PRB

(August 2008) Fertility has declined significantly throughout the developing world, and in Latin America total fertility rates (TFRs) have declined by 50 percent over the last three decades, from 5.0 births per woman in 1970 to only 2.5 today.¹ Service providers have achieved many family planning and reproductive health (FP/RH) successes in Latin America, most notably the increase in modern contraceptive prevalence rates to 64.5 percent of sexually active women in 2007.² These successes have led international health and development agencies to focus their attention on other regions that have yet to show similar improvements in reproductive health.

The successes in Latin America however, mask a great deal of regional variation. In countries such as Bolivia, Guatemala, and Haiti, total fertility rates, a measure of the average number of children a woman will have over her lifetime, are still nearly 4.0 or higher.³ Furthermore, in these countries, between 22 percent and 32 percent of women who do not desire another child or want to space their births still have no access to family planning services.⁴ Within the Latin American countries that have experienced substantial declines in fertility, there are sub-populations and regional pockets characterized by high fertility and lack of access to FP/RH services. Among those with the most limited access to basic reproductive health services are people living in the poorest and most remote communities—on the frontiers of lowland tropical forests like the Amazon and indigenous people living far beyond forest frontiers.

An analysis by the authors of regional and provincial data from Demographic and Health Surveys (DHS) show continued high fertility in the Amazon regions of several countries including Bolivia, Brazil, Colombia, Ecuador, and Peru (see Table 1). Total fertility rates are in most cases substantially higher than national rates: In Ecuador, fertility is higher in the Amazon than in any other region of the country. These averages mask substantially higher fertility in rural areas of the Amazon, which are almost unrepresented in DHS data. The DHS data for the Brazil North region, for example, contains only 14 rural observations. The DHS data from rural Amazon provinces of Colombia report no data. And fertility surveys from Ecuador do not report disaggregated rural data for the Amazon.

Table 1
Total Fertility Rates (TFR) for Select Areas of the Amazon Latin America

Note: The total fertility rate (TFR) measures the total number of lifetime births a woman would have given current birth rates.
Sources: The TFRs for Bolivia, Brazil, Colombia, and Peru were obtained from Demographic and Health Survey (DHS) reports. The TFRs for Ecuador were obtained from the report for ENDEMAIN—a DHS-type survey conducted periodically by MEASURE and CEPAR.

Data on modern contraceptive prevalence rates for these same regions also reveal low rates of modern contraceptive use (see Table 2). The little rural data available suggest that contraceptive prevalence rates (CPR) among sexually active women of reproductive age are under 50 percent for the majority of the Amazon.

Table 2
Modern Contraceptive Prevalence Rates (CPR) for Select Amazon Tropical Forest Areas of Latin America

^a Rural North Region contains only 14 observations.
^b Urban areas only.
^c Women in unions. Rural and urban could not be disaggregated for Ecuador Amazon.
^d Data not available.
Note: The total fertility rate (TFR) measures the total number of lifetime births a woman would have given current birth rates.
Sources: The CPR for Bolivia, Brazil, and Peru were calculated from Demographic and Health Survey (DHS) data and included women ages 15 to 49 who were currently married or in consensual union, and unmarried sexually active women. CPR for Columbia and Ecuador were obtained from the DHS and ENDEMAIN reports respectively.

Indigenous populations in lowland Latin America tend to be particularly underserved by health providers for many reasons, including cultural barriers, language, and accessibility. Available studies among these indigenous populations indicate TFRs from 7.0 to 8.0.⁵ Some researchers have argued that fertility rates among these indigenous women remain high because of a strong desire to have large families. However, survey data from indigenous women in the Ecuadorian Amazon contradict this argument, and indicate that approximately 50 percent do not want another child. Yet 98 percent of these women were not using a modern contraceptive method.⁶ While some might argue that the populations are too small to warrant attention from development agencies, the social and environmental implications of this growth are of great interest to the environmental community.

Conservation, Population, and Indigenous Peoples

Latin American tropical forests, including the Amazon basin, contain the world’s greatest concentration of biodiversity and play a critical role in climate change. More than two decades of conservation efforts have sought to decrease rates of deforestation in Latin American tropical forests. Despite these efforts, estimates of Amazon deforestation from 2002 to 2004 were near their highest levels since monitoring began in 1988, with an average of 2.5 million hectares annually.⁷ After three years of improvement, recent reports of deforestation during the last months of 2007 and first months of 2008 were the highest ever recorded for the wet season.⁸ The causes of this deforestation include underlying forces such as crop prices, land and forestry policies that encourage logging, and weak enforcement institutions at the national and global level. These forces drive local-level human activities such as agricultural expansion, timber extraction, and infrastructure growth that directly result in forest loss.⁹

