Whose Life is it, Anyway? Assessing the
Relative Risks of Contraception and Pregnancy
Adrienne Germain and Ruth Dixon-Mueller
Having sex, using (or not using) a contraceptive, being pregnant, having an abortion, bearing a child: it's all a risky business where health is concerned, especially for low-income women in Southern countries. But how risky is each activity? And how do their risks compare?Health and family planning researchers and practitioners are increasingly using estimates of "relative risk" to guide policy making-to decide who should get what services, and to justify certain contraceptive methods because of their lower risk when compared with pregnancy or childbirth.' But is formalized risk assessment sufficient for making such decisions? Are important considerations left out? Is it fair, or relevant, to use the "probability of dying" (the profession's standard measure) as the primary basis for comparing risks?
The medical and demographic literature use risk assessment in two contexts that have special relevance to women's reproductive health. The first compares the mortality risks of using various family planning methods with the risks of bearing a child. For example, an Egyptian woman is 13 times more likely to die from pregnancy or childbirth ("maternal causes") than from using the pill; a Thai woman is 27 times more likely to die from maternal causes than from using the IUD. Not surprisingly, contraception and sterilization always look good under these circumstances: the higher the prevailing rates of maternal mortality, the "safer" the contraceptive method appears. The second context compares the relative risks of pregnancy and childbirth across different groups of women. Women defined as being at high risk of maternal death (or the death of their newborns) are classified as priority candidates for prenatal care, or, as a preventive measure, for the most effective methods of birth control.
From the provider's perspective, the relative risk approach to allocating scarce resources has a certain logic in meeting institutional needs and improving institutional efficiency. But from the client's perspective, the provider's priorities may not reflect the client's understanding of her own situation at all. A number of questions can be raised about these different points of view. What are some of these questions, and what do they imply about policies and programs?
Comparing the Risks of Contraception and Childbearing
While the argument that contraception is almost always safer than pregnancy and childbirth is true, does it provide sufficient grounds for promoting invasive methods such as hormonal pills, implants, injectables, IUDs, or tubal ligation-which carry greater health risks-over less effective but more benign methods such as condoms, diaphragms, and foams or jellies? Not necessarily.
- Calculations of contraceptive risk are often based on studies of Northern populations that may under estimate the risks to low-income women in Southern countries, many of whom face a limited choice of family planning methods, inadequate medical screening, and poor or non-existent follow-up care.
- Women have very different views on the relative risks of pregnancy, abortion, and contraception, depending on their age, marital and socioeconomic status, cultural and family context, reproductive history, and knowledge of reproductive processes and contraceptive methods. How much risk of contraceptive side effects or failure a woman is willing to take depends on the intensity with which she wants to avoid having a child or an induced abortion.
- Contraceptive users still risk pregnancy if their method fails. Rates of accidental pregnancy among active contraceptors can range from under one percent in a population to more than 50 percent, depending on which methods are used and how carefully. Thus, a woman is not avoiding entirely the risks of pregnancy and childbirth when she uses most methods of birth control. Without the backup of safe pregnancy termination, a woman determined to avoid an unwanted birth may be compelled to use a more effective contraceptive method associated with higher health hazards, or else face the highest mortality risk of all: a clandestine abortion improperly performed.
- Risks that affect a woman's everyday life may be far more pressing than the risk of death. Yet these risks are more difficult to measure because we know so little about what they are and how women perceive them. For example, women often take considerable personal and social risks in using contraceptives. Anxiety about going to a clinic, embarrassment during a physical examination, the anger of a husband, lover, or parent, fears (whether founded or not) of contraceptive side effects or of future infertility, and other concerns make contraception difficult for some women, and perhaps for all women at some point in their lives. Is the distant possibility of death likely to be more persuasive to the individual woman than these immediate but less measurable concerns?
- Contraception and childbearing have very different meanings. For many women, contraception is an unnatural act with an uncertain outcome, whereas pregnancy is a familiar and natural state that is socially rewarded in certain circumstances. A woman may accept substantial health risks of childbearing while rejecting even small health risks from contraception. (The reverse may also be true, depending on the woman's priorities.) Should we assume that women equate the risks of pregnancy and the risks of contraception?
