A tale of two regions: reproductive health in the Caribbean and the Gulf.

INTRODUCTION

REPRODUCTIVE HEALTH CONTINUES TO constitute an important area in the fields of demography and medicine. Reproductive health has evolved from involving contraceptive use, family planning, abortion and related fields to include the attendance of births by skilled health professionals, safe delivery of babies, encouraging women to exercise their right to choose and the practice of healthy life styles during pregnancy and gestation. An integral component of reproductive health today is the integration of HIV/AIDS services and programs in family planning and other reproductive health activities. Today, reproductive health is not only a major health issue, but also a means to sustainable development as well as a human right (UNFPA, 2005).

Many international meetings of demographic and health professionals continue to discuss and investigate improvements in reproductive health. International Planned Parenthood Federation (IPPF) (2004, p. 2) noted that documents formulated at several international meetings--e.g. the 1994 International Conference on Population and Development (ICPD) in Cairo, the 1995 Fourth World Conference on Women in Beijing--reflect a global consensus on women's right to sexual and reproductive health.

Reproductive health is the basis of a society's existence and provides useful insights into a society's ability to replace itself and future population growth. Future population growth has major implications for planning for all sectors but more so health, education, employment, housing and related areas of socio-economic development.

Reproductive health is also emerging as a useful indicator of development. Following advances in medicine (preventative, diagnostic, therapeutic and prognosis), Infant and maternal mortality have both declined in almost every country. So much so that countries with high infant and maternal mortality rates are considered undeveloped and vice versa. Needless to say that reproductive health is closely associated with sexual health, an important global health issue in this age of HIV/AIDS, Hepatitis B & C, etc.

The importance of reproductive health can also be gauged from the number of private agencies and international organizations contributing to and providing services in reproductive health. Many international organizations including IPPF, Population Services International (PSI), the Population Council, United Nations Population Fund (UNFPA), World Health Organization and other arms of the United Nations contribute millions of US dollars annually to support reproductive health activities. These organizations provide direct financial assistance to many countries in Africa, the Caribbean, Asia and the South Pacific for reproductive health activities.

Indeed, UNFPA (2005, p.1) adds that "investments in reproductive health save and improve lives, slow the spread of HIV/AIDS and encourage gender equality. These in turn help to stabilize population growth...."

It is therefore becoming increasingly imperative for demographers, epidemiologists and various other health specialists to take active interest in and investigate patterns and trends in reproductive health and, hence, the rational behind this study.

The purpose of this article is to examine reproductive health in the Caribbean and the Gulf, identifying patterns, trends, similarities and contradictions, with a view to throwing more light on the subject.

DATA AND METHODOLOGY

The data used in this study have been obtained from diverse sources including published statistical data from relevant international organizations as well as unpublished material at the websites of those organizations (UN, UNFPA, IPPF etc). Some information was also obtained from the Ministries of Health/Health Authorities in some of the countries selected.

The methodology is an epidemiological analysis of the data obtained for the various countries in the study. Six countries were randomly selected for each of the Caribbean and Gulf Regions and reproductive health data were obtained and analyzed for each of the selected countries. The selected Caribbean countries were Cuba, Dominican Republic, Haiti, Jamaica, Puerto Rico and Trinidad and Tobago. Iran, Jordan, Kuwait, Syria, the United Arab Emirates (UAE) and Yemen were selected for the Gulf Region.

RESULTS

The findings of the study are presented under broad headings of contraceptive use and unintended pregnancy, total fertility and adolescent fertility, births attended by skilled health professionals, maternal mortality and health expenditure.

Fertility

Table 1 shows total fertility and adolescent fertility rates for the study countries for the 22-year period from 1980 to 2002. It is evident that both Regions have experienced declines in fertility, consistent with the situation elsewhere (see Yeboah, 2001). The declines have been more massive in the Islamic Gulf than in the Christian Caribbean. Gulf countries such as Jordan, Kuwait and Syria recorded larger declines, while the Caribbean countries only managed to marginally reduce the already low total fertility rate. Sight should not be lost of the fact that not all Gulf countries recorded sizeable declines in fertility and that, in Yemen, there was only a slight decline from 7.9 children per woman to 6.4 during the study period (Table 1).

