6 also evidence that women in some socleties have more children partly to lighten their own burden. Given the heavy demands of pregnancy and lactation on the mother, one would expect that many and/or closely spaced births would result in clear evidence of impaired maternal health. We turn now to the scientific evidence.

Noting the cumulative drain of hard labor, poor diet and frequent, closely-spaced pregnancies, Jelliffe (1986) coined the term "maternal depletion syndrome" to characterize the various multi-nutritional deficiency states, for example, iron-deficiency anemia, thought to be responsible. - While the end stages of this "syndrome" a woman with many closely spaced pregnancies who is chronic.-lly fatigued, anemic and perhaps suffering from osteomalacia as a result of calcium and vitamin D deficiency - are often seen by the clinician, it has proved difficult to document with hard statistical evidence. Bernard et al (1978-79) found in an Indian study that almost 40 percent of women having their fourth or later child were anemic, compared to 21 percent having their first child. On the other hand, there was no evidence for the syndrome in four out of nine countries in the WHO Studies on Family Formation Patterns and Health (Population Reports, 1984).

A major review (Population Reports, 1984) cited three methodological problems that often obscure the relationship between maternal age, family size and birth spacing on maternal (and child) health: confounding variables, especially socioeconomic status, questions about the direction of causality, for example, deliberately shortening the birth interval to replace a lost infant, and multiple, interrelated variables. An especially difficult problem is that of disentangling the effect of poverty, as opposed to childbearing, on maternal nutrition. Regardless of the difficulties of documenting a clear-rat syndrome in population-based studies, we conclude that it is plausible to assume that high parity, especially when they are closely spaced, results in substantial maternal morbidity, other things being equal. This morbidity may range from nutritional deficiency states, to a greater likelihood of some life-threatening conditions, e.g., hemorrhage, toxemia, sepsis and abortion, and uterine prolapse. It follows - - that family planning fewer and better spaced pregnancies is likely to reduce maternal morbidity, as well as maternal mortality, and contribute importantly to the health and wellbeing of women in the childbearing years.

# II. HEALTH EFFECTS OF FERTILITY CONTROL

Family planning is generally far safer than childbearing for women in developing countries, as Table 1 demonstrates. We will summarize only briefly the main health effects of contraception, since a separate paper on contraceptive safety has been prepared for the Conference. Contraceptive methods generally are safer and free from substantial risk of complications compared to other drugs and surgical procedures, as well as to childbearing (Gray, 1986). Comparisons with other drugs or common remedies are complicated, however, by the fact that individual contraceptive methods may be used for relatively long periods for preventive rather than curative effect. Antibiotics or anti-malarials, by contrast, are used episodically, usually in the presence of serious disease. Comparisons with childbearing