In response, conservationists are seeking new strategies and new partners to protect the largest remaining tracts of tropical forest. Indigenous lands now encompass the single largest category of protected area in the Amazon, and 20 percent of the Amazon is now under the permanent rights of indigenous people. Indigenous lands are now touted as a critical barrier to future deforestation.¹⁰ Many of the largest conservation groups now work with indigenous groups, and international development agencies are beginning to finance conservation projects that work with indigenous groups. Central to the conservation objectives of these programs is the improved well-being of indigenous populations. Thus, indigenous communities and conservation organizations together should assess how demographic change will impact the health and livelihoods of indigenous households and the ecosystems in which they live.

The direct linkages between fertility and deforestation are often thought to be obvious (for example, more people leads to larger farms and thus more deforestation). In reality, however, the relationship between high fertility and land use has not been found to be as clear as is often stated. Research on the causes of tropical deforestation has found population growth to be a consistent underlying factor contributing to deforestation, though this growth is often due to migration and settlement of new colonists rather than high fertility rates.¹¹ A more established link is the cyclical relationship between fertility and poverty, in which high fertility and poor maternal and child health outcomes are both symptoms of poverty and contributors to impoverishment, and affect the way people use, conserve, or overuse resources.

Changes in indigenous livelihoods are already evident at the household level, where increasing wage employment, market-based agriculture, and migration to cities have begun to replace traditional livelihoods of subsistence agriculture, hunting, fishing, and gathering of forest products. Less understood, however, are how demographic changes might affect the communal management groups that have traditionally managed agricultural lands, rivers, and forests. These communal management groups, for example, often make decisions regarding who can hunt, when they can hunt, and what they can hunt on indigenous lands. Now, these groups must confront the added challenges of greater external pressure from the growing population surrounding indigenous lands as well as greater internal pressure from their own growing populations.¹²

Role of Conservation Organizations

Over the last several years, a few conservation organizations have piloted projects that address the complex links between reproductive health, poverty, and conservation. These projects have adopted an integrated approach to community development that has been termed the Population, Health, and Environment (PHE) approach. The central tenets to this approach are first, that in many remote areas, conservation organizations are among the only institutions providing communities with development assistance; and second, providing men and women with health services and the opportunity to plan their families is beneficial both to the well-being of households and to the long-term sustainability of the forest, fishing, and hunting resources they manage.

The Population Reference Bureau’s PHE Program has been instrumental in developing the PHE approach by providing information to conservation organizations on the links between population, health, and environment, building the capacity of individuals and organizations to work on these cross-cutting issues, and encouraging institutions to form professional networks to share PHE experiences and lessons.

This approach, however, has principally been piloted in Africa and Asia because of the greater need for FP/RH services in these regions and, in part, because of the perception that most Latin American countries no longer need international assistance to provide FP/RH services.¹³ Furthermore, most Latin American ministries of health are just beginning to develop the capacity to procure and manage supply chains for contraceptives and have yet to focus on distribution of services to remote areas.¹⁴ Thus, despite the existence in Latin America of high-priority conservation areas with high unmet need for family planning, there is little indication that the next generation of PHE projects will focus on the unmet need of remote populations in Latin America.

Nonetheless, people in lowland areas of Latin America show an interest in and need for FP/RH services, and conservation organizations are among the few institutions building relationships with indigenous groups. There is, therefore, great opportunity for collaboration between health care providers and conservationists to better the welfare of indigenous peoples, a group typically underrepresented as benefactors of development in the Americas. Responding to this opportunity will require the creativity and commitment of the PHE community and the identification of new priority areas, new partners, and new sources of funding.

Jason Bremner is program director for Population, Health, and Environment at the Population Reference Bureau. Audrey Dorélien was a 2008 Bixby intern at PRB.

References

1. 1. United Nations Department of Economic and Social Affairs, World Population Prospects: The 2006 Revision (New York: United Nations, 2007).

1. 1. United Nations Department of Economic and Social Affairs, World Contraceptive Use 2007 (New York: United Nations, 2007).

1. 1. United Nations Department of Economic and Social Affairs, World Population Prospects: The 2006 Revision.

1. 1. United Nations Department of Economic and Social Affairs, World Contraceptive Use 2007.

1. 1. Kendra McSweeney and Shanha Arps, “A Demographic Turnaround—The Rapid Growth of Indigenous Populations in Lowland Latin America,” Latin American Research Review 40, no. 1 (2005): 3-29.

