Cities Transformed Demographic Change and Its Implications in the Developing World (2003) / Chapter Skim
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6. Fertility and Reproductive Health
6. Fertility and Reproductive Health
Pages 199-258
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From page 199... ...
To begin, we should offer a word of explanation on the meaning of the phrase "reproductive health." It refers to "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its processes" (United Nations, 1994: 202~. The concept provides a framework for thinking about sex and reproduction, highlighting not only family planning, conception, and birth, but also the imbalances in decision-making autonomy between men and women, the possibilities of coercion and even violence in their relations, and the different health risks to which they may be knowingly or unknowingly exposed.
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From page 200... ...
The succeeding sections of the chapter consider three urban groups of particular importance: the urban poor, migrants, and adolescents. We then offer reflections on the distinctive features of urban service delivery.
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From page 201... ...
Franca (2001) illustrates this diversity, showing that the total fertility rates (TFRs)
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From page 202... ...
provided strong evidence that the social networks of urban women supply conduits for the exchange of information about contraception (see Chapter 2~. Recent multilevel, longitudinal research on social networks in the periurban and rural areas of tin multilevel models with individuals clustered within areas, statisticians often introduce unmeasured areal traits termed "random" or "fixed" effects, depending on their relation to the measured traits and commonly find these effects to be statistically important even with controls in place for individual characteristics.
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From page 203... ...
have uncovered substantial differences in fertility rates across this city's neighborhoods. Census data were used to map fertility rates by shiakhas small districts within the Cairo metropolitan area that are akin to U.S.
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From page 204... ...
The theory describes how in certain situations, families will find it in their best interest to bear fewer children but to invest more in developing the human capital of each child. In Chapters 4 and 5, we present empirical evidence showing that children's school enrollment rates are decidedly higher in the cities of developing countries than in rural villages, and that fertility rates are decidedly lower.
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From page 205... ...
can be viewed as examples in which rural parents invested in their children so as to better prepare them for urban livelihoods. In a sense, urban populations provide distant reference groups for rural populations, and in some cases, connections through migration and relatives can provide rural villagers with specific urban examples.
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From page 206... ...
As most of these young women are recent migrants from rural villages, their own parents can provide little by way of guidance about city environments and risks. In conversation, the garment workers exhibit a mix of pride and anxiety about their new situations.
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From page 207... ...
. In the era before these reforms were initiated, responsibility for the delivery of family planning and reproductive health services generally rested with national ministries, which held the requisite funds and technical expertise.
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From page 208... ...
Sixth, the roles that may be played in service delivery by communities and community organizations no doubt differ a great deal between cities and rural villages. Urban neighborhoods can be defined according to social criteria, involving notions of belonging, inclusion, and exclusion that may be difficult for outsiders to discern.
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From page 209... ...
Individuals may have to rely on their social networks and local associations for guidance to services. The localized networks of the urban poor may not offer them many leads, and the poor may not learn of new reproductive health services and initiatives unless special efforts are made to reach them.
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From page 210... ...
.l ._ .. 1 Sub-Saharan Africa South, Central, West Asia North Africa Southeast Asia Latin America FIGURE 6-2 Total fertility rates in rural and urban areas, by region and city population size.
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From page 211... ...
Outside Southeast Asia (a region in which rural populations have often been given high priority in government family planning programs) , the fertility rates of the smallest towns and cities (those of under 100,000 population)
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From page 212... ...
found urban women to be significantly less likely to breastfeed than rural women, and among those who breastfed, the urban durations of feeding were shorter. The differences may be attributable to work outside the home, interventions by hospital staff, and the availability of free infant formula (Adair, Popkin, and Guilkey, 1993)
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From page 213... ...
, there are stages in the process of becoming married that do not allow the event to be confined to a single age or date. Table 6-2 summarizes DHS data on mean age at first marriage for urban and rural women, the 9 The DHS question on first intercourse allows a response of "at marriage." Premarital intercourse is identified in DHS surveys by a gap of a year or more between age at first intercourse and age at first marriage; women with a shorter gap than this cannot be identified as having had premarital intercourse.
