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.     

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.     

Husbands’ versus wives’ fertility goals and use of contraception: The influence of gender context in five Asian countries

Using data from Pakistan, India, Malaysia, Thailand, and the Philippines, we explore how gender context influences (1) husband-wife concordance in the demand for children and (2) the impact of each spouse's fertility preferences on contraceptive use. We also explore whether the husband's pronatalism can explain the wife's unmet need for contraception. The results suggest that gender context has little net effect on couples' concordance, but influences the relative weight of husbands' and wives' preferences in determining contraceptive use. Analysis of women's unmet need for contraception suggests that the husbands' pronatalism contributes to wives' unmet need, but only to a relatively small degree, especially in settings where unmet need is high. This is the case because the proportion of couples with differing fertility goals is small in most communities.     

Barriers to contraceptive use among Pakistani couples

Despite the existence of a family planning program in Pakistan since 1965 and widespread knowledge among Pakistanis about contraception, there is a high level of unmet need for family planning. One recent survey found that while 53% of married women express the desire to avoid pregnancy, less than 20% use contraception. A recent Population Council study conducted in urban and rural areas of Punjab province investigated personal beliefs, family circumstances, social norms, and gender relations among 1310 married women and 554 of their husbands. The unmet need for contraception was highest among women over age 30 years, those with more living children, less educated women, and women living in rural areas. The study found that while most Pakistanis approve of family planning, obstacles to contraceptive use exist in most marriages. 97% of respondents who wanted another child wished for a boy. That preference for sons influences contraceptive use behavior. The fear of social disapproval of contraceptive use, perceived opposition from in-laws and husbands, and fear of health side effects and divine punishment were major reasons identified against contraceptive use. Female contraceptive users were more autonomous and likely to make domestic decisions without consulting their husbands, while husbands defer to social and cultural norms.     

Why women who don't want to get pregnant don't use contraception

In the developing world about 120 million women have an unmet need for contraception. They want to postpone childbearing, yet they do not use contraception, often because of the unavailability of services and supplies. However, according to a recent article by John Bongaarts, the primary factors are lack of knowledge about a contraceptive method, concern about side effects, and the disapproval of the male partner in developing countries. Lack of knowledge means inability to describe the uses of a contraceptive, its side effects, and the locale of its availability. An approximate knowledge index was calculated for such women, which showed that knowledge level positively correlated with contraceptive prevalence. Countries where the index was below 50% had a contraceptive prevalence of 8% only. The determinant reasons why women were reluctant to use the pill, IUD, and sterilization had to do with health and the fear of side effects, such as nausea and increased bleeding. The contraceptive prevalence among these women was reduced by 71% for the pill, 86% for the IUD, and 52% for sterilization. In Sub-Saharan countries nearly 70% of women cited partner disapproval of contraception, although they had never discussed family planning with their partners. The central concept for reducing unmet need is access with quality, which means that services are voluntary, safe, and appropriate in delivery. Some of the recommendations to reduce the unmet need for contraception include: one-on-one same-sex discussions to increase contraceptive knowledge and acceptability; sensitive responses by programs to their client's health concerns; support by service providers to women negotiating with male partners in order to mitigate male disapproval; and sex education and family planning services to reduce unwanted and early sexual contact and pregnancy while girls develop identities apart from mothering roles.     

Determinants of fertility and the unmet need for family planning in Indonesia

Indonesia's fertility has declined to an average of slightly more than 3 children/woman. The islands of Java and Bali have the lowest birth rates. Indonesia's family planning program has been a model of innovation, flexibility, and community involvement, and has been effective in reducing fertility, changing family preferences, and increasing contraceptive use. Fertility decline is also determined by factors other than contraceptive use, as provinces in Jakarta and East Java has low fertility and low contraceptive use. Recent research by Suyono and Palmore found that among cohorts of women in Jakarta lowest fertility rates were explained by greater nonexposure to pregnancy in an unmarried state or by a divorced or widowed status, and by infecundity. In East Java, fertility determinants were the same with the possible addition of lower coital frequency. The study estimated nonexposure due to marriage, infecundity, and contraceptive use. Policy considerations, however, are concerned with the exposed state of the percentage of time women are currently married, fecund, not using contraceptive, and sexually active. Suyono and Palmore also calculated the percentage of time spent in the exposed state by province. The estimates ranged from 12% in Yogyakarta to 25% in West Java and the Outer Islands. Exposed was further divided into groups with a manifest, latent, and no current need. Women with a manifest need for family planning are those who are aware of their contraceptive needs to stop or postpone childbearing and not using. Manifest need was highest in high fertility areas: 12% in Central Java, 13% in West Java, and 12% in the Outer Islands. Programs targeting these women should focus on wider availability of information and services. Women with latent needs are unaware of their need for family planning and are not using contraception. These women were also concentrated in high fertility areas. The percentage of years spent in the latent unmet need state was estimated at 23-24% in West Java and the Outer Islands. Program emphasis should be on education and motivation to show how family size can be controlled. Women with current need can be educated toward future acceptance.     

