Research

The Importance of Family Planning in Reducing Maternal Mortality

At least half a million women die each year of pregnancy-related causes. Ninety-nine percent live in developing countries. Two approaches can reduce these deaths. First, make pregnancy and delivery safer once women become pregnant; second, reduce the number of pregnancies through family planning. Family planning reduces maternal mortality in several ways.

At the individual level, family planning reduces the number of times a woman becomes pregnant. Generally speaking, women of higher parity face greater risks in pregnancy. For example, a woman who has been pregnant six times has twice the risk of dying a maternal death as a woman who has been pregnant only three times.
Family planning reduces the number of unintended and unwanted pregnancies. Unwanted pregnancies are far more likely to end in induced abortion, and are far less likely to receive adequate prenatal care than wanted pregnancies. In some situations, abortions account for up to half of all pregnancy-related deaths. The potential for family planning to reduce these deaths is very great.
At the national level, family planning reduces the number of pregnancies and births. Even without any improvement in obstetric care, a 10% reduction in the number of pregnancies will produce a 10% (or greater) reduction in the number of maternal deaths.
Family planning can be targeted to reduce the number of pregnancies to women in groups at increased risk of maternal death, that is women who are too young (<20), too old (>35 or >39), or women who are high parity (more than 5 previous births).
By far the most important way of reducing maternal deaths is simply by reducing the number of pregnancies. By itself, this is very effective. But it is important to pay simultaneous attention to improving obstetric care. Most women want to have at least two children, and they should have good quality care during pregnancy and for delivery. Ideally, these two interventions -- family planning and obstetric care -- should go hand-in-hand.

An FHI analysis used data from Matlab Thana in Bangladesh to demonstrate the impact of family planning on maternal mortality. The table shows the outcome of this analysis.

Reduction in Maternal Mortality Attributable to Family Planning

Absolute value Percent reduction

Matlab Thana 1968-70 (actual)1

Number of births 20,816 --

Number of maternal deaths 119 --

Eliminating births to women >39 years of age

Number of births 20,369 2.1

Number of maternal deaths 116 2.5

Eliminating births to women <20 years of age

Number of births 16,400 21.2

Number of maternal deaths 81 31.9

Eliminating births to women <20 or >39 years of age

Number of births 15,953 23.4

Number of maternal deaths 78 34.5

Eliminating births to women Parity >5

Number of births 16,134 22.5

Number of maternal deaths 50 58.0
1. Data taken from LC Chen et al. Maternal mortality in rural Bangladesh. Studies in Family Planning 1974; 5:334-441.

The table shows the reduction in the absolute number of births and deaths. The numbers in the table are calculated by subtracting from the actual number of births and deaths (shown in the first row) the number of births and deaths that occurred to the groups of women cited. Taking the second row as an example, there were 447 births to women over 39 and 3 maternal deaths; thus eliminating births to women over 39 would produce 20,816-447=20,369 births and 119-3=116 maternal deaths. For women under 20, the numbers are 20,816-4,416=16,400 births and 119-38=81 deaths. For the last row, the fact that the categories of age >39 and parity >5 overlap must be accounted for.

An important point to notice in the table is that, at least in the study area, it is far more effective (in terms of preventing maternal mortality) to prevent births to young (<20) women than to prevent births to older women. Only 2.5% of the deaths and 2.1% of the births in Matlab occurred to women older than 39, but 32% of the deaths and 21% of the births occurred to women younger than 20; younger women are clearly at increased risk of dying in childbirth and during pregnancy.

Among young married women, many early pregnancies are wanted, but abundant evidence indicates that early childbearing increases the risk of obstructed labor, which can lead to death or long-term disabilities like fistula. Many studies have shown that a large proportion of patients with vaginal fistula (up to 80%) is less than 20 years old. Although family planning can delay first births until reproductive organs are fully developed and pregnancy is safer, many cultures place a high value on early childbearing. Among young unmarried women, pregnancies are rarely welcomed, carrying a high risk of abortion, and potentially high mortality associated with unsafe procedures. In one study in Ethiopia, more than half of maternal deaths to women under 20 were due to abortion; the proportion was much less among women over 20. Abortion accounts for 26% of maternal deaths in Bangladesh, where the risks to unmarried women are greater than to married women. In addition to abortion-related deaths, one study found that homicide and suicide account for a significant proportion of deaths to young unmarried women who are pregnant.

Conclusion

The greatest impact of family planning on maternal mortality is for those women who are <20 years of age. While it is a sensitive issue in many cultures, delaying pregnancy by increasing family planning use among both married and unmarried women <20 could save many lives.

In countries where fertility is already low, the impact on maternal mortality of expanding access to family planning will not be great. There is one important exception to this; where fertility is low because of widespread use of abortion, family planning can save lives by preventing abortions.

April 1995

This work was funded by the FHI Contraceptive Technology and Family Planning Research Program through a Cooperative Agreement with the US Agency for International Development.