Sub-Saharan Africa: population pressures on development

The population of sub-Saharan Africa, estimated at 434 million in 1984, is expected to reach 1.4 billion by 2025. The birth rate, currently 48/1000 population, continues to increase, and the death rate, 17/1000, is declining. Rapid population growth has curtailed government efforts to provide adequate nutrition, preserve the land base essential for future development, meet the demand for jobs, education, and health services, and address overcrowding in urban areas. Low education, rural residence, and low incomes are key contributors to the area's high fertility. Other factors include women's restricted roles, early age at marriage, a need for children as a source of security and support in old age, and limited knowledge of and access to modern methods of contraception. Average desired family size, which is higher than actual family size in most countries, is 6-9 children. Although government leaders have expressed ambivalence toward development of population policies and family planning programs as a result of the identification of such programs with Western aid donors, the policy climat is gradually changing. By mid-1984, at least 13 of the 42 countries in the region had indicated that they consider current fertility rates too high and support government and/or private family planning programs to reduce fertility. In addition, 26 countries in the region provide some government family planning services, usually integrated with maternal and child health programs. However, 10 countries in the region do not support family planning services for any reason. Unfortunately, sub-Saharan Africa has not yet produced a family planning program with a measurable effect on fertility that could serve as a model for other countries in the region. Social and economic change is central to any hope of fertility reduction in sub-Saharan Africa. Lower infant and child mortality rates, rising incomes, higher education, greater economic and social opportunities for women, and increased security would provide a climate more conducive to fertility decline. Given the limited demand, great sensitivity must be shown in implementing family planning programs.     

Integrating reproductive health services into family planning programs

A recent Population Council publication, Reproductive Health Approach to Family Planning, discusses integration of reproductive health into family planning programs in a series of edited presentations that Council staff and colleagues gave at a 1994 meeting of the US Agency for International Development (USAID) cooperating agencies. The presentations reflect the Council's view that family planning programs ought to help individuals achieve their own reproductive goals in a healthful manner. The report discusses four areas of reproductive health: reproductive tract infections (RTIs), including sexually transmitted diseases; prevention and treatment of unsafe abortion; pregnancy, labor, and delivery care; and postpartum care. Christopher Elias (Senior Associate, Programs Division) argued that family planning programs ought to provide services that target RTIs, given that these illnesses afflict a significant proportion of reproductive-age women. The family planning community has an ethical responsibility to provide services to women who experience an unwanted pregnancy. They must have access to high-quality postabortion care, including family planning services. Professional midwives are ideally suited to serve as integrated reproductive health workers trained to combat the five major maternal killers: hemorrhage, sepsis, pregnancy-induced hypertension, obstructed labor, and unsafe abortion. This was demonstrated in a highly successful Life-Saving Skills for Midwives program undertaken in Ghana, Nigeria, and Uganda, and soon to start in Vietnam in conjunction with the Council's Safe Motherhood research program. Family planning services should be viewed as part of a comprehensive set of health services needed by postpartum women, which include appropriate contraception, maternal health checks, well-baby care, and information about breastfeeding, infant care, and nutrition. Family planning programs should incorporate breastfeeding counseling into their services. When programs aim to help individuals meet their own reproductive goals in a healthful manner, this implies that services will not increase clients' risk of morbidity.     

Economic development and fertility decline: lessons from Asia's newly industrialized countries