Unmet need for couples: An analytical framework and evaluation with DHS data

While estimates of unmet need continue to be an important measure of the extent of demand for contraception and family planning programs success in developing countries, there are various reservations about the validity of these estimates. For instance, the traditional formulation of the measurement has relied solely on information from women while inferences from the findings are often drawn for couples. As more survey data have become available for both men and women in a number of countries, there is increasing evidence suggesting that husbands' preferences are indeed important determinants of the reproductive behavior of couples. This paper developsan analytical framework for measuring unmet need for couples. The approach: (1) takes a fresh look at the classification of pregnant and amenorrheic women, and (2) incorporates the contraceptive use and fertility preferences of husband and wife in estimating the level of unmet need in six sub-Saharan African countries. Our findings shows that taking these factors into account results in a 50 to 66 percent reduction in the level of unmet need in these countries. The importance of husbands' variables in determining the level of unmet need is clearly evident when examined among fecund couples in which the wife is neither pregnant nor amenorrheic. The implications of these findings for family planning programs and research are discussed.     

Family planning in choiseul province,Solomon Islands

The results presented are from a rural prevalence survey on family planning in Choiseul Province, Solomon Islands. Married women aged 15–49 years with at least one living child and married men whose wife met the same criteria, provided data on knowledge, attitudes and practices of contraceptive use. Fifty one per cent of the female sample were using some form of contraception, 26 per cent reversible and 25 per cent non-reversible methods. Sixty-five per cent of men claimed that they or their spouse were using a method of family planning. Tubal ligation was the most common currently used method (25 per cent in the female survey). Desired family size was four for both males and females. Knowledge and approval of family planning was high, with 83 per cent of females and 81 per cent of males knowing of at least one method. Problems in accessing information and services for family planning include cultural and logistical constraints. Religious affiliation was the major variable affecting knowledge, use and approval of contraceptive methods. Nearly a quarter of the sample lived further than two hours travel time from the nearest health clinic supplying contraceptive methods. These clinics often have only an intermittent availability of supplies. A strong interest in family planning was demonstrated by both respondents and service providers.     

Unmet Need for Family Planning in Developing Countries and Implications for Population Policy

Unmet need for family planning has been a core concept in international population discourse for several decades. This article reviews the history of unmet need and the development of increasingly refined methods of its empirical measurement and delineates the main questions that have been raised about unmet need during the past decade, some of which concern the validity of the concept and others its role in policy debates. The discussion draws heavily on empirical research conducted during the 1990s, much of it localized, in‐depth studies combining quantitative and qualitative methodologies. Of the causes of unmet need other than those related to access to services, three emerge as especially salient: lack of necessary knowledge about contraceptive methods, social opposition to their use, and health concerns about possible side effects. The article argues that the concept of unmet need for family planning, by joining together contraceptive behavior and fertility preferences, encourages an integration of family planning programs and broader development approaches to population policy. By focusing on the fulfillment of individual aspirations, unmet need remains a defensible rationale for the formulation of population policy and a sensible guide to the design of family planning programs.     

The impact of mass media family planning promotion on contraceptive behavior of women in Ghana

This paper examines the influence of media messages about family planning, and attitudes toward media promotion of family planning, on contraceptive behavior of married women in Ghana. It also examines the problem of reverse causation that arises in studies of this nature when the data used provide no information on the temporal order of the actual time that respondents were exposed to family planning information in the mass media and the time of adoption of contraceptive behavior. The results show that exposure to media messages on contraception exerts strong impact on current practice of, and intention to use, contraception. Women who had heard or seen advert on contraceptive brands, and women who favor broadcast of family planning messages in the media, are significantly more likely to adopt birth control behavior than women who had not heard or seen, and women who do not favor broadcast of such media messages, respectively. Regarding the problem of reverse causation, the study demonstrates that while being exposed to media messages significantly affects a woman's contraceptive behavior, the reverse does not seem to be the case. The policy implications of these results and how mass media could be used to promote family planning in Ghana are discussed.     

