Very pertinent points.
First, fertility decline is underway in much of sub-Saharan Africa. The declines, where they are occurring or have occurred, began later than most other developing regions and countries, but the pattern of decline is similar in that it begins in the largest cities and only gradually moves out, first to secondary cities and towns and then to the rural areas. In much of SSA, rural fertility decline has yet to begin.
Second, fertility decline began earlier and is further advanced in Anglophone countries than in Francophone or Lusophone countries. This difference is more attributable to when the countries adopted population policies and family planning programs than to any other factor.
Given that by most measures, SSA scores lower on most pertinent human development indicators than other regions, it is not surprising that fertility decline began later and is less advanced in Africa than elsewhere. Fertility is highly related to such measures as infant/child mortality; literacy and school enrollment rates, especially for girls; female employment outside the home; and urbanization. On all such measures, SSA lags behind other regions and one must assume that the pace of fertility decline will be strongly determined by how well SSA governments do in raising living standards, particularly with respect to health, education and gender.
Finally, it should be noted that desired fertility (i.e., the number of children women say they would like by the time they complete childbearing)is still relatively high in much of SSA. Desired fertility is strongly influenced by the socioeconomic factors just listed above. However, there is quite a high level of "unmet need for contraception," measured by the proportion of women who say they want to limit or space future births but are not using contraception. If all the unmet need were satisfied, fertility would decline in most countries by between 15 and 30 percent. In other words, alongside efforts to raise living standards in general so as to reduce desired fertility, there is also a need for family planning programs to help women and couples realize their present fertility goals.

Some are, others are not. Generally the Francophone countries are lagging behind the Anglophone in adopting population policies and reproductive health programs. Serious efforts to provide family planning services have only been mounted in a handful of countries and where they have been provided, fertility has declined. The most well known success stories are in South Africa, Botswana, Zimbabwe and Kenya -- and quite recently in Rwanda. In the first four, much of the fertility decline that followed the development of strong programs occurred in the 1980s and '90s. Since 2000, there has been a real leveling off in Botswana, Kenya and Zimbabwe, mostly because priorities changed and much of the effort that had been directed at high fertility was redicrected to AIDS prevention and treatment -- especially treatment. In fact, family planning effort has declined seriously in several countries as population and family planning has declined as a development priority -- in part because it was not included in the initial version of the Millennium Development Goals (MDGs).

There is no reason of which I am aware to assume that Africans have a different nature than people living in every other region of the world. Fertility behavior in, in fact, highly predictable and responds to the conditions in which people find themselves. As living standards improve, as employment and residence shift from rural to urban, as incomes rise, as school fees and other costs of children increase, generally people throughout the globe, including in Africa, decide to have fewer children. Also, as the case of Kenya in the 1980s shows, when political leaders decide that fertility is too high and ought to come down, and when they repeat this message over and over again, people do begin to think about whether or not they can and should have fewer children and many decide to do so. As the famous Australian demographer John (Jack) Caldwell has said, much of dramatic decline in fertility that we have witnessed in Asia, the Middle East and Latin America over the past 40 years was the result of changing family size norms -- norms that changed in part as the result of communications programs that were deisgned to change them. Another famous demographer, Ronald Freedman, an American, called this "ideational change" and said that it had a powerful independent effect, above and beyond what "development" itself brought about, on fertility behavior.

I have addressed this issue in answwers to the previous questions I answered. In short, urban-rural differentials are very marked in Africa and as the continent continues to rapidly urbanize, I anticipate urbaization will continue to have a powerful impact on fertility. A look at the differential fertility between populations living in urban slums and the rural communities from which they migrated underscores this point quite dramatically. For an excellent treatment of this issues, see Demographic and Health Surveys Comparative Reports, # 18, "Fertility changes in sub-Saharan Africa," MEASURE/DHS. September 2008.

Despite the substantial mortality from AIDS, UN projections for all developing regions, including Africa, predict large further population increases. This is because the annual number of AIDS deaths (2 million) is equivalent to just 10 days growth in the population of the developing world. The population of sub-Saharan Africa is expected to grow by 1 billion between 2005 and 2050 (from 0.77 to 1.76 billion). In fact, no African country is expected to see a decline in its population size between 2005 and 2050 due to high AIDS mortality. Even with the steady future declines in fertility assumed by the UN, most populations in sub-Saharan Africa will more than double in size, several will triple and Niger is projected to quadruple by 2050.

Religion, or the attitude of religious leaders, sometimes reinforces traditional conservative attitudes. It is important to distinguish this aspect of religion from formal doctrine. In fact, only Roman Catholic doctrine specifically opposes some modern forms of contraception. Nearly all other religions are silent on the matter. Islam, as a matter of fact, preaches that a household head should have no more children than he can properly care for and support. And many Islamic countries have been in the vanguard of population policies and family planning programs. I would mention Indonesia (the world's largest Muslim country), Iran, Morocco, Tunisia and Bangladesh as just five among several very prominent examples. In other words, religious leaders can sometimes reinforce attitudes and values that are not part of their religion's formal doctrine. And, as the cases of Indonesia and Iran show, religious leaders can also be very influential in the encouragement of family planning if they choose to do so.

I don't think they are spurious and I think the cause is very clear: the redirecting of resources away from family planning and toward other (usually health-related) programs, most especially HIV/AIDS. The data are very clear that expenditures on family planning have declined dramatically (by at least 30 percent between 1995 and 2005)while expenditures on HIV/AIDS, TB and malaria have increased dramatically (by 300 percent over the same period of time). As M. Michel Garenne says in DHS/MEASURE Comparative Studies Report # 18 on Fertiliy change in sub-Saharan Africa, "The speed of the fertility decline, approximately 1 child per decade, also varied markedly among countries, from 1.5 children per decade to less than 0.5 children per decade. In addition, a stall in fertility decline occurred in six of the countries investigated (Ghana, Kenya, Madagascar [urban areas], Nigeria, Rwanda-rural, Tanzania [rural areas]); in five of these countries, this stall occurred in 1995-2005."

As my answers to several of the preceding questions demonstrates, I agree with this statement.

I think the provision of family planning within health services is extremely important. We have seen that wherever reasonably good health services are offered, if family planning is included it will be used and fertility will decline. Perhaps the most dramatic example is in the experimental program run by the Navrongo Health Research Centre in northern Ghana. There, in one of the most remote and disadvantaged parts of Africa, it was shown that community-based contraceptive services, which also emphasised mother and child health (i.e., good antenatal care, immunisations, etc.)lowered the fertility rate by between 15 and 20 percent, compared with no change in the areas without such services.
Having said that, I think that family planning and community health care must be accompanied by other rural services that improve education, employment opportunities, rural incomes, and women's status. African fertility will only decline if, as nearly everywhere else in the world, it is addressed comprehensively, with an approach that focuses on raising living standards of poor families at the same time that it provides contraceptive services.

Thanks, Rei. Always great to hear from you.

Fertility trends are usually monitored in developing countries through a series of surveys -- the Demographic and Health Surveys. Over a period of years, these surveys track fertility trends in many countries. For example, surveys beginning in 1978 and conducted roughly every five years since showed significant fertility declines in Kenya through the 1980s and the first half of the '90s, but then stalling and remaining essentially unchanged since the late 1990s. A recent DHS comparative study (#18 in a series) by M. Michel Garenne, shows contemporary fertility stalls in six African countries -- Ghana, Kenya, Madagascar (urban areas), Nigeria, Rwanda- (rural), and Tanzania (rural).

