Poverty Reduction: Does Reproductive Health Matter?
"Our field got overconfident and wasn't scrambling like other health fields…now we are paying for it," commented Thomas Merrick, a professor in the Department of Global Health in the School of Public Health and Health Services at George Washington University, on the decline in reproductive health funding. On January 24, 2006, the Environmental Change and Security Program and the Global Health Initiative brought together Merrick; Margaret Greene, interim chair of the Department of Global Health; and Rachel Nugent of the Population Reference Bureau to discuss the limitations of existing research—and the promise held by other methods—to assess the affects of reproductive health on poverty reduction, as described in Greene and Merrick's recent World Bank paper, "Poverty Reduction: Does Reproductive Health Matter?"
Shifting Money to Poverty Reduction
At the September 1994 International Conference on Population and Development (ICPD) in Cairo, Egypt, the reproductive health field underwent a major shift, turning from viewing family planning as a means of population control to a more comprehensive approach that included efforts to empower women, meet the reproductive needs of individual men and women, and improve quality of life and sexual health. While this shift spurred donor pledges, actual contributions fell short of need. Recently, donors have begun to prefer multi-sectoral, broad-based initiatives, such as poverty reduction, diverting funds from projects that mostly focused on reproductive heath.
"Poverty Reduction: Does Reproductive Health Matter?" attempts "to clarify reproductive health with a broader development objective," Greene said. Using existing evidence, she and Merrick tried to identify a causal relationship between reproductive health and poverty, in hopes of mobilizing resources "through the new poverty-reduction, MDG [Millennium Development Goal]-focused mechanisms that donors and governments are embracing," she said. But, as Merrick said, "Causality between reproductive health and poverty reduction is very difficult to demonstrate," as child-rearing customs, labor market conditions, and the demographic transition (the move from high birth and death rates to low birth and death rates) all factor into the overall impact.
The Relationship Between Reproductive Health and Poverty
According to Merrick, he and Greene sought to find out "what we know, what we don't know, and what we think we know but we don't" about the relationship between reproductive health and poverty. Their study analyzes how three reproductive health outcomes—rates of early childbearing, maternal survival, and unintended pregnancy—affect poverty. Rather than strictly using economic indicators, such as household wealth and income, in their poverty assessment, they used economist Amartya Sen's "capacity" approach to poverty: they factored in social science data, such as health and education outcomes for mothers and children, as well as household consumption and production effects. Their results show that the reproductive health outcomes most strongly affect overall health, followed by education, with household well-being the most weakly affected. Merrick noted that fairly strong evidence links very early pregnancy to adverse health effects, such as life-long morbidity. For education, however, there was "some evidence of dropping out, but reasons other than pregnancy [were] often [cited] as more important factors," he said.
According to Merrick and Greene, "existing research has not effectively addressed the effects of poor reproductive health"; a more comprehensive approach would clarify the relationship. "Longitudinal surveys offer greater promise" than using survey data from a single point in time, they claim. The authors maintained that it is not necessary to reinvent the wheel: "Rather than propose new survey research, initial research could work with existing data resources." Further, they state that a "more ambitious agenda" would be to push longitudinal studies currently underway to include survey questions that more effectively examine the relationship.
Connections and Considerations
Discussant Rachel Nugent praised Merrick and Greene for helping to clarify the existing evidence linking reproductive health to poverty. Nugent pointed out that in addition to revealing some strong connections, the paper also shows that some connections, previously thought to be obvious—such as early childbearing's effect on schooling and the connection between attended deliveries and the maternal mortality rate—are actually surprisingly weak. Nugent identified some important information omitted from the paper in the interests of length, such as a discussion of the methodologies used in the studies, the cost effectiveness of health program interventions, and statistical variations within studied countries. Nugent said that a causal relationship remains uncertain, and called for more research, as well as caution: "There is a great risk in overstating the relationship [between reproductive health and poverty] and implying to policymakers that [it] would persist." She concluded that the "paper helps assist us in the shift of reproductive health to address other MDGs and other poverty reduction goals."
After the presentation a lively discussion touched on issues such as fragile states, HIV/AIDS funding, as well as whether the reproductive health field holds itself to a higher "gold standard" than other health fields. When asked how to connect reproductive health outcomes to investments in reproductive health, Merrick mentioned that the 2007 World Development Report (supported by the William and Flora Hewlett Foundation) will specifically measure "the impact of investment in reproductive health on poverty reduction." Finally, Greene commented that "reproductive health is a politically vulnerable" field. However, Merrick added that the paper's reception was "friendlier than expected," at the World Bank.
Drafted by Julie Doherty.
Co-Author, Delivering Solutions; Director, GreeneWorks
Senior Research Scientist and Associate Professor, Department of Global Health, University of Washington
Tom Merrick //Program Advisor, Population, Reproductive Health and Health Sector Reform Learning Program, World Bank Institute