We must complete the population control system to control the population peak and achieve our population goal]

Since 1986, China has experienced another baby boom which is expected to last till 1997. If no effective measure is implemented to check population growth, the population target of around 1.2 billion will not be achieved. The author proposed four population regulation mechanisms that need to be strengthened. First, ideological education needs to be used to change people's perceptions about family size, so that couples would willingly accept small families. Second, financial incentives and penalties need to be used to direct people to regulate their fertility. The incentive and penalty technique directly affect the interests of the family and is likely to produce rapid results. Third, legislation can be used to regulate reproductive behavior, the laws and legislation which restrict social behavior should be utilized for population control purposes. Once legislation on fertility regulation is passed, those who violate the law can be penalized. Furthermore, legislation gives family planning (FP) workers legitimacy in implementing the program and can help avoid disputes in the process of FP program implementation. Fourth, provision of contraception and abortion services is an important mechanism to ensure the realization of the objectives of population growth control. Meanwhile, the effectiveness of contraceptive methods and the acceptance of abortion depends on the research and development of contraceptive technology and on abortion techniques. These fertility regulatory mechanisms have not be adequately established, and their functions have not been fully utilized. The current FP program is hampered by simplistic ideological education, abusive use of incentives and penalties, lack of legislation, and unmet needs in contraceptive development. To achieve the population targets, these mechanisms need to be strengthened.     

The fallacy of the five million women: A re-estimate

Explicit policy to control fertility in the United States to date has focussed on the “unmet need” for contraceptive services in 1966 among an estimated five million poor and near-poor women. This paper reestimates the number of women in need of contraceptive services by disaggregating (on the basis of tabulations from the Current Population Surveys for 1966 and 1967, and the 1965 National Fertility Study) all poor and near-poor women into 54 subgroups differentiated by age, marital status, religion, and color. Data from the 1965 National Fertility Study, and from other studies, are then used to estimate for each subgroup deductions for sterility, pregnancy, waiting time for conception, and negative attitudes toward and current use of contraception. The residual number of women who both want and require contraceptive services, but do not have them, is estimated to be 1.2 million, rather than 4.6 million. The fact that the re-estimate takes into account both existing contraceptive practice and negative attitudes toward family limitation accounts for much of the difference between it and the original figure.     

How Do Education and Family Planning Accelerate Fertility Decline?

Education and family planning can both be influenced by policy and are thought to accelerate fertility decline. However, questions remain about the nature of these effects. Does the effect of education operate through increasing educational attainment of women or educational enrollment of children? At which educational level is the effect strongest? Does the effect of family planning operate through increasing contraceptive prevalence or reducing unmet need? Is education or family planning more important? We assessed the quantitative impact of education and family planning in high-fertility settings using a regression framework inspired by Granger causality. We found that women's attainment of lower secondary education is key to accelerating fertility decline and found an accelerating effect of contraceptive prevalence for modern methods. We found the impact of contraceptive prevalence to be substantially larger than that of education. These accelerating effects hold in sub-Saharan Africa, but with smaller effect sizes there than elsewhere.     

Secrecy and silence: why women hide contraceptive use

A recent Population Council survey of 1860 married women and 1056 of their husbands in urban Zambia found that many women who use contraception do so without their husbands' knowledge and that those women who hid their practice of contraception from their husbands did so because they found it very difficult to bring up the subject of family planning with them. These findings indicate that low levels of contraceptive use are not the result of a simple communication matter. Sex and sexuality are often the exclusive domain of African husbands. As such, if a wife initiates a discussion of family planning, she may threaten her husband's sense of control and create discord within the family. The culture of silence about sex and sexuality is very strong in Africa. 57% of women stated that were they to propose contraceptive use with their husbands and the husband opposed such practice, they would nonetheless use them without his knowledge. 7% of the women stated that if their husbands disapproved of contraceptive use, they would nonetheless openly use a method against his wishes. The majority of women correctly perceived their husbands' views on family planning use and fertility preferences. In focus groups, both men and women said that they did not believe that women have the right to independently act upon their reproductive preferences. A husband's inadequate financial support of his children could, however, justify clandestine contraceptive use. These findings point to the need to include easily hidden methods in the mix of contraceptives family planning programs offer. Moreover, service providers should not automatically encourage husbands' involvement. A client's right to privacy should always be respected.     

Dynamics of contraceptive use and breastfeeding during the post-partum period in Peru and Indonesia

This paper examines the interaction between contraceptive use and breastfeeding in relation to resumption of intercourse and duration of amenorrhea post-partum. We used data from the month-by-month calendar of reproductive events from Demographic and Health Surveys (DHS) in Peru and Indonesia. The analyses show that breastfeeding women were less likely than non-breastfeeding women to have resumed sexual intercourse in the early months post-partum in both countries. In Peru, but not in Indonesia, breastfeeding women had a significantly lower odds than non-breastfeeding women of adopting contraception. Although the likelihood of contraceptive adoption was highest in the month women resumed menstruation in both countries, about ten per cent of subsequent pregnancies occurred to women before they resumed menses. These results emphasize the importance of integrating breastfeeding counselling and family planning services in programmes serving post-partum women, as a means of enabling those who wish to space their next birth to avoid exposure to the risk of a pregnancy that may precede the return of menses.     

