Reproductive Health in Developing Countries: Key Features and Key Issues
Joseph M. Kasonde, M.D., F.R.C.O.G.
Acting Regional Adviser, Women's and Reproductive Health, WHO Regional Office for Europe, Copenhagen, Denmark
"Three and a half billion people, three quarters of all humanity, live in the developing countries of the South. These countries vary greatly in size, in levels of development, in economic, social and political structures. Yet they share a fundamental trait: they exist on the periphery of the developed countries of the North. Most of their people are poor; their economies are mostly weak and defenceless; they are generally powerless in the world arena."
South Commission: The Challenge to the South
Oxford University Press 1990
I believe it is appropriate that, as you embark upon the acquisition of knowledge and skills in reproductive medicine, you have in the background an understanding of the environment in which these skills will be applied. The aim of my presentation therefore is to sketch for you the key features and key issues related to reproductive health from the perspective of developing countries.
Let me go straight to the point: the prominent characteristics of reproductive health in developing countries are two: gross reproductive ill-health and excessive fertility. We shall look at the magnitude of these problems, their nature and the underlying factors.
Ninety percent of the 585,000 women who die annually in the world from pregnancy related complications are in developing countries. Maternal mortality ratios range from 200 to over 1000 per 100,000 live births; the lifetime risk of dying from pregnancy related causes can be as high as 1 in 21 in those countries, compared to 1 in nearly 10,000 for industrialised countries (Fathalla, 1992. In most cases the causes - bleeding, infection, eclampsia and obstructed labour - are preventable or treatable, if only the necessary care were available.
For every 1000 women of childbearing age (15-49 years) as many as 20 to 30 have an unsafe abortion; and most of these are in developing countries. Abortion related deaths are therefore common in developing countries, particularly in Asia and Africa. A pregnant woman in a poor developing country runs a risk of dying that is up to 500 times higher than her counterpart in an affluent developed country, and for every maternal death there are at least 20 women suffering from long-lasting pathological sequelae. This unfortunate status of ill-health has been described as "the obstetric pathology of poverty" (Abdel-Aleem et al., 1993).
Reproductive tract infections
The pandemic of AIDS which has gripped the world has disproportionately affected the developing countries. HIV infection in these countries has been mainly transmitted through heterosexual contact. By the end of 1996 more than 22 million people were infected worldwide, of whom 14 million were in sub-Saharan Africa (UNAIDS, 1996). By the time of the last World HIV/AIDS conference in Geneva last year the figure had gone up to 29 million and had increased significantly in South and Southeast Asia (UNAIDS, 1998).
But it is not only the feared AIDS. At least 333 million new cases of curable sexually transmitted diseases (STDs) are estimated by WHO to have occurred globally in 1995 mostly in developing countries. In Cameroon, for example, reproductive tract infections (RTIs) are reported to be among the top five causes of consultation at medical institutions (Meheus, Schultz and Cates, 1990); while in Zimbabwe, up to 10% of the population were reported to have at least one RTI (Laga, 1994). Studies of women in India, Bangladesh and Egypt have shown RTI rates ranging from 52% to 92% (Younis et al., 1993). Syphilis in developing countries remains at levels comparable to those in Europe one hundred years ago.
Pelvic infection may lead to infertility. A multicentre study conducted by the Special Programme assessed the proportion of infectious causes of infertility in different parts of the world: in Africa nearly 80% of infertile couples had an infectious aetiology, compared with about 40% of infertile couples in other developing countries and 20% in industrialised countries (Cates et al., 1985).
Female genital mutilation (FGM) is the most serious trauma to girls and women. The practice is almost entirely limited to the developing countries of Africa and the Middle East.
In the year that Emperor Augustus Caesar died, AD: 14, the population of the world was 260 million (Belloch, 1886). By the year 1815 it had reached 1 billion and increased rapidly thereafter to 2 billion in 1927, 3 billion in 1960, 4 billion in 1976 and 5 billion in 1987. It is now nearly 6 billion. The notable feature is that, of the 2.8 billion people added to the world's population between 1950 and 1990, 87% were in developing countries. Moreover, the number of inhabitants in developing countries more than doubled, while the number in developed countries grew by 45%. By 1990, over three-quarters of the world's population were living in the developing countries (UN, 1991).
