071,416 152,205 1,251,444 5,273 532,551 681,271 246,275 7,944 6,248 31,042 459,761 41,685 431,693 229,737 194,960 30,317 3,592,693 617 15,070 191,466 115,723 269,290 2,021,452 122,682 537 2,772 11,490 196 8,278 23,905 85,091 1,150 165,084 1,275,884 7,739 1,550
69,092,070
27,977,156
1 6 1,910 4 25 16 10 0 664 9,680 2 764 2,586 94 16 6 907 965 209 11 9 31 513 36 928 242 229 29 2,827 1 16 165 68 474 1,908 265 0 3 15 0 10 27 74 2 161 1,460 9 1
27,379
100 100 85 100 10 33 140 50 550 260 50 33 120 35 24 100 110 210 180 100 100 5 270 150 1,100 220 120 4 65 100 20 250 100 170 240 30 100 100 100 100 100 230 65 100 50 43 100 100
187
1 8 3,455 6 4 8 67 2 7,772 53,548 2 536 6,603 164 209 8 1,404 4,312 1,885 23 13 2 6,925 116 14,378 2,661 387 2 9,187 1 4 2,067 341 1,716 9,741 112 1 5 21 1 14 132 68 3 172 1,336 12 2
129,435
1 6 2,142 4 25 16 22 0 3,173 19,463 2 764 3,434 110 23 6 953 1,611 285 14 10 31 1,250 56 5,461 363 237 29 4,035 1 16 451 117 552 4,634 265 0 4 16 0 10 41 74 2 162 1,460 9 1
51,344
43
Totals By Country for the period 1995–2000 Number of Women Aged 15-44
Pregnancies
Births
Abortions
Maternal Abortion Deaths
Maternal Mortality Ratio
Maternal Deaths
Deaths Due to Unintended Pregnancies
Unintended Pregnancies
Unintended Births
813,462 10,372,967
170,906 2,129,065
18 349
2,299,971
366
NORTH AMERICA Canada United States
Total
6,909,206 59,999,288
3,333,712 37,223,769
2,191,100 23,396,317
66,908,494
40,557,480
25,587,417
8 103
642,556 8,243,902
8,886,458
111
6 12
131 2,808
11
2,939
11,186,429
NEAR EAST
44
Bahrain Cyprus Egypt Gaza Strip Iran, Islamic Republic of Iraq Israel Jordan Kuwait Lebanon Libyan Arab Jamahiriya Morocco Oman Qatar Saudi Arabia Syrian Arab Republic Tunisia United Arab Emirates West Bank Yemen
Total
134,136 160,619 15,066,784 174,111 15,420,720 4,652,527 1,233,492 1,024,956 365,466 923,428 1,147,552 6,859,730 420,012 105,586 3,642,732 3,406,066 2,288,797 410,262 337,011 3,158,017
124,581 110,743 14,905,421 369,512 12,356,651 6,393,285 905,404 1,178,380 387,505 711,124 1,068,020 6,136,066 713,426 104,948 6,276,924 4,183,105 1,392,462 382,922 575,417 5,668,740
80,140 63,293 10,590,398 280,656 7,912,478 4,541,010 663,760 804,832 259,210 427,157 790,767 4,515,966 525,771 68,933 4,635,983 2,901,676 1,065,491 246,714 424,399 4,212,092
25,754 30,839 2,079,216 33,429 2,590,681 893,285 105,834 196,792 70,169 177,298 117,050 699,692 80,642 20,272 699,405 653,965 118,102 78,770 64,706 606,339
16 13 2,542 56 5,697 908 23 161 52 85 190 1,084 105 14 927 580 256 49 85 842
38 0 170 120 130 370 8 41 25 130 120 390 120 41 23 200 70 30 120 850
30 0 18,004 337 10,286 16,802 53 330 65 555 949 17,612 631 28 1,066 5,803 746 74 509 35,803
60,932,003
63,944,637
45,010,727
9,342,242
13,685
244
109,684
32,967 42,864 4,218,477 97,980 3,856,677 1,983,127 145,659 362,587 88,314 249,915 259,388 1,336,444 185,796 29,923 1,116,643 1,263,317 296,039 98,507 162,318 1,069,669