I think the principal cause of the fertility stalls in these countries is a decline in the funding for family planning and associated reproductive health services. The experience in Asia showed that most countries maintained strong family planning programs over an extended period, enabling them to bring fertility down from high levels to levels much closer to replacement (slightly more than two children). There were very few stalls in decline until countries began to approach replacement because program support remained constant and strong. In recent years, support for family planning programs in Africa declined as donor funding for sexual and reproductive health has declined, leading to the fertility stalls. In Kenya, the case I know best and the one most closely studied, there seems little question that this is what has happened.

You are quite right that traditional norms mean men prove their strength, masculinity and power through the number of children they father. That is why fertility tends to decline as women gain greater equality with men and are able to have more of a say in how many children they will bear. The education of girls, leading to increasing autonomy and empowerment, is for this reason the single most important determinant of desired fertility. Strong family planning programs then help women to realize their fertility desires.
While the situation varies from country to country, generally fertility is highest in rural Africa where people generally are poorer than those who live in urban centers. Multiple partnerships, such as you describe, don't necessarily mean higher fertility since fertility is measured in terms of how many children on average a woman bears, as opposed to how many a man may father.

Eloquently stated.

Hi John -- I answered the first question just a few minutes ago and you will see the response when my answers are posted.
The second question is much harder to answer, and is not an either/or matter. But generally, I would say that the most effective facilities are not stand-alone family planning centers but neither are they ones that try to offer a full range of comprehensive health services. In other words, in Africa the most effective centers have tended to be those that offer a limited range of the most critical services from the standpoint of protecting women's and children's health. A "selective primary care approach," one that includes a range of services that trained para-professional staff can provide in difficult settings, would include family planning, tetanus toxoid, immunization against major childhood diseases, referrals for obstetrical complications, growth monitoring and nutrition education, and treatment for diarrheal diseases and acute respiratory infections. This was the package offered by the Navrongo project in rural northern Ghana, with dramatic effect on both maternal and child health outcomes, and fertility! I should add that both malaria (esp. bednets) and HIV prevention services (VCT and condoms) need to be included in the updated selective primary care package.

I believe that many countries, such as Niger where at present fertility the population will double in 15 years, would benefit greatly if fertility was lower. This does not mean that Africa needs fewer people. It does mean that strains on African governments would be less and the prospects for sustained economic development would be far better if the rate of population growth were slower. Most African countries, which have committed themselves to achieving the Millennium Development Goals, have practically no chance of meeting any of those goals at present fertility levels, whether one is talking about poverty reduction, reducing hunger, achieving universal primary school enrollments, reducing infant/young child mortality, reducing maternal mortality, reducing new HIV infection rates, or improving the environment.

Men's roles are very important, in Africa and elsewhere. But I don't think the role of men in Africa is different today from what it was in Bangladesh in the 1980s or in Korea in the 1960s and 1970s. Empowering women to negotiate childbearing on equal terms with men is a key factor, and providing women with services that give them a certain degree of independent control over their fertility is equally important. During my time in Kenya, when fertility was falling very fast (1986-1990), I observed that men were especially responsive to the calls of political and other leaders to behave responsibly when it came to childbearing. Helping men to understand the relationship between family size and their aspirations for their children in terms of education and land inhertance played a major role in changing male attitudes, at the same time that family planning services helped women attain greater power in determining the number and spacing of their children.

I doubt it. But if effective primary care programs of the kind I outlined in my response to John Bermingham's question were offered, I think mortality decline would occur at as fast or faster a rate than fertility decline.

I wish I could but this is a huge question. What I will say is that extremely low fertility in Europe will create an increasing demand for labor which Africans and many others will be ready to fulfill. At the same time, very high fertility in Africa creates a large pool of job seekers who cannot find employment at home. If fertility were lower in Africa, the pressure to migrate out would be correspondingly reduced, assuming job creation rates in Africa remain constant or, one could hope, increase. Of course, the most highly educated Africans are the ones most in demand in the low fertility countries, thus contributing to the brain drain that is such a tragedy for African countries. The answer to the brain drain in Africa is not lower fertility -- it is economic development and creation of good employment options in Africa. But economic development itself would be much easier to promote if population pressures were less, enabling governments to invest more in the quality of education and healthcare, thus creating the human capital that is a prerequisite to sustained economic growth.

This is a very difficult question to answer. Fertility goals are generally thought to be influenced not by adult mortality but by under-five mortality. It is the probability that children will survive to adulthood that largely determines how many children a couple will want to bear. So, at the level of individual families, where fertility goals are usually set, I would not expect AIDS mortality to have a major impact. However, at the broader level of societies, one hears political leaders often expressing concern about "de-population" due to AIDS. Where political leaders, fearing the effects of AIDS mortality, withdraw resources from family planning programs, the effect on fertility could be strong, even though fertility desires of families might not change at all.

I believe that female education is an extremely important factor but it may not be enough in a country whose leadership is hostile to family planning.
High birthrates and high under 5 mortality are closely correlated. Bringing down one usually results in declines in the other. If one works on the two together the results are greatly magnified. It's a wonderful example of mutual reinforcement -- or a virtuous circle.
Diet per se is not related to fertility but nutritional status is. Extremely poor and malnourished women have a harder time getting pregnant and carrying pregnancies to term than better nourished women. But what they eat does not affect fertility. Neither am I aware that ART has any impact on what demographers call fecundability -- the ability to conceive.
It is true that PMTCT programs increase the likelihood that children will be born free of AIDS and more likely to survive. Surely that is a good thing! Keeping mortality high is never a good way to approach any population question!

I'm not close enough to the situation to know how the present food crisis is affecting either fertility or migration, nor have I read anything recently that comments on these issues. Certainly economic circumstances have a great deal to do with labor mobility throughout Africa and beyond, and men who leave their families behind often do produce children in the places where they are working. However, this does not necessarily affect fertility rates very much. Men working away from home are also prone to engage in risky sexual practices which can result in them infecting their wives with HIV when they return home -- an increasingly common and tragic phenomenon in many African countries.

Unfortunately, I do not think family planning programs have very often been linked to other social and economic outcomes in Africa, at least not in a programmatic sense. The argument to undertake family planning programs is often made (usually by outside donor agencies) by linking fertility decline to other social and economic goals. For example, today much of the advocacy on behalf of family planning links it to the achievement of the MDGs, with proponents asserting that unless high fertility rates are reduced, the prospects of achieving the MDGs are slim to none. But efforts such as those you describe in the Philippines are few and far between, in my experience. I think, in fact, that family planning programs have suffered to the extent that they are promoted as stand-alone interventions. The more one can associate the benefits of family planning with other aspects of people's lives, the more likely they are to adopt family planning. In Bangladesh, the Grameen Bank and BRAC showed that women involved in micro-enterprise programs were more likely to adopt family planning than women who were not. Likewise, health programs that offer family planning alongside safe motherhood and child survival interventions will be more acceptable than family planning standing alone.

