how increased contraceptive use has reduced maternal mortality
TRANSCRIPT
How Increased Contraceptive Use has Reduced MaternalMortality
John Stover Æ John Ross
Published online: 31 July 2009
� Springer Science+Business Media, LLC 2009
Abstract It is widely recognized that family planning
contributes to reducing maternal mortality by reducing the
number of births and, thus, the number of times a woman is
exposed to the risk of mortality. Here we show evidence
that it also lowers the risk per birth, the maternal mortality
ratio (MMR), by preventing high-risk, high-parity births.
This study seeks to quantify these contributions to lower
maternal mortality as the use of family planning rose over
the period from 1990 to 2005. We use estimates from
United Nations organizations of MMRs and the total fer-
tility rate (TFR) to estimate the number of births averted—
and, consequently, the number of maternal deaths directly
averted—as the TFR in the developing world dropped. We
use data from 146 Demographic and Health Surveys on
contraceptive use and the distribution of births by risk
factor, as well as special country data sets on the MMR by
parity and age, to explore the impacts of contraceptive use
on high-risk births and, thus, on the MMR. Over 1 million
maternal deaths were averted between 1990 and 2005
because the fertility rate in developing countries declined.
Furthermore, by reducing demographically high-risk births
in particular, especially high-parity births, family planning
reduced the MMR and thus averted additional maternal
deaths indirectly. This indirect effect can reduce a county’s
MMR by an estimated 450 points during the transition
from low to high levels of contraceptive use. Increases in
the use of modern contraceptives have made and can
continue to make an important contribution to reducing
maternal mortality in the developing world.
Keywords Family planning � Birth spacing �Maternal mortality ratio
Introduction
Maternal mortality levels remain high in much of the
developing world. The decline over the 15 year period
from 1990 to 2005 was small—both in terms of the
maternal mortality ratio (MMR—the number of maternal
deaths per 100,000 live births) and in terms of the absolute
numbers of deaths. The MMR declined just 30 points, from
480 in 1990 to 450 in 2005. The absolute number of deaths
declined from about 2.91 million in 1990–1995 to about
2.76 million in 2000–2005.
General statements of the relationship of women’s
health status to family planning recount the sequence of
dangers that follow in the train of unintended pregnan-
cies—the risks of unsafe abortions, miscarriages, and
stillbirths, and the risks of giving birth. As one review
states, ‘‘Family planning gives health benefits to the indi-
vidual woman by reducing exposure to unwanted preg-
nancy, pregnancy complications, unsafe abortions,
childbirth complications, and some cancers’’ [1]. The
author notes that abortion rates have declined in countries
where use of modern contraceptives has increased. The
reduction of maternal mortality and high risk births through
family planning use was documented in a thorough review
in 1984, using international data sets then available [2].
Family planning programs that support increases in the
use of modern contraceptives reduce the number of maternal
J. Stover (&)
Futures Institute, 41A New London Turnpike, Glastonbury,
CT 06033, USA
e-mail: [email protected]
J. Ross
Futures Group International, One Thomas Circle, Washington,
DC, USA
e-mail: [email protected]
123
Matern Child Health J (2010) 14:687–695
DOI 10.1007/s10995-009-0505-y
deaths in two ways [3]. The more direct effect comes from
the reduction in the number of births that occurs as contra-
ceptive use increases. With fewer births, a woman’s risk of
maternal death is lower, and the total number of deaths is
fewer. Increasing contraceptive use may also have an indi-
rect effect on the MMR. By averting high-risk births in
particular, rising contraceptive use reduces the average risk
of mortality associated with each birth [3]. This article
considers both effects and estimates their magnitude. Fur-
thermore (although not examined here), by reducing the
number of unintended pregnancies, contraception also can
reduce the number of abortions, which can carry a high
mortality risk when performed unsafely.
