Unwanted fertility among the poor: an inequity?

Abstract

Objective To determine if higher fertility and lower contraceptive use among the poorer segments of society should be considered an inequality, reflecting a higher desire for large families among the poor, or an inequity, a product of the poor being prevented from achieving their desired fertility to the same degree as wealthier segments of society. Methods Using the most recent Demographic and Health Surveys from 41 countries, we analysed the differences in fertility in light of modern contraceptive use, unwanted fertility (defined as actual fertility in excess of desired fertility) and the availability of family planning services found among poorer and wealthier segments of society. The asset index in each survey was used to construct wealth quintiles and the concentration index (CI) of income inequality was found in health variables. Findings The relationship between the CI found in the total fertility rate and the use of contraceptives was linear, R-square of 0.289. Unwanted births in the poorest quintile were more than twice that found in the wealthiest quintile, respectively 1.2 and 0.5, although there was wide variation among the 41 countries. The CI in our measure of family planning availability (radio messages, knowledge of services and contact with field workers) was largely positively associated with the CI in modern contraceptive prevalence, respectively R-squares of 0.392, 0.692 and 0.526. Conclusion In many countries the higher fertility and lower contraceptive use found among poorer relative to wealthier populations should be considered an inequity.Bulletin of the World Health Organization 2007;85:100-107. IntroductionIn 2000, the United Nations Millennium Declaration created the Millennium Development Goals (MDGs).1,2 These goals established the elimination of poverty and the attainment of equity as a core organizing theme for development activities, including health.3-5 A large literature on inequities in health exists, although this knowledge has not consistently translated into programmes designed to fill inequity gaps. 6,7 In contrast, there has been very little research on possible inequities in fertility, the number of children people have. We think an important reason why fertility inequities have not received much attention is that they do not easily fit into the concept of inequity.Although there is not a consensual definition of inequity, most economists and ethicists agree with Whitehead in distinguishing between a difference that has no moral implications, an inequality, and a difference that does have moral implications and is considered unjust, an inequity. Scandinavian-Americans are quite often blond is an inequality with no moral implications. Yet the fact that poor children's mortality rate from preventable diseases is much higher than that found among children from wealthier families raises many moral issues and is considered an inequity.10 A difference labelled an inequity is likely to have a societal response quite different from a difference designated as an inequality. Indee...

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