A report from the Population Information Program of The Johns Hopkins University published at the end of 1992 presents evidence for falling fertility and for the increasing use of effective methods of contraception in developing countries. It is evidence sufficiently striking for the report to be titled The Reproductive Revolution.
The evidence comes mainly from Demographic and Health Surveys and Family Planning Surveys funded by the US Agency for International Development and the Centers for Disease Control, Atlanta. These were undertaken during the last decade in 44 countries representative of the developing world. Additional data came from recent national surveys in several Asian countries and from the World Fertility Survey of the 1970s In the report these findings are considered together with relevant literature in a bibliography of nearly 400 references. Selected items from the data are given in the table.
During the last three decades fertility has declined overall in the developing world by about a third, more in some instances (c 50% in Colombia, Jamaica, Indonesia and Thailand) and most strikingly in China (more than 70%). The decline has accelerated very recently, and though it has been widespread fertility remains high in sub-Saharan Africa (excluding South Africa) where the only substantial declines have been in Botswana, Kenya and Zimbabwe - 26, 22 and 18% respectively.
The overall Total Fertility Rate (TFR) for the developing world has fallen from 6 to 4; but there are considerable variations between major regions, between and within countries and between groups of women depending on religious, cultural and socio-economic factors, particularly levels of education. Fertility is close to replacement level (TFR 2.1) in China, South Korea and Thailand but is more than twice this in Bangladesh and Pakistan. Highest fertility (TFR more than 7) occurs in Niger, Uganda and Yemen. In North Africa and the Near East and in Latin America and the Caribbean fertility levels are generally between high and low.
The high levels (TFR more than 6) in sub-Saharan Africa are related to early start in childbearing, desire for large families and limited access to and effective use of methods of family planning. However, there are some indications of change. TFR fell about a quarter in the decade after the late 1970s in Kenya, a country with some economic development, reducing child mortality, increasing levels of women’s education and greater availability of family planning. More recent information not considered in the Johns Hopkins report points to some evidence of recent falling fertility in south-west Nigeria, and of longer-term decline in the fertility of the black population of South Africa. The latter began slowly in the 1960s, but the TFR 4.6 in the mid-1980s was well below that for countries in sub-Saharan Africa with the exception of Botswana.
Generally fertility decline begins among women of higher socio-economic status and education living in towns and then spreads out to rural areas and less-favoured groups. In Thailand, for example, the fertility of women with some secondary education is below replacement level and is half that of women with no education. But in Thailand, a country with a high degree of cultural unity and where many rural areas have participated in economic development, decline has been more widely spread than in many other countries.
Accumulating evidence suggests that infecundity is less than was previously believed. However, the surveys do not cover some of the countries in sub-Saharan Africa with reported low fertility where sexually-transmitted diseases are thought to be an important factor.
The most important direct factors, which have been termed “proximate determinants”, influencing fertility decline are the use of effective methods of contraception, age at first marriage, post-partum infecundity (from breastfeeding and abstinence from intercourse after childbirth) and induced abortion. Of lesser importance are frequency of intercourse and spontaneous abortion. These direct factors are themselves influenced by the socio-economic status and education of women.
Effective contraception is generally held to have been the most important factor in the decline of fertility in the developing world in recent decades. An increase of 15% in contraceptive prevalence can produce a decrease of one birth in total TFR. In 50 countries differences in levels of contraceptive use explain over 90% of the differences in levels of fertility.
The decline in fertility that has taken place signals major changes in attitudes to reproduction and consequent behaviour. In most developing countries outside sub-Saharan Africa more than half of married women do not want any more children; in sub-Saharan Africa more than half of married women wish to postpone their next pregnancy or to have no more children.
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| Based on data from Population Reports, Series M No 11, Special Topics, December 1992, Population Information Program, The Johns Hopkins University, Baltimore MD. |
It is estimated that in developing countries about 38% of women married or in consensual unions are using family planning methods, about half of the proportion in developed countries. Family planning use by all available methods ranges from under 10% in sub-Saharan Africa to 70% and over in China, Korea and Costa Rica, and approaches 70% in Brazil, Colombia and Thailand. It is mostly above 50% in Latin America and the Caribbean and in Indonesia, Vietnam and Sri Lanka, 40 and 45% in Bangladesh and India respectively, but only 12% in Pakistan. In sub-Saharan Africa it is over 25% only in Botswana, Kenya and Zimbabwe.
In general modern methods of contraception are used increasingly and traditional methods are declining. Voluntary female sterilisation is the most widely used modern method, particularly in Latin America and in some Asian countries (China, Korea, Thailand and Sri Lanka). Other methods, in descending order of importance, are oral, IUD, condom, injectables and vaginal barrier. The use of condoms is very low, a factor of great importance in assisting the spread of AIDS. Male sterilisation (vasectomy) is of limited importance as a method of contraception. Clearly women have the major responsibility in measures for family planning.
