Fertility, Equity and Malaria

A recent issue of the Bulletin of the World Health Organization raises important issues about the relationship between fertility and equity. The authors note that while concepts of equity are embodied in the Millennium Development Goals (MDGs), the relation between fertility and equity has been difficult to conceptualize, hence their article. The question raised is whether there are aspects of fertility that have “moral implications and [are] considered unjust, an inequity,” leading the authors to explore whether unwanted fertility inequities exists among different strata of societies.

Does the link between poverty, disadvantage and inequity apply to fertility? The authors found that total fertility rate in 41 developing countries was higher for poorer people, but they ask whether this in itself constitutes inequity. What if the poor actually desire more children? People can control fertility and access to family planning has enabled poor people to reduce their fertility if they so desire.  Excess mortality is clearly inequitable and undesirable, but is extra fertility on the same plane?  Excess and unwanted fertility does carry serious health and life risks but these paint only part of the picture of fertility. While poorer people were found to have higher unwanted fertility, their desired fertility was still higher than those who were better off, so this still begs the question of whether higher fertility in itself is an inequity.

The authors conclude, among other issues that, “However, high fertility equity should not lead to benign neglect any more than equity in high mortality or very low bed net coverage to combat malaria should lead to complacency.” This leads to thoughts about how much excess infant and child mortality from malaria is affecting fertility preferences among poor people who are more vulnerable to malaria.  Will attainment of the MDG, “Halt and begin to reverse the incidence of malaria and other major diseases,” ultimately have positive effects on fertility inequities?

Just as higher fertility appears to be accepted among disadvantaged populations, excess child mortality expectations too, have a cultural component. The Yoruba concept of abiku, the child who is born to die and then return, embodies a cultural explanation for infant and child mortality.  If children actually survive because of improved access by the poor to malaria control interventions, abiku, excess child mortality and excess fertility may become history.

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