The general thesis that economic development and fertility decline are interrelated is substantiated in literature that discusses the successes of the newly industrialized countries of Hong Kong, Korea, Singapore, and Taiwan. When countries are developing rapidly, family planning accelerates the rate of fertility change, particularly among the poor uneducated rural population. Relying on economic and social development is not enough. National policy in Hong Kong, Singapore, Korea, and Taiwan recognized that population growth drains resources and the family planning programs operating since the 1960s contributed to a drop from 5 children/woman to 2 by 1988, and 70% of married couples used contraception. Coupled with this, age at marriage rose, contraception became more available, and educational and employment opportunities increased. Economically, the growth rate in the 1980's was 6-10% annually, with growth in the manufacturing and service sectors and export trade. Close economic ties evolved between governments and private sectors. Social development programs had been fully funded and gains evident in education, living standards, health care and nutrition, and life expectancy. The success of family planning is attributed to encouraging contraceptive awareness and use. Fertility reduction may occur with social and economic development, but no developing countries have reduced fertility without family planning. The relative importance of family planning may change over time, and reducing the cost through government sponsored family planning programs and encouraging the acceptability of contraceptive usage.     

Future population growth: researchers in three countries quantify causes and propose policies

This article discusses Population Council analyses conducted by social scientists from India, Kenya, and the Philippines. These scientists agreed that population momentum would continue to increase population size, and that governments must strengthen and create a range of economic, health, and social programs and policies to slow population growth. Multiple approaches will be needed. John Bongaarts is credited with being the first to identify the key role of population momentum and to decompose growth into unwanted fertility, high desired fertility, and population momentum. Unwanted fertility is responsible for about 19% of projected population growth in India, 26% in Kenya, and 16% in the Philippines. High wanted fertility accounts for 20% of future growth in India, 6% in Kenya, and 19% in the Philippines. Population momentum can account for under 50% or over 90% of growth. Unwanted fertility can be addressed by fulfilling unmet need and increasing knowledge of methods, reducing the fear of side effects and disapproval, and eliminating poor service. Family planning programs need to be strengthened and integrated with maternal and child health services. Preferred and actual family sizes can be reduced by lowering infant mortality by means of increasing infant and child health services and girls' educational attainment. Population momentum can be addressed by delaying age at marriage and childbearing through improving social conditions. Investments in human development through education, training, and income generation can create the conditions for slowing population growth. Countries should decompose population growth into its components of unwanted and high wanted fertility and population momentum as a means of distributing resources most effectively.     

Estimating unmet need for contraception by district within Ghana: an application of small-area estimation techniques

The importance of meeting the unmet need for contraception is nowhere more urgent than in the countries of sub-Saharan Africa, where the fertility decline is stalling and total unmet need exceeds 30 per cent among married women. In Ghana, where fertility levels vary considerably, demographic information at sub-national level is essential for building effective family planning programmes. We used small-area estimation techniques, linking data from the 2003 Ghana Demographic and Health Survey to the 2000 Ghana Population and Housing Census, to derive district-level estimates of contraceptive use and unmet need for contraception. The results show considerable variation between districts in contraceptive use and unmet need. The prevalence of contraceptive use varies from 4.1 to 41.7 per cent, while that of the use of modern methods varies from 4.0 to 34.8 per cent. The findings identify districts where family planning programmes need to be strengthened.     

Fertility in Kenya and Uganda: a comparative study of trends and determinants

Between 1980 and 2000 total fertility in Kenya fell by about 40 per cent, from some eight births per woman to around five. During the same period, fertility in Uganda declined by less than 10 per cent. An analysis of the proximate determinants shows that the difference was due primarily to greater contraceptive use in Kenya, though in Uganda there was also a reduction in pathological sterility. The Demographic and Health Surveys show that women in Kenya wanted fewer children than those in Uganda, but that in Uganda there was also a greater unmet need for contraception. We suggest that these differences may be attributed, in part at least, first, to the divergent paths of economic development followed by the two countries after Independence; and, second, to the Kenya Government's active promotion of family planning through the health services, which the Uganda Government did not promote until 1995.     