Estimating the direct effect of family planning—that is,
reducing the number of births and, thus, maternal deaths—
is relatively straightforward. In contrast, estimating the
indirect effect—that due to the preferential avoidance of
high-risk births—requires data that report maternal mor-
tality by parity and age. The literature that bears directly
upon the age and parity differentials of maternal mortality
is not extensive. Data sets must be large to yield enough
maternal deaths to permit separation into age and parity
categories. Such large data sets are uncommon.
Nevertheless, the basic differentials of mortality risk by
age and parity are relatively well established.1 As early as
1971 Berelson [4] published mortality differentials show-
ing elevated rates at higher ages and birth orders. He
estimated that, if births occurred only at ages 18–35 in the
developing world, maternal mortality might decline by as
much as 20%. A related technical review by Dorothy
Nortman [5] examined historical data (mid-1960s) from 42
countries with reasonably good data, in Europe, North
America, Latin America, and Asia, and found the classic
J-shaped pattern of mortality by age in each of three sub-sets
of countries with high, medium, and low levels of average
risk. For example, New York State data2 for 1936–1938
show sharply rising risk with age. Nortman observed, ‘‘If
women had births only in the age interval 20–34, maternal
mortality would come down by 19% in Mexico, Thailand,
Venezuela, and the United States; by 23% in Colombia and
France; and by 25% in the Philippines’’ [5]. An unusual
series of maternal mortality ratios recorded from 1954 to
1996 in Sri Lanka [6] shows the rising risk of death with
age, a pattern that persisted even as the overall risk
declined from a historic high level in 1947 of over 1000 to
only 24 by 1996. During part of that period the percentage
of married couples using contraception rose to 68%.
National survey data in Bangladesh [7] also show much
higher risks at older ages. Smaller studies in Honduras ([8],
see also footnote no.3), Guatemala (Edgar Kestler with
data for Guatemala and Honduras, personal communica-
tion), and Burkina Faso [9] show similar gradients.
Evidence is scarcer for parity differentials, but the
studies mentioned for New York State (1936–1938), Ban-
gladesh, Honduras, and Guatemala show increased MMRs
as parity rises from two to five and higher. All but Gua-
temala show higher mortality at parity one than at parity
two and the lowest risk at parity 2. Meanwhile, contra-
ceptive use levels have risen to 43% in Guatemala and 65%
in Honduras but to only 14% in Burkina Faso [10].
Methods and Materials
International information on numbers of deaths and on
MMRs have been compiled for 1990, 1995, 2000, and 2005
[11–14]. The most recent estimates, for 2005, also include
a re-estimation of the MMR in 1990. A comparison shows
that, in the developing world, the MMR declined from 480
in 1990 to 450 in 2005.
No national data sets exist for MMRs by both mother’s
age and parity, but. as noted, we located five data sets for
parity-specific MMRs—from Bangladesh [15], Honduras,3
Guatemala,4 Burkina Faso [9], and Sri Lanka [6]—and 13
data sets for age-specific MMRs as well as the MMRs by
age for 42 countries in Nortman’s 1974 compilation [5].
We use data from Demographic and Health Surveys (DHS)
[16] on contraceptive use and the distribution of births by
risk factor. This data set contains 146 surveys from 68
countries: 33 from sub-Saharan Africa, 13 from Latin
America and the Caribbean, 10 from Asia, 6 from North
Africa and the Middle East, and 6 from Eastern Europe.
We use these data to conduct three separate analyses.
First, we look at the direct effect by estimating the number of
maternal deaths that would have occurred if fertility had not
declined between 1990 and 2005 and if the MMR had not
declined. To do this, we use a demographic projection model
[17] to estimate the number of births that would have
occurred if fertility had not fallen between 1990 and 2005.
We apply the 1990 MMR to those births to calculate the
number of maternal deaths averted by the decline in fertility.
1 Differentials by birth intervals, rather than age and parity, are
reviewed in World Health Organization. Department of Making
Pregnancy Safer (MPS) and Department of Reproductive Health and
Research (RHR). Report of a WHO technical consultation on birth
spacing, Geneva, Switzerland, 13–15 June 2005. ‘‘After a live birth,
the recommended interval before attempting the next pregnancy is at
least 24 months in order to reduce the risk of adverse maternal,
perinatal, and infant outcomes.’’ (Note that this produces a birth
interval of 33 months.)2 Excluding New York City.
