## **_Fertility and maternal mortality_**

Reducing fertility also helps lower maternal mortality (NRC 1989). Abortions following unplanned pregnancies are a significant cause of maternal death. Secondly, the risk of maternal death varies widely with maternal age and birth order ─ it is high for younger teenage mothers, and rises sharply again at higher birth orders and higher ages. Avoiding teen childbearing and having smaller families reduces maternal mortality risks, as does longer spacing between births. And women‘s mortality risk remains elevated for long after childbirth: a study in Bangladesh found that it is nearly twice as high as normal for up to two years after childbirth (Menken et al 2003).

That fertility reduction can help improve women‘s health is suggested by Figure 7, which shows how much female adult mortality improved (relative to male) in India concomitant with fertility decline. The comparison with men provides a rough control for overall health improvements. In the early 1970s, female mortality plummeted relative to males in the early childbearing years, picking up gradually over the lifecycle. By 1990, adult women‘s mortality relative to men‘s had improved sharply, not only in the childbearing years but also up to age 50, suggestive of reductions not only in maternal mortality but also in lagged mortality arising from maternal depletion and maternal morbidity from repeated childbearing. Improved maternal health care is another major factor in maternal mortality decline. Note, however, that these data predate the big donor thrust from the mid-1990s, aimed at improving reducing maternal mortality.

# **6.   Conclusions**

The argument that has raged for half a century over the relationship between population and economic development has distracted people from recognizing that there is in fact little disagreement over the bottom line. There is wide consensus that appropriate policy environments and technological advances are key to improving standards of living ─ and that population dynamics play an important secondary role in this process.<sup>23</sup> A combination of policies is in order, as the World Bank put it: In short, policies to reduce population growth can make an important contribution to development (especially in the long run), but their beneficial effects will be greatly diminished if they are not supported by the right macroeconomic and sectoral policies. At the same time, failure to address the population problem will itself reduce the set of macroeconomic and sectoral policies that are possible, and permanently foreclose some long-run development options. (World Bank 1984:105) Recent studies conclude that reducing fertility facilitates economic growth in low-income countries. Low dependency ratios (resulting from fertility decline) create a window of opportunity for savings, increased productivity, and investment ― which if properly managed can transform living standards permanently. The more rapid the fertility decline in a region, the wider the window of opportunity, though its duration will be shorter because the population will age more rapidly. They also indicate that rapid population growth can be a constraint on economic growth, especially in poor countries with policies that do not encourage rapid rise in productivity. Micro-studies also find that lower fertility is also associated with better child health and schooling, reduced maternal mortality and morbidity, increased women‘s labor force participation, and higher household earnings. This is quite aside from the intrinsic human right of being able to control one‘s own fertility.

Hopefully these recent studies will put this debate to rest. Meanwhile, the debate has helped discourage donors from investing in family planning programs. While these are by no means the only policy lever to help reduce fertility, they are an effective but neglected lever with a clear rationale for public funding. This has been a missed opportunity, especially for the Sub-Saharan African region, where fertility 15