16,896,613
7,213 12,026 2,139,260 64,551 1,265,996 1,089,842 39,826 165,795 18,145 72,617 142,338 636,751 105,154 9,651 417,239 609,352 177,937 19,737 97,612 463,330
17 13 5,665 121 6,431 4,723 25 196 53 165 326 3,414 210 16 940 1,677 338 51 182 4,688
7,554,371
29,251
Totals By Country for the period 1995–2000 Number of Women Aged 15-44
Pregnancies
Maternal Abortion Deaths
Maternal Mortality Ratio
132,677 2,282 169,123 115,842 181,941 949,876 86,938 116,309 511,190 70,123 276,128 105,106 100,974 902 62,218 926,930 155,026 778,547 831 327,325 1,687 1,469 458,827 6,595 30,217 848,627 1,295 1,057,451 141,340 138,277 488 166,679 6,131 77,571 11,693 1,575 240,457 369 49,145 132,963 86,067 4,684,418 323,470 2,357,152 13,659,744 867 705,613 146,736 60,229 310,455 191,552 77,763 396,465 2,301,966 271,442 3,746,314 1,017,342 392,896
4 0 45 1 168 88 1 3 60 3 83 5 0 0 3 12 70 10 0 6 0 0 90 0 1 32 0 1,234 530 0 0 0 0 2 0 0 52 0 9 2 4 368 7 214 1,208 0 8 52 1 22 9 1 921 1,536 556 424 50 2,739
31 10 29 11 37 33 8 15 23 18 14 15 80 100 6 20 22 12 100 2 10 10 23 16 9 11 10 80 80 70 5 27 0 17 0 10 65 15 50 10 9 12 12 60 75 10 50 14 17 8 8 8 120 55 65 45 10 60
62,553,743 39,173,636
10,636
38
Births
Abortions
Unintended Pregnancies
Unintended Births
195,211 2,453 198,272 146,244 384,061 1,148,512 121,293 173,771 626,675 119,740 398,369 130,804 116,164 1,284 86,534 1,427,895 256,668 1,190,700 986 401,112 2,177 1,821 597,336 8,103 89,892 1,006,898 2,017 1,189,386 181,071 169,477 560 204,416 7,451 122,237 15,889 1,930 353,897 467 65,783 225,598 96,695 5,444,856 458,454 2,741,996 16,479,132 935 890,052 205,783 77,838 484,592 213,859 101,650 434,830 3,869,068 302,346 4,566,664 1,289,398 465,173
62,533 171 29,149 30,402 202,120 198,635 34,355 57,463 115,485 49,617 122,241 25,699 15,189 381 24,315 500,965 101,642 412,153 154 73,787 490 352 138,509 1,508 59,675 158,270 722 131,935 39,732 31,199 71 37,737 1,320 44,665 4,196 355 113,439 98 16,638 92,635 10,628 760,438 134,985 384,844 2,819,388 67 184,439 59,047 17,609 174,137 22,307 23,887 38,365 1,567,102 30,904 820,350 272,055 72,276
24,045 49,496,473
10,322,837
Maternal Deaths
Deaths Due to Unintended Pregnancies
EUROPE Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Czech Republic Denmark Estonia Faeroe Islands Finland France Georgia Germany Gibraltar Greece Greenland Guernsey Hungary Iceland Ireland Italy Jersey Kazakhstan Kyrgyzstan Latvia Liechtenstein Lithuania Luxembourg Macedonia, Former Yugo. Malta Man, Isle of Moldova, Republic of Monaco Montenegro Netherlands Norway Poland Portugal Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan
Total