3 1997 RAMOS study and 2001 Honduras Reproductive Health
Survey (ENESF – Encuesta Nacional de Epidemiologia y Salud
Familiar).4 2000 mortalidad materna segun paridad, courtesy of Edgar Kestler.
688 Matern Child Health J (2010) 14:687–695
123
We attribute most of the historic fertility decline to
rising contraceptive use. Among the four primary deter-
minants of fertility identified by Bongaarts, contraceptive
use is the most important to bring fertility down into a low
range [18]. Fertility can decline also from increased abor-
tion, increased breastfeeding, or increased age at marriage.
For abortion the trends are unclear, and we have no reliable
estimate for the developing world as a whole. However, the
abortion rate and the numbers of abortions tend to decline
as rising contraceptive use prevents more unwanted preg-
nancies. Regarding breastfeeding, surveys indicate that the
international trend has been a mix of increases and
decreases, with the net balance being little change. Age at
marriage has risen in most of the developing world but
many unmarried women, especially in sub-Saharan Africa
and Latin America, are users of contraception. This further
dilutes the connection of later marriage to fertility declines.
Data from 135 DHS surveys show that the TFR is highly
correlated with contraceptive use, with an R2 correlation of
0.76 (0.73 between the general fertility rate and the CPR, and
0.69 between the crude birth rate and the CPR). A 10-point
rise in the percentage using contraception is accompanied by
a TFR decline of over half a birth (0.58). Compared with
contraceptive use, change in the percentage married has a
trivial effect in the correlations below. Therefore, we focus
the first part of the analysis on changes in TFR and assume
that changes in the CPR are the major influence.
Crude birth rate General fertility rate
Slope
(beta)
Significance
level
Slope
(beta)
Significance
level
% contracepting -0.33 0.00001 -1.94 0.00001
% married -0.02 0.71 0.0028 0.99
To assess the indirect effect, in a two-stage analysis we
look first at the relationship at the country level between
contraceptive use and demographically high-risk births,
and then at the relationship between demographically high-
risk births and the MMR. It has been shown that births that
are spaced too closely (less than 24 months apart), mothers
giving birth at too young an age (under 18) or too old an
age (35 and over), and high-parity births (parity 4 and
higher) pose an elevated risk of infant and child mortality
[19]. We examine whether these same risk factors also
affect maternal mortality. There is, for example, supportive
evidence from Bangladesh [20]: Matlab data for more than
20,000 births in 1968–1970 show the classic J-shaped
curve for the MMR, with the highest rates at ages 10–19
and 40–44 and, similarly, high rates at birth orders one and
at seven and above. Additional evidence appears below.
To capture all high-risk births, we employ the DHS
variable ‘‘any risk,’’ which includes all births except first
births and births free of the four specific risks named just
above. Births with ‘‘any risk’’ vary from a low of 25% in
Viet Nam in 2002 to a high of 79% in Yemen in 1991–
1992. In the first stage of analysis, we use time trends for
data from countries with more than one survey to compare
the change in the percentage of all births with any demo-
graphic risk with the change in the percentage of women of
reproductive age using contraception (CPR). In the second
stage of the analysis, we look at the relationship between
the percentage of births with a demographic risk and the
MMR. Country-specific estimates of the MMR do not have
enough precision to measure changes over the short periods
between surveys, so we used a cross-section analysis to
compare the levels of MMR with the levels of at-risk
births. We use this two-stage process to relate CPR to
MMR, rather than analyze the direct relationship between
the two, in order to control for social, cultural, and eco-
nomic differences among countries and to focus on a key
pathway by which contraceptive use affects the MMR.
In our third stage of analysis, we used data on variations
in MMR by maternal age and parity to estimate the
expected changes in the MMR if these patterns remained
the same but increasing contraceptive use modified the
distribution of births by age and parity. Data on the rela-
tionship of contraceptive use to this distribution of births
come from the DHS.
