Reproductive Revolution – Update

A decade has passed since the UN Population Conference in Cairo which set targets in family planning for achievement in the next twenty years, in the context of improving women’s rights in general. It is also a decade since an article on the ‘reproductive revolution’ in developing countries was published in the Newsletter (Issue 13, 1994), based primarily on material from the Population Information Programme of the Johns Hopkins University. This Programme material has now been updated and provides examples of changes since the Cairo conference. They are derived mainly from similar surveys to those quoted in the previous report and with an accompanying bibliography.

There has been a continuing but variable decline in fertility in developing countries. In the majority with more than one survey there was a fall in total fertility rate (TFR) but at a slower pace than in the 1970s and 1980s. TFR ranged from 2.3 children per woman in Vietnam to 7.2 in Niger, with an unweighted average of 4.5. It continues to be highest in Sub-Saharan Africa and lowest in Asia, Latin America and the Caribbean, with the Near East and North Africa between. The recent report has some additional information for Eastern Europe and the Central Asia countries formerly part of the USSR, which shows fertility levels (average 2.1) almost as low as those in Western Europe and North America. Fertility varies between countries in the main regions, depending on the availability and use of effective methods of contraception (the most important factor), on the status of women, their levels of education, age at first marriage and post-partum infecundity, plus a range of cultural, political and socio-economic factors.

Fertility declined in almost all countries surveyed; Mali, Niger and Turkey with slight increases were exceptions. India experienced the largest decline, from a TFR of over 4.0 to 3.0. Fertility ranged from 2.6 (Turkey) to 6.5 (Yemen) in the Near East and North Africa; from 2.3 (Vietnam) to 4.9 (Pakistan) in Asia; from 2.5 (Brazil) to 5.0 (Guatemala) in Latin America. In Egypt, Bangladesh and Indonesia there was a slowing in decline. Though by continent fertility remains highest in Sub-Saharan Africa, there was some decline in 9 of 16 African countries with surveys, with the most marked decline in Cameroon where it fell from 6.0 to under 5.0. In African rural areas TFR averages above 5.2, except in Central Africa Republic, Kenya, Zimbabwe and South Africa. It is below that figure for urban areas with the exception of Chad, Mali and Niger. This rural-urban difference is found in other continents, resulting from greater interest in and access to family planning, better education, higher living standards and children having less importance in their contribution to family income. In all African countries infant mortality remains high, economic development is poor and relies to a large extent on subsistence agriculture, and in some countries political upheaval, particularly internal ethnic conflict, has interfered with family planning programmes. Through major ethnic conflict in the mid-1990s contraceptive use nearly halved in Rwanda. Notwithstanding these negative factors the UN projects that the average TFR in Sub-Saharan Africa will fall to below 2.5 during the first half of the present century.

Fertility levels are related closely to contraceptive use and this has increased since 1990 from 41 to 50% for married women of reproductive age in developing countries, involving about 500 million women. The improved figure is markedly influenced by advances that have been made in China and India with their large populations and more advanced family planning programmes, but details on the former are not available in the Johns Hopkins report. Without these two countries the level of contraceptive use would fall to 35% since for millions of married women of reproductive age there is no contraceptive provision. There are wide differences between continents, from 15% in sub-Saharan Africa to 68% in Latin America and the Caribbean. Similarly there are differences within continents; in Sub-Saharan Africa the range is from over 30% in Kenya, Zimbabwe and South Africa to less than 10% in Mauritania, Guinea, Mali, Niger, Nigeria, Chad, Eritrea and Mozambique; in Asia it ranges from 75% in Vietnam to 13% in Yemen; in Latin America it is over 75% in Brazil, Colombia, Costa Rica but only 28% in Haiti. In Eastern Europe and in the former Soviet countries in Central Asia included in the recent report contraceptive use is more than 50% with the exception of Georgia (41%).

In developing countries with survey data, contraceptive use by unmarried women (aged 15 to 49 years) who are sexually active is higher by 5% than among married women. On average in sub-Saharan Africa it is twice as high, and in Latin America the levels are equal to or higher than those for married women. Data are not available for Asia, the Near East and North Africa.

There are the well known links between levels of contraceptive use and education. They are higher for better educated women in all developing countries surveyed since 1990. In all Sub-Saharan African countries the differences between more and less educated women are greatest, but in countries like Bangladesh, Colombia, Jamaica where contraceptive use has spread widely the differences between the better and less well educated are relatively small. In most countries the intention to use contraception is rising and is greater among women with more children. Women give their wish to have more children as the main reason for not using contraception, though for some there are religious reasons and there may also be concern for side effects from contraceptive use. Few of the women who are not practising contraception report a lack of knowledge of family planning.

Child survival and health are significant factors in reproductive decisions and in planning the control of these. Though on average 11 million children under five died annually in the 1990s this was a great improvement on a figure of 20 million four decades previously, with just under half of countries reaching goals set for infant and child mortality. Sub-Saharan Africa was the major exception; deaths of children under 5 years nearly doubled from 2.3 to 4.5 million, accounting for 43% of all child deaths compared with 14% in 1960. Only in Ghana and Malawi did infant mortality improve and improvement was least in Cote d’Ivoire and Rwanda. In Sub-Saharan Africa and other countries failing to reach targets for reduction the main contributing factors were reduced immunization programmes, conflicts and political upheavals and HIV/AIDS transmission from mothers to children

HIV/AIDS is an increasingly important factor in reproductive behaviour having both biological and behavioural influences on fertility, though its precise impact is not clear. HIV/AIDS has raised child mortality in countries with high levels of infection, particularly Sub-Saharan Africa which is experiencing some of the highest. There the UN estimates that between 1995 and 2015 the disease will be responsible for the deaths of nearly 4 million children under the age of five. In Kenya, Malawi, Zambia, Zimbabwe, Botswana, Swaziland, Nambia and South Africa which are most affected the mortality rates for those in this age group are projected to be 2 to 3 times greater than they would be without the infection. However in 25 countries HIV/AIDS is not the most important factor in mortality Other diseases, particularly malaria, together with socio-economic conditions and poor medical provision are more important influences. In Zambia, Zimbabwe, Swaziland and Nambia HIV/AIDS was the cause of 30 deaths per 1000 births while in other countries it was the cause of fewer than 10 per 1000.

The absence of any information on China in the Johns Hopkins Report leaves a great gap in knowing the progress of the reproductive revolution in the country with the largest population in the world and where great progress in family planning has been made. Certainly the reproductive revolution has made progress during the last decade, particularly in India with the second largest population in the world. A recent meeting in London noted that results to date were ‘better than expected’ but that overall hoped-for improvements have not been achieved, particularly in Sub-Saharan Africa and in the Arab countries. Progress has been limited by support from the developed countries being only about half that pledged, and especially from the cutting off of much US aid by the Bush administrations because of opposition to abortion.