812,975 15,849 796,249 1,755,176 1,895,215 2,345,374 2,130,828 807,701 1,660,786 905,985 2,223,250 1,088,050 312,808 8,354 1,036,974 12,458,734 1,179,802 17,073,403 5,773 2,273,090 12,778 13,604 2,203,778 61,066 853,579 12,406,833 19,614 4,014,621 1,051,634 522,591 7,400 807,551 92,891 453,634 81,202 14,580 1,032,893 5,592 150,014 3,409,310 919,518 8,674,848 2,246,318 5,036,650 33,283,977 6,022 2,153,885 1,241,421 432,679 9,077,634 1,707,234 1,542,908 1,345,775 15,346,442 1,007,580 10,915,833 12,180,824 5,549,384
646,546 7,722 462,761 732,410 1,204,832 1,804,820 910,629 444,120 1,069,898 471,652 978,553 596,058 208,143 5,549 487,780 6,260,423 594,723 6,489,335 3,249 1,108,491 9,191 6,328 1,248,284 37,321 405,054 4,722,387 9,250 3,259,879 1,031,895 298,624 3,376 457,251 46,036 301,450 49,021 7,820 687,308 2,745 127,725 1,518,705 518,037 8,396,989 1,174,579 4,449,999 25,547,209 3,004 1,734,244 581,261 200,332 2,926,082 881,456 653,540 1,970,943 11,745,686 1,228,276 7,735,417 6,277,265 4,937,548
190,670,471
119,679,210
416,887 4,281 224,223 506,707 842,167 584,221 687,097 261,193 398,224 330,781 555,643 401,544 75,947 3,815 352,395 4,394,432 350,489 4,737,390 1,930 614,893 6,126 3,910 602,215 25,128 314,079 3,165,404 6,568 1,713,447 735,772 115,553 2,381 221,985 33,000 178,662 29,975 5,072 343,755 1,965 59,422 1,157,937 354,265 2,453,026 674,923 1,425,349 8,055,395 1,686 768,495 347,336 110,054 2,176,716 557,687 477,747 1,278,837 7,681,872 772,593 2,828,793 4,318,335 3,804,022
129 0 65 56 312 193 55 39 92 60 78 60 61 4 21 879 77 568 2 12 1 0 139 4 28 348 1 1,371 589 81 0 60 0 30 0 1 223 0 30 116 32 294 81 855 6,042 0 384 49 19 174 45 38 1,535 4,225 502 1,273 432 2,282
23 0 47 5 203 123 4 11 69 12 83 9 12 0 4 110 72 58 1 7 0 0 101 0 7 47 0 1,244 533 22 0 11 0 9 0 0 108 0 15 11 5 368 22 387 2,900 0 98 52 4 34 11 3 939 2,085 556 670 74 2,739
13,910
45
Totals By Country for the period 1995–2000 Number of Women Aged 15-44
Pregnancies
Births
Abortions
Maternal Abortion Deaths
Maternal Mortality Ratio
Maternal Deaths
Unintended Pregnancies
Unintended Births
1,808,560 4,172 6,912,366 92,714 28,732 1,292,562 56,705,784 2,913 50,966 13,316 7,747 178,146 50,554,333 15,481,176 5,585 1,951,421 501,953 32,214 1,719,306 26,010 5,253 8,232 159,004 3,586,521 755 1,713,306 9,830 4,011 8,304,480 866 275,520 4,856,849 7,475 113,443 31,280 1,046,306 1,396,369 4,666,475 5,285 467 8,861 10,617,241 597
968,155 2,242 2,168,026 25,589 9,715 673,532 9,713,642 324 26,738 6,258 3,800 18,520 13,416,406 2,496,233 3,157 825,751 232,148 6,040 559,237 16,423 3,720 4,680 61,339 1,066,060 432 883,290 4,089 1,247 3,595,757 334 148,643 2,132,762 3,979 8,942 19,860 252,336 212,491 883,377 2,653 158 3,649 1,220,964 209
Deaths Due to Unintended Pregnancies
ASIA
46