Impact of low fertility and early age at sterilisation on women’s formal education and skill development in South India

This paper examines the impact of low fertility and early age at sterilisation on women’s formal education and skill development in South India. Multilevel ordered-logit modelling of pseudo-cohort data re-organised from the three rounds of National Family Health Survey, and thematic analysis of qualitative data collected from Tamil Nadu and Kerala states showed no evidence of women’s resumption of formal education or uptake of skill development training in the post-sterilisation and post-childcare period. While resuming formal education in the post-sterilisation and post-childcare period is harder to achieve for various individual, household, community and policy reasons, there is greater preparedness and support for women to undertake skill development training. As low fertility and early age at sterilisation are widely regarded as the emerging reproductive norm in India, post-sterilisation and -childcare women will be a significant population group both in number and in proportional terms. No government policies or programs have so far recognised this group. India’s new government should consider targeted skill development programs for post-sterilisation and -childcare women appropriate to their social, economic and educational levels. An important contribution of the family planning program, particularly female sterilisation, for the economic and social development of the family and the wider society will otherwise be lost.     

Fertility in Kenya and Uganda: A comparative study of trends and determinants

Between 1980 and 2000 total fertility in Kenya fell by about 40 per cent, from some eight births per woman to around five. During the same period, fertility in Uganda declined by less than 10 per cent. An analysis of the proximate determinants shows that the difference was due primarily to greater contraceptive use in Kenya, though in Uganda there was also a reduction in pathological sterility. The Demographic and Health Surveys show that women in Kenya wanted fewer children than those in Uganda, but that in Uganda there was also a greater unmet need for contraception. We suggest that these differences may be attributed, in part at least, first, to the divergent paths of economic development followed by the two countries after Independence; and, second, to the Kenya Government's active promotion of family planning through the health services, which the Uganda Government did not promote until 1995.     

New perspectives on population: lessons from Cairo

The lessons from the 1994 World Population Conference in Cairo, Egypt, are summarized in this publication. The topics of discussion include the evolution of population policies, the changing policy environment, demographic trends, and solutions in the form of gender equity, provision of reproductive health services, and sustainable social and economic development. The program of action supported by 180 governments and targeted for 2015 articulated the goals of universal access to a full range of safe and reliable family planning methods and reproductive health services, a specified level of reduction in infant and child mortality, a specified level of reduction in maternal mortality, an increase in life expectancy to 70-75 years or more, and universal access to and completion of primary education. Other features include goals for improving women's status and equity in gender relations, expansion of educational and job opportunities for women and girls, and involvement of men in childrearing responsibilities and family planning. Steps should be taken to eliminate poverty and reduce or eliminate unsustainable patterns of production and consumption. Population policy must be integrated within social and economic development policies. About $22 billion will be needed for provision of family planning and reproductive health services by the year 2015. Costs will increase over the 10-year period due to the increased population to be served. Per person user costs for family planning alone are higher in countries without infrastructure and technical skills. Actual costs vary with the cost of contraceptive supplies, patterns of use, and efficiency of delivery systems. Although the plan offers 16 chapters worth of advice and recommends 243 specific actions, countries will have to be selective due to cost limitations. The 20/20 Initiative is proposed for sharing social service costs between international donors (20%) and host countries (20%). A separate UN projection of need is for 33% of support from international donors for family planning and related programs. The constraints to the implementation of the action plan are identified as the rate of demographic change, the extent of public support for population limitation and provision of family planning services, and potential conflicts of interests and funding between cooperating agencies. The World Bank has developed guidelines for policy development according to a country's identification as an emergent, transitional, or advanced country.     

Family planning in Africa

The population growth rates and population policies and programs in African countries are summarized. Individual attention is given to Algeria, Gambia, Ghana, Liberia, Mali, Nigeria, Ethiopia, Kenya, Mauritius, Tanzania, Gabon, Zaire, Botswana and the Republic of South Africa. In addition, cultural and educational obstacles to family planning programs in Africa are briefly examined.     

Women--the deciding factor in family planning?