The United Nations estimates that the percentage distribution of the global population will be 58 in Asia and 22 in Africa by the year 2050, compared to only 7 in Europe and 4 in North America. As early as 2025 Africa's population is expected to have increased by 150%, while Europe's will only have increased by 3%.
Contraceptive prevalence surveys ten years ago showed that, worldwide, about 325 million out of nearly 800 million married couples of reproductive age were estimated to use an effective modern form of contraception (Mauldin & Segal, 1986). Of these, about 135 million relied on voluntary male or female sterilization; 70 million used the intrauterine device (51 million in China alone) and 55 million used oral contraceptives. But, although 40-50% of couples now use contraceptives the percentage in developing countries is low, in some countries as slow as 5%. Developing countries therefore are unlikely to reduce population growth rapidly.
Correspondingly total fertility rates in the developing countries are high, although they are declining slowly.
Maternal health care is poor in developing countries. Bad health services contribute significantly to maternal deaths. For example, a study of 152 maternal deaths in Dakar, Senegal, showed that the following major risk factors were associated with health system failures: medical equipment breakdown, late referral, lack of antenatal care and, most importantly, non-availability of health personnel at the time of admission (Garenne et al., 1997). Indeed the lack of a skilled attendant at the time of childbirth is the most serious risk factor for maternal death and yet the percentage of births attended by a trained person can be as low as 5% in some developing countries. Similarly family planning services can be poor and erratic, contributing to the lack of interest among potential clients.
But behind this health system obstacle to the health of women in developing countries lies a plethora of other factors: social, cultural and political.
Social factors: education
The correlation between lack of education and high risk for maternal mortality has been demonstrated in several studies and reports (e.g. Harrison, 1996; World Bank, 1993). It applies equally to child health, which depends very much on parental schooling, especially the mother's (World Bank, 1993). It has also been shown to determine the level of use of contraception.
Some cultural practices are detrimental to reproductive health. For example, in some societies pregnant women are prohibited from eating certain foods, thus contributing to poor nutritional status and anaemia. It is well known that anaemia is a risk factor for maternal morbidity and mortality (Bagnall, 1974). In other societies the practice of female genital mutilation (FGM) causes pain and difficulties in childbirth: this practice is common in South East Asia and Africa (Toubia, 1994).
Political stability is essential to the sustainability of health programmes. Civil wars and the refugees resulting from them are not and cannot be conducive to the delivery of health care. Moreover, when you compare the percentage of central government spending in such countries on defence, education and health, it is clear that defence is given priority (WHO, 1993).
Ultimately poverty is the underlying determinant and common denominator for all these medical, social and political factors. The sheer magnitude of the difference in Gross National Product (GNP) between countries is appalling. While the industrialised countries have a GNP per capita of $23,262 the least developed countries have a per capita GNP of $200, and the gap is increasing. Income per person remained below $1,500 per year for the poorest in 40 years to 1990 while it rose from under $4,000 to over $10,000 in the rich countries in the same period (Bergström and Syed, 1994). In this period GNP for rich countries has increased three times, compared to 1.5 times for the middle income countries, marginally for the poor and none at all for the poorest countries. The gap between the rich and the poorest countries has increased from 8-fold to reach 30-fold. The relation between wealth and life expectancy is well known (World Bank, 1993).
And that is not all. The debt burden and structural adjustment programmes (SAP) have made their mark on the access of the poor to health care.
Developing countries have had a debt crisis since the seventies (Oxfam, 1986). When the price of oil quadrupled in 1973, the oil producing countries deposited their newly acquired billions in Western commercial banks, which in turn had to find new borrowers. The developing countries swallowed the bait. When interest rates began to rise in the late seventies, the debts increased while exports fell. Today there are developing countries which have a debt burden higher than their GNP. This means that imports such as medicines are outside their reach.