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From page 214... ...
Contraception For many of the reasons mentioned, urban women are generally thought to be more likely than their rural counterparts to use contraception, and an analysis of the DHS data confirms this supposition. As can be seen in Figure 6-3, the level of modern contraceptive use is markedly higher in urban than in rural areas, and it increases with city size when the full sample is considered.
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From page 215... ...
215 o oo ~ oo ~ oo ~ .
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From page 216... ...
T C_ ~ 1~ .......... I, l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' l'''' ~~ 1 1 I-2-2-2-21 1 l~ 1 1 l~ 1 ~-2-2-2-21 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 l 1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 · l""""1 ....122221 l Sub-Saharan Africa Nr~rth Africa South, Central, West Asia Southeast Asia Latin America | - Rural 1 1 1~ < 1 00,000 1 1 ~ 1 00,000- 1 500,000 500,000- 1 1 1 million I |~ 1 million- | | 5 million | | ~ > 5 million | FIGURE 6-3 Current use of modern contraceptives, rural and urban areas, by city size.
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From page 217... ...
I' I' I.... 2:2:2:2:2: ':':':':': 2:2:2:2:2: ':':':':': ,2:2:2:2:2: I:::::::: · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1~ ~ · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 · 1 l Total Sub-Saharan Africa South, Central, West Asia North Africa Southeast Asia Latin America Rural < 100,000 1 00,000500,000 500,0001 million it 1 million5 million > 5 million FIGURE 6-4 Percentage using private medical sources among current users, rural and urban areas, by city size.
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From page 218... ...
million Total Sub-Saharan Africa South, Central, West Asia North Africa Southeast Asia Latin America FIGURE 6-5 Unmet need for contraception, rural and urban areas, by city size. do not share the woman's views about whether additional children are desirable.
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From page 219... ...
{2 The contrast with the patterns of unmet need for contraception is interesting. It appears that although urban women are more likely than their rural counterparts to use modern contraception when they wish to avert births, they may not use their contraceptive methods effectively and may then experience unintended births at about the same rate as do rural women.
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From page 220... ...
. It appears, then, that the lower levels of fertility found in cities relative to rural villages and the higher levels of contraceptive use may not be reliable indicators of the urban state of reproductive health, even in the family planning dimension.
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From page 221... ...
................. 1 t 1 t 1 t 1 t I ~ I ~ I ~ I ~ I ~ I ~ I ~ 1 t 1 t 1 t 1 t 1 t 1 t 1 t 1 t 1 t 1 t 1 t 1 t 1 t 1 I'' 1 I'' Total Sub-Saharan Africa Nor h Africa Rural < 100,000 1 00,000500,000 500,0001 million 1 million5 million > 5 million South, Central, West Asia Southeast Asia Latin America FIGURE 6-6 Percentage of women with all recent births attended by physicians or nurse/midwives, rural and urban areas, by city size.
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From page 222... ...
The most stri ing finding is that the majority of rural women deliver their children at home, while the majority of urban women give birth in public institutions. HIV/AIDS The anonymity of city life, more permissive social and sexual norms, the presence of sex workers, migrants with new sexual networks, and many other factors may contribute to the high urban prevalence of STDs and HIV/AIDS.
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From page 223... ...