Prominent women from Korea, Nepal, India, Philippines, Thailand, and Afghanistan discuss family planning attitudes in broad terms. Educated women in urban areas make decisions regarding birth control and family size, but the tradition in most developing countries is that of the man in the authority role. Family planning is intrinsically a joint decision. Obligations to family and family lineage prohibit family planning. In the Philippines, Catholicism is the dominant religion and because of population density, encourages family planning. For economic and social reasons, rural families prefer more children. The changing role of women to include jobs and education will have a positive effect on family planning. The representative from Nepal points out that it is necessary to have family planning in order to have changing women's roles. Rather than emphasizing smaller family size, it is recommended by concensus, that family planners communicate health and nutritional benefits for each individual child.     

Adolescent fertility programs: responding to the needs of today's youth

The 1983 conference on Adolescent Fertility Management in Asia and the Pacific provided a forum for sharing information and experiences. The project was designed to stimulate interest in and strengthen existing programs on adolescent fertility in participating countries, i.e., Bangladesh, Fiji, India, Indonesia, Nepal, Philippines, Sri lanka, and Thailand. Specifically, the conference sought to identify adolescent fertility problems and share experiences in managing adolescent fertility programs, identify gaps in the development and implementation of adolescent fertility programs and projects, and formulate plans to meet the adolescent fertility needs of the participating countries. Capsule presentations of the experiences of the participating countries are presented. Focus is on the projects they have undertaken and proposed activities. In Bangladesh Jatio Tarum Sangha, the national youth organization, seeks to get youth involved in family planning activities through information/education/motivation programs and community development projects. Fiji proposes to establish a youth center to be operated by the Ministry of Health to reduce the incidence of unplanned pregnancy and sexually transmitted diseases in adolescents and to make them more aware of sex-related health problems and the importance of responsible sex. India's Family Planning Association has initiated population education programs for youth. Several projects have been launched in Jakarta to cope with adolescent fertility problems including the adolescent health project, the Consultation Center for Adolescents, and the university-based family health project. The Family Planning Association of Nepal has completed some major programs under its youth project. The Philippines' proposed youth centers are planned to respond to the fertility related needs and problems of Filipino adolescents. Innovations of the center are: the operation of several youth-serving government and private agencies under 1 roof, and encouragement of youth participation in designing and running the center. Sri Lanka does not have much of an adolescent fertility problem. Virtually all fertility is said to occur within marriage. A study on adolescent fertility is planned. Thailand has launched several government and nongovernment programs to reach adolescents both in and out of school. Government programs include counseling services and the National Family Planning Communication for Premarriage adolescents. Key issues are identified and recommendations are made.     

Men's influence on the onset and progress of fertility decline in Ghana, 1988-98

While lower fertility is commonly associated with women's reproductive autonomy, we demonstrate that the influence of men's education on reproductive decision-making increased during the first decade of rapid fertility decline in Ghana. Husband's education exerts a stronger influence on wife's fertility intentions than does her own education, and the magnitude of the effect of his education increased significantly from 1988 to 1998. Lower fertility in Ghana seems to be associated more with men's declining fertility desires than with women's increasing reproductive autonomy. Nevertheless, there is some indication that women's education may play a relatively greater role in reproductive decision-making as fertility decline progresses still further.     

New strategies for slowing population growth

Growth of world population over the next 100 years, until the year 2100, will produce an estimated 11.5 billion people. The past focus on reducing rapid population growth exclusively through family planning has not been sufficient. Population policy needs to be broadened to include health care, education, and poverty reduction. The population policy recommendations of Population Council Vice-President John Bongaarts and Senior Associate Judith Bruce were to reduce unwanted pregnancies by expanding services that promote reproductive choice and better health, to reduce the demand for large families by creating favorable conditions for small families, and to invest in adolescents. The Population Council 1994 publication "Population Growth and Our Caring Capacity" outlined these issues. Another similar article by John Bongaarts appeared in the journal "Science" in 1994. In developing countries, excluding China, about 25% of all births are unwanted; 25 million abortions are performed for unwanted pregnancies. The provision of comprehensive family planning programs will go a long way toward achieving a reduction in unwanted pregnancies. In addition, changes are needed in male control over female sexuality and fertility and in cultural beliefs that are obstacles to use of contraception. Stabilization of population at 2 children per family will not occur unless there is a desire for small families. In most less developed countries, large family sizes are preferred. Governments have an opportunity to adopt policies that reduce economic and social risks of having small families. This can be accomplished through the widespread education of children, a reduction in infant and child mortality, improvement in the economic and social and legal status of women, and provision of equitable gender relations in marriage and child rearing. The rights of children to be wanted, planned, and adequately cared for need to be supported. These aforementioned measures will help to reduce fertility, provide support for small families, and justify investment in social development. Population momentum will keep population growing for some time even with replacement level fertility. Investment in adolescents through enhancement of self-esteem and promotion of later childbearing can lengthen the span between generations and slow population momentum. Population policies will be more effective when human rights are protected.     

