Contraceptive practice required to meet a prescribed crude birth rate target: a proposed macro-model (tabrap) and hypothetical illustrations

TABRAP (TArget Birth Rate Acceptor Program) is a computer programmed model that provides a direct solution to the problem of determining the total annual numbers of contraceptive acceptors required to achieve a prescribed crude birth rate target path. Applied to an initial population for which age structure, the fertility schedule, and expected trends in life expectancy and age-specific proportions of females married are known, TABRAP incorporates the following factors: age at acceptance, with acceptors drawn from currently married nonusers; age-method-specific attrition rates of users; a potential fertility schedule of acceptors that allows for aging and sterility; and allowance both for postpartum anovulation and nine months for gestation to time properly the averted births. TABRAP generates annual data on acceptors, couple-years of use, births averted and age-specific fertility rates that meet the crude birth rate target. Resulting changes in population size, age structure and crude vital rates, also yielded, are invariant with respect to acceptor age and method mix. Assuming a target to reduce the crude birth rate from 45 to 30 in ten years, TABRAP is illustrated for seven mixes of acceptor age-method combinations applied to a population approximately that of Thailand, circa 1965.     

Assessment of family planning programme effects on births: Preliminary results obtained through direct matching of birth and programme acceptor records

Abstract In order to match birth and family planning acceptance records and thereby to obtain estimates of pre- and post-acceptance fertility, use is made of seven-digit national identity card numbers, issued to all adult West Malaysians. These unique numbers are recorded on live-birth records and national family planning programme acceptor records of West Malaysian women. The application and preliminary results of this method of direct computer matching of these sets of records for assessing the effects of a family planning programme on fertility are described. Pre- and post-acceptance fertility rates are presented in terms of contraceptive methods used, and the key characteristics of race and age of programme acceptors, and are discussed in terms of marital duration and number of children at the time of acceptance.     

Baby boomlet for older mothers?

In recent years, a number of celebrities have begun childbearing after age 35. The phenomena of older first-time mothers has received a great deal of attention in the popular press. Are these celebrities indicative of a national trend? Does the increase in fertility portend a reversal of the declines in fertility which have been occurring since the baby boom? The present paper uses central and cumulative birth rates for cohorts of American white women born between 1882 and 1953 to investigate childbearing between ages 35 and 50. While there has been a noticeable upsurge in first birth rates for cohorts in their mid to late 30s in recent years, overall central birth rates for women in their 30s are among the lowest on record, with cumulative birth rates at record low levels. A major reason for this is that these women are having relatively few third and higher order births. These cohorts will need to have a relatively high proportion of births in their older years of childbearing in order to reach replacement level. However, attaining replacement level is unlikely because such a high proportion of women have remained childless at ages 35–40 and a relatively low proportion are having three or more children.     

The increase in marital status differences in mortality up to the oldest age in seven European countries, 1990–99

We investigate mortality differentials by marital status among older age groups using a database of mortality rates by marital status at ages 40 and over for seven European countries with 1 billion person-years of exposure. The mortality advantage of married people, both men and women, continues to increase up to at least the age group 85–89, the oldest group we are able to consider. We find the largest absolute differences in mortality levels between marital status groups are at high ages, and that absolute differentials are: (i) greater for men than for women; (ii) similar in magnitude across countries; (iii) increase steadily with age; and (iv) are greatest at older age. We also find that the advantage enjoyed by married people increased over the 1990s in almost all cases. We note that results for groups such as older divorced women need to be interpreted with caution.     

The increase in marital status differences in mortality up to the oldest age in seven European countries, 1990-99

We investigate mortality differentials by marital status among older age groups using a database of mortality rates by marital status at ages 40 and over for seven European countries with 1 billion person-years of exposure. The mortality advantage of married people, both men and women, continues to increase up to at least the age group 85-89, the oldest group we are able to consider. We find the largest absolute differences in mortality levels between marital status groups are at high ages, and that absolute differentials are: (i) greater for men than for women; (ii) similar in magnitude across countries; (iii) increase steadily with age; and (iv) are greatest at older age. We also find that the advantage enjoyed by married people increased over the 1990s in almost all cases. We note that results for groups such as older divorced women need to be interpreted with caution.     

Changing vital rates and age distributions

Abstract In a time of rapid change in birth and death rates demographers need to know the consequences of such changes for age distribution. Does the fall in death rates tend to make the age distribution older? It certainly enables individuals to grow older, but for population aggregates the effect depends on the ages at which mortality improves. Coale, Stolnitz, Schwarz, Lorimer, the United Nations and other writers have investigated trends in age-specific birth and death rates. In particular they have demonstrated that the falling mortality which is now nearly universal does not generally make the population older and sometimes makes it younger. The present article contributes a technique for further examination of this phenomenon.     

