Jan 1, 2002
Evidence from Bangladesh
It might seem that increasing contraceptive use would reduce abortion by reducing unintended pregnancies, but, in fact, abortion and contraceptive use have sometimes increased simultaneously in developing nations. For example, in the past two decades, fertility in one rural area of Bangladesh has fallen by about half while both abortion and contraception nearly tripled. Abortion rates sometimes increase as birth rates decrease in developing nations. Social and economic development leads couples to want to invest more in the health and education of their children, raising the "costs" of each child. As these costs increase, couples become more interested in limiting the number of their births. If couples are unable to limit their births through contraception, they may do so through abortion. This can cause particular problems in developing countries where many abortions are performed by unsafe means and thereby carry great risk of maternal morbidity and mortality.
It is difficult to examine the effect of family planning services on abortion because of the lack of good data on abortion and because other factors can affect the availability of family planning services, contraceptive use, and the incidence of abortion. To determine if family planning services can reduce abortion, Mizanur Rahman of Pathfinder International, Julie DaVanzo of RAND, and Abdur Razzaque of the ICDDR,B Centre for Health and Population Research analyzed high-quality experimental data from Matlab, Bangladesh, on nearly 150,000 pregnancy outcomes, including 4,100 abortions, since 1979. By comparing two Matlab areas that differ only in their family planning services, the researchers were able to control for other factors (e.g., social and economic change) that might affect abortion rates. Rahman, DaVanzo, and Razzaque also use data on contraceptive use and fertility preferences from women interviewed in several surveys to analyze abortion rates for women who did and did not want more children. Their results, published in The Lancet, indicate that women who had access to better family planning services were more likely to use contraception and less likely to have unintended pregnancies, and therefore had fewer abortions. The better family planning services prevented abortion rates from increasing in a setting in which they otherwise might have.
Since 1977, the Maternal Child Health and Family Planning (MCH-FP) project in Matlab has provided, in an experimental design, more accessible and higher-quality family planning services in a "treatment" area, known as the "MCH-FP area," than those provided in an otherwise-similar comparison area. Both areas are typical of rural Bangladesh, and, in both, desired family size has been similar and declined at nearly equal rates, from about 4.5 children in 1975 to 2.5 children in 2000. Among the better family-planning services in the MCH-FP area have been more frequent visits by community health workers to provide counseling and to deliver contraceptives, as well as special clinics providing maternal, child health, and family planning services. Women in the comparison area received standard government contraceptive services. The differences in access and quality of contraceptive services led to consistently greater contraceptive use in the MCH-FP area (Figure 1).
The differences in contraceptive use have led to differences in unintended pregnancy, that is, pregnancies to women who said they did not want any more children (Figure 2). In both areas, unintended pregnancies have declined as contraceptive use has increased, with the greater decline occurring in the MCH-FP area. A number of these unintended pregnancies are aborted. In both areas by the 1990s, one in ten unintended pregnancies were being terminated by abortion. The likelihood of these pregnancies being aborted increased between the mid-1980s and the early 1990s in both areas, reflecting the growing desire by couples to limit their number of births.
In the MCH-FP area, the low and declining incidence of unintended pregnancy has offset the increase in the likelihood that unintended pregnancies would be aborted.
This has resulted in a low rate of abortion that has not changed much over time (Figure 3). By contrast, in the comparison area, the likelihood of abortion of unintended pregnancies has increased more than the incidence of such pregnancies has declined. As a result, the abortion rate has been increasing there. When the MCH-FP project began, abortion rates were very similar in the two areas. Shortly afterward, the abortion rate in the MCH-FP area dropped below that for the comparison area. The difference in abortion rates for the two areas has grown steadily; by 1998 the abortion rate in the MCH-FP area (2.0 abortions per 1,000 women) was less than a third that in the comparison area (6.6 abortions per 1,000 women). When the areas are compared at a point in time, it is evident that abortion rates were significantly lower in the area where better family planning services were available.
These changes have occurred as Bangladesh underwent a fertility transition. From the mid-1980s to the late 1990s, fertility declined by nearly one-third in both areas, but these declines were achieved in different ways. Couples in the MCH-FP area were more likely to use contraception to regulate their fertility. Those in the comparison area, lacking the same family planning services available in the MCH-FP area, had more unintended pregnancies, and more abortions. Despite similar desired family sizes in both areas, fertility remains about 20 percent higher in the comparison area, indicating the greater effectiveness of contraception over abortion in regulating fertility in Matlab.
Bangladesh has managed to maintain a very low abortion rate during its fertility transition but it faces increasing challenges in doing so in the face of continuing social transformation and population crowding. Abortion can increase during the fertility transition in developing countries as the intensity of desire to limit family size increases. Widespread availability of quality family planning services, however, by helping couples better limit unintended pregnancies, helps to keep abortion rates lower than they would be otherwise. Policymakers should be wary of drawing erroneous conclusions about contraceptive use and abortion in studies that do not use appropriate comparative data. It is only through such data that the true effects of family planning services on abortion, independent of other variables, are evident. This research demonstrates that better family planning services can help abortion rates remain low in situations where they otherwise might rise. Efforts to reduce abortion by increasing contraceptive use can also benefit public health by reducing the health problems and burdens on health service resources that result from unsafe abortions in particular.