Sex preference and fertility: what is the link?

It is argued that investment in programs for changing attitudes toward sex preference may not have the greatest impact on reducing fertility or increasing fertility control. Arnold's new method of analysis of determining sex preference was applied to data from a 1977 Egyptian survey of 36,000 rural households in Menoufia Governorate. Findings indicated that couples increased their use of modern contraceptives in direct proportion to an increase in the number of sons. Arnold determined that a large majority of all couples would have at least one boy early in their childbearing years. Thus sex preference would not have a large effect on fertility. Arnold's analysis among 27 countries found that without any sex preference, contraceptive usage would increase by an average of less than 3.7 percentage points. Arnold found that sex preference was strongest in Asia, particularly in South Korea and Taiwan that already have reduced fertility levels. In Africa, where fertility is high, the total elimination of sex preference would have only a 2.9 percentage point difference in contraceptive use. Sex preference had small effects on the percent of women who practice contraception, the percent who desire no more children, and the average number of additional children wanted. For example, in Bangladesh having no sex preference would show a percentage difference of 1.6 percentage points for contraceptive use, 4.7 percentage points difference for women desiring no more children, and -0.1 percentage point difference for the average number of additional children wanted. The effect of having no sex preference was strongest in India compared with Bangladesh, Indonesia, Nepal, the Philippines, Thailand, Ghana, Kenya, Costa Rica, Haiti, Paraguay, and Peru. The effect of no sex preference in India would have the respective percentage point effect of 3.7, 8.9, and -0.2. Public policy should be directed to information, education, and communication with other social goals.     

Kenya's record population growth: a dilemma of development

The causes and implications of Kenya's 4% rate of natural increase and fertility rate of 8.1 births per woman were examined. Attention was directed to the following: pronatalist pressures; inadvertent pronatalist impact of development; women's education and employment and fertility; population growth and pressures; mortality decline and population growth; fertility levels and differentials; fertility desires; the family planning program; and family planning knowledge, attitudes, and practice. Kenya's development success has worked to push up the population growth rate. Improved health care and nutrition halved infant mortality from 160 to 87 deaths/1000 live births between 1958 and 1977 and a marked increase in primary school enrollment may be factors in the birthrate increase to 53/1000 population. At this time fertility is highest among women with 1-4 years of education. The 1977-1978 Kenya Fertility Survey showed that only 5.8% of married women were using modern contraception, indicating that the national family planning program, established in 1967, has made little progress. Program difficulties have included shortages of staff, supplies and easily accessible clinic as well as an almost universal desire on the part of Kenyans for families of at least 7 children. Children are viewed as essential to survival and status to the rural population.     