Results
Direct Effect Due to Reduced Numbers of Births
According to the United Nations Population Division [21],
the total fertility rate in all developing countries declined
from 3.63 births per woman in 1990 to 2.83 in 2005. The
declining fertility rate countered by the rising numbers of
women of reproductive age meant that the annual number
of births remained roughly constant at about 122 million
from 1990 to 2005. Applying the MMRs of 480 for 1990
and 450 for 2005 to 122 million births annually suggests
that the annual number of maternal deaths declined
slightly, from 588,000 in 1990 to 550,000 in 2005.
As noted above, if there had been no change in the level
of contraceptive use,5 the TFR would have remained
5 For the developing world, weighting country CPRs by population
size, approximately 53% of married/in-union women (or spouses)
were using contraception in 1990, and approximately 61%, in 2005.
Sources: UN Population Division. (1996) Levels and tends of
contraceptive use as assessed in 1994. New York: United Nations.
Also Carl Haub, C. and Kent, M. 2008 world population data sheet.
Washington, DC: Population Reference Bureau. The 2008 data sheet
figure is based on surveys of earlier dates and approximates the 2005
level of use.
Matern Child Health J (2010) 14:687–695 689
123
roughly constant from 1990 to 2005. In that case the annual
number of births would have risen to 157 million by 2005,
and the number of maternal deaths in 2005 would have
been 705,000—155,000 more maternal deaths than the
actual 2005 estimate. For the 15-year period 1990–2005,
the drop in TFR resulted in an estimated 1.2 million fewer
maternal deaths (9.73 - 8.50; see Table 1).
If the MMR had remained rather constant over this 15-
year period, there would have been 370,000 more maternal
deaths (8.87 - 8.50). Thus, the combined effect of changes
in both TFR and MMR was 1.5 million fewer maternal
deaths between 1990 and 2005 (10.04 - 8.50).
Indirect Effect Due to Lower Proportion
of Births at High Risk
The relationship between changes in CPR and changes in
the percentage of births with any risk factor within coun-
tries over time is shown in Fig. 1. The data clearly show
that the distribution of births by risk factor changes as the
use of family planning changes. The average slope of all
the survey pairs is -0.55. This means that, for each 10
percentage point increase in CPR, the percentage of births
with any risk drops by 5.5.
At low levels of contraceptive prevalence, around 70%
of all births will have one or more of the demographic risk
factors. As prevalence increases toward 80%, the percent-
age of births with any risk drops to nearly 35%. The main
cause of this drop is the virtual elimination of high-parity
births and births with multiple risk factors, such as high
age/high parity. At very low levels of contraceptive use,
about half of all births are parity 4 and higher. As con-
traceptive use increases to 80%, this fraction shrinks to
almost nothing.
Figure 2 shows the relationship that results from
ordering all the DHS data sets from lowest CPR to highest
and smoothing the curves across surveys. As high-parity
births decline, the share of no-risk births rises, and the
share of first births rises steadily as well. Most of the risk
categories decline accordingly. There is rather little change
Table 1 Estimated number of maternal deaths (in millions) in low-
and middle-income countries under alternative scenarios
Period Actual Constant
TFR
Constant
MMR
Both TFR and
MMR constant
1990–1995 2.91 3.04 2.93 3.07
1995–2000 2.83 3.26 2.91 3.36
2000–2005 2.76 3.43 2.91 3.61
1990–2005 8.50 9.73 8.87 10.04
35
45
55
65
75
85
700 10 20 30 40 50 60 80
Contraceptive Prevalence
Per
cen
t o
f B
irth
s w
ith
An
y R
isk
Fig. 1 The relationship between changes in contraceptive use and
changes in the percentage of births with any demographic risk (36
countries with multiple DHS surveys)
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Percent of Births
Contraceptive Prevalence
Short/manyOld/short/manyOld/manyOld/shortYoung/shortManyShortOldYoungFirst birth No Risk
Fig. 2 The smoothed pattern in
the distribution of births by
contraceptive prevalence.