Contraceptive use and risk of pregnancy

The percentage of females aged 15-49 years using any form of contraception is shown in table 2. It is evident from the table that contraceptive prevalence among married women 15-49 years old was higher for the Caribbean countries than the Gulf countries, albeit the proportion was higher in the Islamic Iran than many Christian Caribbean countries. The lowest contraceptive prevalence was 21% and the highest was 78%, recorded in Yemen and Puerto Rico respectively.

Another finding was that, with the exception of Haiti, the countries which provided information on the risk of unintended pregnancy recorded low proportions. In Haiti, 48% of married women aged 15-49 years were at risk of unintended pregnancy during 1990-98, compared to 13% in the Dominican Republic and 22% in Jordan.

BIRTHS ATTENDED BY SKILLED HEALTH PROFESSIONALS AND MATERNAL MORTALITY

Births attended by skilled health professionals and maternal mortality ratios for the study countries during the study period are presented in table 3. For those countries which provided information for 1982 and 1996-98, such as Haiti, Jamaica in the Caribbean and Syria and the UAE in the Gulf, a higher proportion or births attended by skill health staff was recorded in 1996-98 than in 1982. With the exception of Haiti where the proportion actually declined from 34% to 25%, all the other Caribbean countries in the study recorded higher proportions during 1996-98 than in 1982. The pattern was by and large the same for the Gulf countries. While Kuwait recorded no change (98% for both 1982 and 1996-98), Syria (43% in 1982 and 77% in 1996-98) and the UAE (94% in 1982 and 99% in 1996-98) made some progress. Haiti recorded the lowest proportion of 25% both for the Caribbean and for all the study countries and Yemen recorded the lowest proportion for the Gulf countries (43%). Table 3 shows further that 5 of the 6 Caribbean countries recorded 92% or higher proportion of births attended by skilled health professionals, compared to only 3 Gulf countries during the same period. Cuba and Puerto Rico (99% each), Trinidad and Tobago (98%), and Dominican Republic (96%) recorded some of the highest proportions of births attended by skilled health professionals in the Caribbean. The UAE (99%), Kuwait (98%) and Jordan (97%) recorded the highest proportions of births attended by skilled health professionals in the Gulf (Table 3).

With regards to maternal mortality ratio, the results were mixed for both Regions. In the Caribbean, Puerto Rico and Cuba recorded comparatively lower ratios of 21 and 36 per 100 000 live births, while Haiti recorded the highest ratio of 910 per 100 000 live births in the Caribbean. In the Gulf, Kuwait and the UAE recorded lower ratios of 20 and 25 per 100 000 population respectively, compared to 1400 per 100 000 population for Yemen.

HEALTH EXPENDITURE

The study found that total expenditure on health as a percentage of GDP increased slightly for most of the study countries. With the exception of Syria and the UAE in the Gulf and Trinidad and Tobago in the Caribbean where a slight decrease was recorded, all the other 9 countries in the study increased the total expenditure on health as a percentage of GDP during the 1997-2001 period. For example, total expenditure on health as a percentage of GDP increased from 6.6 to 7.2, 5.8 to 6.1, 5.9 to 6.3 and 3.8 to 4.5 in Cuba, Dominican Republic, Iran and Yemen respectively.

DISCUSSION

The whim of reproductive change taking place elsewhere in the world has also occurred in both the Caribbean and the Gulf. In many parts of the world, fertility and maternal mortality levels are declining (see, for example, Yeboah, 2001). It is worthy to note from this study that, even in the Islamic world where the existing institutions support high fertility, some major declines in fertility have occurred. For example, in Iran, total fertility rate declined by a massive 58.2%: Syria, Kuwait and the UAE recorded 46%, 45.2% and 35.2% decline in the total fertility rate respectively.