Negative population growth: how to go about it? (Letter to the editor)

It proves an interesting exercise to try to determine the effects of a national policy of government control developed on the basis of the need to conserve scarce resources, lessen environmental pollution, and to reduce the U.S. population to 1/2 of the 1970 figures within 100 years without increasing the risks of death. Let it additionally be assumed that in order to minimize the required reduction of fertility that there be no net migration. At the end of the reduction process, the stationary state in stable equilibrium might hopefully be achieved. If these are the goals, the process would include 1) reduction of the annual stream of births immediately to the number that would ultimately be required to sustain a population 1/2 as large as the present number and 2) smooth decline of the totals but with constituent age groups shifting drastically as the sharply reduced stream of births spreads upward through the span of life, with those 65 years and older making up 12% of the population. To obtain a fixed annual stream of births from sharply changing numbers of women of childbearing age would require rapid and drastic changes in the rates of childbearing. The same reduced population could be obtained from a system involving less drastic changes in the age composition, but these means would not be positive ones for older individuals. Both fertility and age distribution could move more smoothly if the mortality risks increased or with considerable emigration of the aged. Other means of reducing the population to 1/2 the present size within 100 years would create even more turbulence in the age distribution and rates of childbearing than those just discussed.     

Estimating the Effect of Smoking on Slowdowns in Mortality Declines in Developed Countries

Declines in mortality rates for females at older ages in some developed countries, including the United States, have slowed in recent decades even as decreases have steadily continued in some other countries. This study presents a modified version of the indirect Peto-Lopez method, which uses lung cancer mortality rates as a proxy for smoking exposure, to analyze this trend. The modified method estimates smoking-attributable mortality for more-specific age groups than does the Peto-Lopez method. An adjustment factor is also introduced to account for low mortality in the indirect method’s study population. These modifications are shown to be useful specifically in the estimation of deaths attributable to smoking for females at older ages, and in the estimation of smoking-attributable mortality more generally. In a comparison made between the United States and France with the modified method, smoking is found to be responsible for approximately one-half the difference in life expectancy for females at age 65.     

Is Low Fertility a Temporary Phenomenon in the European Union?

This article addresses two questions: (i) will the mere end of further postponement of fertility in the EU-countries lead to an appreciable rise in European fertility and bring total fertility rates closer to replacement level, as witnessed in the United States? and (ii) what are the chances that such a stop to postponement is imminent? The answer to the first question is positive, but only if there is enough recuperation of fertility at older ages. Translated in the Bongaarts–Feeney framework, this condition means that the birth-order-specific TFRs would indeed remain constant. In the absence of full recuperation at older ages, the induced rise in the national TFRs would be trivial and by no means restore period and cohort TFRs to replacement levels. Hence, caution is needed when using the Bongaarts–Feeney adjusted TFRs for pro-jective purposes. With respect to the second question, female education and employment trends in tandem with ideational and family disruption data are used to speculate about the prospects for such an end to further fertility postponement and for fertility increases at older ages. Strikingly, EU-countries that have the greatest potential for still later fertility are also the ones with very low TFRs (below 1.5) at present. The overall conclusion is that low to very low fertility in the EU is unlikely to be a temporary phenomenon     

Quality of care and family planning drop-outs in Bukidnon province: a survey study

A study was undertaken in the province of Bukidnon in the Philippines to determine the actual percentage of family planning (FP) acceptors who become dropouts, the reasons they drop out, and the factors most strongly associated with this phenomenon. Data were collected through interviews with married women of reproductive age who had been recorded as being a FP acceptor during 1992. The sample size was set at 400 using a probability-proportionate-to-size sampling technique. In examining the extent of the drop-out problem, it was found that the actual FP status of each respondent agreed with the clinic records in 73.4% of cases and that 22% of those thought to be dropouts had actually switched methods. Most of the women who stopped using oral contraceptives said they did so because of side effects. The drop-out problem was most acute among women who were poorer, less educated, and of higher parity. The attitude of a husband towards use of a method was a better predictor of continuation than the wife's attitude. Clients who felt their provider was approachable and friendly were significantly less likely to drop out. Despite the fact that the FP program is modeled on a "cafeteria" approach which provides choices to acceptors, 9.5% of acceptors in this survey claimed they were not offered a choice. Women who received limited information were more likely to become drop-outs. Clients who had to return to clinics frequently for resupply of OCs or condoms were most likely to become drop-outs. While the number of dropouts identified in this study was only half the official estimate for the province, the short time between FP acceptance and the survey may have reduced the number of dropouts. The program implications of these findings are that 1) the occurrence of side effects needs study, 2) groups characterized by high drop-out rates should receive immediate attention, 3) favorable attitudes should be fostered in husbands, 4) women must receive more information on their options, 5) quality of care must be improved, 6) the use of the IUD should be promoted, and 7) resupply procedures should be revised to reduce trips to the clinic.     