Comparing the Risks of Childbearing for Women in Different Circumstances
Health and family planning professionals have also used risk assessment to identify women who may have major medical difficulties during pregnancy or delivery. Typically, they label as "high-risk" those women who get pregnant under 15 or over 40 years of age, who already have many children or a recent newborn, or who have health problems such as malaria, diabetes, heart disease, or hypertension. These assessments are used to encourage non-pregnant women in high-risk categories to practice effective contraception and to monitor pregnant women for special treatment and referral if necessary.There is no doubt that women face pregnancy and childbirth with different levels of risk. This information is important for the woman to know and for the health worker to assess. Targeting high-risk women for special treatment may not be the most effective way to reduce maternal deaths, however, because:
- The majority of women who die from pregnancy, abortion, or childbirth would not have been classified as high-risk according to these definitions. Implementing risk approaches in Southern countries would generally fail to predict about 75 percent of all maternal deaths. Most problems of pregnancy or childbirth are simply not predictable, particularly prior to pregnancy. Many more deaths could be prevented by providing better primary health care to all women, including basic prenatal care and assistance at the time of delivery.
- In countries where safe abortion is legally restricted or inaccessible, as many as one-quarter to one-half of all maternal deaths result from unsafe abortion. Yet under safe conditions, women are less likely to die from all early abortion than from taking the pill, using the IUD, having a tubal ligation, having a child, or even having sex! In the United States, for example, probabilities of dying are estimated as one in 400,000 for an abortion under nine weeks' gestation, compared with one maternal death per 10,000 live births; one death in 16,000 for pill users who are smokers; one in 20,000 for a laparoscopic tubal ligation; one in 50,000 women for having sexual intercourse (deaths from sexually-transmitted pelvic inflammatory disease); one in 63,000 for non-smoking pill users; and one in 100,000 for IUD users. The provision of safe abortion-a technically-achievable and cost-saving measure-could reduce maternal mortality in some populations as much as the elimination of all births to women in high-risk groups.
- The mortality risks of pregnancy and delivery vary markedly with women's socioeconomic status and access to health care. Whereas in the early l980s women in some parts of Africa faced almost one chance in 20 of dying from maternal causes (including abortion) during their reproductive years, women in northern Europe risked only one chance in 10,000. Policies aimed at extending primary health services to low-income populations, particularly in rural areas, may be more effective in reducing maternal deaths than policies aimed at referring some high-risk women to more advanced medical facilities, even assuming that such facilities exist and provide adequate care.
- Many Women in high-risk categories want to have children and are not candidates for contraception. A more effective strategy for delivering family planning services would be to meet the needs of women who do not want to be pregnant but are undeserved by existing programs. These include young unmarried women who are sexually active and are trying to avoid pregnancy, women who are dissatisfied with their current contraceptive method, and women who want to terminate an unwanted pregnancy and need safe services.
Reconsidering Relative Risks
Sex and childbearing are indeed physically risky, but they are also highly emotional events imbued with pleasure and joy, anxiety and pain. The motives for having (or not having) a child at a given time are changeable, contextual, and often contradictory. Although Contraception is a private act, having a child is a social event of great significance to immediate families, extended kin groups, communities, and other social networks. Do we really know how women in different circumstances weigh these alternatives?Calculating the mortality risks of contraception and childbearing under diverse circumstances is undoubtedly useful at the aggregate level. It demonstrates clearly that we need to:
- reduce the risks of childbearing by providing adequate prenatal monitoring and assistance with delivery at the primary level;
- reduce the risks of clandestine abortion by providing safe services; and
- reduce the risks of contraception by providing choices, matching methods to users' needs, screening for medical problems, facilitating good client provider communications, and monitoring side effects.
As a basis for making decisions about health care, the application of formalized risk assessment is too narrow. Moreover, applying group risks to predict individual outcomes, or assuming that the risks of pregnancy always outweigh the risks of pregnancy prevention, can be misleading. We need to listen more closely to how women in different circumstances assess the costs and benefits of alternative contraceptive and childbearing options, because when we recommend that a woman use contraception, we are asking her to take risks that we cannot predict. These include not only physical risks, which are indeed less life-threatening (but perhaps no less feared) than those of having a child, but also social and emotional risks that directly concern her in a multitude of ways unknown to the researcher or practitioner, who inhabits a very different social world.
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