The norms, values and related religious and cultural institutions in the Gulf encourage high fertility, partly manifest in legal and religious provisions which allow males to have four wives and the general belief that procreation is the essence of marriage (Ilkkaracan, 2000). Declining fertility in the Gulf may be attributable to increasing female education and an emerging trend of young generation with a tendency not to adhere strictly to the Islamic code of conduct. As noted by Okasha (2003), the Islamic code of conduct describes the course of action and acceptable behavior, but there is a growing trend of a new young generation the members of which adhere less to this code than their parental generation.

With regards to female education, more and more females are now in the education system in the Gulf than at any other time, similar to the situation in the Caribbean. In the UAE, a whole university has been established for females only. Zayed University was established in 1998 to cater for the tertiary education needs of UAE female citizens and to increase their employability, with inherent implication for lower fertility. In the Caribbean, the University of the West Indies, the region's foremost tertiary education institution, has more female students than male students (Yeboah, 2004), with implications for delays in marriages and procreation.

In many parts of the Gulf, female education and employment are higher now than at any other time, albeit the levels are still comparatively lower than those in western societies (Zuhur, 2003). While female struggles for empowerment and freedom continue (Zuhur, 2002), some improvements have been made. Females now have access to contraceptives and are being appointed to various senior positions in some countries, including a ministerial position in the UAE.

With the exception of Yemen (which recorded the highest adolescent fertility rate), adolescent fertility rates were generally higher in the Caribbean. The Islamic code of conduct and its associated strong religious restrictions together with very harsh penalties for fornication and adultery explain, to some extent, the lower level of adolescent fertility in the Gulf countries. In many of these countries, people are jailed for even kissing in public (Zuhur, 2003), and people who engage in out-of-marriage sexual activity end up in jail. Yeboah (2004), Green (2003) and Remez (1989) provided a synthesis of evidence to demonstrate a culture of high promiscuity in the Caribbean, and hence the difference in adolescent fertility between the two regions.

Again, cultural and religious factors explain the differences in contraceptive use in the Caribbean and the Gulf. Contraceptive prevalence is interestingly and unexpectedly high in Iran, where strict Islamic laws and cultural practices prevail, albeit various types of contraceptives are becoming increasingly available in the region. In general, contraceptive prevalence is higher in the Caribbean because of the right to choose and the unrestricted use of contraceptives as well as the high development of family planning programs and services, ably supported financially by Caribbean governments and international organizations such as IPPF and UNFPA (Yeboah, 2001). With the emerging trend in which the younger generation is seeking more freedom and becoming less adherent to the Islamic code of conduct, contraceptive use in the Gulf would most likely increase (Ilkkaracan, 2000).

Improvements in medicine, medical practice and service availability (preventative, diagnostic and therapeutic) initially occurring in western societies are now evident also in the Caribbean and the Gulf. A substantial proportion of births in both Regions were attended by skilled health professionals, with the Caribbean recording slightly higher proportions than the Gulf. Both regions also recorded increases in the proportion of births attended by skilled health professionals from 1982 to 1996-98. With the exception of Haiti where the proportion of births attended by skilled health professionals declined and Kuwait where no change occurred, most other countries in the two Regions recorded higher proportions in 1996-98 than in 1982. The decline in the proportions in Haiti is attributable to the political situation in the country and poverty.

During the 1990-97 period, Puerto Rico and Cuba recorded low maternal mortality ratios in the Caribbean (21 and 36 per 100 000 live births respectively) while, in the Gulf, Kuwait and the UAE recorded maternal mortality rates of 20 and 26 per 100 000 respectively. These compare favorably with a UNFPA estimated rate of 400 per 100 000 live births globally in 2000. Indeed, the low maternal mortality ratio recorded for the Caribbean countries and some Gulf countries appear consistent with other studies. For example, UNFPA and the University of Aberdeen (2005) reported that maternal mortality ratios are on average the second lowest in the Caribbean and Latin America and only the developed countries have lower rates.

