Statistique, Développement et Droits de l‘Homme
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Statistique, Développement et Droits de l‘Homme
Kunniseri E. VAIDYANATHAN
Consultant in Demography and Social Statistics
3028, 13th Main Road, Anna Nagar
600 040 Chennai, India
T. + 91 44 622 1826 F. + 91 44 621 1937 vaidyake@hotmail.com
ABSTRACT
Statistics of Reproductive Health and Reproductive Rights: An Assessment
Information is required to draw up national level programmes for improvements in the reproductive health status and reproductive rights of couples and to monitor the progress towards the achievement of ICPD goals. The statistics collected through various sources such as population censuses, administrative records and sample surveys suffer from various deficiencies- conceptual, methodological and practical. In spite of the progress made during the last decade in the collection and compilation of data, the database on reproductive health remains weak. Particular areas of deficiency include maternal health status, reproductive morbidity and its correlates, availability and quality of care in maternal health, the extent of unmet needs for family planning, the levels of maternal mortality, abortion and infertility. Reproductive rights imply access to information and services on a broad range of parameters but little information is available regarding them.
Women's ability to exercise reproductive choices are limited by lack of autonomy and unequal gender relations, however, data are wanting on these issues. This paper attempts a review of the limitations in the data in the context of monitoring the achievement of ICPD goals, and presents some suggestions for strengthening the database and remedying the gaps in information.
RESUME
Statistiques sur la santé dans le domaine de la reproduction humaine et droits associés à la reproduction humaine : Une évaluation
Il est nécessaire de disposer d’informations pour élaborer à l’échelle nationale des programmes d’amélioration de la santé dans le domaine de la reproduction et des droits associés à la reproduction humaine et pour contrôler les progrès de la concrétisation des objectifs de la
CIPD. Les statistiques collectées via différentes sources tels que les recensements de population, les registres administratifs et les enquêtes par sondage souffrent de diverses déficiences – conceptuelles, méthodologiques et pratiques. En dépit des progrès enregistrés au cours de la dernière décennie au niveau de la collecte et de la compilation des données, la banque de données sur la santé dans le domaine de la reproduction reste peu fournie. Les domaines de déficiences particuliers incluent le statut de la santé maternelle, la morbidité reproductrice et ses corrélats, la disponibilité et la qualité des soins de santé maternels, l’ampleur des besoins non satisfaits de
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Statistique, Développement et Droits de l‘Homme planification familiale, les taux de mortalité maternelle, l’avortement et la stérilité. Les droits à la reproduction impliquent l’accès à l’information et aux services dans une vaste gamme de paramètres, mais on ne dispose que de peu d’informations à ce sujet. L’aptitude des femmes à exercer leurs choix en matière de reproduction est limitée en raison de leur faible autonomie et de l’inégalité des sexes, mais l’on a besoin de davantage de données sur ces questions. Ce document vise à dresser un tableau des limites des données dans le contexte du suivi de la concrétisation des objectifs de la CIPD et présente des suggestions pour consolider la banque de données et combler les lacunes d’informations.
1. Introduction
The International Conference on Population and Development (ICPD) held at Cairo in 1994 had placed reproductive health and reproductive rights at the center stage of world concern. The conference had called upon the governments to ensure that a wide range of reproductive health care services including family planning are accessible, affordable, acceptable and convenient to all users in order to prevent unwanted pregnancies, reduce the incidence of high-risk pregnancies and the consequent morbidity and mortality, to prevent and reduce the incidence of sexually transmitted diseases including HIV/AIDS and the complications arising therefrom. Reproductive rights were broadly defined as the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and the means to do so.
They also included the right to attain the highest standard of sexual and reproductive health and the right to make reproductive decisions free from discrimination, violence and coercion. (UNFPA,
1994:45-60)
Although there has been a global recognition of the importance of reproductive health as a major component of women's health and well-being , information on reproductive health status, needs and services and the associated socio-cultural factors are lacking in many countries. Lack of reliable information has been a major handicap in addressing reproductive health needs particularly in developing countries. Notwithstanding the progress made during the last decade in the collection and compilation of data, the database in the area of reproductive health remains weak. Particular areas of deficiency include maternal health status and morbidity and their correlates, availability and quality of care in maternal health, the extent of unmet needs for family planning, the levels of maternal mortality, abortion and the incidence of infertility. Women's ability to exercise reproductive choices in developing countries are limited by lack of autonomy and unequal gender relations, however, data are wanting on these issues.
This paper attempts a review of the available data in the context of monitoring the achievement of ICPD goals, and presents some suggestions for strengthening the database.
Following the statement of the problem, section 2 attempts to define reproductive health and reproductive rights as widely understood and as enunciated by the various international conferences on the subject. In the third section the various sources of data and their limitations are discussed, and this is followed by a discussion of the gaps in the available information while the fourth section deals with the various approaches attempted to remedy these gaps. The concluding section presents a summary of the recommendations for future developments in this field.
