 John Stover, Vice President, The Futures Group International, 80 Glastonbury Boulevard, Glastonbury, CT 06033. The proximate determinants of fertility framework, developed in its current form by Bongaarts, has been used extensively by researchers for the past 20 years. Since the initial framework was developed, a wealth of new survey data on the proximate determinants has become available. This article reviews the new data and past experiences and suggests modifications to the framework that would take advantage of this experience. The major modifications suggested are (1) the use of sexual activity rather than marriage to indicate exposure to pregnancy; (2) a revision of the sterility index to measure infecundity from all causes; (3) a revised index of contraception that accounts for the fact that users of sterilization may become infecund before age 49; and (4) a revised definition and estimate of total fecundity. (Studies in Family Planning 1998; 29[3]: 255–267)
Mizanur Rahman, Demographer/Scientist, International Centre for Diarrhoeal Disease Research, Bangladesh, GPO Box 128, Dhaka 1000, Bangladesh. This study analyzes longitudinal data from Matlab, Bangladesh, to examine the impact of child mortality on subsequent contraceptive acceptance and continuation. The strong negative impact is found to attenuate with family size, indicating a "replacement effect." An "insurance effect" is observed as contraceptive acceptance and continuation were negatively associated with the number of previous deaths of children. Couples seem to find contraceptive use acceptable if the child who dies is one of a large family. Potentially, contraceptive use could be acceptable for spacing after a child in a small family dies. Family planning programs can help to reduce fertility and maternal and child health risks substantially by supplying appropriate methods to those couples who have experienced a young child's death; to be most effective, methods should be supplied immediately after the child's death. (Studies in Family Planning 1998; 29[3]: 268–281)
Carine Ronsmans, Clinical Lecturer, and Oona Campbell, Senior Lecturer, Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WCIE 7HT, UK. No previously published study has provided evidence to support the frequently made assertion that closely spaced births increase the risk of maternal death. This study reviews the literature for evidence supporting an association between short birth intervals and maternal mortality and presents empirical evidence to address the question of whether short birth-to-conception intervals alter the risk of maternal death. In this nested case-control study selected from a cohort of women under demographic surveillance in Matlab, Bangladesh, the length of the preceding birth-to-conception interval is found not to affect the risk of maternal mortality. These results do not support the claim that births that are too close increase the risk of maternal death. (Studies in Family Planning 1998; 29[3]: 282–290)
ReportsAt the time this report was written, Jayanti Tuladhar was Program Associate, Population Council. He is now Advisor, RHFP Management Information Systems, UNFPA/Country Support Team, Office for East and Southeast Asia, 14th Floor, United Nations Building, Rajdamnern Avenue, Bangkok 10200, GPO Box 618, Thailand. Peter J. Donaldson, President, Population Reference Bureau, Washington, DC. Jeanne Noble, Michigan Fellow, INOPAL, Population Council, Lima, Peru. In this study, patterns of Norplant® use in Indonesia are reviewed to assess the implications of this experience for the introduction of new contraceptive methods. Data from the Norplant Use-Dynamics Study and the 1994 Indonesia Demographic and Health Survey are analyzed, and patterns of acceptance, continuation, and removal are described. Acceptance of Norplant has increased steadily since it was first introduced. The method is now used by more than 5 percent of all married women of reproductive age. Continuation rates among Norplant users are higher than among users of the IUD. One factor behind high continuation rates may be that a substantial proportion of acceptors were not told that removal before five years was possible. Results indicate that deficits occurred in the quality of service delivery and that a need exists for improved provider training, better supervision, and clearer and better-enforced guidelines regarding women's right to have Norplant removed on demand. (Studies in Family Planning 1998; 29[3]: 291–299)
Shireen J. Jejeebhoy, Consultant, Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Avenue Appia, CH-1211, Geneva 27, Switzerland. This report examines the linkages between wife-beating and one health-related consequence for women, their experience of fetal and infant mortality. Community-based data are used drawn from women surveyed in two culturally distinct sites of rural India: Uttar Pradesh in the north, in which gender relations are highly stratified, and Tamil Nadu in the south, in which they are more egalitarian. Results suggest that wife-beating is deeply entrenched, that attitudes uniformly justify wife-beating, and that few women can escape an abusive marriage. They also suggest that the health consequences of domestic violence in terms of pregnancy loss and infant mortality are considerable and that Indian women's experience of infant and fetal mortality is powerfully conditioned by the strength of the patriarchal social system. Results are tentative because of data limitations, but they are consistent and strong enough to warrant concern. They argue for the integration of services to identify, refer, and prevent domestic violence in the primary or reproductive health programs of the country and for the safe motherhood programs to be particularly vigilant, sensitive, and responsive to the conditions of battered women during pregnancy and the postpartum period. (Studies in Family Planning 1998; 29[3]: 300–308)
Thomas T. Kane, Operations Research Scientist, Operations Research Project, Health and Population Extension Division, International Centre for Diarrhoeal Disease Research, Bangladesh, GPO Box 128, Dhaka1000, Bangladesh. Mohamadou Gueye, Senior Demographer, CERPOD, Bamako, Mali. Ilene Speizer, Assistant Professor, Tulane University School of Hygiene and Tropical Medicine, New Orleans, LA. Sara Pacque-Margolis, United States Agency for International Development Liaison Officer to CERPOD, Bamako. Danielle Baron, Program Officer, Johns Hopkins University Center for Communications Programs, Baltimore, MD. An integrated multimedia campaign featuring family planning messages saturated the 900,000-person city of Bamako, Mali, for three months during the spring of 1993. With traditional theater and music, family planning messages were repeatedly broadcast on radio and television that conveyed information about modern contraceptive methods, the need for male sexual responsibility, the health and economic advantages of family planning, the need for communication between spouses, and that Islam, the predominant faith of Mali, does not oppose family planning. A separate sample pretest-post-test quasi-experimental research design was used to evaluate the effects of the campaign and exposure to specific messages on changes in contraceptive knowledge, attitudes, and practice. Results indicate a high level of exposure to and agreement with the messages. A dramatic drop was found in the proportion of men and women who believe that Islam opposes family planning. Logistic regression results indicate that contraceptive knowledge and use and more favorable attitudes toward family planning are positively associated with intensity of exposure to the project interventions, after controlling for relevant variables. (Studies in Family Planning 1998; 29[3]: 309–323)
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