The increasing proportion of births attended by skilled health professionals has not manifested itself consistently in lower levels of maternal mortality across all the study countries. Other factors, such as good facilities and increasing female education, could have also made a useful contribution. The point is that it would generally appear logical that countries with higher proportions of births attended by skilled health professionals will exhibit lower maternal mortality. Supporting this position, UNFPA and University of Aberdeen (2005: 5) stated that an inverse relationship exists between the proportion of deliveries assisted by a skilled health professional and the mortality ratio in developing countries, and that skilled delivery can protect millions of babies and their mothers (see also WHO, 2005).

However, this thinking was vitiated in this study as some countries did not conform to this statistical relationship. While Haiti's higher maternal mortality ratio of 910 per 100 00 live births appears logically consistent with the very low proportion of births attended by skilled health professionals (only 25%), this potential consistency was missing for the other Caribbean countries in the study.

Similarly, while the low maternal mortality rates for Kuwait and the UAE (20 and 26 per 100 000 live births) appear logically consistent with the higher proportion of births attended by skilled health professionals (98% and 99% respectively), the situation in the Gulf was not consistent for most of the other countries. Like Haiti, Yemen's very high maternal mortality ratio of 1400 per 100 000 live births could partly be attributed to the relatively low proportion of births attended by skilled health professionals (43%).

The other notable factor contributing to improvements in maternal mortality is female education. As stated earlier, throughout the Gulf, female education is improving and this means that more and more females are spending more time in the educational system. This practice has the potential of delaying fertility and reducing the risk of pregnancy and child birth and, thus, maternal mortality. Besides, educated females are more likely to take good care of themselves and the pregnancy during the gestational period and, thus, achieve lower maternal mortality.

It should further be noted that increasing expenditure on health could have contributed to declining fertility and improvements in maternal mortality. Evidence from the study indicates that most of the study countries recorded increases in the total expenditure on health as a percentage of GDP, and it appears logical that part of these increases would be spent on reproductive health (see also WHO, 2005).

In sum, reproductive health is improving in the two regions, and is evident in decreasing fertility and lower maternal mortality rates. Most likely that this trend will continue as more and more females become educated and participate in the labor force, and as government expenditure on health continues to increase.

CONCLUSION

This study has provided some insights into reproductive health in selected Caribbean and Gulf countries, demonstrating that the changes in reproductive health taking place in other parts of the world are emerging in both the Gulf and the Caribbean. While low fertility and maternal mortality rates remained salient features in the developed world for many years, this study found that many Caribbean and Gulf countries were exhibiting these characteristics, traditionally associated with the developed countries. This emerging feature, the study noted, is attributable to improvements in medicine and medical services, increasing proportion of births attended by skilled health professionals, moderate increases in total expenditure on health as a percentage of GDP and improving female participation in education and the labor force.

It is the conclusion of this study that, while many factors could have contributed to declining fertility, increasing contraceptive use and risk of unintended pregnancy, cultural and religious factors explain some of the differences between the Caribbean and the Gulf. The strong affiliation and adherence to Islamic laws and religious practices in the Gulf and the prevalence of Christianity and less restrictions on sexual activity explain in part the patterns of reproductive health in the two regions.

REFERENCES

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Green, E. C: Faith-based organizations contribution to HIV prevention: The Synergy Project. Washington, DC: United States Agency for International Development, 2003.

Ilkkaracan P. (Ed): Women and sexuality in Muslim societies. Istanbul, Turkeu: Kadinin Insan Kahlari Projesi, 2000.

International Planned Parenthood Federation: IPPF medical and service delivery guidelines on sexual and reproductive health. London, UK.: IPPF, 2004.

international Planned Parenthood Federation : "Access to safe abortion services to the fullest permitted by law." Medical Bulletin, Vol. 38, No. 4, 2005, pp: 1-7.

Okasha A: "Mental health services in the Arab world." Arab Studies Quarterly, vol. 25, no. 4, 2003, pp 39--52.

Remez, L. "Adolescent fertility in Latin America and the Caribbean: Examining the problem and solutions." International Family Planning Perspectives, 15 (4), 1989, pp 144-148.