Afghanistan American Samoa Bangladesh Bhutan Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong S.A.R. India Indonesia Kiribati Korea, North Lao People's Democratic Rep Macau S.A.R. Malaysia Maldives Marshall Islands Micronesia, Federated States of Mongolia Myanmar Nauru Nepal New Caledonia Northern Mariana Islands Pakistan Palau Papua New Guinea Philippines Samoa Singapore Solomon Islands Sri Lanka Taiwan Provence of China Thailand Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna Islands
Total
5,002,409 15,315 28,240,121 399,555 79,236 2,579,293 300,077,531 20,555 192,287 56,016 31,327 1,761,880 221,059,090 54,103,930 19,267 5,211,436 1,124,189 121,173 4,833,620 57,064 12,169 28,191 628,476 10,501,920 2,564 4,940,571 45,570 21,937 28,028,114 4,221 1,006,958 18,160,581 27,749 1,095,403 90,634 4,726,010 5,480,919 15,762,907 20,884 2,449 41,370 18,800,075 3,082
8,107,493 14,261 28,354,947 580,710 74,325 3,558,236 198,132,453 6,219 165,271 41,770 34,446 732,500 223,055,285 51,090,334 23,490 4,099,948 1,754,863 70,272 5,234,939 91,784 21,697 29,206 515,809 9,236,184 2,689 6,717,728 36,819 13,734 38,080,439 3,245 1,242,232 18,985,499 25,392 473,610 124,697 3,309,008 3,665,424 11,769,481 22,604 2,057 41,903 23,125,255 2,910
6,050,968 10,192 19,357,376 426,478 44,160 2,405,472 121,420,528 2,696 116,253 28,447 25,332 462,999 152,459,160 30,441,863 17,539 2,359,287 1,221,829 33,558 3,289,631 68,430 16,909 21,273 340,773 5,330,300 1,963 4,880,056 25,554 8,910 27,659,666 2,226 929,021 13,413,595 18,087 298,067 94,573 2,018,689 1,931,733 6,220,966 16,582 1,440 30,405 10,260,200 2,086
840,405 1,930 4,744,340 67,125 19,017 619,030 46,992,141 2,590 24,228 7,058 3,947 159,626 37,137,927 12,984,943 2,428 1,125,670 269,805 26,173 1,160,069 9,587 1,533 3,552 97,665 2,520,461 323 830,016 5,742 2,764 4,708,723 532 126,877 2,724,087 3,496 104,501 11,420 793,970 1,183,878 3,783,098 2,631 309 5,213 9,396,277 388
4,357 5 13,937 307 29 1,588 1,988 1 59 15 13 2 109,771 20,092 9 48 806 1 2,171 49 9 11 4 3,518 1 3,514 13 5 19,915 1 474 8,853 9 197 48 1,453 15 4,106 8 1 16 6,772 1
820 20 600 500 22 590 60 20 20 20 12 7 440 470 20 35 650 20 39 390 20 20 65 170 10 830 10 20 200 20 390 240 15 9 60 60 10 44 20 20 32 95 20
49,618 2 116,144 2,132 10 14,192 72,852 1 23 6 3 32 670,820 143,077 4 826 7,942 7 1,283 267 3 4 222 9,062 0 40,504 3 2 55,319 0 3,623 32,193 3 27 57 1,211 193 2,737 3 0 10 9,747 0
734,418,042
642,671,167
413,765,269
132,505,496
204,190
298
1,234,165
174,188,402
11,598 5 25,384 417 29 5,117 7,657 1 59 15 13 3 159,143 30,176 9 320 2,162 2 2,171 101 9 11 43 4,627 1 10,209 13 5 24,518 1 978 12,564 9 197 50 1,453 34 4,106 8 1 16 7,126 1
41,682,906
310,363
DEVELOPED PACIFIC Australia Japan Korea, South New Zealand
Total
4,137,671 25,279,652 11,902,453 833,190
2,425,367 12,217,244 7,364,107 496,401
1,510,426 7,351,104 4,331,297 339,955
551,138 3,033,558 1,928,197 81,986
14 38 24 2
6 12 20 15
42,152,965
22,503,120
13,532,782
5,594,879
77
14
91 882 866 51
671,972 3,327,602 2,447,953 115,981
120,834 294,044 519,756 33,996
20 72 125 7
1,890
6,563,509
968,629
223