The impact of freedom on fertility decline.

Although fertility decline often correlates with improvements in socioeconomic conditions, many demographers have found flaws in demographic transition theories that depend on changes in distal factors such as increased wealth or education. Human beings worldwide engage in sexual intercourse much more frequently than is needed to conceive the number of children they want, and for women who do not have access to the information and means they need to separate sex from childbearing, the default position is a large family. In many societies, male patriarchal drives to control female reproduction give rise to unnecessary medical rules constraining family planning (including safe abortion) or justifying child marriage. Widespread misinformation about contraception makes women afraid to adopt modern family planning. The barriers to family planning can be so deeply infused that for many women the idea of managing their fertility is not considered an option. Conversely, there is evidence that once family planning is introduced into a society, then it is normal consumer behaviour for individuals to welcome a new technology they had not wanted until it became realistically available. We contend that in societies free from child marriage, wherever women have access to a range of contraceptive methods, along with correct information and backed up by safe abortion, family size will always fall. Education and wealth can make the adoption of family planning easier, but they are not prerequisites for fertility decline. By contrast, access to family planning itself can accelerate economic development and the spread of education.

New hope: community-based misoprostol use to prevent postpartum haemorrhage.

The wide gap in maternal mortality ratios worldwide indicates major inequities in the levels of risk women face during pregnancy. Two priority strategies have emerged among safe motherhood advocates: increasing the quality of emergency obstetric care facilities and deploying skilled birth attendants. The training of traditional birth attendants, a strategy employed in the 1970s and 1980s, is no longer considered a best practice. However, inadequate access to emergency obstetric care and skilled birth attendants means women living in remote areas continue to die in large numbers from preventable maternal causes. This paper outlines an intervention to address the leading direct cause of maternal mortality, postpartum haemorrhage. The potential for saving maternal lives might increase if community-based birth attendants, women themselves, or other community members could be trained to use misoprostol to prevent postpartum haemorrhage. The growing body of evidence regarding the safety and efficacy of misoprostol for this indication raises the question: if achievement of the fifth Millennium Development Goal is truly a priority, why can policy makers and women's health advocates not see that misoprostol distribution at the community level might have life-saving benefits that outweigh risks?

Setting priorities for safe motherhood interventions in resource-scarce settings.

OBJECTIVE: Guide policy-makers in prioritizing safe motherhood interventions. METHODS: Three models (LOW, MED, HIGH) were constructed based on 34 sub-Saharan African countries to assess the relative cost-effectiveness of available safe motherhood interventions. Cost and effectiveness data were compiled and inserted into the WHO Mother Baby Package Costing Spreadsheet. For each model we assessed the percentage in maternal mortality reduction after implementing all interventions, and optimal combinations of interventions given restricted budgets of US$ 0.50, US$ 1.00, US$ 1.50 per capital maternal health expenditures respectively for LOW, MED, and HIGH models. RESULTS: The most cost-effective interventions were family planning and safe abortion (fpsa), antenatal care including misoprostol distribution for postpartum hemorrhage prevention at home deliveries (anc-miso), followed by sepsis treatment (sepsis) and facility-based postpartum hemorrhage management (pph). CONCLUSIONS: The combination of interventions that avert the greatest number of maternal deaths should be prioritized and expanded to cover the greatest number of women at risk. Those which save the most number of lives in each model are 'fpsa, anc-miso' and 'fpsa, sepsis, safe delivery' for LOW; 'fpsa, anc-miso' and 'fpsa, sepsis, safe delivery' for MED; and 'fpsa, anc-miso, sepsis, eclampsia treatment, safe delivery' for HIGH settings. Safe motherhood interventions save a significant number of newborn lives.

The worldwide burden of postpartum haemorrhage: Policy development where inaction is lethal.

Most maternal deaths occur to women who are not attended by trained health professionals. Postpartum hemorrhage is the single most common cause of maternal death. The delivery of large haemochorial placenta in our species predisposes to heavy bleeding and can be dealt with only by using effective uterotonics. The 1987 Safe Motherhood Initiative has failed to reduce maternal mortality significantly, and shortages of trained personnel will not be remedied in the foreseeable future. Bold new policies are imperative and need to be derived from an appropriate evidence base. It is suggested that these should include the low-cost shock garments in primary health facilities and making misoprostol easily accessible in both the public and private sector.

Barriers to fertility regulation: a review of the literature.

The evidence in the demographic and family planning literature of the range and diversity of the barriers to fertility regulation in many developing countries is reviewed in this article from a consumer perspective. Barriers are defined as the constraining factors standing between women and the realistic availability of the technologies and correct information they need in order to decide whether and when to have a child. The barriers include limited method choice, financial costs, the status of women, medical and legal restrictions, provider bias, and misinformation. The presence or absence of barriers to fertility regulation is likely an important determinant of the pace of fertility decline or its delay in many countries. At the same time, barriers inhibit women's ability to avoid unintended pregnancy. Problems of quantifying barriers limit understanding of their importance. New ways to quantify them and to identify misinformation, which is often concealed in survey data, are needed for future research.

Revisiting community-based distribution programs: are they still needed?

Community-based distribution (CBD) programs are the optimum way of reaching people in rural areas of developing countries where conventional methods of delivery do not exist or fail. This paper reviews findings and experiences from over 30 years of efforts to implement CBD of family planning methods around the world. Although research suggests that community-based service delivery can contribute to contraceptive use, the magnitude of impact is often in doubt or its existence is questionable when compared to alternative family planning delivery services. After the review of more than 30 years of CBD work, we found that these programs are still needed to meet the needs for contraception in rural communities and isolated city neighborhoods in developing countries. Integration with other health outreach programs, effective management, keeping training of agents brief and letting them distribute contraceptives and keeping all or part of the profits instead of paying them salaries are some of the strategies that can make CBD programs more efficient.

Two pills, two paths: a tale of gender bias.

In Japan, it took over 30 years to register the contraceptive Pill, but it took only six months to approve Viagra. The Pill was developed in an academic institution and no large pharmaceutical manufacturer wished to market it. Viagra was developed inside a big company and actively promoted. In the USA, the Pill was almost removed from the market because of widely publicized reports of deaths, but mortalities associated with Viagra do not make the headlines. Viagra has been promoted by the famous, whilst those who use the Pill do not appear in advertisements. Even theologians have treated these two drugs according to different standards. It is suggested that this asymmetry is not accidental, but is an expression of a deep-seated dual standard that is ultimately driven by biosocial differences in male and female power, and reproductive agendas rooted in human evolution.