1. 1. Jason Bremner et al. “Fertility Beyond the Frontier: Indigenous Women, Fertility, and Reproductive Practices in the Ecuadorian Amazon,” Population Environment (forthcoming).

1. 1. Instituto Nacional de Pesquisas Espaciais, Annual Estimates of Deforestation 1988-2007, accessed online at www.inpe.br, on June 5, 2008.

1. 1. Alexei Barrionuevo, “Brazil Rainforest Analysis Sets Off Political Debate,” The New York Times, May 25, 2008.

1. 1. Helmut J. Geist and Eric Lambin, “Underlying Driving Forces of Tropical Deforestation,” Bioscience 52, no. 2 (2002): 143-50.

1. 1. Daniel Nepstad et al., “Inhibition of Amazon Deforestation and Fire by Parks and Indigenous Lands,” Conservation Biology 20, no. 1 (2005): 65-73.

1. 1. Geist and Lambin, “Underlying Driving Forces of Tropical Deforestation.”

1. 1. Jason Bremner and Flora Lu, “Common Property Among Indigenous Peoples of the Ecuadorian Amazon,” Conservation and Society 4, no. 4 (2006): 499-521.

1. 1. John Pielmeier et al., Assessment of USAID’s Population and Environment Projects and Programming Options (Washington, DC: United States Agency for International Development, 2007).

1. 1. Thais Aguilar, Safeguarding the Contraceptive Supply in Latin America in an Era of Donor Phase Out (Washington, DC: Population Reference Bureau, 2006.

(March 2008) Over the past two decades, the government of Peru has instituted a series of laws and policies designed to expand access to family planning services. A recent article in International Family Planning Perspectives notes that in practice, these policies have not always achieved their desired effect. Between 1996 and 2004, for example, a growing share of government family planning clients in Peru consisted of wealthier women. The share of government clients composed of women in the richest three-fifths of the population rose from 46 percent to 53 percent. And the percentage of clients that were from the poorest two-fifths dropped from 54 percent to 47 percent.

James N. Gribble, lead author of the article and director of the BRIDGE Project at the Population Reference Bureau, says the outcome is not surprising: “Policies aimed at promoting equity and serving the poor often ultimately benefit those who are better off, but not their intended target.”

Reference

James N. Gribble, Suneeta Sharma, and Elaine P. Menotti, “Family Planning Policies and Their Impacts on the Poor: Peru’s Experience,” International Family Planning Perspectives 33, no. 4 (2007): 176-81.

(September 2004) A new comparative study using nationally representative information on domestic violence in nine developing countries finds that women whose fathers abused their mothers are twice as likely to suffer domestic abuse themselves.

The report, Profiling Domestic Violence: A Multi-Country Study, published by ORC Macro, also finds that domestic violence in these countries is highly correlated with a husband’s drunkenness and controlling behaviors. But the study did not find that a woman’s poverty, lack of education, or lack of decisionmaking control consistently elevate her risk of being abused.¹

“Gender-based violence is a gender issue,” explains Kiersten Johnson, a co-author of the study and a researcher at ORC Macro. For example, the study found that women who shared the bulk of household decisions with their male partners were at a lower risk of abuse—regardless of their household’s income levels.

Domestic Violence is a Worldwide Problem

The report is based on data from the Demographic and Health Surveys (DHS) in nine developing countries: Cambodia, Colombia, Dominican Republic, Egypt, Haiti, India, Nicaragua, Peru, and Zambia. These surveys, conducted mostly after 1998, collected comprehensive demographic and health data from women ages 15 to 49. In addition, information was collected on “empowerment” indicators such as education, employment, and participation in household decisionmaking.

Researchers also asked the women about their experience of domestic violence throughout their adult lives, including detailed questions about their experience of physical, sexual, and emotional violence within their current relationships. The percentages of women who said an intimate partner had ever abused them ranged from 48 percent in Zambia and 44 percent in Colombia to 18 percent in Cambodia and 19 percent in India. (A 1998 Commonwealth Fund study put levels of similar violence in the United States at 31 percent.²)

More than one in six married women in each country that was studied reported being pushed, shaken, slapped, or targeted with a thrown object by their male partners. At least one in 10 has been threatened or publicly humiliated by their husbands.

Co-author Sunita Kishor, a senior gender specialist at ORC Macro, cautioned that survey questions differed across some of the countries, making absolute comparisons of domestic-abuse prevalence problematic. But Profiling Domestic Violence makes clear that domestic violence remains a problem in these nine countries—and that in at least several of them, women are socialized into accepting its legitimacy under some circumstances.