2. Meaning of Reproductive Health and Reproductive Rights
Maternal health as understood in the past referred to conditions of women during pregnancy, childbirth and post-partum period. The International Conference on Population and Development held in Cairo (hereinafter referred to as ICPD.1994) widened its scope by defining reproductive health as follows: "Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system
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Statistique, Développement et Droits de l‘Homme and to its functions and processes". (UNFPA, 1994, 7.2). On account of this broader definition, reproductive health covers the entire life time of an individual from the time of adolescence. Such a definition is inclusive of the sexual health of men and women, their access to health care services and family planning and their ability to have safe pregnancy and childbirth. Moreover, reproductive health is gender neutral and includes safer sex, prevention of sexually transmitted diseases and enabling of couples to have a satisfactory sexual life. Another major thrust of this definition is prevention of reproductive health problems alongside the solution of these problems. The new definition has resulted in a broader and comprehensive approach to reproductive health instead of the compartmentalized approach adopted earlier. For instance, the earlier maternal and child health programmes were focussed on the health of mothers and their children while the family planning programmes were aimed at providing information and services on contraception. On the other hand reproductive health programmes are meant to promote the reproductive health of men and women in a comprehensive manner promoting appropriate social behaviour and cultural practices. (United
Nations, 1996, p2) .
Reproductive rights are defined as the "basic rights of couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence as expressed in human rights documents". (UNFPA, 1994, 7.2). Reproductive rights as defined above recognizes the rights of individuals and couples to have access to information and services related to family planning, infertility, abortion etc, prevention of harmful practices such as forced marriages, female genital mutilation, discriminatory practices against women and girls and promotion of equitable gender relations. Although the concept of reproductive rights is of recent origin, many of these rights are enshrined in the documents and treaties such as the International
Covenant on Civil and Political Rights, International Covenant on Economic, Social and Cultural
Rights etc. The Convention on Elimination of All Forms of Discrimination against Women (1979) has explicitly endorsed these rights. There are great obstacles to the realization of reproductive rights due to the sensitive nature of sexuality, contraception, empowerment of women etc in many societies. Ignorance and superstitions are added complications. Examples are the practices of child marriages in some parts of India and the practice of female genital mutilation in many parts of
Africa. In many countries archaic laws and customs place limitations on the personal status of women, restrict their access to resources and make them subordinate to men. Low educational level of women compared to men also results in their lack of awareness of their rights.
3. Sources of Data and their Limitations
Statistics and indicators required to draw up national level programmes for improvements in the reproductive health status and reproductive rights of couples are collected through various sources such as population censuses, administrative records and sample surveys. However, all these sources of data suffer from various deficiencies- conceptual, methodological and practical.
3.1 Population Censuses
Population censuses provide demographic, economic and social information that is vital for social and economic planning. Censuses provide the basis for estimating the population base for computing the vital rates. The topics related to reproductive health generally included in population censuses are the following: sex, age, marital status, marital status, form of marriage, age at first marriage (cohabitation)/duration of marriage (cohabitation), number of spouses, children ever born and surviving children, births to ever married women during the past 12 months, survival status of the births during the past 12 months, deaths in the household during the past 12 months etc. The
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Statistique, Développement et Droits de l‘Homme sex, age and marital status composition of population has been useful for determining the target populations in reproductive health and family planning programmes. The data on livebirths and living children are the basis for indirect estimation of fertility, infant mortality and adult mortality.
The proportion married obtained from censuses provide estimates of singulate mean age at marriage and other nuptiality characteristics. Information on geographic, social and economic characteristics included in the census enable the analysis of the differentials in the above reproductive health indices. Censuses also provide some information on the extent of infertility, but none on the factors associated with it. Population censuses have their limitations as sources of information on reproductive health. Population censuses are undertaken usually in intervals of ten years, and consequently the information become out dated. Secondly, censuses are not suitable for asking questions that require probing, for example, health status, utilization of health services, knowledge and practice of contraception, prevalence of HIV and STD etc.
3.2 Administrative Records
Administrative records are another major source of information on reproductive health, unfortunately they are of varying types a quality in different countries. The most commonly found are the civil registration system and hospital/clinic records. The civil registration systems generally collect information on the following:

Livebirths: Date and place of occurrence, type of birth (single, multiple), and attendance at birth, sex of the child and some characteristics of the mother (usual place of residence, nationality, age, and birth order). In some countries the weight of the baby at the time of birth is also recorded.

Deaths: Date and place of occurrence, usual place of residence, sex and age of the deceased, cause of death, attendance at the time of death. If the deceased is an infant, its age is recorded in days for that less than one month and in months for those above one month).

Foetal Deaths: Date and place of occurrence, type of birth (single, multiple), and attendance at the time of delivery, cause of foetal death and some characteristics of the mother (usual place of residence, nationality, age, and birth order).

Marriages: Date and Place of Occurrence, characteristics of bride and groom (place of usual residence, date of birth and age, nationality, ethnic group, whether previously married).

Divorces: Date and Place of Occurrence, place of usual residence, date of marriage, duration of the marriage, number of children from the marriage, number of dependent children and their age), characteristics of the husband and wife (date of birth, age, nationality, ethnic group).
The birth and death records, if accurate, could yield measures of fertility and mortality for the different geographic areas and for different sections of the population (sex, age, socioeconomic groups etc). Likewise, if the causes of death are recorded correctly, the death records will be able to provide estimates of maternal mortality and causes of maternal deaths, which are key parameters in reproductive health programmes. Unfortunately, most deaths in third world countries occur without any medical attendance and medical certification of causes of death is practically non-existent. Even if there is a system of medical certification they are not necessarily accurate.
Other administrative records are those kept by the health system, for example, utilization of hospitals and health facilities. The records generally include information on the following: Name of the patient, date of admittance, sex, date of birth and age at the time of admission, reason for hospitalization, diagnosis and treatment given, date of discharge and result of the treatment. In the
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Statistique, Développement et Droits de l‘Homme event of death, the cause of death is also recorded. Where there are active family planning programmes, there are numerous other records such as household register, eligible couple register, contraceptives distribution register etc which are intended to identify the couples eligible for family planning advice or services and their follow-up. The administrative records provide information on the utilization of health care facilities rather than the extent of morbidity; consequently changes in morbidity patterns are difficult to interpret. Moreover, it is difficult to relate these data to the population at risk, or to socio-economic and household characteristics which are not available in the administrative records.
3.2 Surveys
During the past three decades sample surveys have emerged as the major source of information on health conditions in general and that of reproductive health in particular. This has been due to the programme of World Fertility Surveys (WFS) during the 1970s, the Demographic and Health Surveys (DHS) in the 1980s and the Safe Motherhood Surveys in the1990s carried out with the support of UNFPA, USAID and other funding agencies in several developing countries.
The main aim of WFS was to obtain information on fertility, mortality and other related factors with a view to enhancing our understanding of demographic processes. The WFS also included questions relating to respondents' background, marriage, pregnancies, knowledge and use of contraception, and factors affecting fertility such as breastfeeding, postpartum amennorhea, post partum abstinence etc. The DHS included questions on marriage, fertility, family planning, and maternal and child health, reproductive history, maternal mortality and harmful practices (such as FGM). The Safe
Motherhood Surveys included additional questions relating to reproductive morbidities, obstetric complications, and their treatment, induced abortion, knowledge of HIV/AIDS, current use and intentions to use family planning, and more detailed information on prenatal care, delivery care and postpartum care. These surveys have also resulted in considerable international comparative research on the biological, environmental and socio-cultural factors affecting reproductive health.
The advantage of sample surveys is their flexibility, lower cost compared to population censuses and administrative record systems and greater control over the sources of errors. Many of these surveys were carried out in the context of an international commitment to support them through funds and technical assistance. Many developing countries lack the resources to carry out such surveys on a regular basis. With the reduction of UNFPA's support for data collection the programme of surveys have come to a halt at a time when there is a greater awareness about the need to address issues relating to reproductive health and empowerment of women.
4. Information Gaps
There are six areas where information gaps are quite glaring, that are discussed below:

Reproductive Health of Adolescents

Extent of Abortion and related problems

Gynecological Morbidity

Maternal Mortality and Morbidity

Sexually Transmitted Diseases including HIV/AIDS

Reproductive Rights
4.1 Reproductive Health of Adolescents
Currently adolescents (15-20) constituted 7 percent of population of developed countries and
10 percent of population of developing countries. While the age at menarche among females has been declining, the age at marriage has been rising in many developing as well as developed
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Statistique, Développement et Droits de l‘Homme countries. The rise in age at marriage does not necessarily imply an increase in age at initiation of sexual activity. The rise in the number of women living in consensual unions and the increase in the number of births taking place out side wedlock in Europe and Latin America would indicate an initiation of sexual activity during adolescence. Information regarding this aspect is totally lacking for many countries. The National Family Health Survey of India revealed a median age at first marriage of 16 years and the median age at first cohabitation of 17 years. (NFHS, 1995 p77&84)
The survey did not cover unmarried women, and consequently information is not available on the sexual activity of adolescents, the extent of pregnancies and their reproductive health. Limited hospital or clinic based data suggest the occurrence of unwanted pregnancies and unsafe abortions among adolescents. Large-scale surveys will not yield accurate information regarding adolescent sexuality and reproductive health. While large surveys like NFHS can throw light on the awareness, attitudes towards sex, contraception etc a more appropriate approach to elicit information on the reproductive health of adolescents could be small community based surveys and focus groups.
4.2 Abortions and Related Problems
WHO has estimated that worldwide 25 million legal abortions and 20 million unsafe abortions took place in 1990 (WHO, 1994). Unsafe abortions involve great risk to the health and life of women, especially those who are poor, malnourished and anaemic. The ICPD has expressly discouraged the recourse to abortion as a method of family planning and has called upon governments to improve family planning services to avoid unwanted pregnancies and the consequent recourse to abortion. Most information available on abortions in developing countries is anecdotal rather than factual since most abortions are done by private practitioners and even quacks.
The women are brought to the hospital for treatment only in the case of complications. An additional problem has arisen in India from the prevalence of amniocentesis (sex determination tests) although prohibited by law. There is widespread abortion of female foetuses, but information on this is not obtainable. According to the National Family Health Survey of India about 1.7 percent of all pregnancies among married women resulted in induced abortions. This figure is obviously an underestimate. In some countries induced abortion is being promoted as a method of family planning. For example, in Bangladesh "menstrual regulation"(an euphemism for abortion) is actively encouraged. Where qualified practitioners perform abortions under hygienic conditions it may not pose any hazard to the health of the woman. However when abortions are performed by quacks in unhygienic conditions it poses great risk to the health of the woman and in some cases this results in the death of the woman. It is not possible to obtain accurate information on a sensitive subject like abortion and its complications through large-scale surveys. What is required is a combination of small-scale community based surveys pooling information from households and private practitioners and knowledgeable informants. Even in such an approach cases of complications due to abortions are likely to be underreported.
4.3 Gynecological Morbidity
This is an area where very little information is available and conventional survey approaches do not yield good results due to two reasons: (I) many women do not recognize gynecological conditions as health problems; (ii) they do not wish to undergo a medical examination which are considered invasive. Surveys in parts of India and Africa involving screening of small samples of women indicate that 30-50 percent of women suffers from gynecological morbidity. Some common gynecological problems observed are reproductive track infections, cervical cell changes and genital prolapse. Some of the leading reproductive track infections observed during clinical examinations are cervicitis, vaginitis and pelvic inflammatory disease (Jejeebhoy, 1999). Large-scale reproductive health surveys are not suitable for gathering data on gynecological morbidity. We need
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Statistique, Développement et Droits de l‘Homme small-scale surveys in different areas and different cultural groups, carried out with the assistance of medical and para-medical personnel using a checklist of symptoms expressed in the language of the respondants.
4.4 Maternal Mortality and Morbidity
Maternal Mortality Ratio defined as the number of maternal deaths per 100000 livebirths differs greatly between countries and within the countries according to the levels of development.
Maternal mortality ratio circa 1990 was estimated at 27 for the developed regions and 480 for the developing regions. In many African countries the estimates of maternal mortality ratio exceeded