1985 6.90 1991 9.20 2.3 Djibouti 1993 4.00 1995 6.10 2.1 Cole d'Ivoire 1989 6.00 1997 15.90 9.9 Ethiopia 1991 10.70 1996 17.90 7.2 Gabon 1998 0.50 1994 1.70 1.2 Ghana 1992 1.20 1996 2.20 1 Guinea 1990 1.10 1996 2.10 1 Guinea-Bissau 1990 0.90 1997 2.50 1.6 Kenya 1992 14.40 1995 18.50 4.1 Lesotho 1991 5.50 1996 20.60 15.1 Liberia 1992 3.70 1993 4.00 0.30 Malawi 1991 22.00 1995 27.60 5.60 Mali 1988 1.30 1994 4.40 3.10 Mozambique 1994 10.70 1998 17.00 6.30 Namibia 1991 4.20 1996 16.00 11.80 Niger 1988 0.50 1993 1.30 0.80 Nigeria 1992 2.90 1994 5.40 2.50 Rwanda 1989 26.80 1992 28.90 2.10 South Africa 1994 6.40 1997 16.10 9.70 Swaziland 1993 21.90 1998 31.60 9.70 Tanzania 1986 3.70 1996 13.70 10 Togo 1995 6.00 1997 6.80 0.80 Uganda 1996 15.30 1997 14.70 - 0.6 Zambia 1990 24.50 1994 27.50 3 Zimbabwe 1990 23.80 1995 30.00 6.20 Bahamas, The 1990 3.00 1993 3.60 0.60 Barbados 1991 1.30 1996 1.10 - 0.2 Belize 1993 0.20 1995 2.30 2.10 Dominican Republic 1995 1.20 1999 1.70 0.50 Guatemala 1991 0.00 1998 0.90 0.90 Guyana 1990 1.50 1991 1.87 0.37 (continued)
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From page 224... ...
In India, the epidemic appears to be taking hold in Mumbai but remaining steady in Calcutta (United States Government, l999~. HIV transmission in Latin America and the Caribbean is increasing in many cities, mainly as a result of heterosexual transmission and needle sharing among injection drug users.
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From page 225... ...
. ~ 1- ~ 1~ Southeast Asia Latin America Sub-Saharan Africa South, Central, West Asia Rural < 1 00,000 1 00,000500,000 500,0001 million 1 million5 million En, 5 million FIGURE 6-8 Among women aware of AIDS, percentage knowing that using condoms or limiting sexual partners reduces risk, rural and urban areas, by city size.
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From page 226... ...
Although they are not well informed about risks, urban women appear to be somewhat better informed than rural women. FERTILITY TRANSITIONS AND ECONOMIC CRISES A comparison of trends in urban and rural fertility is desirable on several counts.
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From page 228... ...
i7The region-specific trend estimates from fixed-effects models are —0.085 for North Africa; —0.108 for sub-Saharan Africa; - 0.068 for Southeast Asia; - 0.090 for South, Central, and West Asia; and—0.053 for Latin America. All these estimates are significant at the 0.001 level.
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From page 229... ...
229 o o o o oo o o o o o o o o o oo o o o o o o N 00 0 0 O O O o (~ O 0 a, a, n' U)
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From page 230... ...
Many of the socioeconomic elements shaken by the African crises of the 1980s have now settled into place, leaving the economies of the region with drastically reconfigured prices and public sectors, and leaving in tatters much of the logic that supported high fertility in earlier eras. Recent research in Dakar, Bamako, Yaounde, and Antananarivo shows that residents of these cities are adjusting their marriage and fertility behavior in response to high unemployment rates and reduced access to formal-sector salaried employment (Antoine, Ouedraogo, and Fiche, 1999; Antoine, Razafindrakoto, and Roubaud, 2001~.
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From page 231... ...
THE URBAN POOR In this and the next two sections of the chapter, we consider several subgroups of the urban population that are of particular interest: the urban poor, migrants, and adolescents. This section documents some of the demographic disadvantages 20As noted above, evidence for more rapid rural decline is slim.
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From page 232... ...
It begins by contrasting the circumstances of poor urban women with those of urban nonpoor and rural women, relying on data from the DHS. It then examines the implications of spatially concentrated poverty, drawing on a set of case studies of urban slums and squatter communities.
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From page 233... ...
(Note that in Southeast Asia, the urban poor exhibit higher fertility than rural women.) Poor urban women have significantly higher levels of fertility than urban women who are not poor.
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From page 234... ...
TABLE 6-8 Proportion of Contracepting Women Using Private Medical Sources of Contraception, by Residence and Poverty Status DHS Surveys in Region North Africa Sub-Saharan Africa Southeast Asia South, Central, West Asia Latin America All Urban Urban Rural Poor Nonpoor 0.52 0.49 0.62 0.29 0.33 0.37 0.20 0.29 0.46 0.26 0.23 0.36 0.49 0.49 0.64 0.35 0.36 TOTAL 0.46 NOTE: See notes to Table 6-4. The figures shown are predicted values for ever-married women who currently use a modern method of contraception, based on estimates from a probit model adjusted for age in rural areas and for age and city size in urban areas.