Pakistan's population growth: the need for action

Despite the existence of a national family planning program that dates to 1965 Pakistan has not seen a reduction in the fertility rate. One of the poorest countries in the world, Pakistan has 1 of the highest population growth rates in the world at about 3.0% annually. For over 2 decades, the average woman in Pakistan has given birth to more than 6 children. At the current fertility rate, the country's current population of 120 million will increase to over 150 million by the year 2000, and it will increase to 280 million by 2020. And even if today every woman were to begin having only 2 children, the population would still reach 160 million before leveling off. But reducing fertility in Pakistan will prove difficult. One of the leading obstacles is the low status of women. Few women in Pakistan have advanced education or professional jobs. Only 1/4 of those women without education or who are not working have any knowledge concerning contraception. Family size and composition also fuel the high rate of fertility. On the average, women desire 5 children (the fact that women average more than 5 suggests an unmet need for contraception). And due to social, cultural, and economic conditions, Pakistanis generally prefer male offsprings. Islamic opposition to family planning has also contributed to the continued high rates of fertility. Finally, administrative and management weaknesses have hindered Pakistan's family planning program. In order to overcome these obstacles, Pakistan will have to enlist the commitment of political, religious, and community leaders. The status of women will have to be improved, and the attitudes of people will need to change.     

A components method for measuring the impact of a family planning program on birth rates

One of the major goals of family planning programs worldwide has been to reduce the level of fertility in hopes of slowing the rate of natural increase and promoting social and economic development. Such programs have now been in existence for sufficient lengths of time to have had an impact on fertility levels. In general countries with organized family planning programs, marked declines in fertility levels have been observed. The extent to which such declines may be credited to organized programs has not been rigorously measured because an appropriate research methodology has been lacking. This paper describes one method of directly linking declines in fertility levels to the contraceptive protection experienced by a population. The contribution of organized family planning programs is estimated by decomposing the amount of total contraceptive protection into within-program and outside-program sources.     

A couple analysis of micro-level supply/demand factors in fertility regulation

Demographic research in developing countries has traditionally neglected the role of male input into reproductive decision making. This has contributed significantly to the general inability to resolve the fertility problem in sub-Saharan Africa. The principal aim of this study is to apply a joint- or couple-model to the analysis of one such population problem in order to illustrate the potential avenues that emerge when the input of male spouses is considered. The 1988 Ghana Demographic and Health Survey is used to examine the need for supply- and demand-side policy in achieving fertility declines. The data indicate that, although there is some evidence of the benefit of family planning programs, it appears that there is much room for further success. Also, there is a strong indication that the demand side of the fertility equation must be addressed more, by tackling the issue of individual motivations, particularly of males, for childbearing.     

Effects of education on reproductive behavior: lessons from Pakistan

Evidence from the Pakistan Demographic and Health Survey 1990/91 (PDHS) and a 1987 study by Zeba A. Sathar and Karen Oppenheim on women's fertility in Karachi and the impact of educational status, corroborates the correlation between improved education for women and fertility decline. PDHS revealed that current fertility is 5.4 children/ever married woman by the end of the reproductive period. 12% currently use a contraceptive method compared to 49% in India, 40% in Bangladesh, and 62% in Sri Lanka. The social environment of high illiteracy, low educational attainment, poverty, high infant and child and maternal mortality, son preference, and low status of women leads to high fertility. Fertility rates vary by educational status; i.e., women with no formal education have 2 more children than women with at least some secondary education. Education also affects infant and child mortality and morbidity. Literacy is 31% for women and 43% for men. 30% of all males and 20% of all females have attended primary school. Although most women know at least 1 contraceptive method, it is the urban educated woman who is twice as likely to know a source of supply and 5 times more likely to be a user. The Karachi study found that lower fertility among better educated urban women is an unintended consequence of women's schooling and deliberate effort to limit the number of children they have. Education-related fertility differentials could not be explained by the length of time women are at risk of becoming pregnant (late marriage age). Fertility limitation may be motivated by the predominant involvement in the formal work force and higher income. The policy implications are the increasing female schooling is a good investment in lowering fertility; broader improvements also need to be made in economic opportunities for women, particularly in the formal sector. Other needs are for increasing availability and accessibility of contraceptive and family planning services and increasing availability and accessibility of contraceptive and family planning services and increasing knowledge of contraception. The investment will impact development and demography and is an adjunct to child health an survival.