“Educated women tend to disagree [with the practice of domestic abuse] more, but it’s not as if you get a zero-level of disagreement even among them,” says Kishor. “In most countries, the gender-role norm violation that woman are most likely to agree with as deserving of a beating is a woman’s neglect of her children. This is very, very telling—there’s a huge buy-in to the care of children being a very fundamental duty of women.”

Culture of Violence ‘Akin to Second-Hand Smoke’

The wealth of data collected by DHS also enabled Kishor and Johnson to identify common global risk factors for domestic violence—all of which, they stress, are largely beyond a woman’s control.

“Often there’s this belief that you see in public discourse that women who are beaten are in some way to blame—they’re too fat or unattractive, for example,” says Johnson. “But it’s not any one characteristic or aspect of your life. Instead, there are multiple factors at the individual, husband, and family level—including your ‘inheritance’—that are dynamically interacting.”

By “inheritance,” Johnson means a woman’s experience as a child of her mother’s abuse. Such experience, Kishor says, has “tremendous intergenerational implications.”

“I don’t think enough attention is being paid to these matters,” says Kishor. “The data shows that even exposure to a mother’s experience of abuse, not just firsthand violence, almost doubles your risk [of being abused yourself]. It’s akin to the literature about secondhand smoke—even exposure to it can have ill-effects” (see Table 1).

Table 1
Percentages of ever-married women age 15-49 who experienced spousal violence ever and in the past 12 months, by whether their mother was ever beaten by their father

u = Unknown (not available)
Note: Data not available for remaining three countries studied in report.

Profiling Domestic Violence also found that other common correlates of domestic abuse—besides having husbands who frequently get drunk or exhibit controlling behaviors (such as limiting her outside contact or repeatedly accusing her of infidelity)—include:

• Being married more than once;
• Being married young;
• Having multiple children; or
• Being older than your husband.

In addition, Kishor and Johnson found that many abused women in developing countries do not seek help, ranging from 41 percent in Nicaragua to 78 percent in Cambodia. And those who do reach out often contact people they know rather than health professionals.

Disempowerment and Violence: No Clear Connection

Surprisingly, several measures of female empowerment—employment, education, or attitudes related to gender equity, such as believing that women have the right to refuse sex to their husbands—did not directly correlate in the study with a reduced risk of abuse. And women who make most of their household’s decisions alone—such as whether to make large purchases or to have another child—were victims of domestic violence at the same rate as those with little say in the allocation of their family’s resources. Instead, the study found that women who made decisions jointly with their male partners suffered far less abuse.

“The causality is not clear from these data between increased risk of abuse for women who make most of the decisions alone,” Kishor says. “Is it because she is in such a dysfunctional relationship that she is forced into taking charge? Or is it because she’s taking the decisions alone that she’s actually being beaten?” This uncertainty, she adds, raises questions about conventional indices of empowerment.

“We need to be looking closely at a lot of these indicators and asking what they’re really telling us in different contexts,” Kishor says. “While empowerment usually implies that you are in control of your life, the data suggest that, within a marital context, ‘dominating’ [these] decisions may not equate to empowerment.”

The Health Consequences of Abuse

The study found clearer connections between abuse and degraded health for victimized women and their children. For instance, women in almost all the surveyed countries who had experienced abuse from their intimate partners had higher rates of unwanted births and nonlive births (by 33 percent to 72 percent) than those who had never been abused.

Women who experienced violence were also more likely to have had sexually transmitted infections, their pregnancies were substantially less likely to have received first-trimester antenatal care, and their children between the ages of 12 months and 35 months were less likely to have been fully vaccinated. The children of abused women were also more likely to die before age 5.

Both authors stress that including national domestic violence statistics alongside health and demographic information is a large step forward in addressing the roots of abuse.

“Up until recently, there wasn’t the kind of impetus or interest in this kind of data, or even the recognition of domestic violence as an issue of public health and development,” Johnson says. “It’s important to know that there are multiple factors involved, and thus multiple arenas in which interventions can occur.”

Robert Lalasz is a senior editor at PRB.

References

1. Sunita Kishor and Kiersten Johnson, Profiling Domestic Violence: A Multi-Country Study (Columbia, MD: ORC Macro, 2004).
2. Karen Scott Collins et al., Health Concerns Across a Woman’s Lifespan: The Commonwealth Fund 1998 Survey of Women’s Health, accessed at www.cmwf.org/usr_doc/Healthconcerns_surveyreport.pdf, on Sept. 14, 2004.

For More Information

Profiling Domestic Violence: A Multi-Country Study is available at www.measuredhs.com/pubs/pdf/OD31/DV.pdf.