850 (WHO, 1996). Most developing countries do not have accurate vital registration and cause of death statistics, and consequently most estimates are based on mathematical models or indirect estimation procedures such as the "sisterhood method". These estimates can provide only an approximate indication of the level of maternal mortality for an indefinite period in the past. They do not provide time series and cross sectional estimates of maternal mortality. An approach adopted in some countries with the encouragement of WHO and UNICEF is the Reproductive Age Mortality
Survey (RAMOS). Here an attempt is made to pool the information on deaths among women in the reproductive ages from several sources-civil registers, health facility records, health care providers, community leaders, undertakers etc. followed by interviews with household members to detect maternal deaths. Getting an accurate count of maternal morbidity and causes of deaths is even more difficult than estimating maternal deaths. Small community based surveys in developing countries indicate that the major causes of maternal mortality include hemorrhage, sepsis, hypertensive disorders and eclampsia, obstructed labour, and unsafe abortion. Other complications arising from pregnancy that have a bearing on the health of the mother and the newborn child include severe anaemia, hepatitis and malaria. One approach to obtaining information on maternal morbidity is through specially designed sample surveys. (Jain et.al, 1996) An alternative and perhaps more productive approach could be regular follow-up of pregnant women either by home visits by health workers or by encouraging the women to visit the health centres and sub centres. The Eligible
Couple Register maintained by health workers in India could be a useful tool for getting information on reproductive morbidity. Health workers win the confidence of the mothers by providing iron and folic acid tablets, treating minor ailments, referring complicated cases, offering advice and supplies of contraceptives and even escorting them to health institutions. The advantage of this approach is that treatment can follow the identification of the morbidity.
4.5 Sexually Transmitted Diseases including HIV/AIDS
According to WHO estimates there were 330 million new STD cases in 1995 and 20 million cases of HIV in 1995. (quoted in United Nations, 1996, pp35-37). The main sources of data on prevalence of STD and HIV/AIDS are from STD clinics and surveillance of high-risk groups such as truck drivers, commercial sex workers, drug addicts etc. More recently surveillance of patients admitted into hospitals, blood donors and persons suffering from chronic ailments has been attempted. Surveys have tended to focus upon awareness and knowledge about the symptoms and methods of prevention of HIV/AIDS rather than on the extent of prevalence. The information available is rather sketchy, and consequently resort is made to epidemiological models to estimate the levels and patterns of STD and HIV/AIDS. In developing countries with high levels of illiteracy self-administered questionnaires are not workable, consequently there is need for small community based surveys utilizing para- medical personnel alongside screening of high risk groups, patients attending clinics and hospitals.
4.6 Reproductive Rights
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Statistique, Développement et Droits de l‘Homme
Reproductive rights denote a wide range of subjects and can be operationalized in terms of the access and utilization of the following:
1.
Information and services suitable to adolescents;
2.
Information and family planning services of one's choice
3.
Appropriate antenatal, natal and post-natal health care services
4.
Safe abortion for women wanting to have abortion
5.
Prevention and treatment of gynecological morbidity
6.
Prevention and treatment of STD and HIV/AIDS
7.
Prevention and treatment of infertility
8.
Prevention of harmful practices such as FGM, female infanticide, abortion of female foetuses etc
9.
Empowerment of women to participate in decisions concerning their sexual and reproductive lives as well as education, employment and other matters;
10.
Quality of care taking into account the needs and preferences of women
While this is not meant to be an exhaustive list, this would provide an indication of the broad range of parameters that fall under the category of reproductive rights. This is an area where much work remains to be done. UNFPA has proposed a comprehensive set of indicators for monitoring national population and reproductive health programmes (UNFPA, 1997). Without going into the merits of these indicators, it can be said that these require to be tested under the socio-cultural and institutional settings of different countries and some consensus reached on the indicators that are most useful for national level programs and for international comparisons. Particular attention need to be given to evolving a set of indicators on (a) Unmet need for family planning and obstetric services; (ii) coverage, access and utilization of reproductive health services; (iii) quality of care.
5. Fresh Approaches to Data Collection