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From page 235... ...
The gap between poor and nonpoor urban women is statistically significant and is as large as 20 percentage points in the case of Southeast Asia.23 The urban poor are, however, relatively fortunate by comparison with rural women, whose deliveries are attended even less often. The absence of trained personnel at childbirth may result in unnecessary delays in diagnosing the need for medical intervention, and by leaving it to family and neighbors to decide where emergency care should be sought, may create further delays in reaching modern care.
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From page 236... ...
. The level of unmet need for the urban poor exceeded that for rural women in no surveys in North Africa; 9 surveys in Sub-Saharan Africa; 3 in East and Southeast Asia; 2 in South, Central, and West Asia; and 1 in Latin America.
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From page 237... ...
To sum up, poor urban women appear to be more exposed to the risks of unintended pregnancy than are nonpoor urban women; at the time of delivery, they are not as likely to be protected by trained medical personnel; and they lack the knowledge to protect themselves effectively against the risks of HIV/AIDS and other STDs. In most of the surveys we examined, these poor women retain an advantage over rural women, but the margin of difference can be very slim, and in 24In sub-Saharan Africa, the poverty measure is statistically significant in 12 of 21 surveys; in the other regions, it is significant in 2 of 2 surveys in Southeast Asia; not significant in the single survey for South, Central, and West Asia; and significant in 7 of 7 surveys in Latin America.
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From page 238... ...
As the conditions of the urban poor are scrutinized, it often appears that the time and money costs of access to services are understood by women less as economic than as social barriers. When services require payment in cash, women must often negotiate for the money with their husbands and other family members.
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From page 239... ...
Yet residents of the slums say they think 3.2 children would be the ideal, a number only slightly above that found elsewhere in Nairobi and in other Kenyan cities. Contraceptive use is lower in the slums, and there are indications of an unmet need for family planning services.
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From page 240... ...
In addition, poor families tend to seek local care first, going from place to place in the neighborhood before making an effort to reach the modern facilities outside the neighborhood (Fariyal Fikree, personal communication, 2002~. The reproductive morbidities affecting poor urban women were examined by Mayank, Bahl, Rattan, and Bhandari (2001)
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From page 241... ...
It appears that the urban poor can suffer from health disadvantages not unlike those that afflict rural residents. In the poor communities of Karachi, some 68 percent of births are delivered at home, and 59 percent are attended by traditional birth attendants (TBAs)
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From page 242... ...
The panel's examination of DHS data for urban women of reproductive age (Chapter 4) found that among the women who had moved to their current residence in the preceding 5 years, about two-thirds had arrived from another town or city.
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From page 243... ...
found that unmarried rural women were more than twice as likely as married women to migrate to urban areas.27 The married women who migrated were found to be less likely than urban natives to live with their husbands during their first few months in the city, as predicted by the disruption hypothesis. Evidence from the DHS generally conforms to the hypothesis of adaptation.
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From page 244... ...
A study of Hubei Province showed that migrant fertility was no higher there than the fertility of urban natives, and might well be lower because of spousal separation (Goldstein, White, and Goldstein, 1997~. A study in Anhui province came to a similar conclusion, suggesting that temporary migrants in China may actually have lower fertility than long-term urban residents (Liu and Goldstein, 1996~.
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From page 245... ...
In Cochabamba, Bolivia, young rural migrants living in periurban areas are significantly less likely to use prenatal care and to have a trained birth attendant at delivery (Bender, Rivera, and Madonna, 1993~. Similar findings from Cape Town, South Africa, indicate that in large squatter settlements with many rural migrants, women tend to postpone prenatal care and have fewer prenatal visits, and are likelier to have preterm and low-birthweight babies than other women in the city (Rip, Keen, Woods, and Van Coeverden De Groot,1988~.
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From page 246... ...