Source: demographic and health
surveys
690 Matern Child Health J (2010) 14:687–695
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in the share of short interval births since many young
couples wish to have one to three children early in their
marriage and then stop.
The cross-section comparison of the percentage of births
with any risk, on one hand, and the estimated MMR for the
date closest to the date of the DHS, on the other, is shown
in Fig. 3. To adjust the relationship for economic and
social factors, we included two control variables in the
regression analysis: female primary school enrollment and
the Gross National Income per capita expressed in pur-
chasing power parity (data from World Bank sources). The
results are shown in Table 2. The coefficient of 11.3 on
high-risk births means that, for each reduction of 10 per-
centage points in the percentage of births with a demo-
graphic risk, the MMR falls by 113 points.
Using both stages of this analysis, we can estimate the
full effects of contraceptive use on the percentage of births
that are high risk and then on the MMR. As a country
transitions from a very low CPR to a high CPR, the per-
centage of births at risk can be expected to drop from
around 75% to nearly 35% (see Fig. 1). As a result of this
change in the percentage of births at high risk, the MMR
can be expected to drop by about 450 points (40 percentage
point decline in high-risk births multiplied by the regres-
sion coefficient of 11.3)—a change due entirely to the
effects of contraceptive use.
Country-Specific Patterns of MMR by Parity
The most important impact of increasing contraceptive use
on at-risk births is the reduction in high-parity births.
Figure 4 shows the relationship between MMR and parity
for four locations: Bangladesh, Guatemala, Honduras, and
New York State (1936–1938) in the United States. The
patterns are similar, except that Bangladesh has such a high
risk at parity 1 that the risks at all other parities are lower.
The elevated MMR at parities 5 and above is important
because, across all the DHS data sets used here, 29% of
births are in this category. Even a partial shift away from
0
200
400
600
800
1000
1200
1400
1600
1800
2000
30 35 40 45 50 55 60 65 70 75 80
% of Births in Any Risk Category
MM
R
Fig. 3 Relationship of the MMR to the percentage of births in any
risk category
Table 2 Regression results to
estimate the MMR
* PPP purchasing power parity
Variable Coefficient Range of coefficient P value
Intercept 202.664 -521, 926 0.578
GNP PPP* per capita -0.067 -0.095, -0.039 0.000
Female primary school enrollment -0.313 -3.973, 3.347 0.865
% births with any risk 11.319 2.108, 20.530 0.017
0
1
2
3
4
1 2 3 4 5+
Ratio of MMR to MMR at Parity 1
Parity
BangladeshHondurasGuatemalaNY State 193638
Fig. 4 The relationship between the MMR and parity, with MMR
values normalized to 1 at parity 1
Table 3 MMR by parity for Honduras, showing current values and
illustrative estimated values for lower and higher levels of contra-
ceptive prevalence
Parity Resulting
MMR1 2 3 4 5?
MMR by parity 62 56 91 77 183
% of births 25% 21% 15% 11% 28% 101
% births if CPR = 10% 20% 17% 12% 14% 36% 110
% births if CPR = 70% 37% 31% 22% 3% 7% 76
Matern Child Health J (2010) 14:687–695 691
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these highest parity births can lead to important reduction
in the overall MMR.
Table 3 illustrates this effect using the Honduras set of
MMR values.6 Some 39% of births are high parity—11%
are parity 4 and 28% are parity 5 or higher. Judging by the
patterns in Fig. 2, 50% of births would be high parity (4?)
if contraceptive prevalence were only 10%, and just 10%
would be high parity if contraceptive use were 70%. If
these illustrative birth distributions applied to the pattern of
MMR by parity in Honduras, the MMR for all births would
fall from 110 at 10% contraceptive use to 76 at 70%—a
drop of 31%.
The 39% of births in Honduras that currently are at
parity 4 or higher is similar to the average percentage
across all DHS data sets, as are the other percents shown.