The Rwandan case is Africa's latest "success story." I don't know the story in detail but it's my understanding that it's quite similar to the Kenyan story a decade ago. Pres. Paul Kagame has become convinced that Rwanda's development depends heavily on bringing down the very high fertility rate, and consequently the population growth rate, in the country. He has made family planning a top priority and is committing the resources necessary to provide reproductive health services to the entire population. He speaks publicly and forcefully about responsible parenthood and encourages other officials to reverse taboos regarding contraception and traditional sexual practices. The public response to Pres. Kagame's policies has been swift and impressive, just as it was in Kenya when Pres. Moi and then V.P. Kibaki implored Kenyans to have fewer children and provided the resources to enable them to do so. BTW, I understand that, as in the Kenyan case, USAID has played a very important role in support Pres. Kagame's policies.
From these cases (and one could add Botswana and Zimbabwe in the late 1970s and 1980s to this tale), I conclude that political leadership is absolutely essential to bringing about fertility declines in Africa and that strong leadership in a relatively stable political envirnment can bring about very impressive results in a relatively short period of time. Unfortunately, as the case of Kenya also shows, when this leadership diminishes, programs can quickly collapse and progress can stall or even reverse.

As is often the case, where the problem is the greatest is where we have the least information. 98%+ of stillbirths occur in the developing world and we know much much less about causes of stillbirth than we do about the magnitude. Lawn and colleagues undertook a large literature review to estimate the percent of intrapartum stillbirths, that is stillbirths occurring after the onset of labor. Their work suggests that just under 1 in 3 stillbirths occur during the intrapartum period. If ever there was an issue that serves as a bridge between the concerns of the maternal AND the newborn health communities, it is intrapartum stillbirth. Improved care at delivery, particularly for women with complications, is key to progress for both.

The fact that we consider "intrapartum" stillbirth a cause (strictly speaking it is timing of death and not biological cause) speaks volumes about the specificity of information that we have on SB cause of death. There are many different stillbirth cause of death classification schemes, many of which are highly sophisticated for use in developed countries and not really applicable in developing countries. However, there are quite a few that are applicable in low resource settings. Some of these schemes are more programmatically relevant than others. However,given the lack of consensus on a classification scheme, comparisons across study sites is very difficult. As part of the Global Alliance for the Prevention of Preterm Birth and Stillbirth (www.gappsseattle.org), I am working with colleagues on a set of global estimates of SB cause of death now, which is to be completed next spring. But, again, these are estimates from a statistical exercise, and what is needed is empirical data from improved cause of death registration in countries.

I agree, but I suspect the need is broader than that. When there are problems around delivery, women need to recognize them and seek care in a timely manner in order to benefit from the services available at facilities (ie, birth preparednes and all the things the safe motherhood community has been promoting for a couple of decades). Appropriate diagnosis and treatment is needed during pregnancy re: maternal infections and other maternal health conditions associated with stillbirth. I think there will always be a question of coordinating supply and demand.

Only 3% of stillbirths occur in countries with complete civil registration. What we know about the magnitude of stillbirths globally comes from 2 separate statistical exercises, which surprisingly came to the same global totals (3.2 million - Stanton et al. (uncertainty 2.5-4.1 million) 2006; and 3.3 million stillbirths - WHO 2006). However, despite agreement at the global level, the two series of estimates differ substantially at the country level, where the data are needed most. The concern is that where different sources provide highly varying estimates or estimates with great uncertainty, policy makers and others who could/should use the data, lose faith and find it easy to dismiss these numbers. All of the authors above acknowledge that these estimates are not precise and are a first attempt to prompt discussion/debate and hopefully improved data collection.

Given that household-based surveys of women of reproductive age will probably remain the source of data that we all need to rely on in the immediate future (ie, while civil registration systems improve over time), there is a tremendous need to improve methods re: retrospective data collection. Current methods (or current practices at implementing existing methods) tend to seriously under-estimate stillbirths. However, health facilities can be a very important source of routine data, particularly in countries with fairly high institutional delivery. In those settings, one can benefit from a broader array of data re: cause of death, maternal condition and the health care received - all of which can be used to improve outcomes.

Thanks for bringing up CLAP. It is a wealth of information and a great example of what routine data can provide, and how it can be presented in programmatically relevant ways. Realistically, some very low resource settings in sub-Saharan Africa or South Asia would have a hard time collecting the breadth and depth of CLAP data, but certainly adaptations could be made and stillbirths could be added to routine health information systems.

It's been said so many times re: the MDGs: what you count is what you do. If stillbirths are not on anyone's agenda, they will not be (and are not being) counted or addressed. Many people these days think that we currently have a real opportunity to change that now. Several things support this idea - but particularly the focus (and increased funding) on newborn health/survival and a renewed focus on maternal survival.

Hi Elizabeth!
As mentioned below, only about 3% of stillbirths occur in countries with complete civil registration (not surprisingly these are high income countries), so yes, this is a huge constraint. A number of other countries do have stillbirth death certificates/registration but have highly incomplete data. However, what you describe is not just a constraint re: registration. Most people feel quite certain that these events (the birth and the stillbirth, and no doubt some deaths to liveborn babies during the first week of life) simply do not get mentioned at all during household surveys when women provide basic data re:their birth or pregnancy histories (ie the section of survey questionnaires that give us the data to calculate SB, neonatal, infant, child mortality rates). Education is needed to recognize these events at all levels (women/families; health care providers and health planners). At the level of women/families/communities, I think we need substantial qualitative research to learn "how" to talk/inquire about these events. At the level of health care providers and planners, education is needed to recognize the burden of stillbirth - there are about 4 million neonatal deaths, of which 3 million occur during the first week of life (the majority on days 1 and 2) and 3 million stillbirths (about 1/3 of which occur after the onset of labor). It just makes so sense to ignore this loss.
Anecdotally, I had a conversation with a colleague of mine last week who told me that when she drew attention to the issue of stillbirths in a conversation with a Ministry of Health official, he said "but they are already dead, why do we care?" I'm sure there are many people who think this way, and just do not realize the important proportion of these fetal deaths that could be prevented.

In only partially agree. I'm not convinced that lack of resources is the primary reason why we have so very little data on stillbirths. I think many simply do not recognize the numbers or the extent to which stillbirths can be prevented. Awareness is needed at all levels, from families up to Ministries and to the MDGs and Countdown to 2015. A clarification for this question and questions above: when I say that women/families do not report stillbirths - I am in no way implying that these losses do not have a profound effect on the woman/families. There may be cultural reasons for not reporting these events, and/or it may well be that we just do not know how to ask the questions in a way to elicit the correct response.

You are right that this discussion is about stillbirths, so that is what we are sticking to here today. However, when discussing stillbirth, the issue of not recognizing other types of pregnancy loss is often the white elephant in the room. It is unclear how much, if any, avoidance of this discussion and the inevitable debates that would ensue, have contributed to the invisibility of stillbirths on national and international health agendas.

Certainly there are many areas of research that are needed, but routine data sources (health facility registers, adding stillbirths to existing community registers, for example) could be an immediate (relatively immediate) source of data on stillbirths. Of course, collecting data serves no purpose unless it is compiled, reviewed and acted upon and there is no guarantee that that would happen. Implementing such a system would require political will and leadership. The magnitude of the problem, however, justifies such effort.

RE: starting a regional alliance, my suggestion would be to pursue this effort through existing organizations. For example, the Partnership for Maternal, Newborn and Child Health, the International Stillbirth Alliance, Saving Newborn Lives/Save the Children, the White Ribbon Alliance and/or your regional professional organizations (Pediatrics, OB/GYN, midwifery association,etc.)

Two decades of safe motherhood (and common sense) has certainly made clear that institutional delivery or antenatal care will not lead to improvements in maternal or newborn health if the quality of care (skills, use of evidence-based practices) provided is low and if women/newborns are not able to access care in a timely manner. There are also additional risk factors such as inter-generational nutritional issues that lead to low birth weight that influence pregnancy outcome. So, as with maternal mortality,there is a lot of scatter in the relationship between stillbirth and institutional delivery. RE: medical assistance at home-based delivery, there are not that many places in the developing world where this is common (Indonesia stands out with their bidan di desa program. A recent analysis using DHS data suggested that a home-based professional was not associated with lower risk of first day or first week deaths. Data were not available re:stillbirths). And, yes,stillbirths are associated with maternal complications - if you write me,I can send you 2 articles that might be of interest to you.