Structural Adjustment Programmes (SAP)
The World Bank and the International Monetary Fund, in an attempt to save the collapsing economies, introduced structural adjustment programmes (SAP), the aim being to recover debts in the short term and increase wealth through sustained economic growth. But in the health sector, hospital fees introduced as part of these SAPs deterred women from using health services and this led to an increase in maternal mortality (Ekwempu et al., 1990).
Poverty is the root cause of the double tragedy of high maternal mortality rates and excessive fertility in developing countries. It exerts its influence through illiteracy, malnutrition and a low status of women. It weakens the health care system and reduces access to the little there is. It determines whether health services are utilised or not.
Thus, reproductive health in developing countries is a complex issue, involving an interaction between demographic, socio-cultural and medical factors, all in turn determined by poverty. These factors may be summarised by paraphrasing the paradigm proposed by Griesgraber and Gunter (1996). It is important to bear in mind this background as you study in depth the application of current interventions to improve reproductive health.
- Abdel-Aleem et al., (1993). The obstetric pathology of poverty in Bergström S, Molin A and Poverty WG. Poverty and reproductive Health. Uppsala University, Uppsala, Sweden
- Bagnall D (1974) Obstetric rituals and taboos. Nursing times, July 18, 1974, pp 1130-1133
- Belloch J (1886), quoted by Tarver JD (1996) in JD Tarver, The demography of Africa, p13. Praeger Publishers, Westport, USA
- Bergström S and Syed SS (1994) Population control: controlling the poor or the poverty? In: Lankien KS et al. Eds. Health and disease in developing countries, 1994:31. MacMillan Press
- Cates WJr., Farley TMM, Rowe PJ and the WHO Task Force on the Diagnosis and treatment of Infertility. Worldwide patterns of infertility: Is Africa different? Lancet 2: 596-598
- Ekwempu CC, Maine D, Oloruka MB, Essien ES, Kisseka MN (1990) Structural adjustment and health in Africa. Lancet, 336:56-7
- Fathalla MF (1992) Inequity in reproductive health: the challenge to obstetricians/gynaecologists. European Journal of Obstetrics and Gynaecology and Reproductive Biology, 44: 3-8
- Garenne M, Khadidiatou M, Bah MD and correa P (1997) Risk factors for maternal mortality: a case-control study in Dakar Hospitals (Senegal). African Journal of Reproductive Health, 1: 14-24
- Griesgraber JM and Gunter BG (1996). Development: New paradigms and principles for the twenty-first century. Pluto Press, London, UK, p93
- Harrison KA (1996) Macroeconomics and the African Mother (Editorial). Journal of the Royal Society of Medicine, 89: 361-2
- Laga M (1994) Epidemiology and control of sexually transmitted diseases in developing countries. Sexually transmitted diseases 21: 545-550
- Mauldin WP and Segal SJ (1986). Prevalence of contraceptive use in developing countries. The Rockefeller Foundation, New York, USA
- Maheus A, Schulz KF and Cates WJr (1990) Development of prevention and control program for sexually transmitted diseases in developing countries. In K.K. Holms, P.-A. Mardh, P.F. Sparling, P.J. Wiesner, W. Cates, Jr., S.m. Lemon and W.e. Stamm, Eds., Sexually transmitted diseases, Second edition, pp 1041-1046. New York: McGraw-Hill
- Oxfam (1986) For richer for poorer. Pp59-74. Oxfam, Oxford, UK
- South Commission (1990) The challenge to the south. Oxford University Press, Oxford, UK
- Toubia N (1994) Female genital mutilation: a call for global action. Women, Inc. New York, USA
- UNAIDS (1998) Report on the global HIV/AIDS epidemic
- United Nations (1991) World Population Prospects 1990. New York
- World Bank (1993). Investing in Health. Oxford University Press, New York, USA
- World Health Organization (1993) Implementation of the global strategy for health for all by the year 2000. Second evaluation. P19
- Younis N, Khatrab H, Zurayk H, El-Mouelhy M, Amin MF and Farag AM (1993) A community study of gynaecological and related morbidities in rural Egypt. Studies in family planning, 24: 175-186