Increasing contraceptive use in Bangladesh: The role of demand and supply factors

This article analyzes the determinants of contraceptive use in Bangladesh, focusing on the roles of demand for additional children and of family planning service supply. Data from the Matlab Family Planning Health Services Project are used to examine the contributions of these factors to the difference in prevalence of modern contraceptive use between the project area and a control area served by the government family planning and health programs. Results of multivariate analysis deriving from the Easterlin synthesis framework show the importance of family planning supply factors in reducing psychic and resource costs of fertility regulation and in activating latent demand for contraception. Demand for birth limiting and for birth spacing emerge as important explanatory factors; demand for birth spacing is greater in the project area, and both demand measures exert a stronger effect on contraceptive behavior in that area.     

The evolution of family planning in an African city: Ibadan, Nigeria

Summary Data drawn from a 1973 probability sample of 6,606 Yoruba females, 15-59 years of age in Ibadan City, Nigeria, are employed to analyse changing family planning practice over time. Usage and method rates are calculated for broad age groups from 1930 to 1973. Contraceptive practice is shown to have increased rapidly during the 1960s and early 1970s, from a very low initial base with a doubling period for the proportion of contraceptors of about four years, so that by 1973 one-sixth of the women had practised contraception and one-ninth were currently doing so. The major determinant of contraceptive practice is education. Oral contraceptives and IUDs account for an ever larger proportion of all contraception over time and together made up over 50 per cent by 1973. The Ibadan data give strong support to a suggestion emanating from scattered findings elsewhere that there is a special pattern of sub-Saharan contraceptive use: it begins with use in pre-marital and extra-marital relationships; then is increasingly employed as a substitute for post-marital sexual abstinence, and only later becomes the means for limiting the size of the family. Hence, the success of a family planning programme is indicated by rising average parity among the acceptors. Most couples in Ibadan will probably be practising contraception at some time in the 1980s, but even then such rates will probably still be low in rural areas.     

Decision-Making Patterns and Contraceptive Use: Evidence from Uganda

Literature on the effect of decision-making patterns on contraceptive use often does not (1) distinguish between women participating in decisions and controlling them, and (2) account for effects of common decision-making patterns within the community. In Uganda where high fertility persists, both of these factors may be relevant to adoption of contraception. We used data from the 1995/96 Negotiating Reproductive Outcomes (NRO) Study which surveyed 1,750 women in 78 communities located in two districts in Uganda. We assessed the effects of individual and community factors on the adoption of modern contraceptive methods using multilevel logistic regression. We included measures of decision-making patterns at both the individual and community levels that distinguished husband-dominated, joint, and wife-dominated decision-making patterns. Contraceptive use is 29% more likely in communities where women more commonly have unilateral control over household decisions. This strong effect of normative decision-making patterns within the community is net of individual education and community education, both of which had strong and significant effects. Less traditional gender roles as measured by normative decision-making patterns seem to support more innovative fertility behavior. Community decision-making patterns matter importantly for contraceptive use in this low contraceptive prevalence setting and need to be assessed elsewhere. Further, women’s influence is inadequately measured where joint decision-making and wife-dominated decision-making are considered together.     

Gender inequalities and demographic behavior

A summary was provided of the central findings about gender inequalities in Egypt, India, Ghana, and Kenya published by the Population Council in 1994. These countries exhibited gender inequalities in different ways: the legal, economic, and educational systems; family planning and reproductive health services; and the health care system. All countries had in common a high incidence of widowhood. Widowhood was linked with high levels of insecurity, which were linked with high fertility. Children thus became insurance in old age. In Ghana, women's insecurity was threatened through high levels of marital instability and polygyny. In Egypt, insecurity was translated into economic vulnerability because of legal discrimination against women when family systems were disrupted. In India and all four countries, insecurity was reflective of limited access to education, an impediment to economic autonomy. In all four countries, women's status was inferior due to limited control over reproductive decision making about childbearing limits and contraception. In India, the cultural devaluation of girls contributed to higher fertility to satisfy the desire for sons. In India and Egypt, family planning programs were dominated by male-run organizations that were more concerned about demographic objectives than reproductive health. The universal inequality was the burden women carry for contraception. Family planning programs have ignored the local realities of reproductive behavior, family structures, and gender relations. The assumption that husbands and wives have similar fertility goals or that fathers fully share the costs of children is mistaken in countries such as Ghana. Consequently, fertility has declined less than 13% in Ghana, but fertility has declined by over 30% in Kenya. Family planning programs must be aware of gender issues.     

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.