Interestingly enough, it looks like Bangladesh seems to have had greater success at measuring stillbirths in large population-based surveys than any other country. The stillbirth rates from the DHS (ranging from around 27-33 per 1000) are quite close to high quality data from the Matlab Demographic Surveillance Site of ICDDR,B where a sophisticated, prospective data collection system is in place. (And, yes, one should not always compare Matlab data to the whole country, but I will here given the lack of other data sources). So, I think we all have much to learn from Bangladesh interviewers or respondents or both. In many of the other countries where this type of data has been added to surveys, the estimates appear implausibly low, particularly relative to early neonatal mortality (which may also be under-estimated in survey-based data). I have wondered if the seeming success in Bangladesh at identifying pregnancy losses in surveys was due to the great interest that exists re: menstrual regulation - leading to very careful completion of data on pregnancy, outcomes, gestational age, etc, and that improved stillbirth rates were just a lucky by-product of those practices. This is just speculation on my part. I do think we need to learn more from Bangladesh.

See responses to similar questions in this discussion. Among other things, the lack of prioritization may be due in part to a lack of knowledge re: the magnitude of the problem (if it is never counted, who would know?) and recognition that interventions to address many of causes of SB are readily available.

Infant mortality rates vary from around 5 per 1000 live births in industrialized countries to about 110 per 1000 live births (West Africa), with the highest IMR for an individual country at 165 (Afghanistan) and the lowest at 2 (Sweden) (source: Unicef's State of the World's Children). Stillbirth rates for industrialized countries are around 5 per 1000 births (live and stillbirths), again with northern European countries as low as about 3 per 1000. The stillbirth rates for sub-Saharan Africa and South Asia according to the global estimates I worked on, as well as the WHO estimates, are both at 32 per 1000 births. At an individual country level, one sees estimates of the (population-based) stillbirth rate as high as 45-60 per 1000 births.

I've never seen a cross-country comparative study of stillbirth by SES differentials among low income countries. Disparities re: stillbirth have been documented for high income countries (see Goy et al Pediatric and Perinatal Epi 2008 as an example). I just ran perinatal mortality by woman's education on the DHS Statcompiler. At quick glance, you do not see a strong relationship (in some countries there is a clear gradient - decreasing SBRs with higher education), but not really in the majority. However, this is NOT an authoritative answer to your question. Such surveys do not measure SBRates very well.

I can answer some of your questions, but all of them.

RE: what have various agencies have done to date:
1) WHO developed one of the two existing series of global stillbirth rates, and raised the issue of global perinatal mortality back in the 1980's. WHO staff along with members of the Child Health Epidemiology Reference Group (CHERG) and the Global Alliance for the Prevention of Prematurity and Stillbirth (GAPPS) are currently working on updating/improving the global estimates for 2005. GAPPS staff is working on generating global stillbirth cause of death estimates and updated estimates for intrapartum stillbirth are in preparation. Dean Jamison authored a chapter in the recent edition of Disease Control Priorities in Developing Countries showing how burden of disease can be calculated for stillbirths. Just last week the International Stillbirth Alliance had a large conference in Norway - from which I am sure there will be proceedings with results from very recent research on the topic. From May 7-10,2009 in Seattle, there will be a Gates-funded Landscape Review of Prematurity and Stillbirth in order to highlight a) prioritized research questions urgently needing attention and b) existing evidence-based interventions which require immediate action re: scale up (see: www.gappsseattle.org). Findings from a validation study in Ghana of verbal autopsy for stillbirth cause of death was recently published (Edmond, K and colleagues). This is not at all meant as a definitive list of efforts that are underway. These are merely the efforts that immediately came to mind as I respond to these questions. The takehome message is that a great deal of exciting work is underway and it seems that the invisibility of stillbirths may be changing.

Just a few notes:
RE measuring stillbirths in a census, this is not something that I personally would advise, and I suspect many demographers would agree. The census interview is simply not appropriate for in-depth questioning and very careful formulation of potentially sensitive questions, etc.
However, I am a proponent of trying to measure stillbirths using other data collection approaches and feel that improving existing methods in use in household-based surveys is a top priority.

This is not straight forward to answer. Birth weight and/or gestational age cut-offs determine when pregnancy losses are considered spontaneous abortions versus late fetal death (actually, stillbirth is a colloquial term, the term used by the International Classification of Diseases, Rev 10, is late fetal death, at least for pregnancy losses at 1000 grams birthwt or 28 weeks gestation or more). If I remember correctly, when my colleagues and I were working on the literature review for the global stillbirth estimates, we identified around 20 different definitions of stillbirth used by statistical agencies in various countries; gestational age cut-offs were as low as 20 weeks; birthwt as low as 500 grams. So, in short, it varies from country to country.

RE: cause of death, as mentioned elsewhere, there are many different stillbirth cause of death classification schemes, and they are infrequently comparable. My colleagues and I are close to finishing a systematic review of SB cause of death, and we are abstracting data into the following common categories:
Maternal conditions (eclampsia/PIH, other maternal pre-existing conditions); abruption or antepartum hemorrhage; infections (syphilis and other maternal and fetal specific infections); congenital abnormalities; intrapartum (fresh SBs - obstruction, CPD); unexplained intrapartum causes, unexplained antepartum causes and unclassifiable. This does not constitute a "classification scheme" - it was designed to capture data from a variety of different classifications. To note - after reviewing over 36,000 abstracts, applying inclusion/exclusion criteria, etc for the review, we will end with SB cause of data from only approximately 100 papers. In other words, there are not a lot of data out there, particularly for low income countries.

Education at the community level is needed, and I do not see why community registers could not track stillbirths, as some do for maternal deaths. One thing that I have not mentioned here yet is the problem of misclassification between stillbirths and early neonatal deaths. THis is a problem when women are asked to report their pregnancy outcomes, as well as a problem at health facilities. In the case of home-based births, a woman may never be shown a fetus born dead or a child that dies very quickly after birth. Thus, she may really not know the status of the fetus/infant at birth. Or, even if she does, there may be cultural or other reasons for claiming the outcome as stillbirth versus death following live birth. The same issue exists in health facilities world wide. Providers' perception of the viability of the infant (particularly very preterm births) and other reasons may well affect their final call re: its status at birth.

The good news is that much of what needs to be done to reduce stillbirths is included in maternal/newborn health care packages now being promoted.

Hi Farid,
I completely agree - see answers to previous questions. One could also argue that it is important to track stillbirths in order to be able to interpret possible changes in early neonatal mortality (as obstetric care improves, it is likely that some fetuses that would have died (ie stillbirths) will survive delivery but may die shortly thereafter. As health care systems and general health improve, both indicators improve.

I don't know of any truly multi-disciplinary teams, as you describe. I do agree that anthropologists, sociologists and political scientists could assist these efforts by exploring societie's reluctance to address or even acknowledge the loss represented by stillbirths.