Age reporting among white Americans aged 85+: Results of a record linkage study

This study investigates age reporting on the death certificates of older white Americans. We link a sample of death certificates for native-born whites aged 85+ in 1985 to Social Security Administration records and to records of the U.S. censuses of 1900, 1910, and 1920. When ages in these sources are compared, inconsistencies are found to be minimal, even beyond age 95. Results show little distortion and no systematic biases in the reported age distribution of deaths. To explore the effect of age misreporting on old-age mortality, we estimate "corrected" age-specific death rates by the extinct-generation method for the U.S. white cohort born in 1885. With few exceptions, corrected and uncorrected rates in single years differ by less than 3% and are not systematically biased. When we compare corrected rates with those for the same birth cohort in France, Japan, and Sweden, we find that white American mortality at older ages is exceptionally low.     

US mortality in an international context: age variations

Compared to other developed countries, the United States ranks poorly in terms of life expectancy at age 50. We seek to shed light on the US's low life expectancy ranking by comparing the age-specific death rates of 18 developed countries at older ages. A striking pattern emerges: between ages 40 and 75, US all-cause mortality rates are among the poorest in the set of comparison countries. The US position improves dramatically after age 75 for both males and females. We consider four possible explanations of the age patterns revealed by this analysis: (1) access to health insurance; (2) international differences in patterns of smoking; (3) age patterns of health care system performance; and (4) selection processes. We find that health insurance and smoking are not plausible sources of this age pattern. While we cannot rule out selection, we present suggestive evidence that an unusually vigorous deployment of life-saving technologies by the US health care system at very old ages is contributing to the age-pattern of US mortality rankings. Differences in obesity distributions are likely to be making a moderate contribution to the pattern but uncertainty about the risks associated with obesity prevents a precise assessment.     

Sex role effects on female response to illness

This study of sex differentials in health behavior and health service choice among the Korean rural population is based on 1421 individuals aged 14 and over who received medical care at hospitals or clinics, pharmacies, a government health center, or through Chinese medical practices. Logistic regression is used to explore the relationship between the dichotomous variable, the log of the odds of the probability of using formal health care services, and the independent variables (sex, age, education, marital status, perceived health status, perceived medical care need, illness days in bed, limited activity days, total sick days, date of illness). A profile of rural Korea shows for all ages fewer adult females than males, but more females 65 years who have been previously married, which suggests higher male mortality rates in the middle ages. Health service usage is higher among the elderly. Higher level of education is associated with greater use of formal medical service. The results of binomial and multinomial analysis indicate that women receive less medical care from the formal system in spite of complaints and restricted activity, and least of all from health centers. It is suggested that personnel at health centers may reduce the desire for care because of incompatible social backgrounds (young single males who are inexperienced, city bred, and completing required service). A woman must carefully choose from the formal system and may more easily use the informal system of pharmacies and Chinese medicine practice. The responses to self rated health showed many differences; males report better health than females and older people consider themselves more unhealthy than young or adult groups. Those with lower educational attainment also consider themselves unhealthy, and indicate greater need for health services. Females and older age groups also stated their need for professional medical care for an illness within 15 days prior to the survey. The mean number of bed days followed a similar pattern as the perceived need and self rated health. However, women had a lower volume of bed days than men in contrast to typical Western trends. Females reported more restricted days of activity. The old age group had the same restricted days but more bed days than the adult group. Reported chronic diseases were greater for lower socioeconomic groups.     

A study on the demographic impact of an IUD programme

Abstract This paper discusses and presents data obtained through various studies and surveys on the effect of the IUD contraceptive programme in Taiwan. It has been demonstrated that the fertility of IUD acceptors before first acceptance was 58 % higher than that of married women in general and that, after acceptance, it declined by about 76%. The corresponding fertility decline among married women in general was only about %. Acceptors had had more recent births, as indicated by their shorter 'open interval' of 20.7 months, compared with 374 months among the women in the KAP survey sample. If the fertility of IUD acceptors had declined at the same rate as that of married women in general in the absence of IUD, the insertion of about 4 IUDs would probably prevent one live birth in the following year. Observation over a longer period, however, is needed to determine the demographic effect of IUD. Data on fertility control practice after termination, type of termination of pregnancies after first acceptance, life-table rates by various socio-demographic characteristics of acceptors, and the 'life expectancy' of the first segment of IUD are also presented.     