Contraceptive use is lowest among young women, indicative of a initial desire for children. It rises to a maximum for women in their mid-30s and then declines in their later reproductive years. In general contraceptive prevalence is higher in urban than in rural areas. Women in the former are more educated, have a greater perception of socio-economic pressures in towns where the economic importance of children is not as great as in rural areas, and have better access to knowledge and supplies of modern contraceptives. Where overall contraceptive prevalence is low the contrast between urban and rural areas is greatest, and vice-versa. In South Korea, for example, overall prevalence is 77% and the figures for urban and rural areas are approximately of the same order.
Knowledge, if not the use, of family planning is now widespread in the developing world, more than 75% of women are aware of at least one modern method of contraception. The exception is sub-Saharan Africa where the proportion is less than 40%. Awareness of methods is greater with higher levels of education and socio-economic status, and in urban as compared with rural areas. This awareness has been increased through the media, particularly by radio and television, and family planning information in these and other forms is increasingly regarded as acceptable.
Governments are the main providers of family planning in more than a half of the countries surveyed. Official provision is supported by various organisations (eg UN Fund for Population Activities, International Planned Parenthood Federation, national planning family planning associations, non-government aid agencies). Contraceptives are also supplied by the commercial market.
375 million women are using family planning, a further 120 million are not but would wish to do so. The potential demand is large. In 14 of the countries surveyed more than 80% of the demand was met, but overall the proportion was less than 50%. In sub-Saharan Africa it was less than 30% and below 20% in Liberia, Mali and Uganda. In general services are less available in rural than in urban areas and for more poorly educated women compared with the better educated. In Egypt 72% of demand is met in urban areas but just over 40% in rural. Some family planning programmes are directed to reduce urban/rural differences, as in Indonesia and Thailand, with a consequent more even fall in fertility across these countries. Overall the strength of family planning programmes is of major importance and helps to counter other factors which militate against reduced fertility. Bangladesh has one of the ten strongest national family planning programmes and in the last two decades, despite being one of the poorest countries in the world with high child mortality and with women having low status, contraceptive use has increased from 3 to 40% and the TFR has reduced from 7 to 5.5.
In the past high mortality among infants and children under the age of 5 has been an important influence in maintaining high fertility. Changing circumstances relating to child survival are therefore important. Since the 1950/60s child mortality in developing countries has been reduced by more than a half, but still between 13 and 15 million children below the age of 5 die each year and mortality is 7-times greater than in the developed countries. It is highest (200 deaths/1000 live births) in sub-Saharan Africa, followed by North Africa and the Near East (140), but is much lower in Asia (55) and Latin America (40). By country, mortality ranges from 250/1000 in Mali to 35/1000 in Colombia and Sri Lanka. Economic circumstances, wars and other disruptions are contributory to higher mortality, particularly in Africa.
Two groups of diseases are responsible for approximately a half of child mortality. About 4 million die each year from diarrhoeal diseases which are particularly common after the ending of breastfeeding and in the early stages of weaning. A further 3.7 million die from six infectious diseases (TB, measles, diphtheria, whooping cough, tetanus and polio). Malnutrition, much influenced by socio-economic factors, maternal education, child-spacing and displaying marked rural-urban contrasts, affects about a third of all young children and increases their susceptibility to diseases.
Diarrhoeal conditions can be countered by oral rehydration therapy but only about a quarter of cases are so treated. The infectious diseases can be prevented by immunisation and this has been important in improving child survival, but is far from universal in developing countries. Campaigns supported by international agencies like WHO and UNICEF aimed to immunise 80% of children by 1990 but this was not achieved; coverage has been greatest for TB, measles and polio. Survey data indicate that lower rates of immunisation have been achieved than those claimed by national health authorities.
Child mortality has been reduced and levels of health have been improved by medical interventions, but their successful application is much influenced by a wide range of cultural and socio-economic factors. There should be further improvements in the future, but with a major reservation in respect of AIDS and its continuing impact on morbidity and mortality, particularly in sub-Saharan Africa.
If all family planning needs were met it is estimated that TFR would fall from the present average of 4 to 3. The impact on population growth would be considerable. To meet present needs would require a 50% increase on current expenditure on family planning. At present governments contribute between a half and three-quarters of costs and external agencies between 15 and 20%. The latter represents about 1% of the total assistance to the developing countries and if this could be raised to over 3% then the financial needs for family planning would be met. It would be a small price to pay for the benefits which would result.
R Mansell Prothero