Hi Rachel,
That is a very good question and not one for which even high income countries have found an answer. (Some argue that differences in infant mortality across developed countries are to some extent due to differences in practices re: defining a live birth.) Personal practices and beliefs come into play, as well as issues regarding things like insurance coverage. I guess the bottom line is that when something is recognized as important, individuals and the systems in which they work, establish expectations to accomplish their goals. I do not have evidence of this, but I strongly suspect that medical and midwifery schools in developing countries pay little heed to the finer points of these definitions. Certainly, few developing countries have stillbirth death certificates, another signal from the government and society as a whole, that a stillbirth is important.

Very quickly, before we close out today - see Dean Jamison's chapter on the calculation of disability-adjusted life years (DALY's) for stillbirth in the recent edition of Disease Control Priorities in Developing Countries.

John -- I read your article; thanks for sending it to me. The outlook for US demography has not changed much since 2003. However, there are a couple of points that struck me. You mention that the TFR had fallen to 1.7 in the mid-1970s, which is approx true; however, it subsequently rose to replacement level and has been bouncing around between 2.0 and 2.1 for many years. So this is a sharp contrast to the other industrial nations which generally have considerably lower fertility. Second, you refer to the UN study on the amount of immigration that would be required to maintain the old age dependency ratio at its 1995 level through 2050, and report that the UN calculates a total of 593 million would be needed, if retirement remains at 65. I myself did a calculation of the pace of immigration that would be required to make Soc Sec finances balance through 2075 (that is, make the summary actuarial balance equal roughly zero) and found 5 million per year, which over 75 years would be 375 million, a bit less than the UN number. However, the basic conclusion is the same as yours either way: that level of immigration is not an appealing policy option.

Tina -- I agree that population aging is inevitable. I think that many of our institutions that are impacted by aging are rather inflexible, and were originally developed to be effective in a different demographic context. Social Security, Medicare, Institutional Medicaid, many private pension plans -- all these get into fiscal trouble with longer life and population aging. I think we need to redesign these institutions so that they at least permit individuals to respond to their circumstances in ways they views appropriate. Social Security has gone a good distance in this direction, trying to present workers with a fair tradeoff between continuing to work longer and getting a higher pension when they do retire, or retiring earlier and receiving a lower pension. Personally, I don't think policies should take for granted that the best solution is for people to retire later. I think we should let people choose, but set things up in such a way that their choice does not impose costs on others. In fact, I would like to see our institutions permit leisure (time not doing wage labor) to be taken throughout the life cycle as a person chooses, rather than being all bunched together at the end of life.

Barbara -- The Total Dependency Ratio is the ratio of the youth population plus the elderly population to the working age population. A more refined measure is the Support Ratio based on empirical age profiles of consumption and labor income, used to form the ratio of equivalent workers to equivalent consumers. This ratio declines at .2% per year from now through 2050 (analogous to a rise in the dependency ratio). This rate of decline is, I think, very slow, particularly in comparison to the much bigger changes in the finances of the Social Security system or Medicare. But by construction, it is considering not only these govt programs targeted to the elderly, but rather all govt programs and also the age patterns of private consumption.

You raise a good point about the payroll tax being regressive. I agree. The original idea was that the progressivity of the benefit schedule would out-weigh the regressivity of the payroll tax, but because poor people die younger than rich people, it is not clear whether actual benefits are progressive.

One could, of course, fund old age benefits out of the income tax, but I think most people would rather see a tighter relation between what benefits you receive and what contributions (payroll taxes) you pay. One way to do this is the so-called National Defined Contribution systems that are common in Europe, but these do nothing to make the system more progressive. That then requires a separate redistributive component, which some plans like the Swedish one have.

I don't recall the details, but the metric I have often seen is something like the number of years it took for the proportion 65+ to go from 5% to 10%. Those thresholds aren't right, but I think that concept is the one most commonly used.

As I recall, a person gets to choose whether to take a Soc Sec benefit based on their own earnings history or on that of their spouse (or someone to whom they were previously married for at least ten years), where they would be entitled to 50% of the spouses benefit level. I am not sure I have that exactly right, but that is the general idea.

Female labor force participation is really quite high, as you note, but many of those women have had quite interrupted work histories and lots of part time work, while they took time out to raise children. The benefit they would qualify for based on their earnings histories would often be very low. And for those women who were out of the labor force for most of their lives, the benefit level based on their earnings might be zero (if they didn't work for at least ten years).

I would prefer other policies to deal with the projected shortfall in Social Security.

There are reverse mortgages, but few older people use them. there are also special investment funds that automatically adjust the risk-rate of return tradeoff as people age. Probably there are many others, but this is not an area I know much about, despite the title of this discussion. However, I suspect that there is a lot of room for development of other special financial instruments for the elderly.

Immigration as a way to moderate the extent of population aging in the industrial nations is, of course, quite controversial. From a demographic point of view it certainly has some effect on the age distributions in the receiving industrial nations, and less so in the Third World sending nations because the that population is so much larger. However, the demographic effects on the receiving countries' old age dependency ratio are surprisingly small, particularly in the longer run, since the immigrants grow old themselves. Also, the TFRs in the sending countries are often not much higher, and may be even lower, than in the receiving country (e.g. China and the US), so there will be less and less affect on fertility in the industrial nations. There is a fiscal gain per immigrant in the US, given the current composition of the immigrant stream, and that effect is large on a per immigrant basis but not very big on a national basis (see Chapter 7 in the New Americans, a Nat Acad Press report).

I should know more about this than I do. The main thing that comes to my mind is switching to National Defined Contribution (NDC) public pension programs in Sweden, Latvia, Italy, and to systems with similar features in Germany and France.

These systems are designed to mimic Defined Contribution systems (like 401Ks in the US), in the sense that each individual has a (imaginary) fund based on the amount contributed in the past and a rate of return that is determined by a simple rule, like the rate of growth of the labor force plus the rate of growth of the wage. these systems should adjust automatically to demographic change, for example low fert causes slow labor force growth which reduces the rate of return earned on these accounts. And mortality decline raises life expectancy and means that the fund accumulated at the time of retirement, which must be converted to an annuity by the govt, converts to lower benefits per year.

I can well imagine a system like that in the US, but it does require some sort of safety net or redistributive program to round out the system.

Well, population aging in the US is much more mild than in other industrial countries because our fertility here is around replacement level, rather than being way below it as in europe and Japan. In my view, we could keep our current Soc Sec system in its present form if we wanted to, by raising the payroll tax by about 4 or 5% which would achieve indefinite sustainability. This is not an option in these other countries because their aging will be so much greater, their public pensions are much more generous than ours, and their ages of retirement are generally younger.

Health care is a different matter, and I won't try to address that although it is extremely important.

In the US, financial private transfers or actual support for their consumption, to the elderly by family members is not common and averages out to close to zero. But in most of the Third World, family support is the main source of support for the elderly, and indeed pop aging imposes heavy burdens on these families and may compete with their ability to fund their children's education. In many of these countries, private spending on children's education is substantial.

In the industrial nations, the competition between consumption costs of the elderly and education for the children plays out in the public sector rather than in private spending, and I believe it is a grave concern. I am very worried about what will happen, in the US and in other industrial nations.

Carl -- I agree with your framing of the question: immigration helps to some degree with the old age dependency ratio, but the effect here is much smaller than most people would expect, because of your second point -- that the immigrants age too. So in my view, the fiscal effects of immigration are not very important, and I think immigration policy should be set based on other considerations.

Meir:

A tough question. As you say, consumption per capita rises strongly with age in the US and in many European and other industrial nations, although it is flat with age in most Third World countries (all this in cross-sectional terms). But what is the composition of that rising consumption in the US? A great deal of it is due to a higher proportion of spending on health care, both through private spending and through public spending (Medicare, Medicaid). And after age 80 or so, long term care kicks in dramatically.