Thus, increasing contraceptive use from the historically
low levels to a high level in all developing countries par-
allels a 31% decrease in the overall MMR (down from 110
to 76).
The effect of changing parity distributions on the MMR
can also be seen by examining recent trends in DHS data
on births by parity. For 46 countries with DHS data
available from multiple surveys, we calculated the change
in the parity distribution of births between the earliest and
latest surveys. By applying a fixed schedule of MMR by
parity (using the Honduras schedule in Table 3) to these
parity distributions, we calculated how the MMR changed
solely because of the way that the parity distribution
changed. The results—expressed as the expected decline in
a 10-year period—show small increases in MMR for six
5 0 5 10 15 20 25 30 35 40
Mozambique 1997-03Chad 1996-04
Guinea 1999-05Uganda 1988-06
Kazakhstan 1995-99Ethiopia 2000-05
Niger 1992-06Eritrea 1995-02
Mali 1987-01Burkina Faso 1992-03
Togo 1988-98Nigeria 1990-03
Tanzania 1992-04Rwanda 1992-05Zambia 1992-01Ghana 1988-03
Senegal 1986-05Cameroon 1991-04
Bangladesh 1993-04Guatemala 1987-98
Bolivia 1989-03Madagascar 1992-04
India 1992-98Armenia 2000-05
Haiti 1994-05DR 1986-02
Philippines 1993-03Benin 1996-01
Colombia 1986-05Indonesia 1987-03
Turkey 1993-98Malawi 1992-04Kenya 1989-03
Nicaragua 1997-01Peru 1986-00
Zimbabwe 1988-06Jordan 1990-02
Namibia 1992-00Yemen 1991-97
Nepal 1996-06Egypt 1988-05Brazil 1986-96
Cote d'Ivoire 1994-98Vietnam 1997-02
Cambodia 2000-05Morocco 1987-03
Percent Decline in MMR
Fig. 5 Percentage declines in MMRs expected over a 10 year period due to improved parity distributions of births using a fixed (Honduras)
schedule of MMR by parity
-20
-10
0
10
20
30
40
50
-10 0 10 20 30 40 50
Percent Decline in Deaths
Percent Decline in Births
Fig. 6 Comparison of the expected percentage declines in deaths and
in births due to changes in the parity distribution of births between
earliest and latest DHS
6 Parity data and MMR from a survey published in 1997. In 2001 the
CPR in Honduras was 62 (65% in 2005).
692 Matern Child Health J (2010) 14:687–695
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countries and declines for 40 countries, with an average of
7.3% and ranging up to more than 35% (see Fig. 5). These
are reasonably impressive declines, achieved only by
changing the distribution of births by parity. Actual
declines in MMRs can be larger where health system
improvements have lowered the parity-specific risks.
Another way to look at the same phenomenon is to
compare the change in numbers of births that is expected as
the parity distribution changes with the change in the
numbers of maternal deaths. When women begin to have
fewer births, logically the higher parity births, with their
especially elevated risks, are eliminated first. As a result,
the percentage decline in deaths should exceed the per-
centage decline in births. Indeed, that occurs in almost all
countries (see Fig. 6). Most countries lie above the diag-
onal line, meaning that the shift in parity distributions
would cause the number of maternal deaths to fall more
than the number of births would fall. The result is a drop in
the overall MMR.
Finally, regarding mortality patterns by age rather than
by parity, we compiled the schedules of MMR by the age
of the mother at the time of birth from the few examples
available (see Fig. 7 and Appendix 1). The risk at ages
above 35 is at least double that at ages 20–24 in most
data sets. In fact, in half of the data sets the risk rises to
4.5–8 times higher. We conducted analyses parallel to
those above—for the impact on mortality of changing age
distributions of births between two surveys—and found the
impacts to be much smaller than those for changing parity
distributions. The reasons are two-fold. First, as contra-
ceptive use increases, the changes in age distribution are
much less than changes in parity distribution. Second,
births at older ages are always relatively few, whereas
births at the higher parities are numerous, many occurring
at younger ages, before contraceptive use starts to rise from
low levels.
