John Cleland

Family planning: the unfinished agenda

Promotion of family planning in countries with high birth rates has the potential to reduce poverty and hunger and avert 32% of all maternal deaths and nearly 10% of childhood deaths. It would also contribute substantially to womens empowerment, achievement of universal primary schooling, and long-term environmental sustainability. In the past 40 years, family-planning programmes have played a major part in raising the prevalence of contraceptive practice from less than 10% to 60% and reducing fertility in developing countries from six to about three births per woman. However, in half the 75 larger low-income and lower-middle income countries (mainly in Africa), contraceptive practice remains low and fertility, population growth, and unmet need for family planning are high. The cross-cutting contribution to the achievement of the Millennium Development Goals makes greater investment in family planning in these countries compelling. Despite the size of this unfinished agenda, international funding and promotion of family planning has waned in the past decade. A revitalisation of the agenda is urgently needed. Historically, the USA has taken the lead but other governments or agencies are now needed as champions. Based on the sizeable experience of past decades, the key features of effective programmes are clearly established. Most governments of poor countries already have appropriate population and family-planning policies but are receiving too little international encouragement and funding to implement them with vigour. What is currently missing is political willingness to incorporate family planning into the development arena.

Demand Theories of the Fertility Transition: An Iconoclastic View

This paper challenges the widely held and influential view that the fertility transition is largely the consequence of changing parental demand for children brought about by changes in the economic costs and benefits entailed in childbearing. Using evidence from both historical and contemporary populations we argue that demand theories do not offer a plausible explanation of the fertility transition. Instead, we propose that ideational, rather than structural, economic change lies at the heart of the transition. In particular, we suggest that attitudes to birth control, broadly defined, play a crucial role.

Contraception and health

Increasing contraceptive use in developing countries has cut the number of maternal deaths by 40% over the past 20 years, merely by reducing the number of unintended pregnancies. By preventing high-risk pregnancies, especially in women of high parities, and those that would have ended in unsafe abortion, increased contraceptive use has reduced the maternal mortality ratio--the risk of maternal death per 100,000 livebirths--by about 26% in little more than a decade. A further 30% of maternal deaths could be avoided by fulfilment of unmet need for contraception. The benefits of modern contraceptives to womens health, including non-contraceptive benefits of specific methods, outweigh the risks. Contraception can also improve perinatal outcomes and child survival, mainly by lengthening interpregnancy intervals. In developing countries, the risk of prematurity and low birthweight doubles when conception occurs within 6 months of a previous birth, and children born within 2 years of an elder sibling are 60% more likely to die in infancy than are those born more than 2 years after their sibling.

The weight of nations: an estimation of adult human biomass

BackgroundThe energy requirement of species at each trophic level in an ecological pyramid is a function of the number of organisms and their average mass. Regarding human populations, although considerable attention is given to estimating the number of people, much less is given to estimating average mass, despite evidence that average body mass is increasing. We estimate global human biomass, its distribution by region and the proportion of biomass due to overweight and obesity.MethodsFor each country we used data on body mass index (BMI) and height distribution to estimate average adult body mass. We calculated total biomass as the product of population size and average body mass. We estimated the percentage of the population that is overweight (BMI > 25) and obese (BMI > 30) and the biomass due to overweight and obesity.ResultsIn 2005, global adult human biomass was approximately 287 million tonnes, of which 15 million tonnes were due to overweight (BMI > 25), a mass equivalent to that of 242 million people of average body mass (5% of global human biomass). Biomass due to obesity was 3.5 million tonnes, the mass equivalent of 56 million people of average body mass (1.2% of human biomass). North America has 6% of the world population but 34% of biomass due to obesity. Asia has 61% of the world population but 13% of biomass due to obesity. One tonne of human biomass corresponds to approximately 12 adults in North America and 17 adults in Asia. If all countries had the BMI distribution of the USA, the increase in human biomass of 58 million tonnes would be equivalent in mass to an extra 935 million people of average body mass, and have energy requirements equivalent to that of 473 million adults.ConclusionsIncreasing population fatness could have the same implications for world food energy demands as an extra half a billion people living on the earth.

Self-reported symptoms of gynecological morbidity and their treatment in south India.

This article presents an analysis of self-reported symptoms of gynecological problems among 3,600 recent mothers in Karnataka State, India. Approximately one-third of all women reported at least one current symptom; the most common were a feeling of weakness and tiredness (suggestive of anemia); menstrual disorders; white or colored vaginal discharge (suggestive of lower reproductive tract infection); and lower abdominal pain and discharge with fever (suggestive of acute pelvic inflammatory disease). Obstetric morbidity, associated with the last live birth, was strongly predictive of current gynecological symptoms. Women who delivered their last child in a private institution were significantly less likely to report symptoms than were those who delivered at home or in a government hospital. Nonusers or users of reversible contraceptive methods were also less likely to report symptoms of morbid conditions than were sterilized women. These associations persisted in analyses controlling for potentially confounding economic and demographic characteristics, and have far-reaching policy implications.