Prostitutes are in need of reproductive health services to protect themselves, including contraceptives and both information and services related to STDs and HIV/AIDS, but there is also a powerful public health rationale based on externalities. The direct connections of prostitutes to male migrants and the broader sexual networks of migrants, encompassing girlfriends and wives, make prostitutes critical targets for health interventions.33 Although the expanded urban social networks of migrants may increase the likelihood of exposure to HIV/AIDS and other STDs, these networks can also provide opportunities for education and intervention.
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From page 247... ...
Hence, if information about adolescents is scanty in general, it is especially so for those living in cities, who are less likely to be married. To judge from the scattered studies available, it appears that out-of-wedlock teen births have been common in urban sub-Saharan Africa and Latin America, and may be increasingly so (Alan Guttmacher Institute, 1998~.
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From page 248... ...
In KwaZulu-Natal province, some 49 percent of the boys and 46 percent of the girls reported having had intercourse in the preceding year; among those who had had intercourse, condoms were reported to have been used at the time of last intercourse by 49 percent of the boys and 46 percent of girls. Recent intercourse was much more likely among the black South African adolescents than among the whites or Indians in the sample, but for blacks no urban/rural difference could be detected, other things held constant.34 For adolescent girls but not for boys several measures of neighborhood context appeared to reduce the likelihood of recent sex.
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From page 249... ...
(The urban interviews were conducted in Soweto, the collection of townships to the southwest of Johannesburg.) Although accounts of rape and coercion often appear in studies of adolescent pregnancy elsewhere, the participants in this South African study infrequently mentioned coercion and forced sex in discussions of why girls get pregnant; these were acknowledged as possibilities, but not represented to the interviewers as common occurrences.
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From page 250... ...
Social marketing programs (including Social Marketing for Adolescent Sexual Health [SMASH] , which has run projects in Botswana, Cameroon, Guinea, and South Africa)
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From page 251... ...
URBAN SERVICE DELIVERY As we noted at the beginning of this chapter, to date there has been no comprehensive appraisal of reproductive health services in urban areas. In discussing the urban poor, migrants, and adolescents, we referred to literature specific to these subgroups.
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From page 252... ...
The increase in the number of contending groups and interests in a decentralized system can hinder service delivery, as noted by Aitken (1999: 117~: In the Philippines, a newly appointed provincial governor stopped the implementation of a ... health project in his province because he opposed the family planning component.
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From page 253... ...
To assess the evidence on family planning services, the Family Planning Service Expansion and Technical Support (SEATS) project conducted a comprehensive examination of family planning service delivery in the urban and rural areas of several countries in Africa (Ross)
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From page 254... ...
The Private Sector in Family Planning Services funded and delivered by the public sector have been a mainstay of reproductive health in rural and urban areas alike. As we have seen, the urban poor can be as dependent on the public sector as rural residents.
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From page 255... ...
Among the private-sector health facilities in several African cities, only 35 percent offer family planning services (Ross)
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From page 256... ...
Conclusions Fertility behavior and trends The urban/rural gap in fertility levels has remained roughly constant since the late 1970s in each of the developing regions of Africa, Asia, and Latin America. The panel's analysis of urban and rural fertility trends since the late 1970s uncovered no clear tendency for rural fertility rates to fall more rapidly than urban rates.
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From page 257... ...
Urban women are much more likely than rural women to have a physician or nurse/midwife present at childbirth, and we found this to be the case even among the urban poor. The urban poor are little better Nathan rural residents in several dimensions of reproductive health and access to services, and in some cases, they appear to be worse of: When attention is focused on poor urban residents, especially those who live in settlements of concentrated poverty, the urban advantage in terms of unmet need for contraception and mistimed and unwanted births almost disappears, and can even be reversed to become a disadvantage.
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From page 258... ...
As this infection spreads from the large cities to rural areas and smaller cities, both the urban poor and the residents of small cities need to be carefully considered in health policies and programs. Recommendations Decentralization of reproductive health The decentralization initiatives being undertaken by many national governments are introducing a new cast of policy makers and program implementors at the regional and local levels of government.
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