If we focus on the non-health care and long term care part of private spending, I am not very sure about how the composition of spending changes. A student here at Berkeley in Demography, Emilio Zagheni, did a very interesting research paper on this topic, as part of looking at how pop aging would affect the CO2 emissions, but I don't recall his findings.

Charlie:
Immigration of younger workers has less demographic impact than one might expect on, say, the old age dep ratio in 2050, because they also grow old. To have a big and lasting effect, there must be an accelerating rate of immigration. The fiscal gain is greater if we restrict immigration to those with higher skills or higher education, but I am not suggesting that as a policy because there are many other considerations. The question of health care workers is certainly important, and I am not very well informed on this. But I see it has having two parts: first, there is immigration of less skilled workers who take low paying jobs in nursing homes and hospitals, helping to keep those institutions running at a lower cost than otherwise. Second there are the higher skilled immigrants who have been trained as nurses and doctors. Well, others will know better what the issues are here.

John -- Ken Manton has done very important work in this area, and was the first to show this decline in disability rates, which is extremely important for our long term outlook. But the picture now looks more complex, e.g. as discussed in an article in Demography a couple of years ago by multiple authors, perhaps including Manton, Schoeni, Martin, Freeman. They reported that while IADLS, the less severe forms of disability, have been declining steadily, the ADLs, which are more basic and lead to nursing home stays, have not been declining. So I am less clear on what the bottom line is here than I was a few years ago. I want to see more of the international evidence. Also, the role of assistive devices and other new technologies is very important and may make it possible for people to remain active and at home for much longer even if their biological functional status has not improved much compared to earlier people of the same age.

This is all very important, not only for its fiscal implications, but also for quality life implications of older people.

Kelvin -- important question. 1) I think immigration policy should be determined on the basis of other considerations; I don't think the fiscal implications of immigration are very important when you combine federal, state and local impacts. 2) Population aging in the US is much more mild than in other industrial nations. Other things equal, pop aging and rising old age dependency ratios will lead to about .2% per year slower growth in consumption per equivalent adult consumer than otherwise. This strikes me as being really quite small. Of course, this effect is concentrated in certain areas, particularly in public pensions, health care, and long term care, and if we focus on those alone the effect is much, much bigger, proportionately. My own view is that we should stick with our current Soc Sec benefit structure, while raising payroll taxes by about 4 to 5%, which would put the system on a sustainable basis for the indefinite future. We could then have some sort of govt managed private program on top of this, perhaps, but without reducing the current PAYGO benefit structure. 3) The really big issues is health care and perhaps long term care. ("perhaps" because of uncertainty about disability trends). I am not going to discuss those.

Dana -- a good question, and I am the wrong person to answer it. Nonetheless, I will try to say something here, although this may be wrong. I think that indeed the costs of employer provided health benefits for the elderly is high, and discourages them from hiring or retaining older workers. This exacerbates the problems of population aging, since it makes it harder for older workers to work, perhaps leading to earlier retirement etc. Wish I could say more.

John -- Good question, and I am not up on what has been done on this lately. Of course the numbers of the oldest old are rising very rapidly, and those are the main clients for long term care. But, as has come up earlier in this discussion, disability rates have also been declining, at least as measured by IADLs, but perhaps not for ADLs. This means (I say optimistically) falling rates of long term care usage at a given old age, but increasing numbers at risk at each age. What this will mean in terms of long term care use per working age person, I don't know.

Phil -- I only know of one such study, but I bet there are others. The study I have seen is by Gruber and Wise, the same guys who did pathbreaking work on retirement. This study looked at govt spending in OECD countries over a few decades, in relation to proportion elderly. As I recall, they found that for each 1% increase in the proportion elderly in a country, there was .5% increase in public spending on the elderly. This meant that with pop aging, the benefit levels per old person tended to drop slightly (because .5%<1%). But they also found that total govt spending was unaffected, and that means that the 1% increase in proportion elderly, leading to .5% increase in spending on the elderly, was crowding out .5 percent of spending on other things, including education.

There have also been a number of studies of the effects of varying proportions of elderly across school districts or larger geographic units in the US and school spending per pupil. I think the results have been inconclusive. But in this case, it is a matter of voting behavior rather than of crowding out in the govt budgets, I think. We found that in California, at the state level older people pay more in taxes than they cost in benefits. Not sure about the local level, but I would expect the same to be true there.

Marlene -- in the US, I think around four times as much is spent per elderly person as per child, combining federal, state and local programs. Of course, at the private level, we spend a great deal more on rearing our children than we do on supporting our elderly parents. That is the public/private division of labor in the US and most industrial nations including Japan at this point, but in many countries it is quite different.

Providing economic stimulus: Here I am not sure. My first inclination is to say that a dollar spent for an old person has just the same effect as a dollar spent for a child, but I have not thought about this before and could be missing a key point.

Meir:

Tim Miller and I published a paper in Demography, maybe it was 2003 or 2004, on assessing the performance of the Lee-Carter method. I think that article has the information you are asking about. Since that time, i think there have been quite a few studies, including a recent one Soc Sec, on this. The Lee-Miller paper looked at imaginary forecasts done using the method starting in around 1920, for all forecast horizons, and then 1921 etc., so there was a huge data base developed.

Ron

Mexico’s mortality rate for children below five years of age has decreased from 44.2 for each 1,000 births in 1990 to 25 in 2003. In terms of infant mortality, in the same period, the country’s rate went from 36.2 to 20.5 deaths- These numbers place Mexico slightly below the average for Latin America and the Caribbean, which is 34 deaths of children below the age of five for each 1,000 births. Within the country, there is a high degree of unevenness in these indicators. The highest infant mortality rates are in the states with the greatest levels of marginalization and poverty. In the states with the highest infant the risk of dying was 60 per cent greater than in all the states with lower levels of marginalization. The variations within some states are even greater, especially in those with higher levels of marginalization. In Oaxaca, for example, a child from the indigenous municipality of Santiago Amoltepec has three times the risk of dying before reaching his first year of life than a child from the urban municipality of Santa María del Tule.

You can look for more information in the report “Growing Up in North America: Child Health and Safety in Canada, the United States, and Mexico” www.childreninnorthamerica.org. Information in Spanish in www.infanciacuenta.org.mx

In Canada, roughly 12% of children under age 18 are poor – according to national sources – roughly the same proportion as twenty years ago, this despite sustained economic growth up until recently. Levels of child poverty are lower in Canada than in the United States or Mexico - in part because of transfers to families and the availability of universal health care. That said, many Canadian children face high levels of persistent poverty. According to the 2001 Census, 40 percent of Aboriginal children under age 18 lived in households below Canada’s pre-tax poverty line. Visible minority children, many living in new immigrant families, struggle economically as well: One in every two children in recent immigrant families (49%) lived in poverty in 2000. The poverty rate for children with disabilities was 28% in 2000; families with a parent or child with a disability are much more likely to rely on social assistance as a primary source of income.

In Mexico remittance flows are the second largest source of external funding, after oil sales. Mexico is [one of] the top four remittance recipients in the world, [and] reported remittance inflows for $25 billion in 2007. According to recently published official data, migrant remittances to Mexico declined by 2.6 percent during January-May 2008, compared to the same period last year. The relation between lower poverty, better health and higher levels of education for children and remittances is clear, if you considered that remittances mostly or sometimes completely cover general consumption and/or housing in the poorest states in the country. One estimate indicates that 80 percent of the money received goes for food, clothing, health care, transportation, education and housing expenses.