All the available sources of information should be exploited to obtain additional information on reproductive health. Censuses are by far the most important source of information on demographic, social and economic characteristics of the entire population. A question on the survivorship of the first wife (in the case of ever-married men) could be included, and if deceased, whether she died due to maternal causes. Some developing countries have included a question in their censuses on the deaths among the members of the household during the preceding 12 months, and the sex and age of the deceased at the time of death. Experience shows that the one-year reference period is not adequate to yield sufficient number of deaths. The number of reported deaths would be substantially greater if the reference period is increased to two years. An additional question on cause of death may be included, and in the case of death of females, whether it is due to maternal causes. Probing may be needed to obtain correct information.
Improvement of administrative records including civil registration is essential for formulating and monitoring health programmes. Before recommending any new systems of recording information, the existing systems should be strengthened and revitalized by a "proactive" approach.
For instance the reporting of vital events can be made more complete by pooling the information gathered through informants like health workers, teachers, undertakers, community leaders etc. The
Sample Registration System in India is an example of how a proactive approach could result in a more complete recording of vital events. The media (TV, radio, newspapers etc) should have regular spots on the need to register births and deaths. The records of primary health centres and family planning clinics can provide information on the regularity and continuity of health service utilization, the method-mix of family planning and the side effects reported in the case of sterilization, IUD and oral pills.
Sample surveys are the major source of information on reproductive health. In the past such surveys have yielded information on nuptiality, fertility, biological factors affecting fertility,
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Statistique, Développement et Droits de l‘Homme fertility intentions, family planning knowledge, attitude and practices, infant and child mortality and its correlates etc. They have also provided information pertaining to maternal mortality both by a direct question on the deaths among the members of the household during the preceding two years and by a question on the survival of sisters (utilized in the sisterhood method of estimating maternal mortality). Many surveys also include information for deriving the indicators of unmet need for family planning and obstetric services, and indicators of access, coverage and utilization of reproductive health services (Vaidyanathan, 1998). Large scale surveys could include questions on
(a) maternal health status and morbidity and their correlates; (b) quality of care in maternal health, family planning and other aspects of reproductive health; (c) women's ability to exercise reproductive choices (Jejeebhoy, 1999). In the past such surveys covered only the married women in the reproductive age groups. We need small scale community based surveys to obtain information on sexual behaviour, gynecological morbidity, abortion, infertility, STD/HIV infections and other sensitive matters which require considerable probing or use of qualified medical personnel. For example, information on post-partum hemorrhage and sepsis are best obtained by using a combination of retrospective oral autopsies and clinical and observational records. (UNFPA,
1998, pp18). These surveys should provide not only quantitative information, but help to identify women's needs perspectives and perceptions as well. There is need to utilize qualitative approaches such as focus groups, in-depth interviews, direct observation, working with key informants etc. to supplement the quantitative information obtained in these surveys.
6. Conclusions
Reproductive health and reproductive rights are fairly new concepts which have gained importance since the ICPD, 1994. These relate to sensitive issues of human sexuality, reproduction, gender relations etc. Formulation of programmes in the area of reproductive health requires information on a number of issues. Moreover, accurate information is needed to arrive at sensitive indicators for monitoring the progress towards the achievement of ICPD goals at the global and national levels. During the last three decades considerable progress has been made in the expansion of the database, but inadequacies persist. Data collected through various sources such as population censuses, administrative records and sample surveys suffer from various deficiencies- conceptual, methodological and practical. Inspite of the progress made during the last decade in the collection and compilation of data, the database in the area of reproductive health remains weak. Particular areas of deficiency include maternal health status and morbidity and their correlates, availability and quality of care in maternal health, the extent of unmet needs for family planning, the levels of maternal mortality, abortion and the incidence of infertility. Women's ability to exercise reproductive choices in developing countries are limited by lack of autonomy and unequal gender relations, however, data on these issues are wanting. This paper recommends various measures for strengthening the database by improving the methodologies of censuses, administrative records and surveys. It also recommends the use of quantitative and qualitative approaches to obtain sensitive information. Necessary technical assistance and funding support may be provided to developing countries for developing the methodologies and survey instruments, and for implementing the surveys and utilizing the information for programming purposes.
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