United Nations Population Fund: Preventing HIV infection, promoting reproductive health. New York, NY: UNFPA, 2003.

United Nations Population Fund: Improving reproductive health. New York, NT: UNFPA, 2005.

United Nations Population Fund and the University of Aberdeen: Maternal Mortality Rates update 2004,New York, NY: UNFPA, 2005.

World Bank (1999): World Development Indicators. Washington, DC: World Bank.

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Yeboah D A: "The provision of family planning programs in the Caribbean." Journal of Biosocial Science. Vol. 34, 2001, pp 379-394.

Yeboah D A: "HIV/AIDS and its causes in the Caribbean." Journal of Education and Development in the Caribbean, Vol. 7, Nos. 1 & 2, 2004, pp 59-71.

Zuhur S: "The mixed impact of feminist struggles in Egypt during the 1990s." Middle East Review of International Affairs, Vol. 5, No. 1, 2001, pp 78-89.

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David A. Yeboah teaches in the Health Sciences Program, Zayed University, United Arab Emirates.

TABLE 1. FERTILITY IN SELECTED CARIBBEAN AND GULF COUNTRIES, 1980-97

Country       Total Fertility Rate   Adolescent Fertility per
                                     1000 women aged 15-49

              1980          2002     1997

Cuba          2.0           1.6      65
Dominican     4.2           2.7      13
Republic
Haiti         5.9           4.0      70
Jamaica       3.7           2.4      104
Puerto Rico   2.6           1.9      69
Trinidad &    3.3           1.6      46
Tobago
Iran          6.7           2.8      50
Jordan        6.8           3.6      42
Kuwait        5.3           2.7      34
Syria         7.4           3.4      44
UAE           5.4           2.9      56
Yemen         7.9           7.0      105

Source: World Bank 1999, p. 98;; World Health Organization, 2005,
p. 112.

TABLE 2: CONTRACEPTIVE USE AND RISK OF UNINTENDED PREGNANCY, 1990-98

Country       Contraceptive prevalence   Women at risk of unintended
              (% of Married women aged   pregnancy (% of Married
              15-49)                     women aged 15-49)

Cuba          --                         --
Dominican     64                         13
Republic
Haiti         18                         48
Jamaica       65                         --
Puerto Rico   78                         --
Trinidad &    --                         --
Tobago
Iran          73                         --
Jordan        53                         22
Kuwait        --                         --
Syria         40                         --
UAE           --                         --
Yemen         21                         --

Source: World Bank 1999, p. 98.

TABLE 3: BIRTHS ATTENDED BY SKILLED HEALTH STAFF AND
MATERNAL MORTALITY RATIO, SELECTED CARIBBEAN AND GULF
COUNTRIES, 1982-1998

Country             Births attended by             Maternal Mortality
                    skilled health professionals   Ratio per 100 000
                    (% of total)                   live births

                    1982              1996-98      1990-97
Cuba                --                99           36
Dominican           --                96           110
Republic
Haiti               34                25           910
Jamaica             86                92           120
Puerto Rico         --                99           21
Trinidad &          --                98           90
Tobago
Iran                --                74           120
Jordan              --                97           150
Kuwait              98                98           20
Syria               43                77           180
UAE                 94                99           26
Yemen               --                43           1400

Source: World Bank 1999, p. 98.

TABLE 4: HEALTH EXPENDITURE SELECTED CARIBBEAN COUNTRIES, 1997-2001

Country       Total expenditure on health as a % of GDP

              1997           1999           2001

Cuba          6.6            7.1            7.2
Dominican     5.8            5.7            6.1
Republic
Haiti         4.9            4.9            5.0
Jamaica       6.5            6.1            6.8
Puerto Rico   --             --             --
Trinidad &    4.5            4.5            4.0
Tobago
Iran          5.9            6.5            6.3
Jordan        8.2            8.6            9.5
Kuwait        3.7            3.9            3.9
Syria         5.5            5.8            5.4
UAE           3.6            3.7            3.5
Yemen         3.8            4.0            4.5

Source: World Health Organization, 2005, pp. 138-140.