Trends in Late-Life Activity Limitations in the United States: An Update From Five National Surveys

This article updates trends from five national U.S. surveys to determine whether the prevalence of activity limitations among the older population continued to decline in the first decade of the twenty-first century. Findings across studies suggest that personal care and domestic activity limitations may have continued to decline for those ages 85 and older from 2000 to 2008, but generally were flat since 2000 for those ages 65–84. Modest increases were observed for the 55- to 64-year-old group approaching late life, although prevalence remained low for this age group. Inclusion of the institutional population is important for assessing trends among those ages 85 and older in particular.     

Measuring acceptances in a family planning program: the decomposition of rates by eligibility criteria

Acceptance rates in family planning programs can be broken into components useful in analyzing programs and in evaluating success. In almost any program some couples can be defined as "ineligible" on the basis of alternative criteria. (Sterilized couples are an obvious example.) Then, the total acceptance rate can be initially separated into two components-the proportion eligible and the acceptance rate among the eligible. If some of those initially defined as ineligible become acceptors, there is a third component-the ratio of all acceptances to acceptances among the eligible only. These various components can be used to analyze the basis for varying acceptance rates between different strata of a population.     

Diverging Trends in Female Old‐Age Mortality: The United States and the Netherlands versus France and Japan

In the most advanced countries, child mortality and adult mortality under age 65 years have fallen so low that further improvement in life expectancy relies almost completely on the decline of mortality at older ages. This phenomenon is particularly pronounced among women, who are far ahead of men in survival rates. Thus, to project the future of life expectancy, this study focuses on trends in female life expectancy at ages 65 and older. Four countries are selected for this analysis: the United States, Netherlands, France, and Japan. It is particularly interesting to understand why American and Dutch trends in female old‐age mortality have been diverging from those in France and Japan for two decades. It is shown here that most of the divergence derives from the fact that decline in cardiovascular mortality is more and more offset by increases in other causes of death in the United States and the Netherlands, while the other two countries are more successful in reducing mortality from all causes at increasingly older ages. This latter phenomenon could represent a new stage of the health transition.     

The Old Old — or the New Old?

This paper gives an account of the demographic trends that are bringing about changes in the population aged 80 years and older in Australia. The old old population of the future will differ in size and structure from earlier cohorts reaching advanced age: an examination is made of the contribution of the effects of past birth rates; recent changes in mortality at older ages; the impact of immigration especially on the cultural diversity of the old old; and changes in sex ratios and marriage patterns that result in changes in social circumstances. The indications are that a much more dynamic view of the old old is required. The present report is the first in a three-part study which mill cover social and health trends and discuss the implications of the newly emergent old old population for social policy.     

Perceived factors of family planning clinic performance and service quality

As part of a larger operations research project, this 1990 study analyzed the performance of the Philippine Department of Health's (DOH) family planning (FP) clinics. Specific study objectives were 1) to measure acceptor targets, servicing capacity utilization, outreach, and costs; 2) to determine what providers believed affected performance; 3) to record which quality indicator providers use; and 4) to determine the perceptions of acceptors about clinic personnel, the clinic as a FP outlet, FP service processing, and FP service quality. Data were gathered from clinic records and from sample surveys in 25 clinics in four specified locations. Eight clients were sampled from each of the 100 clinics. It was found that clinic staff accepted low attainment of FP acceptor targets and that clinic capacity utilization levels were at 25% of capacity. Providers were unaware of the number of potential FP acceptors in their areas and had no information about the costs of running their clinics. The FP clinic managers identified 34 major determinants of clinic performance, but more than half reported that they had very little control over these determinants. The providers described quality service from the point of view of the acceptors and described the quality of a clinic in terms of the minimal physical characteristics required. The acceptor survey revealed that acceptor satisfaction depends upon 1) clinic accessibility and lay-out, 2) intensive personal contact, and 3) clinic infrastructure. The study uncovered a need for the DOH to institute management training programs for clinic managers and to provide managers with the resources and personnel to shift priorities in favor of FP coverage and prevalence. Managers, who are resource allocators, must also receive information about the costs of FP services in their clinics. In addition, the DOH's determination that its FP program would be facility- rather than community-based should be modified to incorporate community outreach elements. The DOH can also make a big impact on perceptions of quality (of both providers and acceptors) by improving clinic conditions to meet basic standards. Once these basic needs are met, additional needs of acceptors can and must be addressed.