|08. Maternal Mortality and Unsafe Abortion: A Heavy Burden for Developing Countries|
Attitudes concerning ideal family size and the best time to have children are the complex product of social expectations, cultural values and politico-economical circumstances. The desire to have a small family (between 2 and 3 children) has clearly become more common, even in developing countries.
A study based on Demographic and Health Surveys and Contraceptive Prevalence Surveys in 41 developing countries showed that the demand for family limitation is increasing throughout the developing world. The women of Asia, North Africa, Latin America, and the Caribbean tend to want to limit the number of births and family size, whereas those from Sub-Saharan Africa wish simply to space births (Westoff & Bankole 2000).
Unfortunately there is a wide gap between these fertility aspirations and reality, and there are therefore many unwanted or unplanned pregnancies (Bankole et al. 1998).
Worldwide, an estimated 38% of the 210 million pregnancies each year are unplanned, and 22% end in abortion. In Africa, 30% of the 40 million pregnancies each year are unplanned, and 12% end in abortion. in Eastern Europe, 63% of the 11 million pregnancies are unplanned, and 57% end in abortion. By analyzing data from the National Survey of Family Growth, Henshaw found that 49% of the pregnancies that ended in 1994 in the United States were unintended, and that 54% of these ended in abortion (Henshaw 1998).
It therefore appears obvious that reducing the number of unplanned pregnancies by family planing methods would reduce the total number of pregnancies and the number of abortions. Unfortunately, things are not that simple.
Firstly, exposure to the risk of an unwanted pregnancy is as high as the number of children desired is small. As shown in Figure 5, a women who aims to limit her family to two children without requiring an abortion, must successfully practice birth control for 25 of her 30 child-bearing years.
Figure 5. Number of months a women should use a birth control method if she wishes to have only two children
Regarding exposure to the risk of becoming pregnant, sexual relations are beginning increasingly early in adolescents (Görgen et al. 1993, Berglund et al. 1997) (with frequent ambivalence towards the question of pregnancy at this age) (Manning et al . 2000), and extra-marital sexual relation frequently occur phenomenom in married couples (information brought to light by studies on AIDS).
Family planning methods are certainly the most efficient way, to avoid unplanned pregnancy during this long period of exposure to the risk of pregnancy.
Nevertheless, the failure rates of the various family planning methods are non-negligible, associated with methods themselves or with their discontinuation (Skjeldestad 1997). These failures in family planning methods result in a large number of unplanned and unwanted pregnancies, and consequently in numerous abortions (Fu et al. 1999). In France, where more than 1 million women use the IUD, the frequency of unplanned pregnancies linked to IUD failure is estimated at 15 to 20,000 (giving an IUD failure rate of about 1.5%). Around two thirds of these IUD failure end in abortion, accounting for more than 5% of the 200,000 abortions registered annually in France. In Denmark, where the abortion rate has been constant since the early 1980s, half the women undergoing abortions became pregnant despite contraceptive use (Knudsen 1997). In USA, 58% of women having abortions had experienced contraceptive failure, 31% had used a method in the past but were not using contraception during the month in which they conceived, and 11% had never used any method. The proportion of abortion patients whose pregnancy resulted from condom failure increased from 15% in 1987 to 32% in 1994! (Henshaw & Krost 1996)
Although improvements have been made in delivery systems, widespread availability and the broad acceptability of methods remain elusive goals in many developing countries (especially in countries with disorganized and inefficient health systems), contributing to discontinuous use, and resulting in substantial numbers of unplanned pregnancies (Ali & Cleland 1995). In the countries of Central and Eastern Europe, the high cost and poor availability of modern methods of contraception almost certainly account for the high frequency of abortion.
Finally, of course, a large number of men, women and couples not wishing to have children have sexual relations with no contraception, thereby exposing themselves to the risk of unwanted pregnancy and abortion. It is clear that these populations at risk of unwanted pregnancies account for a large proportion of the total number of abortions. In the US, women using contraception are only 15% as likely as women using no method to have an abortion.
Considering the consequences of unplanned pregnancy (particularly in developing countries) it is surprising that couples take so high risk by neglecting or refusing to use a family planning method. However, the decision as to whether or not to use a fertility regulation method is associated with numerous complex factors such as the perceived risk of pregnancy, the openness of communications between partners, the support of parents and peers, desensitization society towards of sex as a taboo topic, the communitys attitude towards sex education and the influence of specific guidance by health staff (Shapiro & Tambashe 1994, Renne 1996).
In industrialized countries in which family planning has long been available and accessible, abortions still take place, the rate depending on the country (low in the Netherlands and Scandinavian countries, higher in France, Great Britain and the USA) with no clear tendency to decrease observed. In developing countries, several different patterns are observed simultaneously. In some developing countries [South America and South-East Asia (Singh & Sedgh 1997)], the desire to have small families is leading to the extensive use of contraceptive methods and abortion. In countries in which access to modern methods of contraception is limited [as in Central and Eastern Europe (Johnson et al . 1993, Kulczycki 1995)] and in countries in which the acceptability of modern methods of contraception is low [Sub-Saharan African countries (Shapiro & Tambashe 1994)] many families use abortion as a means of regulating their fertility.
As stated by Henri David, the evidence is persuasive that people can be motivated to prevent unwanted pregnancies when they perceive themselves as playing an active role in determining their own future and in improving their own and their familys quality of life (David 1992).
So, could family planning decrease the number of unwanted pregnancies? The answer is of course yes but is almost certainly also not completely. No matter how effective family planning services and practices become, unwanted pregnancies will still occur and there will therefore always be a need for access to safe abortion services.