Conclusion
This article has explored the effects that increasing con-
traceptive use has had on maternal mortality. The direct
effects are clear and large. The drop in the TFR from 1990
to 2005, due primarily to increasing contraceptive use,
resulted in 1.2 million fewer maternal deaths—15% fewer
than would have occurred with no fertility decline. These
1.2 million additional deaths averted between 1990 and
2005 can be added to those that were already being averted
by the level of contraceptive use in 1990. Future increases
in contraceptive use will further reduce women’s exposure
to the risks associated with pregnancy and will keep many
more mothers alive.
There is strong evidence that contraceptive use also
affects the maternal mortality rate. Time-series survey data
show a clear pattern of smaller percentages of high-risk
births as contraceptive use increases. The greatest effect is
the reduction of high-parity births, which are virtually
eliminated at high levels of contraceptive use. Cross-
national data show that the MMR is highly correlated with
the percentage of high-risk births, even with controls for
differences in economic and social conditions. In addition,
declines in maternal deaths are greater than the corre-
sponding declines in births in nearly all countries, due to
the selective effect of increasing contraceptive use averting
6
7
8
9
Ratio of maternal mortality at each age to
maternal mortalityat 20-24
Bangladesh
Honduras
Guatemala
Burkina Faso
Nortman Low
0
1
2
3
4
5
15-19 20-24 25-29 30-34 35-39 40-49
Nortman Medium
Nortman High
Sri Lanka 1954
Sri Lanka 1960
Sri Lanka 1970
Sri Lanka 1980
Sri Lanka 1996
NY State 1936-38
Fig. 7 Age-specific MMR
values in relation to the MMR at
ages 20–24
Matern Child Health J (2010) 14:687–695 693
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the high-parity/high-risk births first. Together, all this
evidence suggests that the reduction in high-risk births
brought about by contraceptive use lowers the MMR.
Other interventions also reduce maternal mortality by
directly addressing the medical causes of maternal mor-
tality—primarily severe bleeding, infection, abortion
complications, hypertensive disorders such as pre-
eclampsia and eclampsia, and obstructed labor—through
better and more widely available prenatal care and emer-
gency obstetric services. Clearly, there is a need to improve
the coverage and quality of all safe motherhood services to
save as many women’s lives as possible. This paper has
tried to bring attention to the role that family planning can
play in the broader effort to reduce maternal mortality in
developing countries—not only through a reduction in the
number of births but also through a reduction in the MMR
as a result of better distributions of births to lower risk
categories, primarily lower parities.
Acknowledgments Thanks to Mary Ellen Stanton and Marge
Koblinsky for their assistance in identifying relevant literature and
data sources and to Jacqueline Bell for providing data for Burkina
Faso, Kim Streatfield for Bangladesh, and Edgar Kestler for Guate-
mala and Honduras. This research was funded by the U.S. Agency for
International Development (USAID) | Health Policy Initiative, Task
Order 1. The views expressed do not necessarily reflect the views of
USAID or the U.S. Government.
Appendix I
See Table 4.
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Table 4 MMR values and patterns, by age
MMR by age
15–19 20–24 25–29 30–34 35–39 40–49
Bangladesh 170 237 358 516 492 2000
Honduras 76 74 75 144 207 263
Guatemala 110 107 122 185 280 436
Burkina Faso 317 271 487 601 714 1262
Nortman low 13 12 16 31 65 99
Nortman medium 34 34 41 70 136 200
Nortman high 134 91 119 192 289 434
Sri Lanka 1954 440 365 370 500 800 900
Sri Lanka 1960 250 260 250 300 450 650
Sri Lanka 1970 95 100 140 150 225 230
Sri Lanka 1980 50 40 50 60 160 110
Sri Lanka 1996 20 20 20 20 25 90
NY State 1936–1938 156 166 234 329 499 747
694 Matern Child Health J (2010) 14:687–695
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