The ministry of social development already declares that as result of the decline of remittances, poverty rates will began to grow. As you see we are going to have problems: less income and people that are beginning to come back unemployed. In recent weeks, Mexican newspapers have been filled with news about the imminent return of thousands of Mexican migrants because of the economic crisis facing the United States. These news [reports] are talking about the return of 500 people a day for Sonora (El Financiero, 25/10/08), 4 thousand migrants from Chicago who returned to the Federal District (The Weekly, 14/10/08), 20 thousand families living in the United States who have returned to Michoacan so far this year (La Jornada Michoacán, 10/10/08). Finally, the National Migration Institute said it had detected a growing number of Mexican immigrants who return to Mexico in its final form by the economic crisis in the U.S. (El Universal, 30/9/08).

“Globalization” is a somewhat vague concept but I think of it in terms of the increasing flow of people, tasks, and ideas across national borders. In the United States, globalization is linked to a decline in blue-collar manufacturing jobs, although automation and technological advances has also played a role in that decline.

Today, most high-paying jobs require a college degree, so those with only a high school diploma or less are at a major disadvantage. From a children’s policy perspective, we need to make sure that today’s youth can compete in the global economy by providing them with the necessary education and skills.

You can find more information about this in PRB’s recent report on the U.S. Labor Force: http://www.prb.org/Publications/PopulationBulletins/2008/uslaborforce.aspx

Given what we know, there are a few key policy areas where governments can make a difference in the lives of children growing up in poverty. Building and sustaining services and supports for children and their families is essential to creating a context within which children can grow and thrive. Government income programs can and do play an important role in preventing and alleviating child and family poverty. Similarly, quality child care, affordable housing, and universal health care are key components of a comprehensive poverty reduction strategy. Targeted programs that address the challenges of particular groups of children such as Aboriginal children are needed as well. Adjustment assistance for those families directly impacted by economic dislocation is also important as its absence can devastate families and whole communities.

Education is another area in which government policies help children position themselves in the new global knowledge economy. Although education by itself does not guarantee economic security, education has become more important in all three economies. Lack of education has brought real losses in income and relative social status to workers and their families. Improving the quality of education, especially in Mexico, is important to realizing the potential of children.

Investment in children and youth is critical in good economic times and bad. The danger as recessions take hold and public revenues decline is that supports and services for those children and youth will be scaled back. Such a strategy is short-sighted in the extreme – even a year is a long time in the life of a child. Investment in children is an essential strategy in development productive economies and societies, able to adapt and thrive in the face of global pressures such as we are experiencing today.

We need to think about children as an investment, just like the Dow Jones Industrial Average. Invest in the long term, and eventually you will see big dividends. Given the current problems in the U.S. economy, there may be a temptation to reduce spending on health, education, or other programs that invest in children’s development. But we need to ensure that children have the resources and skills they need to become productive adults. In 10 or 20 years, today’s children will provide the backbone of the U.S. economy.

Head Start funding has increased over the years but has not kept up with inflation and many argue it has not kept pace with the growing needs of America’s disadvantaged youth (see National Head Start Association at http://www.nhsa.org/). You may also be interested in the Urban Institute’s report called “Kids’ Share,” which provides an overview of federal funding for children’s programs. (see http://www.urban.org/publications/411699.html.)

One of the big challenges for Head Start, from a demographic perspective, is the rapid growth of low-income children living in immigrant families.

The international research is mounting, showing the value of early child development programs – for children and societies as a whole. Certainly early child development is a critical plank in poverty reduction strategies. Unfortunately, in Canada, we have been a laggard in this regard, certainly compared to European countries, with the notable exception of the province of Quebec. The availability of regulated child care is very uneven across the country. Some provinces are only just introducing kindergarten for 4 and 5 year-olds. There are “Head Start” style programs in many communities and on reserve for Aboriginal children, but the need certainly outstrips supply.

In 2000, the federal government in Canada sets aside funds for early childhood development and subsequently announced plans to expand child care. With the change of government in 2006, these plans were shelved. A new child benefit was announced to assist with the cost of child care – but the amount is meager, poorly targeted, and the program itself has done nothing to expand supply or improve working conditions in the child care sector. Much remains to be done.

For Canada, please see: Friendly, Terns, Beach and Turiano (2007), Early Childhood Education and Care in Canada, 7th edition. http://www.childcarecanada.org/ECEC2006/index.html
Tracey Bushnik (2006), Child Care in Canada. http://www.statcan.ca/english/research/89-599-MIE/89-599-MIE2006003.pdf

We don't have that kind of program in Mexico. Less than 8% of the child population (from Birth to three years) is covered by initial education. Pre-school education is predominantly (over 80%) state provided. In November, 2002, the Law of Obligatory Pre-schooling became oficial, not only makes it obligatory for the State to provide pre-school education services for children 3 to 6 years of age when that is demanded, but also makes it obligatory for parents to see that their children, of those ages, attend a public or private pre-school. The law sets a schedule for attaining universal enrolment: for children age 5 that should occur at the beginning of the 2004-5 school year, for age 4, in 2005-6, and for age 3, in the 2008-9 school year. It also states that pre-school teachers should have professional preparation. In the beginning of these years the government released [a report stating] that reaching that goal was nearly impossible, and made changes in the law, making only 4 and 5 years obligatory.

If you want to have more inforation, Mexico, Canada and USA are part of the twenty-one countries that have volunteered to participate in the Thematic Review of Early Childhood Education and Care Policy, a project launched by the OECD’s Education Committee. These countries provide a diverse range of social, economic and political contexts, as well as varied policy approaches toward the education and care of young children, several reports from the review may be viewed on the project web site http://www.oecd.org/edu/earlychildhood.

Obesity and being overweight are emerging as a major concern throughout North America. Being overweight or obese during childhood can and does have a lifelong impact on health and quality of life. Researchers in each country are working to identify the best strategies for promoting healthy weight in children and youth, and preventing the development of chronic diseases associated with obesity such type 2 diabetes, hypertension, heart disease, arthritis, and cancer. What we do know is that individual- and population-level strategies are needed to tackle the complex social and environmental factors linked to obesity.

Successful programs are dynamic, designed to meet the needs of specific population groups. Research shows that the promotion of breastfeeding, creating opportunities for regular physical activity, changing dietary patterns, and reducing the time children are engaged in passive activities like watching television are all important in reducing obesity. To this end, schools are key settings for programming. Existing programming, however, tends to focus on individual behaviour. There is also a critical need for more upstream, population-focused interventions that address issues such as food distribution networks, lack of opportunities for physical activities, community access to recreation.

Some examples include:

• Staple food-pricing policies that protect the price of food staples like milk and whole grain bread and make these foods more affordable for families with children;
• Policies that support local farmers and provide low income families access to local farm produce;
• Nutrition policies that support healthy food in schools and classroom education that encourages healthy eating behaviours and attitudes.
• Access to recreation programs - and all the supports that make that happen.