Monitoring sexual behaviour in general populations: a synthesis of lessons of the past decade

This supplement contains selected papers from a workshop on the measurement of sexual behaviour in the era of HIV/AIDS held at the London School of Hygiene and Tropical Medicine in September 2003. The focus was on low and middle income countries, where the majority of HIV infections occur. The motive for holding such a meeting is easy to discern. As the AIDS pandemic continues to spread and as prevention programmes are scaling up, the need to monitor trends in sexual risk behaviours becomes ever more pressing. Behavioural data are an essential complement to biological evidence of changes in HIV prevalence or incidence. Biological evidence, though indispensable, is by itself insufficient for policy and programme guidance. AIDS control programmes need to be based on monitoring of not only trends in infections but also of trends in those behaviours that underlie epidemic curtailment or further spread.

Sexual Abstinence, Contraception, and Condom Use by Young African Women: A Secondary Analysis of Survey Data

BACKGROUND Drug therapy for people with AIDS is a humanitarian priority but prevention of HIV infection remains essential. Focusing on young single African women, we aimed to assess trends in a set of behaviours-sexual abstinence, contraceptive use, and condom use-that are known to affect the rates of HIV transmission. METHODS We did a secondary analysis of public-access data sets in 18 African countries (132,800 women), and calculated changes in a set of behavioural indicators over time. We standardised these trends from nationally representative surveys to adjust for within-country changes in age, education, and type of residential location. FINDINGS Between about 1993 and 2001, the percentage of women reporting no sexual experience changed little. During the same period, the percentage of sexually experienced women who reported no sexual intercourse in the previous 3 months (secondary abstinence) rose significantly in seven of 18 countries and the median for all 18 countries increased from 43.8% to 49.2%. Use of condoms for pregnancy prevention rose significantly in 13 of 18 countries and the median proportion increased from 5.3% to 18.8%. The median rate of annual increase of condom use was 1.41 percentage points (95% CI 1.12-2.25). In the 13 countries with available data, condom use at most recent coitus rose from a median of 19.3% to 28.4%. Over half (58.5%) of condom users were motivated, at least in part, by a wish to avoid pregnancy. INTERPRETATION Condom promotion campaigns in sub-Saharan Africa have affected the behaviour of young single women; the pace of change has matched the rise in contraceptive use by married couples in developing countries over recent decades. Thus continuing efforts to promote condom use with emphasis on pregnancy prevention are justified.

Do unintended pregnancies carried to term lead to adverse outcomes for mother and child? An assessment in five developing countries

This paper investigates whether children later reported as having been unwanted or mistimed at conception will, when compared with children reported as wanted, show adverse effects when the following criteria are applied: receipt of antenatal care before the sixth month of gestation, supervised delivery, full vaccination of the child, and child growth (stunting). The study uses data from five recent Demographic and Health Survey enquiries in Bolivia, Egypt, Kenya, Peru, and the Philippines. In Peru, children unwanted at conception were found to have significantly worse outcomes than other children, but in the other countries, a systematic effect was found only for receipt of antenatal care. Weak measurement of the complex concept of wantedness may have contributed to these results. Birth order of the child, with which wantedness is inextricably linked, has more powerful and pervasive effects, with first-born and second-born children being much less likely to show adverse effects.

Reproductive change in developing countries : insights from the World Fertility Survey

This book assesses the role which the Survey has played in documenting and understanding the emergence of new trends in fertility behaviour which are of the utmost important to the future of mankind. It is the first time that these results have been placed in a broad perspective of scientific knowledge and political relevance. Demographers; social researchers; family planning administrators; students of these and development studies.

Institutional delivery in rural India: the relative importance of accessibility and economic status

BackgroundSkilled attendance at delivery is an important indicator in monitoring progress towards Millennium Development Goal 5 to reduce the maternal mortality ratio by three quarters between 1990 and 2015. In addition to professional attention, it is important that mothers deliver their babies in an appropriate setting, where life saving equipment and hygienic conditions can also help reduce the risk of complications that may cause death or illness to mother and child. Over the past decade interest has grown in examining influences on care-seeking behavior and this study investigates the determinants of place of delivery in rural India, with a particular focus on assessing the relative importance of community access and economic status.MethodsA descriptive analysis of trends in place of delivery using data from two national representative sample surveys in 1992 and 1998 is followed by a two-level (child/mother and community) random-effects logistical regression model using the second survey to investigate the determinants.ResultsIn this investigation of institutional care seeking for child birth in rural India, economic status emerges as a more crucial determinant than access. Economic status is also the strongest influence on the choice between a private-for-profit or public facility amongst institutional births.ConclusionGreater availability of obstetric services will not alone solve the problem of low institutional delivery rates. This is particularly true for the use of private-for-profit institutions, in which the distance to services does not have a significant adjusted effect. In the light of these findings a focus on increasing demand for existing services seems the most rational action. In particular, financial constraints need to be addressed, and results support current trials of demand side financing in India.