For additional information, see World Health Organization (2000) “Obesity: Preventing and Managing the Global Epidemic.” WHO Technical Report Series 894. Available at: http://www.who.int/bookorders/WHP/dartprt1.jsp?sesslan=1&codlan=1&codcol=10&codcch=894 For information on obesity in Canada, see Canadian Population Health Initiative (2006), Improving the Health of Canadians: Promoting Healthy Weights. Available at: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_470_E&cw_topic=470&cw_rel=AR_1217_E

The report “ Growing Up in North America: Child Health and Safety in Canada, the United States, and Mexico” www.childreninnorthamerica.org, points out that all three countries report that the rates of obesity among young people are rising rapidly. More than a quarter of children in each country are obese. You can also have information related to current policies and programs, lessons learned from current interventions, and potential public policy approaches, in the report “Joint U.S.–Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin” available in the The National Academies Press web site (http://books.nap.edu/catalog.php?record_id=11813#toc)

This is a real challenge in the U.S. because there are many structural and financial barriers for families—especially lower-income minority groups—to eating right and staying physically fit. We need to address physical fitness and healthy eating habits for families but we also need to provide affordable access to healthy foods.

The Institute of Medicine conducted a study a few years ago and has several recommendations to address childhood obesity. You can view their report online at http://www.iom.edu/?id=25048.

Good question. I don’t know that this has been attempted for counties along the northern U.S. border but the Annie E. Casey Foundation has done some research on kids living in counties bordering Mexico: http://www.aecf.org/upload/publicationfiles/sw3622h40.pdf

To my knowledge, there hasn't been a project that looks at the well-being of children along the US - Canadian border, certainly not like the Border Kids Count project. There have been any number of environmental, economic, transportation and security studies of different border regions, for example, around the Great Lakes. But children haven't figured prominently in these.

You can look for a overview of data on children living on the Southwest Border of the USA and Mexico's northern border region, in the Borders Kid Count Reports.
http://www.aecf.org/KnowledgeCenter/PublicationsSeries/KCDatabookProds.aspx and www.lainfanciacuenta.org.mx

International migration is shaping the futures of children across North America. In Canada, the scale of immigration is changing the face of the population. It is estimated that 20 percent of Canadians under age 18 are immigrants or the children of immigrant parents. In some of Canada’s major cities, it is estimated that half the population will be foreign-born by 2020. Immigration represents a tremendous opportunity for Canada. At the same time, there are issues related to settlement that are having a negative impact – certainly on children and their families. In particular, it is taking longer for recent immigrants to find and secure good employment, in many instances, despite high levels of training and skill. As a result, new immigrants struggle with high levels of poverty in Canada. Education, health care and social services are also struggling to serve increasingly diverse populations. Confusion and conflict over responsibility for immigration and settlement between the federal and provincial governments continues to hinder efforts to develop effective programs, compounding disadvantage for many groups of immigrant children and youth.

Mexico is mostly an emigration country, the migration to the United States of America is
one of the main generative fonts of income in many poor communities of the southern states. According to recent reports, around 20% of all families with female members (especially mothers and wives) in Mexico receiving remittances and usually are the recipients of money transfers. The most important thing in this paper is that about 80% of all remittances are used to meet the basic needs of families, such as food, rent, education, health and public services. As you can see the money received in rural communities’ impact directly on better conditions for the children. Nevertheless [there are] studies regarding the negative impact of the absence of the father and in sometimes mother. You can also look for information around migration in the Americas and its impact on child well-being and child welfare policy, systems, and services, in the Migration and Child Welfare National Network (http://www.americanhumane.org/site/PageServer?pagename=pc_initiatives_migration) and
Data Snapshot: One Out of Five U.S. Children is Living in an Immigrant Family and
Children in Immigrant Families: U.S. and State-Level Findings from the 2000 Census (http://www.aecf.org/KnowledgeCenter/) and

There are two major groups of immigrants coming to the United States. Those arriving from Mexico and other Latin American countries tend to have less education and fewer skills than the U.S.-born population, while those arriving from Asia tend to be highly-skilled workers recruited to work in high-tech fields. So the prospects for children vary a great deal, depending on the circumstances of their parents’ migration to the United States.

We need to pay attention to how these kids are doing because they make up large and growing share of the child population. More than one in five U.S. kids is foreign-born or lives with a foreign-born parent.

Kids prospects are closely tied to parental income and work, so the current crisis is likely to have a big impact on children in the U.S. Many kids who were living in low-income working families are likely to find themselves in poor families that are out of work.

Health care costs and food costs have risen dramatically in recent years, and many families are going to have trouble paying for these basic necessities. Look for an increase in the number of children without health insurance, and living in food-insecure households.

What our report shows it that there are marked disparities in the economic well-being of children and their families between Canada and the United States and Mexico and within each country as well. The current period of economic crisis can be expected to compound these divisions, putting at risk the healthy development of many more children.

The global character of the current economic crisis demonstrates how interconnected the future of children in North America – and those around the world – is. A financial crisis originating in the United States is now reaching down to touch the lives of children in far distant places. In Canada, several industries are under intense pressure as access to credit has declined precipitously and markets for their goods have started to dry up. Lay-offs in manufacturing continue. Commodity prices have collapsed. Families are wondering whether their savings and pensions will recover. Government revenues are declining. All agree that the coming year will be very difficult.

In Canada, there is a real concern that cutbacks in income security programs in the 1990s will significantly hinder the ability of governments to provide transitional support to children and families. Unemployment insurance and welfare programs, in particular, were scaled back and eligibility requirements changed. Already there are signs that community service providers are struggling with growing demand for service.

During economic crises, perversely, inequality tends to decrease as families across the income spectrum experience declines. At the same time, economic crises tend to deepen or entrench existing disparities. For its part, Canada hasn’t experienced a deep recession in 17 years. It remains to be seen what the impact of the current crisis will be. We can say with some certainty, however, that millions of children and youth across North America are at substantial economic risk.

[English translation follows]
Ante el tamaño de la crisis financiera que se vive en el mundo, is impensable que esto no tendrá impacto en un México. En el caso de nuestro país además hay que considerar la fuerte integración económica con los Estados Unidos, así como la dependencia en las remesas. Los signos comienzan ya a sentirse disminución del flujo de remesas, retorno de migrantes y reducción en el gasto social dentro del Presupuesto Federal progamado para 2008. La infancia mexicana sentirá esta crisis en su alimentación (se están presentando ya incrementos en los productos de la canasta básica), hay que considerar en este aspecto que la economia de subsitencia en el campo mexicano ha sido fuertemente golpeada a partir de la firma del Tratado de Libre Comercio. También la sentirá en su salud y en la educación por la anunciada disminución en el gasto social.

[Given the size of the global economic crisis, Mexico will surely suffer the impact. And, in our case, we have to take into account the level of economic involvement we share with the U.S. as well as our dependency on remittances. The signs are already visible: reduced flow of remittances, migrants returning to Mexico, and a reduction of social expenditures within the federal budget planned for 2008. The nutrition of Mexican children will be affected (basic food items are going up in price). In this regard, we have to consider that the subsistence economy in rural Mexico was already affected by the Free Trade Agreement. Children's health and education will also be affected because of the reduction in social expenditures that has been announced.]

I doubt that the food crisis would be enough to raise mortality to such a level. It would have to be something bordering on widespread famine, something usually precipitated by political events and/or crop failure. There is also the prospect of hopefully improved and more universal health care, including immunizations, acting to reduce child and adult mortality. And, apparently, we now have the prospect of declining oil prices, at least for the moment. But we should also not ignore the fact that many families cannot afford a sufficient diet now.

Your question is really very appropriate as nearly all developing countries have widely varying TFRs across geographic regions, income groups, etc. PRB has primarily given significant publicity to those differentials through its publications, seminars, and extensive work with journalists in the affected countries. To your last question, I would point you to the many Demographic and Health Surveys available online at www.measuredhs.com which have preceisely what you are inquiring about.